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4 Perioperative Management
55
from 1h to 30min prior. A recent meta-analysis showed that the pre-anesthesia does
not involve a substantial reduction of postoperative pain but leads to an extended
phase of postoperative unconsciousness [10].
The use of anxiolytics with short action is preferred in ERAS protocol and can
help anxious patients during insertion of the epidural catheter and generally in the
postoperative period in controlling the pain and avoiding the excessive use of opioids. Long half-life sedatives should not be used for routine procedures and should
be avoided 12h prior to the surgery as they can hinder a rapid recovery of mobility
and oral nutrition.
4.5.2 The Intraoperative Phase
Antibiotic prophylaxis, in the elderly as in younger patients, is effective in reducing
infectious complications and therefore uniformly recommended for all major surgical operations. The single-dose (“ultra-short-term prophylaxis”) and a multidose
regimens (“short-term prophylaxis”) have proven equally effective, although multiple doses are indicated for interventions exceeding 3h, in accordance with the
pharmacokinetics of the chosen antibiotic [11].
In traditional management opioids are often used for intraoperative analgesia.
The choice of the anesthetic technique specied in the ERAS protocol must take
two fundamental aspects into account: on the one hand the use of short-acting agents
(such as Propofol
the other, an anesthetic procedure that minimizes surgical stress.
Epidural analgesia is an important anti-catabolic tool, used to prevent postoperative insulin resistance. The surgical trauma causes the stimulation of central and
peripheral nerve pathways and leads to the catabolic response to surgery. In this
light, the nociceptive segmental block at the spinal cord level guarantees not only
adequate pain control but helps to limit catabolic effects, participating directly in a
better outcome.
The anesthetic technique with neuraxial block and epidural analgesia is the only
one able to alter the stress response. The benets could result from different mechanisms, including an increase in blood ow, more effective breathing without pain,
and, not least, by a reduction of multifactorial components of the response to surgical stress. The use of epidural catheters is also increasingly widespread in the management of postoperative pain: it provides for the systemic administration of
different types of analgesics or for the application of systemic and regional analgesia together, making the control of pain and the reduction of side effects associated
with the use of opioids possible in this way.
Epidural analgesia has also been shown to be superior to intravenous analgesia in
postoperative pain control in both traditional surgery and in minimally invasive surgery, allowing a reduction in the paralytic ileus due to selective blockade of δ nociceptive bers. Although there are few studies that have evaluated the impact of different
anesthetic techniques on postoperative outcomes, there is no evidence that compares
intravenous anesthetic to that of inhaled. It seems clear that the ERAS protocol makes
®
) that allow a more rapid onset of postoperative recovery and, on
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P. Palumbo et al.
a great effort to minimize the impact of anesthetic agents in order to promote rapid
postoperative awakening and thus facilitate the recovery of the functions [12].
For this reason, the use of short-acting hypnotic inductor agents, such as propofol, is recommended, combined with a short half-life opioid such as fentanyl and
remifentanil in bolus or continuous infusion. With regard to the maintenance phase,
the ERAS method does not provide for the use of exclusive inhaler agents, in order
to obtain the reduction in the incidence of PONV caused by nitric oxide, even if it
is administered in the antiemetic prophylaxis.
The blockade of the neuraxial system prolonged to the postoperative phase
involves additional benets in many patients: a recent meta-analysis showed an
overall reduction in mortality of 30% and signicant reduction of other complications [13].
By virtue of these multiple benets of epidural analgesia, this procedure is preferable in the ERAS protocol.
The trauma resulting from surgery involves two types of damage:
1. The primary injury determined by surgical incision, by tissue manipulation, and
by the mobilization of the viscera
2. Secondary damage related to blood loss during surgery, the effects of the anes-
thetic technique, and the intraoperative administration of drugs
Reduction of these two types of damage can be obtained by exploiting the advantages offered by the use of minimally invasive surgical techniques.
Minimally invasive surgery allows the optimization of surgical damage through
minimizing the incision extent and carefully carrying out dissection without compromising radicality and surgical accuracy.
In this way, the muscle bers are moved away from each other instead of being
etched (splitting vs. cutting); also, a better hemostatic control can be achieved, with
easier identication of cleavage planes in a bloodless eld. The magnication of
images also proves benecial in reducing the irritation of the serous, in limiting the
formation of adhesions and incidence of hematoma or postoperative bleeding.
The minimally invasive approach seems to have signicant short-term advantages over open surgery, such as the reduction of postoperative pain, early recovery
of intestinal motility, improved lung function, reduced hospitalization, and a better
quality of life in the rst 30days.
However, the use of minimally invasive techniques proved that it is not possible
to completely change the effects of the endocrine-metabolic responses to surgical
stress while limiting the immunodysfunction, the inammatory response, pulmonary stress, and hypoxemia when compared with the laparotomic approach.
Moreover, some long-term outcome studies do not reveal the substantial difference expected, but report as equivalent the use of open and minimally invasive techniques [
14].
By contrast, the multicenter study “LAFA Study 1” and other scientic research
demonstrated a real benet in the application of laparoscopic techniques in the multimodal strategy of rapid postoperative recovery [15, 16].
4 Perioperative Management
57
In recent years, the spread of new and alternative minimally invasive surgery
techniques, including robotic surgery, laparoscopic techniques with single incision
(SILS), and the “hand-assisted laparoscopic surgery” (HALS), has shown that it is
possible to reduce invasiveness.
These techniques are mainly used in highly specialized centers, but their use is
still not widespread, as there are not substantial data in favor of showing any real
advantage to justify their becoming more widespread.
The metabolic response to surgical stress determines the alteration of the balance
of uids and electrolytes, as well as temperature and blood rheology. Through the
AT1 receptor placed on the muscular coat of the vessels, angiotensin causes vasoconstriction and the production and release of several proinammatory cytokines.
The resulting water retention is accompanied by a reduced excretion of sodium and
increased excretion of potassium.
In addition, the activation of inammatory responses compromises the ability of
the organism to achieve a proper metabolic balance and to maintain the volume and
composition of the extracellular and intracellular uid constant. The colloid osmotic
pressure is altered in a negative sense, and this leads to an increased permeability of
capillaries and a passage of uids from the capillary bed interstitium.
The management of uid therapy provided in the ERAS protocol is designed to
counter these events: strong recommendations in this program suggest the adoption
of a restrictive regime, as the excessive administration of uids can affect the circulatory district and heart function.
Therefore, it must be recommended to limit the infusion of colloids and crystalloids, generally administered in order to avoid transfusions and the reduction in
renal blood ow. In fact, excessive preload, particularly in the elderly, may depress
cardiac function and lead to increased comorbidity such as cardiology and pulmonary ones, to the point of acute lung injury (ALI) and acute respiratory distress
syndrome (ARDS).
The physiological electrolyte balance should therefore remain stable throughout
the perioperative period, and in every single moment of the care path, this should be
monitored to achieve the maintenance of the “steady state,” which represents the
state in which the volume and composition of the body uids remain constant
despite the quantitative and qualitative changes of water and solutes.
For this purpose, not more than 3L of uid per day is administered, and a bowel
preparation is avoided; moreover, uid intake control before treatment also allows
the prevention of edema, associated with a prolongation postoperative ileus and
reduced cell oxygenation.
“Goal-directed uid therapy” involves the administration of intraoperative crystalloid at a rate of 2–3mL/kg/h adequate to prevent an increase in weight of more than
2.5kg, preferring isotonic and balanced solutions than the 0.9% saline solution.
Regarding colloidal solutions, their adoption has been deprecated by recent studies. In elderly patients, they signicantly alter hemostasis and can lead to acute renal
failure.
The ERAS protocol provides for the removal of the nasogastric tube even
before the patient’s awakening from anesthesia. There is no evidence to support
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its use in the postoperative period; a Cochrane meta-analysis of 37 studies, enlisting more than 5000 patients undergoing laparotomy for abdominal surgery, documented a slower functional recovery after surgery, a higher incidence of
postoperative ileus, and an increased risk of complications in subjects in which
the SNG is left in place [17].
Finally, intraoperative hypothermia prevention reduces the endocrine response
and the sympathetic reexes, allowing a limitation of the body’s response to surgical stress caused by the intervention; in addition, it does not impair the coagulation
tests, resulting in a reduction of bleeding.
Preventing hypothermia through the infusion of uids at appropriate temperatures or the use of a thermal blanket reduces surgical site infections, cardiac complications, bleeding, and the need for blood transfusion.
In the immediate postoperative period, it also prevents the effects of desaturation
and myocardial ischemic accidents due to the sudden increase in blood concentrations of norepinephrine caused by the drop in body temperature and prolongs the
overall time for anesthesia.
4.5.3 The Postoperative Phase
Postoperative nausea and vomiting (PONV) are the most common complications in
the immediate postoperative period, affecting 20–30% of patients undergoing
abdominal surgery.
It appears within 24h after surgery and contributes to postoperative morbidity, as
possible causes of aspiration pneumonia, wound dehiscence, and hydroelectrolytic
alterations.
Some endogenous molecules such as serotonin (5-HT), substance P, and other
mediators capable of transmitting a signal to the afferent nerve bers would assume
relevant importance.
Various risk factors have been associated with the development of postoperative
nausea and vomiting. Among them the strongest predictor appears to be gender,
with women at double the risk compared to men. A system of stratication of the
PONV risk is represented by the Apfel simplied score.
To avoid the unpleasant effects of PONV, it is necessary to focus attention on
strategies that include the use of regional anesthesia, the use of short-acting anesthetic agents, the avoidance of nitric oxide, adequate hydration, and a restricted use
of opioids.
In addition, administration of supplemental oxygen has been shown to have a
clear benet in reducing PONV. Goll et al. in a randomized study observed 240
patients and concluded that 2h of oxygen at 80% is more effective and less costly
than ondansetron in reducing PONV [18].
In high-risk patients, a combination therapy with the use of multiple drugs is
recommended, increasing the probability of success over monotherapy, since the
use of just one drug has only proved able to reduce the incidence by around 25%.
Delirium is perhaps the most signicant age-related postoperative complication.
4 Perioperative Management
59
It is characterized by a sharp decline in cognitive function and attention and
episodes of consciousness uctuation and occurs in approximately 40% of patients
undergoing surgery. It can occur in patients of any age but is most common in the
elderly, especially those who have already shown cognitive impairment in the preoperative stage. Its etiology is multifactorial, depending on physiological imbalances caused by stress related to the intervention, the use of drugs in the
intraoperative and postoperative period, or by a pre-existing condition of fragility
and the susceptibility of the patient. The pathogenetic mechanism is not entirely
clear, but several studies show a predominant role of the pathways of systemic
inammation and increased production of cytokines such as TNF.Delirium is associated with worse surgical outcomes, longer hospital stays, functional decline,
higher institutionalization rates, mortality, and costs due to increased resource
utilization.
To fully understand the pathophysiological basis of this phenomenon, consideration must be given to the risk factors and precipitating factors; for this purpose,
different scores are considered to assist in recognizing patients at higher risk of
postoperative delirium. The basic elements for risk stratication are age; preexisting cognitive impairment; the use of antianxiety drugs such as benzodiazepines
(BDZ); sleep disorders; alteration of laboratory values, particularly the function
tests of the liver and kidney; and a history of alcohol abuse.
Hospital environments should favor proper hydration, the limited use of opioids
and benzodiazepines, and an early empowerment.
Postoperative pain is one of the main variables in the recovery of patients and is
one of the main factors that contributes to prolonging the postoperative hospital
stay.
Traditionally, the control of postoperative pain is entrusted to plentiful intravenous administration of morphine. However, its use is burdened by side effects
poorly tolerated by the patient especially if elderly, important among which are
respiratory depression, inhibition of cough reex, paralytic ileus, orthostatic hypotension, nausea, and vomiting. Moreover, the activation of opioid receptors for neuropeptides in the myenteric plexus inhibits the release of acetylcholine from the
nerve endings, causing a decrease in the tonus of the smooth muscle cell and an
impaired motility of the intestinal wall.
In the geriatric patient, multimodal pain control is more appropriate. The surgical
incision and the manipulation of the intestinal bowel tissue cause the release of
chemical mediators such as adenosine, bradykinin, cytokines, prostaglandins, TNF,
and IL-1 that determines a sensitization of the peripheral sensory system, resulting
in a lowering of the threshold of activation of nociceptors.
In particular, the prostaglandin 2 (PGE-2) at the spinal level leads to liberation of
additional excitatory mediators, amplifying pain and allowing maintenance.
The thoracic epidural analgesia (TEA) involves the insertion of the catheter preferably at the mid-thoracic level (T6–T7, T7–T8) for both analgesia and the sympathetic block, avoiding the paralysis of the intestinal tract. This method is the gold
standard for proper pain management in patients undergoing laparoscopic abdominal surgery [19].
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If activated before the surgery, neuraxial blockade prevents hormonal release and
attenuates postoperative insulin resistance, reducing the need for administering
anesthetic agents.
Alternatives for the control of postoperative pain are represented by the use of
opioids intravenously issued from a patient’s device on demand (patient-controlled
analgesia—PCA). An additional method is the “continuous wound infusion of local
anesthetic”; in this technique, a “multiholed” catheter (multiperforated) is placed by
the surgeon at the end of the intervention, increasing the duration of action of the
drug and the tissue inltration effectiveness. The incidence of failure of this technique is very low (1%) and its toxicity almost none. In addition, further multimodal
analgesia strategies are to be considered. The block of the transverse abdominis
plane (TAP) and the rectus fascia represents alternative solutions and may play an
important role in the context of major abdominal surgery. Finally, another technique
is represented by the inltration of local anesthetic into the peritoneal cavity (IPLA)
by elastomeric pump: it allows the blocking of nociceptive pathways of visceral pain.
The postoperative ileus is one of the main iatrogenic complications occurring in
the postoperative period; its onset is part of the metabolic response to surgical stress.
Its etiology is multifactorial: factors favoring and triggering are represented by
inammation, changes in uid and electrolytes, and the administration of drugs; the
set of these triggers determines the contractility and altered bowel motility and
edema of the wall.
It is one of the major factors that increases the morbidity of the patient, resulting
in prolonged recovery time and hospital stay, but nevertheless is considered a normal and inevitable response to laparotomy and other surgical procedures.
The postoperative ileus involves a series of negative and unpleasant consequences, especially for the geriatric patient submitted to surgery: an increase of
postoperative pain, an increased likelihood of pulmonary complications, and a postponement of the return to a normal oral feeding are observed. This latest issue is of
crucial importance for the activation of the immune system and in the recovery of
residual functionality.
In ERAS protocol, epidural analgesia is essential to prevent postoperative paralytic ileus and to stimulate intestinal motility. At the level of the abdominal area, it
allows a reduction of the adrenergic tone and the pathway’s transmission of the
nociceptive signal activation. Furthermore, the use of restrictive infusion therapy
prevents the accumulation of liquids in the intestine, thus preventing an overdistension of the bers of the bowel wall. Also available to the ileum, prevention tools are
the “opioid-sparing analgesia,” the avoidance of the use of SNG in the postoperative
phase, early removal of urinary catheter and drainage when positioned, the use of
magnesium oxide per os, as well as early oral nutrition.
This should be initiated some hours after surgery, with at least the administration
of clear liquids and, in the absence of PONV, continuing with solid foods from the
rst postoperative day. This supports the early resumption of intestinal motility.
The lure not only promotes the risk of venous thrombosis, insulin resistance, and
muscle breakdown resulting in decreased strength and osteoporosis but also has a
negative effect on lung function and oxygenation of tissues.
4 Perioperative Management
61
Patients should be encouraged to early mobilization as from the rst postoperative day. A daily exercise program must be established, and the daily compilation,
in patient care, of a diary helps achieve the objectives. From the day of surgery,
patients should stay out of bed for 2h, increasing to at least 6h after the rst postoperative day.
Various factors oppose early mobilization, poor compliance by patients, comorbidities, and the effects of any complications occurring after surgery; these all represent barriers to early ambulation and are the main causes of failure in the ERAS
protocol.
The rationale behind early mobilization is in reducing the length of hospital stay,
but, above all, it conveys a positive and important message of psychological empowerment for elderly patients, which in turn plays an active role in the healing and
recovery process, essential to a speedy return to normal daily life.
Conclusions
Geriatric patients, always considered “unt” for their poor performance status,
are often excluded from the development of ERAS paths because they are con-
sidered high risk.
In several randomized controlled trials, the elderly represented only a small part
of the recruited sample. A recent systematic review by Bagnall etal. [20] reports
that the ERAS protocol is safe and can be applied in elderly patients, allowing a
reduction in postoperative morbidity and a reduction in the length of stay (LOS)
when compared with traditional care pathways. In addition, the data show that
neither advanced age nor a high degree ASA has resulted in a higher rate of complications or postoperative mortality, in contrast to what is generally stated.
Patient compliance is considered, on the basis of the scientic evidence, as a
predictor of success of the surgical procedure, as well as having a better postoperative outcome and a lower rate of complications; this is valid in the advanced
age of the patient, in whom the overall health status components are closely connected to each other.
Few data have been reported regarding the compliance of the elderly patient,
but recent studies show that optimal compliance can also be obtained in these
subjects, with a positive impact on outcome in the short term, even in patients
with a higher ASA grade and poorer performance status [21].
Evidence shows that the multidisciplinary team should always work toward a
strong common goal and make a continuous effort to educate patients in order to
involve them in all stages of the surgical pathway.
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4 Perioperative Management
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Risk ofVenous Thromboembolism
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inSurgical Elderly Patients
AnnaFalanga andViolaMilesi
5.1 Introduction
Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and
pulmonary embolism (PE), is recognized as a complex multifactorial disease,
involving clinical and genetic risk factors as well as environmental interactions. The
annual incidence varies from 1 to 3 events for every 1000 people in the world. In
particular, the annual incidence of VTE in Europe varies from 104 to 180 per
100,000 persons per year [1]. Numerous factors, both transient (i.e., surgery, trauma,
prolonged immobility, long trips, hormone therapy, pregnancy, and postpartum) and
permanent (i.e., incurable tumors, antiphospholipid syndrome), favor its development. Therefore, when VTE occurs concomitantly or after any of these recognizable
risk factors, it is classied as “secondary” VTE.Otherwise, when it occurs in the
absence of any of these risk factors, it is classied as “idiopathic” VTE.
Survival after VTE is worse than expected, and survival after PE is even worse
than after DVT alone; in fact the risk of early death among patients with symptomatic PE is 18-fold higher compared to patients with DVT alone [2]. PE is an independent predictor of reduced survival for up to 3months after onset. For almost
one-quarter of PE patients, the initial clinical presentation is sudden death.
Independent predictors of reduced early survival after VTE include increasing age,
male gender, lower body mass index, connement to a hospital or nursing home,
congestive heart failure, chronic lung disease, serious neurological disease, and
active malignancy [
VTE also recurs frequently. About 30% of patients develop recurrences within
the next 10years. The hazard of recurrence varies with the time since the incident
event and is highest within the rst 6–12months. However, even 10years after an
3].
5
A. Falanga, MD (*) • V. Milesi
Division of Immunohematology and Transfusion Medicine, Thrombosis & Hemostasis
Center, Hospital Papa Giovanni XXIII, Piazza OMS, 1, Bergamo 24127, Italy
© Springer International Publishing AG, part of Springer Nature 2018
A. Crucitti (ed.), Surgical Management of Elderly Patients,
https://doi.org/10.1007/978-3-319-60861-7_5
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