Preoperative and postoperative care

The increase in the average life that is observed in our country and in general in the Western world has conditioned an increase in life expectancy. Consequently, there is an increase in senile-age patients. It is calculated that More than 40% of the patients admitted to Spanish hospitals are over 65 years of age.

At the same time, there is an increase in chronic degenerative pathologies that manifest themselves with a higher incidence in the geriatric population. These diseases, associated with the natural biological involution processes typical of older age, create peculiar dilemmas related to the management of the geriatric patient candidate for surgical intervention.

On the other hand, the improvement of surgical techniques and the development of anesthesiological and resuscitation and resuscitation support systems have made it possible to increase the number of patients of advanced age and / or carriers of morphological or functional imbalances that can undergo surgical intervention.

Operations in older people

But perhaps one of the most important advances that has allowed increase interventions in the elderly It has been the best knowledge of the risk factors that regulate biological aging.

Not many years ago an arbitrary limit of surgical indication in the 70s. Currently, age does not represent by itself a significant risk factor for surgery, but rather the general state of health, functional reserve and previous quality of life.

Consequently, the current problem consists of locating and correcting the so-called risk factors in order to identify in the preoperative period the patients with a higher risk of complications or mortality and thus be able to apply support treatments aimed at assessing the functional reserve of each patient. For this reason, age does not currently represent a significant risk factor for surgery by itself.

The emergency surgery it presents a higher risk and complications in the elderly than in younger adults, due to its lower organic reserve. For this reason, the convenience of elective surgery is clear, whenever possible.

One must be especially careful in the evaluation of elderly patients, which must be multidimensional, considering and differentiating the patient with good previous health from those with associated morbidity or in emergency situations, since what does give a clear pattern of recovery and even survivalIt is the functional situation prior to the intervention, the autonomous elderly being much better in every way than those with a higher degree of dependency.

Minimally invasive surgical techniques have made it possible to improve the prognosis of many surgical procedures in the elderly and their development is in full swing. La, the practice of local or regional anesthesia, the use of precision technology such as lasers, etc., have allowed older people to benefit from surgery in selected situations. The modification of a technique to minimize your risk, which benefits the entire population, but particularly the elderly.

Preoperative in older

In general, in the preoperative phase, the so-called surgical risk must be assessed, which is evaluated taking into account factors such as:

• Physical assessment: control of pre-existing chronic diseases and assessment of basic complementary tests such as laboratory tests, pulmonary radiographs and electrocardiograms, or other more specific ones, such as respiratory function tests, etc.
• Functional assessment: knowing how the patient performs their basic and instrumental activities prior to surgery will provide a lot of information about how they will endure the surgery and set realistic recovery goals.
• Psychological assessment: not only knowing the emotional load inherent to the surgery, but also the previous one and anticipating a confusional syndrome.
• Social assessment: it is also important to know the environment to which the elderly patient must return after surgery.
• Type of surgery: it is evident that there are types of surgery with greater risk than others, a cataract intervention is not the same as a colon one. The affected region, the technique used and the surgical time must be taken into account.
• Type and time of anesthesia: the elderly are more sensitive to anesthetic effects due to changes in drug metabolism than younger adults, delaying anesthetic recovery time.

It is important to enter the surgery in the best possible general condition, with adequate ventilation and oxygenation, no water and electrolyte imbalances, with an adequate intravascular volume and normalized vital signs (temperature, heart rate and blood pressure).

Postoperative in older

Likewise, it is important to adapt the drugs taken by the elderly person to surgical stress and interactions that may arise with anesthetics.

Another important part is to ensure adequate prior nutrition, since malnutrition delays healing, favors postoperative infection and increases mortality.

Regarding the immediate postoperative care, in older patients, special care must be taken with:

• Level of consciousness: 15 to 30% (depending on the type of intervention) of elderly patients who undergo major surgery develop a confusional syndrome, due to causes such as the effects of anesthetics, pain, alterations in oxygenation and electrolytes, among others. Prevention of this confusional syndrome is very important, since mortality in these patients is up to 30%.
• respiratory function: in major surgery there is a decrease in the mobility of the rib cage, which leads to microcollapses at the base of the lungs and a decrease in the mobilization of bronchial mucus, worsening oxygenation. Likewise, the laryngeal reflex may be decreased in older people, contributing to the risk of bronchial aspiration.
• Hemodynamic function: in older patients, the decrease in cardiovascular recovery capacity makes decompensation due to overexertion easier in these patients after surgery and there is also a greater risk of postoperative hypothermia.
• pain control: Poor pain management contributes to lengthening the recovery process; Although it is true that analgesics can interact with other concomitant drugs or associated diseases, denying their use also has serious consequences.
• Prevention and detection of complications: such as thromboembolism, pneumonia, confusional syndrome, arrhythmia, heart failure, pressure ulcers, urinary infection ... For this reason, early mobilization and removal of ventilatory supports, catheters and catheters are important.