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404 J. Menaker and T.M. Scalea
CASE STUDY
AB, a 77-year-old female, with past medical history of
atrial fibrillation, hypertension, and osteoporosis, was a
restrained driver involved in a motor-vehicle collision.
The patient was t-boned on the driver side by a car traveling at approximately 45 miles/h. On arrival, she denies
any loss of consciousness, complains of some left-sided
hip pain, which is worse with movement. In addition, she
complains of left-sided chest pain, which is worse with
deep inspiration. She denies any abdominal pain or back
pain.
Past medical history: atrial fibrillation, hypertension, and
osteoporosis
Past surgical history: appendectomy
Medications: warfarin, aspirin, metoprolol, alendronate,
and multivitamin.
Allergies: none
Social history: denies alcohol, tobacco, or drug use
Family history: noncontributory
Physical Exam
Vital signs:
Height – 65 in.
Weight – 65 kg
Heart rate – 70 beats/min
Blood pressure – 105/60 mmHg
Respiratory rate – 30 breaths/min, shallow in nature
Oxygen saturation – 95% on 6 L by nasal cannula
EKG – rate-controlled atrial fibrillation
On exam, there is a left-sided scalp hematoma and
small laceration that is not currently bleeding. The patient
has significant left-sided rib tenderness on palpation; no
subcutaneous soft tissue air is appreciated. She also has
significant right hip and pelvis pain on palpation. The
pelvis does not appear to be unstable. Distal extremities
are cool to the touch. Pulse is intact. All other aspects of
the physical exam are normal.
Lab work:
Sodium – 139 mmol/L Chloride – 109 mmol/L
Potassium – 4.0 mmol/L Bicarbonate –
19 mol/L
Glucose –
100 mg/dl
BUN – 35
mg/dl Creatinine – 1.75 mg/dl
White blood cell count – 12 k/mcl INR – 2.1
Hemoglobin – 10 g/dl PTT – 30 s
Hematocrit – 32.0% PT – 19.5 s
Platelets – 175 k/mcl
Serial cardiac enzymes are normal
Lactic acid – 4.5 mmol/L
Arterial blood gas:
pH – 7.30
pCO
2
– 40 mmHg
pO2 – 90 mmHg
O
2
Saturation – 95%
Base deficit – 6.5 mmol/L
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and crosswalk signs, tighter speed-limit enforcement, and
safety-education presentations at senior centers.
End of Life/Withdrawal of Care
End-of-life and withdrawal-of-care discussions are often
very difficult for families as well as the care providers.
Although many elderly have advanced directives or living
wills prior to getting injured, many do not. Despite good
intention, the documents are often not helpful. It is then left
to members of the patient’s family to help guide the physician to provide the care the patient would want. It is often
difficult to get the families to understand that they are to
make decisions based on what their loved one would want,
not what they would want.
The discussion regarding end of life and withdrawal of
care is often a multistep process. The decision not to perform
cardiopulmonary resuscitation or to intubate is often the first
decision that families make. Often, it takes families some
time to come to the reality that despite all medical advances,
their loved will not survive. It is imperative to get as many
family members as possible that want to be involved in the
decision process together at one time. Although there is a
hierarchy of legal decision makers, having all family members agree on the decision, can be critical. Utilizing pastoral
care and or palliative care services often makes the process
easier for all involved.
When the decision is made by the family to withdraw
care, the physician must ensure a smooth process. Some
families want to be present during the removal of life support, some do not. Adequate narcotics and sedatives help
prevent any additional suffering. In addition, adequate medication can help minimize any visual discomfort, especially
during removal from the ventilator. Turning off monitors
and intravenous pumps and ensuring a quiet peaceful atmosphere for the patient and family enhances the family’s
experience.
(continued)
40531 Care of the Injured Elderly
Radiographs:
Chest X-ray – multiple left-sided rib fractures, no pneu-
mothorax, no hemothorax
CT scan
Head – scalp contusion, no intraparenchymal hemorrhage
Cervical spine – degenerative changes, no acute fractures
or subluxations
Chest with IV contrast – left-sided rib fractures 5–10, no
pneumothorax, small hemothorax, normal aorta
Abdomen/pelvis with IV contrast – left-sided inferior
and superior rami fracture. Left-sided sacral fracture.
Active extravasation in the pelvis. No solid or hollow
viscous organ injury
Things to Consider
1. Early intubation in an elderly person with multiple rib
fractures and labored breathing.
2. Insertion of an epidural catheter for administration of
narcotics to assist with pulmonary toilet in setting of
multiple rib fractures.
3. Mild hypotension and normal heart rate in setting of
acute trauma may be related to medications patient is
taking, i.e., beta blockers.
4. Administration of IV contrast for CT scan in the
elderly patient with a decreased GFR and creatinine
clearance.
5. The need for warfarin reversal in lieu of active bleeding in the pelvis.
6. The method by which warfarin can be reversed.
7. The need for invasive monitoring in the elderly trauma
patient.
Hospital Course
AB received 2 U of fresh frozen plasma, which corrected
her INR to 1.5. Her elevated INR and the fact that she has
been on aspirin precluded her from getting an epidural
catheter for pain management. However, she did receive
a patient-controlled analgesia (PCA) pump to help with
pain control and assist in pulmonary toilet.
Due to AB’s signs of hypoperfusion including cold
extremities, acidosis, and base deficit, a pulmonary artery
catheter was placed. Initial cardiac index was 1.8
L/min/
m2, and mixed venous oxygen saturation was 55%. She
was started on 2.5 mcg/kg/min of dobutamine, and a
transthoracic echocardiogram was ordered.
Based on her abdominal and pelvic CT scan, it was
felt that AB would best benefit from an interventional
radiology consult, for possible embolization to stop
her pelvic bleeding. At this time, AB was ordered a
bicarbonate infusion as a strategy to help protect her
renal function in the setting of an additional IV dye
load. In addition, orthopedics was consulted regarding
her pelvic fracture.
AB had successful angioembolization of pelvic bleeding; however, upon arrival at the intensive care unit, her
work of breathing had increased. This was most likely
multifactorial in nature, including volume from the fresh
frozen plasma, volume from the bicarbonate infusion as
well as supine posture for the angiographic procedure.
AB was subsequently intubated for airway protection and
maintenance of adequate oxygenation and ventilation.
The next day, AB had a repeat head CT to rule out
delayed intraparenchymal hemorrhage, which was negative. The transthoracic echocardiogram demonstrated
mildly depressed left ventricular function with an ejection
fraction of 35% and no other abnormalities. Repeat lab
values were significant for a decrease in hematocrit to 23%
and a rise in the creatinine to 2.1
mg/dl; however, AB had
adequate urine output. Because of the decreased hematocrit, she received 2 U of packed red blood cells. Following
the transfusion, her cardiac index and mixed venous saturation were 2.9 L/min/m2 and 68% respectively. Thus, AB
was weaned off her dobutamine without incident.
Six days into her hospital course, AB was weaning
from the ventilator, hemodynamically stable, and the pulmonary artery catheter had been removed. At this point,
it was felt safe to place an epidural catheter for pain management to help facilitate extubation. AB was successfully extubated; however, approximately 36 h later, she
was reintubated due to increased work of breathing and
dropping oxygen saturation. After a discussion with her
family as well as AB, it was determined that the safest
thing for her was, as there was a likelihood of getting her
successfully off the ventilator, to perform a tracheostomy.
On day 9 of her hospital stay, AB had a tracheostomy
performed and within 48 h, she was off the ventilator.
She subsequently passed a swallow study and was able to
eat on her own. Thirteen days after admission, AB was
transferred to a rehabilitation center for further care.
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CASE STUDY (continued)
406 J. Menaker and T.M. Scalea
https://t.me/med1917
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Chapter 32
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Maximizing Postoperative Functional Recovery
Leo M. Cooney
CASE STUDY
An 82-year-old man entered the hospital with fever and
confusion. He had previously been living by himself in a
small apartment, but had been going out of the apartment
less and less over the past 6 months. His family noted that
his memory had started to become impaired. They brought
him to the Emergency Department because of acute confusion and a fever to 102°F. His evaluation revealed that
he had acute cholecystitis with bacteremia. He was initially treated with antibiotics and a surgical drain. He then
underwent a laparoscopic cholecystectomy.
A higher and higher percentage of surgical procedures are
now being done on patients 65 and older. The successful outcome of these procedures goes beyond traditional concerns
about morbidity and mortality. For most patients, the most
important result of these procedures is the ability to continue
to live independently. Hospitalizations and surgical procedures often result in a decrease of older persons’ ability to care
for themselves, resulting in the need for daily care at home or
nursing home placement. Surgeons must understand how to
return their patients to the highest possible level of function, if
they are going to provide them the best possible care.
Katz in 1963 outlined those functions that an individual
must be able to do independently to live without the assistance of another individual. These “activities of daily living”
include the ability to bathe, groom, dress, feed, and toilet oneself independently, as well as being able to transfer out of bed
or chair and walk independently [1] (Table 32.1). “Instrumental
activities of daily living” describe higher levels of activities
needed to live independently in the community. These include
L.M. Cooney (*)
Yale – New Haven Hospital, 20 York Street, Tomkins 17,
New Haven, CT 06504, USA
e-mail: leo.cooney@ynhh.org
During his hospitalization, he continued to be acutely
confused. He required sedating medications and physical restraints, as he frequently tried to pull out his drains
and intravenous lines. He developed a grade two pressure sore on his sacrum. He was initially treated with a
Foley indwelling bladder catheter and later with an
external catheter.
By the tenth hospital day, he had a normal white count,
was afebrile, and his surgical wound had healed nicely.
He was, however, unable to get out of bed by himself and
unable to control his bladder and bowels and was still
acutely confused. He required nursing home placement.
preparing meals, shopping, using the telephone, cleaning one’s
home or apartment, driving or using public transportation,
and managing one’s own finances.
The ability to perform daily living activities is not only
essential for the independence and life satisfaction of older
adults, but also is the single most important predictor of mortality for older individuals. Virtually every study of prognosis has found that these seven daily living activities are more
strongly associated with mortality than standard physiologic
parameters. In many studies, the only condition that has a
larger impact on mortality than function is metastatic cancer
[2]. Difficulty with these daily living activities is also strongly
predictive of nursing home placement.
Unfortunately, the process of hospitalization itself often
causes a decline in function in older individuals; and 35–50%
of patients over 65 experience a decline in function during
hospitalization [3]. This decline is often unrelated to the reason for hospital admission and is associated with a prolonged
hospital length of stay, increased need for nursing home
placement, and increased mortality [4].
Older individuals are at a much higher risk for the complications of hospitalization and medical and surgical interventions
than younger people [5]. The limited mental and physiologic
reserve of older adults often contributes to these complications.
R.A. Rosenthal et al. (eds.), Principles and Practice of Geriatric Surgery,
DOI 10.1007/978-1-4419-6999-6_32, © Springer Science+Business Media, LLC 2011
411
412 L.M. Cooney
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Ta b l e 32.1 Activities of daily living
Transfer
Walk
Bathe
Dress
Feed go to toilet
Continent of urine and stool
Elderly patients have a high incidence of complications with
therapy, including drug reactions, adverse effects of procedures,
hospital-acquired infections, and other iatrogenic events [6].
When older patients are evaluated in acute hospitals, they
often have significant functional problems. Warshaw found
that 50% of patients over age 65 in a community hospital had
mild or moderate confusion, 47% were incontinent of urine
or catheterized, 65% could not ambulate independently, and
40% needed help with eating [7].
The most important contributor to loss of functional status during a hospitalization is altered mental status. The
development of delirium, or acute confusional state, during a
hospitalization has a major impact on a patient’s function
and long-term outcome. The major predisposing factor for
the development of delirium is underlying dementia.
Delirium can now be easily diagnosed. Sharon Inouye’s
Confusion Assessment Method has become the international
standard for the diagnosis of delirium. The four components
of this instrument are (1) acute onset and fluctuating course,
(2) inattention, (3) disorganized thinking, and (4) altered
level of consciousness. The patient is classified as delirious if
he/she exhibits
1 and 2 and either 3 or 4. Inattention is the
key feature of delirium. Patients with inattention have difficulty focusing attention, are easily distractible, and have difficulty keeping track of what is being said [8].
The hospital environment itself can also precipitate delirium. There is a very high incidence of delirium in patients in
intensive care units. The use of physical restraints can themselves produce delirium, and often severely complicate this
condition. Lack of sleep caused by in-room intercoms,
administration of medications, and the frequent measuring of
vital signs often results in acute confusion.
Preoperative Assessment
The first step in promoting postoperative recovery is to assess
the patient preoperatively for predictors of functional decline.
The most important predictors of functional decline following surgery are patient’s preexisting mental status, physical
function, and social activities. Dementia is an extremely
important predictor of outcome following surgical interventions. As noted above, dementia greatly increases the probability of a patient becoming delirious following surgery.
T
a b l e 32.2 Predictors of hospital decline
Altered mental status
Physical function prior to admission
Social function prior to admission
Frequency of going out of the home
Dementia increases the mortality for hip fracture patients
almost threefold [9]. Patients with dementia are two to three
times as likely to die from pneumonia as patients without
this condition [10].
Dementia is very common in older adults. The prevalence
of this condition is roughly 1.5% between the ages of 65 and
70 and then doubles for each 5-year period after that. Thus,
nearly 25% of individuals between 85 and 90 have some
degree of dementia and almost 50% of those 90 and above
have dementia [11]. Cognitive losses can be subtle. Many
patients with mild-to-moderate dementia still have good social
graces and do not appear, on casual observation, to have any
major problems with their mental status. Although socially
appropriate, patients with dementia are at very high risk for
the development of delirium following a surgical procedure.
Memory loss is the most common feature of dementia. The
best mental status screening test is the Folstein Mini Mental
Status Test. This 30 point test takes only 5 min to administer.
It has been studied and validated in populations throughout
the world. The level of the patient’s education must be considered in the interpretation of the results of this test. Patients
with a high school education who scored 24 or less on this test
should be evaluated for the presence of dementia. For individuals with an eighth grade education or less, a score of 19 is
the level which requires a dementia evaluation.
It is important to determine how functional a patient is
prior to hospital admission. Was that person able to get in
and out of bed and walk independently, climb stairs, and
walk good distances? Did that patient frequently fall?
Such measures of independence as how often one goes
outside one’s home or participates in outside social activities
are excellent predictors of return of function following hip
fracture surgery. Patients who are socially active have a much
better outcome than individuals who stay in their own home
or apartment and have limited social contacts.
The best screen for altered physical function is to observe
the patient. The “get up and go” test observes the patient getting on and off a chair, walking a short distance, turning, and
walking back to the chair. In addition, the surgeon should
determine whether the patient can climb stairs, is still driving
an automobile, does his/her own shopping, meal preparation,
housekeeping, and other such activities. It is also extremely
important to know patient’s social support. Does that person
have someone else living with him or her or other family
members who can be available for assistance at home following hospital discharge? (Table
32.2).
41332 Maximizing Postoperative Functional Recovery
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Maintaining Function During Hospitalization
“Geriatric Vital Signs”
An older patient’s physical, cognitive, and nutritional function is as vital to their assessment as blood pressure, pulse,
and temperature. The geriatric vital signs are (1) Mental status (confused), (2) the ability to transfer in and out of bed and
walk (immobility), (3) the patient’s ability to take in adequate
nutrition (poor nutrition), (4) continence of bowel and bladder (incontinence), and (5) the presence of any skin breakdown or pressure sores (skin breakdown) (Table 32.3).
Managing patients throughout their hospitalization is an
essential step in returning patients to the highest possible
level of function. In the first instance, patients who are at
high risk for delirium and loss of physical function should be
evaluated prior to surgery. Those patients at high risk should
be monitored closely throughout their hospital stay. Patients
with early or moderate dementia would benefit from close
supervision on the part of families. Medications likely to
produce delirium should be kept to a minimum.
Although dementia rarely has a medical cause, delirium is
often caused by medical problems. The most common precipitants of delirium are an acute illness, being in an unfamiliar environment, and complications of medications [12]. The
medications that are most likely to produce delirium are anticholinergic medications as well as sedatives and hypnotics.
Long-acting sleep medications are particularly problematic.
Medications such as diphenhydramine, often used for its
sedating effects, are very apt to produce delirium because of
strong anticholinergic qualities. Sedating medications such
as benzodiazepines also frequently produce delirium. Longacting pain medications can be another cause of confusion in
elderly patients [13].
Any alteration in a patient’s ability to follow the train of
a conversation or follow the instructions of nurses or therapists should initiate an evaluation for delirium. The clinician
should determine the presence of inattention, an acute onset
and fluctuating course of the confusion, disorganized thinking, or altered level of consciousness. If these symptoms
indicate that the patient is delirious, then the surgeon and
nurse caring for that patient need to undertake a coordinated
effort to control this condition. The surgeon should evaluate
the patient for precipitants of delirium such as an acute
Ta b l e 32.3 Geriatric vital signs
Confusion
Incontinence
Immobility
Skin breakdown
Poor nutrition
illness, electrolyte or other physiologic abnormalities, or
medications with anticholinergic, sedating, or hypnotic
properties. The clinician should try and remove as many
external devices as possible, such as indwelling bladder
catheters, intravenous lines, and telemetry, and contact the
patient’s family to inform them about the nature and natural
history of delirium. The nursing staff should place the patient
under close observation, make sure that the patients have
eyeglasses and hearing aids, provide continual orientation to
the patient, and work with the patient’s family to provide the
patient with as much family assistance and supervision as
possible. The use of physical restraints should be avoided, if
at all possible. It is best to avoid medications in the management of delirium. If medications are necessary, most geriatric physicians suggest the use of low doses of antipsychotic
agents such as haloperidol or risperidone if sedation is not
needed, or quetiapine or olanzapine if the patient needs
sedation in addition to control of agitation. Benzodiazepines,
as noted above, should be avoided, as they often worsen
delirium.
The very nature of nursing care can contribute to a loss of
function for older hospitalized patients. Such activities as
providing a bed pan, bathing, dressing, feeding, or administering medications may decrease the patient’s ability to care
for him or herself. Nurses prepare patients better for discharge if they assist them with various tasks and ensure that
they can carry them out independently, rather than performing the tasks for the patient.
Continence of bowel and bladder is essential to an individual’s independence. Indwelling bladder catheters should
be removed as soon as possible after surgery. Transient urinary incontinence is common following surgery. Appropriate
management of this problem can decrease the chances of
permanent difficulties. If the nursing staff manages the
incontinent patient with diapers and external catheters, it
may be difficult to regain bladder control. Reassurance, frequent toileting of the patient, and assistance with mobility
are likely to result in return of bladder control.
Physicians may also play a major role in the development
of patient dependence. Sedatives and sleeping pills should be
used with caution in older individuals. These medications
often have a prolonged half life in the elderly and can cause
lethargy and confusion. They are particularly problematic if
the patient has any element of baseline dementia. The use of
indwelling or external bladder catheters to monitor urine
volume can result in at least temporary result of bladder control. The surgical approach to early postoperative ambulation
has been well recognized for a number of years. Physicians
and surgeons should realize, however, that the ability to
transfer out of a bed or a chair is a more difficult task than
walking and is more important to a patient’s ability to live
independently (Table
32.4).
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