ASSESSMENT OF CARDIOVASCULAR RISKS AND OVERALL RISKS FOR NONCARDIAC SURGERY - 08/09/11
Résumé |
Patients older than 65 years of age account for up to 40% of surgical procedures, 50% of emergency procedures, and 75% of surgical mortality. The elderly have two to three times the risk of mortality for a given surgical procedure compared with middle-aged adults. This greater perioperative mortality relates, in part, to the physiologic changes of aging (see the article by Schulman), but associated diseases are a powerful predictor of postoperative morbidity and mortality.2, 23, 25, 32, 50 In patients older than age 70, most perioperative morbidity and mortality can be attributed to cardiovascular (50%), pulmonary (20%), and renal (10%) comorbidities, not only frequent sites of disease, but also organs with major age-related physiologic deterioration. Palmberg and Hirsjarvi46 studied elderly patients undergoing general surgery and found mortality was increased 17% by cardiac disease, 26% by diabetes, and 45% by dementia. Emergency procedures are much more frequently performed in the elderly and increase the risk of death by two to four fold.23, 33 The elderly patient's reserve capacity to withstand the stress of surgery is difficult to measure, but the heterogeneity of aging (see the articles by Schulman and by Friesinger elsewhere in this issue) is a major consideration. Reserve capacity may be reduced as a result of the pathophysiologic effects of aging as well as the effects of disease on organ function. Preoperative evaluation of the elderly patient must assess risk and identify measures to minimize morbidity and mortality. Factors that affect risk include the nature and duration of the illness requiring an operation, other comorbidities, age, and nutritional status65 as well as the type of operation.
Perioperative issues can be assessed by considering the four Ps: (1) patient, (2) procedure, (3) provider, and (4) protocols.55 The risk classification scales discussed subsequently include patient and procedure characteristics, and the approach to noninvasive testing in vascular patients highlights the protocol aspect of risk stratification. Thoughtful and closely coordinated efforts among providers, including the referring physician, surgeon, consultants, and anesthesiologists, are essential for optimal care and a highly individualized approach for elderly patients undergoing surgery.
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| Address reprint requests to Ok Yung Chung, MD, MBA, Department of Anesthesiology, Vanderbilt University Medical Center, 504 Oxford House, 1313 21st Avenue S., Nashville, TN 37212 |
Vol 17 - N° 1
P. 197-211 - février 1999 Retour au numéro
Article précédent
- VENTRICULAR ARRHYTHMIAS, ELECTROPHYSIOLOGIC STUDIES, AND DEVICES
- Anwer Dhala, Jasbir Sra, Zalmen Blanck, Sanjay Deshpande, Mohammad R. Jazayeri, Masood Akhtar
- CARDIOVASCULAR SURGERY IN THE ELDERLY
- Salim Aziz, Frederick L. Grover
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