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PERIOPERATIVE POCKET MANUAL 2005  (Contents)  - 3rd Edition

Maracus Magallanes, MD 2005

13. AGE and OBESITY

ADVANCED AGE

*Overall surgical mortality for all adults under 65 is 0.9% as compared to 5-10% in patients 65 to 80 and 10-20% in patients over 80; however, these statistics do not take into account any surgical risk factors apart from age. Older patients are more likely to have underlying medical conditions, and it is felt that these conditions-and not the age-account for the majority of the increased surgical risk. Normal aging itself as a surgical risk factor remains controversial. Studies that control for underlying disease have failed to show an independent effect of age on surgical risk, and mortality among older patients free of disease is very low.

SPECIFIC CONCERNS IN THE ELDERLY:

  1. Cognitive function-preoperative status is the most important risk factor for postoperative delirium. (In general, I try to avoid using demerol and benzodiazepine drugs in very elderly patients due to delirium risk.)
  2. Nutritional status and activity level-key indicators of underlying physical condition.
  3. Fluids-elderly patients are more sensitive to changes in fluid status. They react more adversely to hypovolemia than younger patients, yet they also are more easily put into fluid overload. Be cautious with the IV fluids. (In general, maintenance IV fluid should be run at a lower rate in the euvolemic elderly patient to avoid fluid overload.)
  4. Drug dosing-elderly patients are more sensitive to medications and are more likely to suffer side effects/toxicity. Initiating medications at lower doses is the safest strategy.
  5. Cardiac issues-risk of hypotension, conduction disturbances, arrhythmias, and CHF is increased (due to myocardial fibrosis, decreased LV compliance, and degeneration of pacemaking/conducting tissue). Also, baseline heart rate tends to be lower.
  6. Prostatic hypertrophy-risk of postop urinary retention is increased.

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OBESITY

*Obese patients do have a higher risk of surgical complications, although mortality is NOT significantly increased due to obesity alone. (Comorbid conditions, however, are common in obese patients and can increase perioperative morbidity/mortality themselves.)

SPECIFIC CONCERNS IN OBESE PATIENTS:

1)      Thromboembolic disease—DVT prophylaxis is essential for hospitalized obese patients.

2)      Wound complications—antibiotic wound prophylaxis is generally given; should also consider other measures for high-risk wounds (such as aggressive intraoperative warming and tight glycemic control if diabetic).

3)      Pulmonary complications—restrictive lung disease at baseline.  Obese patients need to sit up in bed and get up to a chair as soon as possible postop to maximize lung expansion.  Incentive spirometer is essential; suctioning device may also be needed to avoid aspiration.

4)      Sleep apnea—nasal CPAP should be continued if patient is already using.  Ideally, patient should have his/her own CPAP machine brought from home to use while in-house.

If patient has only suspected sleep apnea by history (but not documented) or if patient with known sleep apnea does not tolerate CPAP, then recommended measures include head of bed elevation (60 to 90 degrees), continuous pulse oximeter while in bed (especially overnight), and supplemental oxygen to maintain 02 sat >90%.  A trial of nasal CPAP can also be attempted for patients who experience desaturation overnight despite supplemental oxygen.

5)      Comorbid conditions—hypertension, diabetes, cardiac disease, etc.

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