A best practices guideline “Optimal Perioperative Management of the Geriatric Patient” jointly developed by the American College of Surgeons and the American Geriatrics Society was recently published (Mohanty 2016).
As you’d expect, there is a preoperative emphasis on establishing goals, expectations and preferences for the patient. That also includes ensuring that there is an advance directive in place and that a health care proxy has been identified. And, where appropriate, consideration should be given to obtaining a palliative care consultation.
Preoperative care should also include a shortened liquid fasting period (clear liquids up to two hours before surgery). Discontinuing non-essential medications but ensuring that the patient is compliant with essential medications is important. Best practices for DVT prevention and antibiotic prophylaxis are also discussed.
Intraoperative management includes attention to fluid and hemodynamic status but also stresses use of regional anesthesia techniques and multimodal opioid-sparing analgesia techniques and reducing postoperative nausea. Prevention of decubiti or nerve damage are important and preventing postoperative pulmonary complications are stressed. Patients should also continue indicated cardiac medications. Avoiding hypothermia is another important consideration.
The postoperative section contains a good discussion on preventing and managing delirium and fall prevention and prevention of UTI’s, topics we’ve discussed in numerous columns. A section on nutritional needs is very good. The postoperative section even includes a postoperative rounding checklist. There are also very good discussions on functional decline and care transition planning.
Overall, this is a concise yet focused document with excellent recommendations. It is also very well referenced with links to the cited documents.
Mohanty S, Rosenthal RA, Russell MM, et al. Optimal Perioperative Management of the Geriatric Patient: A Best Practices Guideline from the ACS NSQIP/American Geriatrics Society. J Amer Coll Surg 2016; Published online: January 4 2016