Monday, June 13, 2016

Guidelines Updated for Optimal Perioperative Geriatric Care

Extensive updates to best-practice recommendations for the perioperative care of patients 65 years of age and older have just been released; anesthesiologists take note.

“Optimal Perioperative Management of the Geriatric Patient: A Best Practices Guideline,” provides a management checklist for anesthesiologists and other medical professionals when caring for older patients facing surgery.

The guidelines cover the use of anesthesia and perioperative analgesia in older patients. Best practices for dealing with perioperative nausea and vomiting, preventing postoperative complications including hypothermia and fluid management are also detailed.

The report was published online on the American College of Surgeons (ACS) website and is scheduled to run in the Journal of the American College of Surgeons and the Journal of the American Geriatrics Society later this year.

The guidelines were developed by the ACS National Surgical Quality Improvement Program and the Geriatrics-for-Specialists Initiative of the American Geriatrics Society (AGS). The John A. Hartford Foundation provided financial support.

Mark D. Neuman, MD, assistant professor of anesthesiology and critical care and assistant professor of medicine (geriatrics) at the Perelman School of Medicine, University of Pennsylvania, in Philadelphia, helped write the new guidelines.

He said the ultimate aim is to help anesthesiologists and other medical practitioners “deliver great care for older adults.”

Clinical Implications
“I think that individual practitioners may take a look at these guidelines and take input from them on how they may improve their individual practices,” said Dr. Neuman, who also is chair of the American Society of Anesthesiologists’ Committee on Geriatric Anesthesia.

Anesthesiologists need to consider some of the physiologic changes common to older patients when drawing up an anesthetic plan, according to the recommendations.

Physiologic alterations in the cardiovascular, pulmonary, nervous, endocrine and hepatic systems of older adults can have significant clinical implications for the use of anesthesia. Decreased venous compliance, for example, can lead to susceptibility to hypotension, while a drop in neurotransmitters can lead to an increased risk for cognitive dysfunction and postoperative delirium, for instance.
However, there is not enough evidence for a single, recommended approach when drawing up an anesthesia plan for older patients, with anesthesiologists urged to use their best clinical judgment, the guidelines noted.

Regional anesthesia can be a beneficial alternative to general anesthesia in some surgical procedures in older adults, leading to reduced postoperative confusion.

The use of regional anesthesia may be considered as an alternative to general anesthesia in appropriate patients for hip fracture repair, with benefits including a lower chance of 30-day mortality and reduced need for sedatives, the guidelines noted.

Elective hip and knee arthroplasty and lower limb revascularization are surgical procedures in which regional anesthesia may be an appropriate alternative.

Regional anesthesia can lead to reduced mortality in patients undergoing elective hip and knee operations, while also resulting in better pain scores, a lessened risk for infection, and reduced need for sedation and critical care.

For lower limb revascularization, the main benefit of regional anesthesia is a lowered risk for pneumonia.

Still, there is insufficient evidence for a blanket recommendation that regional anesthesia be considered the dominant approach for older adults and other groups of patients, the guidelines cautioned.

Anesthesiologists also are called upon to take a multimodal approach to treating pain in older adults, emphasizing alternatives to the use of opioids.

Anesthesiologists should be sparing in their use of opioid-based medications in older adults, who can experience problems including cognitive dysfunction or delirium, with a higher risk for hemodynamic and respiratory issues, according to the guidelines.

When treating older adults, anesthesiologists are urged to develop an analgesic plan before surgery that considers altered physiology and increased sensitivity. The patient’s pain history and a physical exam should be noted.

Nerve Blocks and Epidurals
Some regional techniques for analgesia also may be appropriate in older patients as an alternative to opioid-based pain medications.

Combined with general anesthesia, the use of nerve blocks and epidurals can have multiple benefits, reducing pain, sedation and tracheal intubation/mechanical ventilation time while cutting the risk for perioperative myocardial infarction and perioperative cardiovascular complications. Gastrointestinal function returns faster.

In particular, major abdominal surgery, hip fracture repair, thoracotomy, and elective hip and knee arthroplasty are procedures for which epidurals with regional anesthesia or nerve blocks are viable options.

Pre- or postoperative nerve blocks are particularly effective during hip fracture repair, and should be for “all patients” undergoing the procedure.

Thoracic epidural anesthesia also should be considered for “appropriate” thoracotomy patients.
Local anesthetic delivered with an epidural may be considered for major abdominal surgery, including the repair of an open abdominal aortic aneurysm.

Paravertebral blocks failed to get an endorsement for use in older adults. The guidelines state that the “role of paravertebral blocks in this patient group is not clear,” and note an increased risk for hypotension.

When dealing with older adults scheduled for surgery, anesthesiologists are asked to carefully assess risk factors for postoperative nausea and vomiting (PONV), weighing risk mitigation strategies for those patients considered to be moderate or high risk.

There are also several PONV drugs on the AGS updated Beers list of medications that are not recommended for use in older patients.

Special care also is needed to prevent hypothermia in older adults undergoing surgery and following the administration of IV fluids. The health care team should monitor core temperature in surgeries lasting more than a half hour, while forced air warmers and warmed IV fluids should be used as well, the guidelines recommended.

When administering IV fluids, “the combined effects of aging, anesthetics, analgesics and anxiolytics on physiology” should be carefully weighed.

However, there is not enough evidence to support a best-practice recommendation for any particular fluid management strategies.

“More than ever, 80-, 90- and even 100-year-olds are undergoing surgery,” noted Terry Fulmer, PhD, RN, FAAN, president of the Hartford Foundation, in a press statement.

—Scott Van Voorhis
 Source: Anesthesiology News

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