17 - Surgery in Older Ps Flashcards
What happens to oxygen requirements post op?
They increase - from 110 to 170ml / min = uptake 50% increase
What guarantees better outcomes for older Ps undergoing surgery?
An individualised approach - as each P is very different
What age related changes can make perioperative care more challenging?
Fluid management - complicated by reduced cardiac and vascular compliance
Thermoregulation - inc risk of perioperative hypothermia
Predisposition to pneumonia - due to chest wall rigidity and reduced lung function
Altered kidney and hepatic function => electrolyte disorders an altered kinetics of drugs
What do we look at when assessing functional capacity?>
Frailty index
Sarcopenia
Physical activity levels
What are the major factors in determining survival post operatively in elderly Ps?
Aerobic conditioning
Frailty
What is the patient-centred, multidisciplinary, integrated care of medical Ps prior to surgery called?
Perioperative medicine
Involves optimising Ps prior to surgery
What comorbidities inc risk for elderly Ps during surgery?
Which surgeries are the riskiest?
Emergency surgery
Major vascular surgery
Anything with 500ml + blood loss
Why is breast surgery lower risk?
Dont go into a cavity as such = therefore the inflammatory response is lower.
What are second insults in terms of surgery?
A second insult is another injury that happens in the recovery period (such as a post op complication) - can lead to poor prognostic outcomes.
Which national programme combines organisation of care + clinical management through the surgical patient pathway with the aim of improving postoperative outcomes?
Enhanced Recovery Programme
Why can impaired blood flow to organs occur during surgery?
Due to anaesthetic drugs, blood loss, fluid shifts
What can we do post-operatively to minimise risk to Ps?
+ Early restart of usual meds
+ Planned discharge to appropriate place
+ Post op targeted aerobic exercise and strengthening programme to ensure optimal QOLW
What is the BRAN tool?
Used to decide
- Benefits
- Risks
- Alternatives
- what happens if we do Nothing
in deciding whether to do a procedure
What can happen to Ferritin levels in acute inflammation and infection?
Can go up
What is silver trauma defined as?
Major trauma in Ps over 65
What is the most common mechanism of trauma in elderly Ps?
Fall from <2m
How do we score the severity of injury to elderly Ps in a trauma setting?
Injury Severity Scoring
> 15 - major trauma
What are the commonest places that elderly Ps get injured in trauma?
Head
Thorax
Spine
Limbs
Why does silver trauma have a higher mortality and morbidity than in younger Ps?
Combo of less likely to be examined properly + less functional status prior to injury
Why can a normal GCS be falsely reassuring in silver trauma?
Older Ps can have a loss of density in their cerebrum - means there is more space to bleeding in to
What is Cushing’s triad?
Cushing’s triad refers to a set of signs that are indicative of increased intracranial pressure (ICP), or increased pressure in the brain.
Cushing’s triad consists of
- bradycardia (caused by increased BP)
- irregular respirations
- widened pulse pressure.
Why can elderly Ps present as less ill than they are in trauma?
- Anti-HTs give false BP - hides Cushing’s triad
- Polypharmacy
- Reduced physiology
can both hide changes in observations of baseline
If an elderly P has a brain injury, what should you also image?
The neck!
What systolic BP is defined as hypotensive in a P over 65?
<110
110 = to morality of <90 in a younger P
Why can rib fractures kill Ps?
Fractures of which ribs has the greatest physiological significance?
1-7 (Vertebro-sternal)
How should you manage silver trauma?
CT
Anticoagulant reversal
Pain relief
Hydration
Refer
What are the physiology red flags to be wary of in silver trauma?
SBP <110
HR > 90
GCS < 15
Anticoagulants
