This column is for my non-medical layperson readers. Your 85-year-old grandmother had two gallstone attacks in the past 6 months. Is she too old for surgery? Is it safe for her to have her gallbladder removed?
It depends. A general surgeon would serve as the consultant as to the natural history of the gallbladder disease. He may opine that future gallstone attacks are likely, and that the severe pain and fever of acute cholelithiasis is possible.
If your grandmother was 50 years old, you’d expect the surgical team to operate on her. For an 85-year-old patient, the surgical prognosis depends on her medical condition. She needs preoperative assessment from a specialist, and that specialist would be an anesthesiologist.
At Stanford University the anesthesia department is known as the Department of Anesthesia, Perioperative and Pain Medicine. The word perioperative refers to medical practice before, during, and after surgical operations. Preoperative assessment refers to the medical work-up before a surgical procedure—the work-up which establishes that all necessary diagnostic and therapeutic measures have been taken prior to proceeding to the operating room.
Age alone should not be a deterrent to surgery. Increased life expectancy, safer anesthesia, and less invasive surgical techniques such as laparoscopy have made it possible for a greater number of geriatric patients to undergo surgical intervention. The decision to operate should not be based on age alone, but should be based on an assessment of the risk-to-benefit ratio of each individual case. Surgical risk and outcome in patients 65 years old and older depend primarily on four factors: (1) age, (2) whether the surgery is elective or urgent, (3) the type of procedure, and (4) the patient’s physiologic status and coexisting disease. (reference: Miller’s Anesthesia, Chapter 71, Geriatric Anesthesia, 7th Edition, 2009).
Let’s look at each of these four factors:
1) Age. Data support that increasing age increases risk. Complication rates and mortality rates are higher for patients in their 80’s than for patients in their 60’s.
2) Emergency surgery. Patients presenting for emergency surgery are often sicker than patients for elective surgery, and have increased risk. There may be insufficient time for a full preoperative medical workup or tune-up prior to anesthesia.
3) Type of procedure. A trivial procedure such as finger or toe surgery carries significantly less risk than open heart surgery or intra-abdominal surgery.
4) Coexisting disease. The American Society of Anesthesiologists has a classification system for patients which categorizes how healthy or sick a patient is (see the American Society of Anesthesiologists Physical Status Class categories below). A patient with severe heart or lung disease is at higher risk than a rigorous patient who hikes, bikes or swims daily without heart or lung pathology.
Let’s examine these four factors in your 85-year-old grandmother. Regarding factor (1), she is old, and therefore she carries increased risk solely because of her advanced age. Regarding factor (2), her surgery is non-emergent, and this is in her favor. Regarding factor (3), her procedure requires intra-abdominal surgery, which is more invasive and carries more cardiac and respiratory risk than a trivial hand or foot or cataract surgery. She’ll have to cope with post-operative abdominal pain and pain on deep breathing, each of which can affect her lung function after anesthesia. Factor (4), her pre-existing medical history and physical condition, is the key element in her pre-operative consult.
The American Society of Anesthesiologists Physical Status Class categorizes patients as follows:
Class I – A normal healthy patient. Almost no one over the age of 65 is an ASA I.
Class II – A patient with mild systemic disease.
Class II – A patient with severe systemic disease.
Class IV – A patient with severe systemic disease that is a constant threat to life.
Let’s say your grandmother has well-treated hypertension, asthma, hyperlipidemia, and obesity. She is reasonably active without limiting heart or lung disease symptoms, and she can climb two flights of stairs without shortness of breath.
She is an ASA Class II.
What if your grandmother had a past heart attack which left her short of breath walking up two flights of stairs, or she has kidney failure and is on dialysis, or she has severe emphysema that leaves her short of breath walking up two flights of stairs? These problems make her an ASA Class III, and she is at higher risk than a Class II patient.
If your 85-year-old grandmother is short of breath at rest or has angina at rest, due to either heart failure or chronic lung disease, she is an ASA Class IV patient, and she is at very high risk for surgery and anesthesia.
Laypersons can access an online surgical risk calculator, sponsored by the American College of Surgeons, at www.riskcalculator.facs.org, and enter the specific data for any surgical patient, to estimate surgical risk.
If your grandmother has well-treated hypertension, asthma, hyperlipidemia, and obesity as described above, then her operative risk is moderate and most anesthesiologists will be comfortable giving her a general anesthetic. The American College of Surgeons risk calculator estimates her risk of death, pneumonia, cardiac complications, surgical site infection, or blood clots as < 1%. Her risk of serious complication is estimated at 2%.
How will the anesthesiologist proceed?
For an 85-year-old patient, most anesthesiologists will require a written consultation note from an internal medicine primary care doctor or a cardiologist prior to proceeding with anesthesia. The anesthesiologist will then confirm that all necessary diagnostic and therapeutic measures have been done prior to surgery. Routine lab testing is not be ordered because of age alone, but rather pertinent lab tests are done as indicated for the particular medical problems of each patient.
The anesthesiologist then explains the risks of anesthesia and obtains informed consent prior to the surgery. He or she will explain that an 85-year-old patient with treated hypertension, asthma, hyperlipidemia, and obesity has a higher chance of heart, lung, or brain complications than a young, healthy patient. Your grandmother will have to accept the risks as described by the anesthesiologist.
What do anesthesiologists do differently for geriatric anesthetics, in contrast to anesthesia practice on young patients?
(1) Anesthesiologists use smaller doses of drugs on elderly patients than they do on younger patients. Geriatric patients are more sensitive to anesthetic drugs, and the effect of the drugs will be more prolonged.
(2) Geriatric patients have progressive loss of functional reserve in their heart, lungs, kidney, and liver systems. The extent of these changes varies from patient to patient, and each patient’s response to surgery and anesthesia is monitored carefully. (Miller’s Anesthesia, Chapter 71, Geriatric Anesthesia, 7th Edition, 2009). The anesthesiologist’s routine monitors will include pulse oximetry, electrocardiogram, automated blood pressure readings, temperature monitoring, and monitoring of all inspired gases and anesthetic concentrations. Because most anesthetic drugs cause decreases in blood pressure, anesthesiologists slowly titrate additional anesthetic doses as needed, and remain vigilant for blood pressure drops that are excessive or unsafe.
What about mental decline following geriatric surgery?
Postoperative short-term decrease in intellect (decrease in cognitive test performance) during the first days after surgery is well documented, and typically involves decreases in attention, memory, and fine motor coordination. Early cognitive decline after surgery is largely reversible by 3 months. The reported incidence of cognitive dysfunction after major noncardiac surgery in patients older than 65 years is 26% at 1 week and 10% at 3 months. (reference: Johnson T, Monk T, Rasmussen LS, et al: Postoperative cognitive dysfunction in middle-aged patients. Anesthesiology 2002; 96:1351-1357).
In conclusion, the decision to proceed with your grandmother’s surgery and anesthesia requires an informed assessment of the benefit of the surgery versus the risks involved. Well-trained anesthesiologists anesthetize 85-year-old patients every day, with successful outcomes. My advice is to choose a medical center with fine physician anesthesia providers, and heed their consultation regarding whether your grandmother poses any unacceptable risk for surgery and anesthesia.
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Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
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