What’s different about the population?
What’s different pre op?
However, being more specific they have given some good advice on important points to include in the pre-operative assessment of these patients. This includes some areas that might not be an obvious part of a general pre-op assessment; risk factors for post-op delirium, nutritional status, and risk scoring to name just a few. They also highlight the importance of close collaboration between the anaesthetic and surgical teams about the respective plans and approaches of each team. Can a minimally invasive procedure be performed that allows a minimally invasive anaesthetic to be given? What is the overall aim for this patient (return to baseline independence, palliation)?
Finally, they discuss the importance of optimisation of patients. This is especially important (and more achievable) in the elective setting, and they highlight a variety of domains where thought needs to be directed in order to prepare patients for surgical procedures. Again, whilst some of these are no different from the younger population, instead maybe just more prevalent (e.g. management of diabetes, management of anaemia), some may not be initially obvious, such as treatment of malnutrition (iron, B12 and folate supplementation, if deficient, reduces morbidity and mortality), and preparation to minimise the risk of post operative cognitive decline (POCD) and delirium. The balance of optimisation in emergency cases is also touched upon, though they direct us towards specific guidance on management of different acute pathologies. The examples they use (those of hip fracture and emergency laparotomy) are there to demonstrate that, yes the patient may be sub-optimal with regards to their comorbidities and frailty, but in these examples time to theatre is important to the outcome of these patients and optimisation should run parallel to getting the operation done and not be a delaying factor.
What’s different intra-op?
Other components are perhaps more obvious but still very valid. Careful adherence to temperature maintenance is one they particularly flag up, but they also describe some of the ways that increased use of invasive arterial blood pressure monitoring, cardiac output monitoring and careful assessment of depth of anaesthesia (either through BIS, age-adjusted MAC calculations or TIVA software) can potentially minimise complications. It would have been great to have included some specific advice on fluid management in this patient group, but as they point out (and as is the problem for much of anaesthetic management in the older patient) there isn’t clear guidance or evidence out there yet (more on this later). This shortcoming continues into the guidance on the choice of anaesthetic technique itself, with the advice generally being; it’s up to you to tailor the technique to your patient.
What’s different post-op?
There are a few other points of recommendation here that can lead back to the choice of anaesthetic. Ideas such as using multi-modal analgesia (including nerve blockade) to reduce NSAID and opioid use and subsequently try and reduce post-op delirium, NSAID related complications, and improve post op nutrition through better oral intake. They also flag up that post-op pain and delirium are both complications that can go undiagnosed and unrecognised unless they are specifically sought, advising that this should be done from as early as recovery.
Many thanks for reading and I hope it has been of some interest to you at least. As always, please leave your feedback and comments as they are always welcome.