Alessandro PUZZIELLO | Progetti

PERIOPERATIVE MANAGEMENT OF ELDERLY PATIENTS WITH CANCER

In preoperative management the following items are identified that will be discussed with the multidisciplinary geriatric surgery team:History and nutritional status, Mental status,Physical examination, Cardiovascular diseases, Pulmonary and renal disease,Thromboembolic disease, Diabetes,Neuropsychiatric disorders.1. The health care team (including the surgeon and anesthesiologist) should ensure that they discuss personal goals and treatment preferences prior to surgery, including specific outcomes that may be important to older adults, such as postoperative functional decline, loss of independence, and skilled care burden.2. The health care team should ensure that older adult patients undergoing surgery have an advance directive and a designated health care proxy (or surrogate decision-maker). This information should be documented in the patient’s medical record 3.Whenever possible, the health care team should consider early (postoperative) palliative care consultation in older adult patients with poor prognoses undergoing surgery, especially those not expected to survive more than six months postop.Older persons who are hospitalized for acute illnesses, including surgical interventions, often lose their independence and are discharged to institutions for long-term care. Specific changes in the provision of acute hospital care can improve the ability of a heterogeneous group of acutely ill older patients to perform basic activities of daily living at the time of discharge from the hospital and can reduce the frequency of discharge to institutions for long-term care. Specialized acute-care geriatric units have been created and have shown improved patient outcomes without increased costs.Health care for the elderly has remained a prominent concern in the literature during the past decades. Aging alone is associated with an overall decline in reserves, and even the fittest elderly do not recover from a major stress as quickly as the young. It has been shown that substantial proportions of patients had protracted dis- ability after elective major abdominal operations and had not recovered to preoperative status by 6 months. Although we, as surgeons, may be pleased with our- selves for successfully getting an older patient through an operation, a poor functional recovery may be even more devastating to that patient. With the increasing numbers of elderly patients undergoing operations, attention to the quality of surgical care is of great importance Surgery can often be safely conducted but requires meticulous perioperative care to avoid com- plications and is best accomplished with an integrated, multidisciplinary approach. To minimize postopera- tive adverse events in the elderly, the following rec- ommendations for clinical management have been proposed:1. Preoperative assessment to determine the elderly patients at high risk of postoperative adverse outcome.2. Preoperative testing (invasive or non-invasive) only when test results are likely to change the proposed surgery or intervention, or to indicate the need for high risk invasive monitoring such as pulmonary artery catheterization.3. Effective perioperative control of coexisting disease. 4. Maintenance of stable perioperative hemodynamics for all elderly patients using vasopressor or vasodila-tor drugs, or betaadrenoceptor block, or a combination of appropriate therapies.5. Where possible, use of a less invasive surgical procedure, e.g., laparoscopy on an ambulatory basis.6. Intensive perioperative monitoring of high-riskpatients.7. Prevention of hypoxemia, hypothermia, and delirium.8. Effective postoperative pain control.