New perioperative guideline released for geriatric surgical patients

A new collaborative best practices guideline has been released for care of older adults immediately before, during, and after surgical operations.

The new consensus-based guideline was developed by the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and the American Geriatrics Society’s (AGS) Geriatrics-for-Specialists Initiative (GSI), with support from The John A. Hartford Foundation.

Optimal perioperative management of the geriatric patient: A best practices guideline is available for download at bit.ly/1OHl6ZW. It also has been published online on the Journal of the American College of Surgeons (JACS) website and will appear in print edition of JACS and the Journal of the American Geriatrics Society this year.

Building on a 2012 collaboration on joint guidelines addressing the preoperative care of older patients, the groups again partnered for the new best practices guideline. (For more information on the 2012 guidelines, see “Preop guidelines published for geriatric surgery patients,” Same-Day Surgery, December 2012. The story can be accessed at the reliasmedia.com page at bit.ly/1P6q1rU.)

The new guideline addresses the perioperative care of all surgical patients 65 years old and older as defined by Medicare regulations. The guideline provides a framework for thinking about the complex issues these patients face because they are more prone to experience postoperative complications and prolonged recovery with advanced age.

The ACS Geriatric Surgery Task Force developed the guideline with a multidisciplinary panel, which evaluated current evidence and best practices in the medical literature to arrive at a set of recommendations targeting surgeons, anesthesiologists, and allied healthcare professionals. While this consensus-based guideline is “not a substitute for clinical judgment and experience,” it can do much to support tailored, comprehensive geriatrics evaluations, the authors explain.

“This new interdisciplinary guideline provides us with another meaningful tool for improving geriatric surgical care,” said guideline coauthor Clifford Y. Ko, MD, MSHS, FACS, director of ACS NSQIP and principal investigator of the Coalition for Quality in Geriatrics Surgery (CQGS) Project. “We now have expert recommendations in place for older patients that range from preoperative assessment to perioperative management.”

The perioperative guideline is organized into three sections:

• Immediate preoperative management.

This section addresses patient goals, preferences, and advance directives; preoperative fasting; antibiotic prophylaxis; venous thromboembolism prevention; and medication management.

• Intraoperative management.

This section provides a management checklist for the intraoperative period. It addresses the use of anesthesia in older adults, perioperative analgesia in older adults, perioperative nausea and vomiting, patient safety, strategies to prevent postoperative complications and hypothermia, fluid management, and the targeting of physiologic parameters.

• Postoperative management.

This section provides a postoperative rounding checklist. It covers postoperative delirium, methods for preventing pulmonary complications, fall risk assessment and prevention, postoperative nutrition, ways to prevent urinary tract infections, functional decline, and pressure ulcer prevention and treatment.

A final section of the document guides clinicians in managing transition to care following surgery. It provides helpful appendices on a wide range of issues, from advance directive position statements to perioperative risk factors for delirium.

Guideline coauthor Sanjay Mohanty, MD, a general surgery resident at Henry Ford Hospital, and an ACS/AGS James C. Thompson Geriatrics Surgical Fellow, said, “As a start, this guideline functions as an unprecedented educational resource, one that organizes all of the components of perioperative care of the older adult in one place. Moving forward, perhaps it will one day play an important role in informing us about process and providing us with insightful metrics on outcomes for geriatric surgical patients.” (For more information on caring for geriatric patients, see these stories in the December 2015 issue of Same-Day Surgery bit.ly/1YgJCID: “4 steps to avoid hospital admissions that are unanticipated with elderly patients” and “What makes seniors more likely to have unanticipated admissions?”)