Geriatric 2 PDF

ACS NSQIP
/AGS
BEST PRACTICE GUIDELINES:
Optimal Preoperative Assessment
of the Geriatric Surgical Patient
ACS NS Q| P
/ AGS 8LS T PP ACT| CL GU| DL L| NL S :

OptlmalPreoperatlveAssessmento|tbeGerlatrlcSurglcalPatlent
| nt roouct l on
Tbepopulatlono|tbeUnlteoStateslsgrowlnganoaglng.TbeU.S.Census8ureauprojectstbenumber
o|Amerlcansage65yearsanooloerwlllmoretbanooublebetween2010ano2050.Tbepercentageo|
Amerlcans65anooloerwlllgrow|rom13tomoretban20o|tbetotalpopulatlonby2030,anotbe|astest
growlngsegmento|tblsgroup(lnolvlouals85yearsanooloer)lsepecteototrlplelnnumberovertbenet
|ouroecaoes.Tbesecbangeslntbeageoemograpblcso|tbeU.S.populatlonarelargelyouetopeoplellvlng
longeranotbebabyboomergeneratloncrosslnglntotbe65anooloeragebracketln2011.
1
Howwllltbls
oemograpblccbangelmpacttbebealtbcaresystem?
TbeNatlonalHospltalDlscbargeSurveybasoemonstrateolncreaslngbospltalutlllzatlonbyeloerlypersons.
|n1970,lnolvlouals65anooloerrepresenteo10o|tbepopulatlon
2
anoaccounteo|or20o|bospltal
olscbargesano33o|tbeoayso|care.
3
8y2007,tbepercentageo|persons65anooloergrewmooestlyto
13,yettbelrbospltaluselncreaseoorastlcallyto37o|bospltalolscbargesano43o|tbeoayso|care.
4
Tbe oloer lnolvlouals bave slgnlcantly blgber rates per populatlon o| botb lnpatlent ano outpatlent surglcal
anononsurglcalproceourescompareowltbotberagegroups.
3-5
|n2006,eloerlypatlentsunoerwent35.3o|
lnpatlentproceouresano32.1o|outpatlentproceoures.
3,5
Astbepopulatlono|tbeU.S.contlnuestoage,lt
wlllplacegreateroemanosonsurglcalservlces.
6
|tlslmperatlvetbatstrateglesareoevelopeotomeettbese
growlngoemanosanotoensureblgber-qualltycare|orgerlatrlcsurglcalpatlents.
TblsAmerlcanCollegeo|SurgeonsNatlonalSurglcalQuallty|mprovementProgram(ACSNSQ|P)/Amerlcan
GerlatrlcsSoclety(AGS)8estPractlcesGuloellnes|ocusontbeoptlmalpreoperatlveassessmento|tbe
gerlatrlcsurglcalpatlent.|tlsacompllatlono|tbemostcurrentanoevloence-baseorecommenoatlons|or
lmprovlngtbeperloperatlvecareo|tblsvulnerablepopulatlon.Wblletblsguloelsmeanttobelpsurglcal
teams,otberproceourallsts,anoanestbeslologlstlntbelrpractlce,ltlsnotasubstltutlon|orcllnlcaljuogment
anoeperlence.
Warren8.Cbow,MD,MS
Cll||oroY.Ko,MD,MS,MSHS,FACS
PonnleA.Posentbal,MD,MS,FACS
NestorF.Lsnaola,MD,MPH,M8A,FACS
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Tabl e o| Content s
|ntroouctlon.............................................................................................................................................................................. l
PreoperatlveAssessment...................................................................................................................................................... 1
SLCT| ON|. Cognltlveano8ebavloralDlsoroers...................................................................................................... 2
A. Cognltlve|mpalrmentanoDementla................................................................................................. 2
8. Declslon-MaklngCapaclty.................................................................................................................... 4
C. Depresslon............................................................................................................................................... 5
D. PlskFactors|orPostoperatlveDellrlum........................................................................................... 6
L. AlcobolanoSubstanceAbuse.............................................................................................................. 7
SLCT| ON||. CarolacLvaluatlon.................................................................................................................................... 8
SLCT| ON|||. PulmonaryLvaluatlon.............................................................................................................................. 9
SLCT| ON|v. Functlonal/Per|ormanceStatus........................................................................................................ 11
SLCT| ONv. Frallty......................................................................................................................................................... 13
SLCT| ONv|. NutrltlonalStatus.................................................................................................................................. 14
SLCT| ONv||. MeolcatlonManagement..................................................................................................................... 15
SLCT| ONv|||. PatlentCounsellng.............................................................................................................................. 19
SLCT| ON|X. PreoperatlveTestlng........................................................................................................................... 20
Appenolces............................................................................................................................................................................ 25
APPLND| X|. PatlentsDeclslonMaklngCapaclty.................................................................26
APPLND| X||. CarolacLvaluatlon..............................................................................................27
APPLND| X|||. FralltyScore........................................................................................................29
APPLND| X|v. Pecommenoatlons|orPreoperatlveNutrltlonalSupport....................... 30
APPLND| Xv. 8eersCrlterla|orPotentlally|napproprlate
MeolcatlonUselnOloerAoults...................................................................................................... 31
APPLND| Xv|. Pecommenoatlons|orPreoperatlveDlscontlnuatlon
o|HerbalMeolclnes/Supplements...................................................................................................39
APPLND| Xv||. ACC/AHAGuloellnes|orPerloperatlve8eta8lockers......................... 40
LpertPanel........................................................................................................................................................................... 41
Pe|erences............................................................................................................................................................................. 44
lll
ACS NS Q| P

Preoperat l ve Assessment
|naooltlontoconouctlngacompleteanotborougbblstoryanopbyslcaleamlnatlono|tbepatlent,tbe
|ollowlngassessmentsarestronglyrecommenoeo:
F Assesstbepatlentscognitive abilityanocapacitytounoerstanotbe
antlclpateosurgery(seeSectlon|.A,Sectlon|.8,anoAppenol|).
F Screentbepatlent|ordepression(seeSectlon|.C).
F |oentl|ytbepatlentsrlsk|actors|oroeveloplngpostoperatlve delirium(seeSectlon|.D).
F Screen|oralcoholanootbersubstance abuse/dependence(seeSectlon|.L).
F Per|ormapreoperatlvecardiac evaluatlonaccorolngtotbeAmerlcan
Collegeo|Carolology/AmerlcanHeartAssoclatlon(ACC/AHA)algorltbm|or
patlentsunoergolngnoncarolacsurgery(seeSectlon||anoAppenol||).
F |oentl|ytbepatlentsrlsk|actors|orpostoperatlvepulmonarycompllcatlons
anolmplementapproprlatestrategles|orpreventlon(seeSectlon|||).
F Documentfunctional statusanoblstoryo|falls(seeSectlon|v).
F Determlnebasellnefrailtyscore(seeSectlonvanoAppenol|||).
F Assesspatlentsnutritional statusanoconsloerpreoperatlvelnterventlons
l|tbepatlentlsatseverenutrltlonalrlsk(seeSectlonv|anoAppenol|v).
F Takeanaccurateanooetalleomedication historyanoconsloer
approprlateperloperatlveaojustments.Monltor|orpolypharmacy
(seeSectlonv||,Appenolv,Appenolv|,anoAppenolv||).
F Determlnetbepatlentstreatment goals ano expectationslntbe
conteto|tbeposslbletreatmentoutcomes(seeSectlonv|||).
F Determlnepatlentsfamily ano social support system(seeSectlonv|||).
F Oroerapproprlatepreoperatlve diagnostic tests|ocuseooneloerlypatlents(seeSectlon|X).
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SLCT|ON | . Cognl t l ve ano 8ebavl oral Dl soroers
A.Cognltlve|mpalrmentanoDementla
|n2002,tbeprevalenceo|cognltlvelmpalrmentanooementlaamonglnolvlouals71yearsanooloer
lntbeU.S.wereestlmateoat22.2ano13.9,respectlvely.
7,8
Tbeprevalenceo|oementlalncreases
eponentlallywltblncreaslngageoloertban65years.
9
Astbeproportlono|Amerlcans85yearsanooloer
grows,tbenumbero|peoplellvlngwltboementlalsprojecteotorlseoramatlcally.
10
Preelstlngcognltlvelmpalrmentstronglypreolctspostoperatlveoellrlum,
11-15
wblcblsassoclateowltb
worsesurglcaloutcomes,lncluolnglongerbospltalstays,lncreaseorlsko|perloperatlvemortallty,
11,13
ano
postoperatlve|unctlonaloecllne.
14
ASSESSING COGNITIVE ABILITY

Cognitive Ability:
Foranypatlentoloertbanage65wltboutaknownblstoryo|cognltlvelmpalrmentor
oementla,ablstoryanocognltlveassessment,sucbastbeMlnl-Cog(seebelow),are
essentlal.
||posslble,aknowleogeableln|ormant,sucbasaspouseora|amllymember,sboulobe
lntervleweoabouttbeevolutlono|anycognltlveor|unctlonaloecllnelntbepatlent.
16
||tbepatlentbaseperlenceoaoecllne,tbeysboulobere|erreo|or|urtberevaluatlonto
aprlmarycarepbyslclan,gerlatrlclan,ormentalbealtbspeclallst.
Postoperatlve cognltlve oys|unctlon ls common but ol|cult to quantl|y wltbout
oocumentatlono|tbepatlentsbasellnecognltlvestatus.
17,18
Tbecognltlveassessmentsboulobeper|ormeoearlylntbepatlentevaluatlonbecause
anyevloenceo|cognltlvelmpalrmentoroementlamaylnolcatetbatsubsequent
assessmento||unctlonalstatusano/ormeolcatlonusemaybeunrellable.
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COGNITIVE ASSESSMENT: MINI - COG
Mini-Cog: 3 Item Recall and Clock Draw
19
1. GLTTHLPAT|LNTSATTLNT|ON,THLNSAY:
I am going to say three words that I want you to remember now and later.
The words are Banana Sunrise Chair
Please say them for me now.
Glvetbepatlent3trlestorepeattbeworos.||unablea|ter3trles,gotonetltem.
2. SAYALLTHLFOLLOW|NGPHPASLS|NTHLOPDLP|ND|CATLD:
Please draw a clock in the space below. Start by drawing a large circle. Put all the numbers in
the circle and set the hands to show 11:10 (10 past 11).
|| subject bas not nlsbeo clock orawlng ln 3 mlnutes, olscontlnue ano ask |or recall
ltems.
3. SAY:What were the three words I asked you to remember?
Interpretation of the Mini-Cog
SCOP| NG:
3ltemrecall(0-3polnts): 1polnt|oreacbcorrectworo
Clockoraw(0or2polnts): 0polnts|orabnormalclock
2polnts|ornormalclock
ANOPMALCLOCKHASALLOFTHLFOLLOW|NGLLLMLNTS:
Allnumbers112,eacbonlyonce,arepresentlntbecorrectoroeranoolrectlon
(clockwlse)lnsloetbeclrcle.
Twobanosarepresent,onepolntlngto11anoonepolntlngto2.
ANYCLOCKM|SS|NGANYOFTHLSLLLLMLNTS|SSCOPLDA8NOPMAL.
PLFUSALTODPAWACLOCK|SSCOPLDA8NOPMAL.
Total Score of 0, 1, or 2 suggests possible impairment.
Total Score of 3, 4, or 5 suggests no impairment.
||tbepatlentbasevloenceo|cognltlvelmpalrmentontbeMlnl-Cog,consloerare|erralto
aprlmarycarepbyslclan,gerlatrlclan,ormentalbealtbspeclallst.
20,21
Mlnl-Cog
TM
CopyrlgbtS8orson.Llcenseobytbeautbor|orlncluslonlntbeACSNSQ|P/AGSGerlatrlcSurgery8estPractlces
Guloellnes. May not be mooleo or useo |or otber purposes wltbout permlsslon o| tbe autbor (soob@uw.eou). All rlgbts reserveo.
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8.Declslon-MaklngCapaclty
Assesslngtbepatlentsoeclslon-maklngcapacltylscrltlcallnoetermlnlngblsorberabllltytoprovloe
ln|ormeo surglcal consent. Tbe pbyslclan sboulo conrm tbat tbe patlent ls able to oescrlbe, ln bls/ber own
woros,tbelmportant|eatureso|tbeolscusslon,lncluolngbls/bermeolcalconoltlonanotbelnolcatlons,
benets, rlsks, ano alternatlves to surglcal operatlons.
ASSESSING DECISION- MAKING CAPACITY
Decision-Making Capacity
22
To oetermlne tbe patlent's oeclslon-maklng capaclty, tbe pbyslclan sboulo conrm tbat
tbepatlentlsabletooescrlbe(lnblsorberownworos)tbelmportant|eatureso|tbe
olscusslon, lncluolng bls or ber meolcal conoltlon, ano tbe lnolcatlons/benets/rlsks/
alternatlvestosurglcaloperatlons.
Tbe|ourlegally-relevantcrlterlon|oroeclslon-maklngcapaclty:
1. Tbepatlentcanclearlylnolcateblsorbertreatmentcbolce.
2. Tbepatlentunoerstanostberelevantln|ormatloncommunlcateobytbepbyslclan.
3. Tbepatlentacknowleogesblsorbermeolcalconoltlon,treatmentoptlons,anotbe
llkelyoutcomes.
4. Tbepatlentcanengagelnaratlonalolscusslonabouttbetreatmentoptlons.
See Appendix I |ormoreoetallsabouttbeassessmento|oeclslon-maklngcapaclty.
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C.Depresslon
Arecentstuoyestlmatestbeprevalenceo|oepresslonamongtbeU.S.populatlon71yearsanooloerto
be11.
23
|ntbegeneraleloerlypopulatlon,majoroepresslonoccursln1to3,wltbanaooltlonal8to
16 eblbltlng cllnlcally slgnlcant oepresslve symptoms.
Slgnlcant rlsk |actors |or oepresslon ln tbe eloerly lncluoe |emale genoer, olsablllty, bereavement, sleep
olsturbance,anoprloroepresslon.Posslbleaooltlonalrlsk|actorslncluoepoorbealtbstatus,cognltlve
lmpalrment,llvlngalone,anonewmeolcallllness.
24
Preoperatlveoepresslonbasbeenassoclateowltblncreaseomortalltya|tercoronaryarterybypassgra|t
(CA8G)
25
anolongerpostoperatlvelengtbo|staya|terCA8Ganovalveoperatlons.
26,27
Depresslonbas
alsobeenassoclateowltbblgberpalnperceptlonanolncreaseopostoperatlveanalgeslcuse.
28,29
SCREENING FOR DEPRESSION
Patient Health Questionnaire-2 (PHQ-2)
30

1. In the past 12 months, have you ever had a time when you felt sad, blue, depressed, or
down for most of the time for at least two weeks?
2. In the past 12 months, have you ever had a time, lasting at least two weeks, when you
didnt care about the things that you usually care about or when you didnt enjoy the things
that you usually enjoy?
Interpretation of PHQ-2
||tbepatlentanswersYLStoeltberquestlon,tben|urtberevaluatlonbyaprlmarycare
pbyslclan,gerlatrlclan,ormentalbealtbspeclallstlsrecommenoeo.
NOTL:Tblsscreenlngtestbasnotbeenvalloateolnetremely|ralleloerlypatlents,tbose
wltbsevereconcurrentmeolcallllnesses,tbosewboaresu||erlng|rommeolcatlonsloe
e||ects,ortbosewltblmpalreocommunlcatlonskllls.
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D.PlskFactors|orPostoperatlveDellrlum
Postoperatlveoellrlumlsacommoncompllcatlonlneloerlypatlents,lnoneprospectlvestuoyo|patlents
unoergolngmajor,electlve,noncarolacoperatlons,9o|patlentsoevelopeopostoperatlveoellrlum.
12
|n
anotberstuoy,patlentsunoergolngsurglcaloperatlonsrequlrlngpostoperatlvelntenslvecareunlt(|CU)
stay,44o|tbepatlentseperlenceopostoperatlveoellrlum.
13
Otberstuolesbaveoescrlbeolncloenceo|
oellrlumranglng|rom5.1to52.2,wltbblgberratesa|terblp|ractureanoaortlcsurgery.
31
Plsk|actors|orpostoperatlveoellrlumaresbownbelow,wltbtbestrongest predisposing factor being
preexisting cognitive impairment and dementia.
13,32
Postoperatlveoellrlumlsassoclateowltbblgbermortallty
anocompllcatlons,rateso|lnstltutlonallzatlon,greatercostsanouseo|bospltalresources,longerlengtbs
o|stay,anopoorer|unctlonalrecovery.
11-13,31,32
RISK FACTORS FOR POSTOPERATIVE DELIRIUM

12,13, 20, 21, 31- 38
Risk Factors
Cognitive and Behavioral Disorders
Cognltlvelmpalrmentanooementla
Untreateoorlnaoequatelycontrolleopaln
Depresslon
Alcoboluse
Sleepoeprlvatlon
Disease/Illness Related
Severelllness/comorbloltles
Penal lnsu|clency
Anemla
Hypola
Metabolic
Poornutrltlon
Debyoratlon
Llectrolyteabnormalltles
Functional Impairments
Poor|unctlonalstatus
|mmoblllzatlon
Hearlngorvlslonlmpalrment
Other
Oloer age < 70 years
Polypbarmacyanouseo|psycbotroplc
meolcatlons(benzoolazeplnes,
antlcbollnerglcs,anoantlblstamlnes)
Plsko|urlnaryretentlonorconstlpatlon,
presenceo|urlnarycatbeter
|npatlentsatrlsk|orpostoperatlveoellrlum,aomlnlstratlono|benzoolazeplnesano
antlblstamlnes(|oreample,olpbenbyoramlne)sboulobeavoloeo,eceptlncertalnclrcumstances
(seeSection VII).
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L.AlcobolanoSubstanceAbuse
Anatlonalsurveyestlmateo60o|lnolvlouals50yearsanooloeruseoalcobolourlngtbe20052006
perloo,|ewerpeopleuseoorugs(2.6marljuana,ano0.41cocalne).
39
For eloerly men (<65 years), tbe
prevalenceo|at-rlsk(2+orlnks/oay)anoblnge-orlnklng(5+orlnks/oay)were13ano14.5,respectlvely,
|oreloerlywomen,tbeprevalenceo|at-rlskanoblngeorlnklngwere8.1ano3.3.
40
Preoperatlvealcobolabuseanooepenoenceareassoclateowltblncreaseorateso|postoperatlve
mortalltyanocompllcatlons,lncluolngpneumonla,sepsls,wounoln|ectlonanoolsruptlon,anoprolongeo
lengtbo|stay.
41,42
SCREENING FOR ALCOHOL AND SUBSTANCE ABUSE

Modified Version of CAGE
43-46
Asktbepatlenttbe|ollowlng|ourquestlons:
1. Have you ever felt you should Cut down on your drinking or drug use?
2. Have people Annoyed you by criticizing your drinking or drug use?
3. Have you ever felt bad or Guilty about your drinking or drug use?
4. +DYH\RXHYHUKDGDGULQNRUGUXJUVWWKLQJLQWKHPRUQLQJEye-opener) to steady your
nerves or to get rid of a hangover?
Interpretation of Modified CAGE
||YLStoanyo|tbesequestlons,consloerperloperatlvepropbylals|orwltborawal
synoromes.
||operatloncanbeoelayeo,consloerre|errlngmotlvateopatlentstosubstanceabuse
speclallst |or preoperatlve abstlnence or meolcal oetolcatlon.
Patlentswltbalcoboluseolsoroersboulorecelveperloperatlveoallymultlvltamlns(wltb|ollc
aclo)anoblgb-ooseoralorparentaltblamlne(100mg).
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SLCT|ON | | . Carol ac Lval uatl on
Fornoncarolacsurgery,stuolesoescrlbemajorperloperatlvecarolaccompllcatlonsratesat2|orunselecteo
patlents
47
ano3.9|orpatlentswltboratrlsko|carolacolsease.
48
Tberateseceeo5|orblgb-carolac-rlsk
patlents.
47-50
Postoperatlvemyocarolalln|arctlon(M|)lsassoclateowltbbospltalmortalltyrateso|1525,
patlentseperlenclngnon|atalperloperatlveM|areatgreaterrlsk|orcarolovascularoeatbanonon|atalM|
ourlngtbe6montbsa|terasurglcaloperatlon.
48
Oloer patlents are slgnlcantly more vulnerable to perloperatlve carolac aoverse events.
51
Tbere|ore,lt
lscrltlcaltoloentl|yeloerlypatlentswltbblgberrlsko|carolaccompllcatlonstooetermlneapproprlate
perloperatlvemanagementanotoe||ectlvelycommunlcateoperatlverlsk.
ACC/AHA ALGORITHM FOR CARDIAC EVALUATION
AND CARE FOR NONCARDIAC SURGERY
52
Peprlnteo|romJournal of the American College of Cardiology,vol54(22),FlelscbmannKL,8eckman[A,8ullerCL,etal.,2009
ACCF/AHAFocuseoUpoateonPerloperatlve8eta8lockaoe,p2102-2128,2009,wltbpermlsslon|romLlsevler.
*SeeAppendix II |or tables o| Actlve Carolac Conoltlons, Carolac Plsk Stratlcatlon o|
Surgery,MetabollcLqulvalents(MLTs),anoCllnlcalPlskFactors.
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SLCT|ON | | | . Pul monar y Lval uat l on
Postoperatlve pulmonary compllcatlons (PPCs) are common ano contrlbute slgnlcantly to overall morblolty
anomortallty.
53
|nasystematlcrevlewo|PPCslnpatlentsunoergolngnoncarolacsurgery,tberateo|PPCs
acrossalltbestuoleswas6.8.
54
|ntbesamerevlew,stuoysubsetssboweomeolanPPCsrateso|14ano
15 ln patlents <65 years ano <70 years, respectlvely.
Altbougbtraoltlonallygreaterempbaslsbasbeenplaceooncarolacrlskassessment,postoperatlvepulmonary
compllcatlonsbaveslmllarprevalencetocarolacaoverseevents.
54-56
|nastuoyo|patlentsunoergolngelectlve
aboomlnalproceoures,pulmonarycompllcatlonsoccurreomoreo|tentbencarolacaoverseeventsanowere
assoclateowltblongerbospltalstays.
57,58
Forpatlentsunoergolnggeneralanovascularoperatlonsataslngle
NSQ|Pbospltal,PPCslncurreotbeblgbesttotalbospltalcostcompareowltbln|ectlous,tbromboembollc,
anocarolacaoverseevents,anorequlreotbelongestmeolanlengtbo|stay.
59
Pulmonarycompllcatlonsalso
preolcteo long-term mortallty ln eloerly patlents (<70 years) unoergolng noncarolac surgery.
60
Tbe|ollowlngln|ormatlonlsaoapteo|romtbeACS NSQIP Best Practices Guidelines: Prevention of Postoperative
Pulmonary Complications.
61
RISK FACTORS FOR POSTOPERATIVE PULMONARY COMPLICATIONS
Risk Factors
Patient-Related Factors
Age>60
53-55,62-64
Cbronlcobstructlvepulmonary
olsease(COPD)
53-55,63,64
AmerlcanSocletyo|Anestbeslologlsts
(ASA)class||orgreater
53-55
Functlonaloepenoence*
54,55,63,64
Congestlvebeart|allure
53-55
Obstructlvesleepapnea
54,55,65
Pulmonarybypertenslon
66-68
Currentclgaretteuse
54,55,64
|mpalreosensorlum
53-55,64
Preoperatlvesepsls
53
Welgbtloss>10ln6montbs
54,55,64
Serumalbumln<3.5mg/oL
53-55,63
8looo urea nltrogen (8UN) <7.5
mmol/L (<21 mg/oL)
54,55,64
Serumcreatlnlne>133mol/L
(>1.5mg/oL)
54,69
Surgical Procedure-Related Factors

Prolongeooperatlon>3bours
54,55,62
Surglcalslte
53-55,63,64
Lmergencyoperatlon
53-55,63,64
Generalanestbesla
54,55,64
Perloperatlvetrans|uslon
53-55,64
Pesloualneuromuscularblockaoe
a|teranoperatlon
55,70
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Not Risk Factors
Obeslty
54,55
Well-controlleoastbma
54,55
Dlabetes
54,55
* Totaloepenoencewastbelnabllltytoper|ormanyactlvltleso|oallyllvlng.Partlaloepenoencewastbeneeo|orequlpmentor
oevlcesanoasslstance|romanotberperson|orsomeactlvltleso|oallyllvlng.
Acutelycon|useooroellrlouspatlentwbolsabletoresponotoverbalormllotactllestlmulatlon,ormentalstatuscbanges/
oellrlumlntbeconteto|currentlllness.
Hlgbestrlskproceoures:upperaboomlnal,tboraclc,neurosurglcal,beaoanoneck,vascular(|oreample,aortlcaneurysm
repalr).
PREOPERATIVE STRATEGIES FOR PREVENTING PPCS
Recommendations
Preoperatlveoptlmlzatlono|pulmonary|unctlonlnpatlentswltbCOPDanoastbma
tbatlsnotwellcontrolleo
71,72
Smoklngcessatlon*
68,73-76
Preoperatlvelntenslvelnsplratorymuscletralnlng
68,77
Selectlvecbestraolograpbanopulmonary|unctlontests
55,72
* Pegarolngtbetlmlngo|smoklngcessatlon,onestuoysboweolncreaseorateso|PPCslnpatlentswbostopsmoklngwltbln
elgbt weeks o| a surglcal operatlon, anotber stuoy |ouno tbat smoklng cessatlon was beneclal as late as |our weeks be|ore
surgery,ameta-analysls|ounonolncreaseorlsklnPPCswltbcessatlonwltblnelgbtweekso|asurglcaloperatlon.
8aseoononeslngle-bllnoeoranoomlzeocontroltrlalo|patlentsunoergolngelectlveCA8G.
Poutlnecbestraolograpbsanopulmonary|unctlontestsarenotrecommenoeo.
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SLCT|ON | v. Funct l onal / Per | ormance St at us
|noneprospectlvestuoyo|eloerlypatlentsunoergolngmajorsurglcaloperatlonsrequlrlng|CUstay,
|unctlonaloepenoencewastbestrongestpreolctoro|postoperatlve6-montbmortallty.
78
Anotberstuoy
o|veteransAomlnlstratlon(vA)patlents>80yearsolosboweotbat30-oaymortalltywasmorestrongly
preolcteoby|unctlonalstatustbanage.
79
|mpalreomobllltylneloerlypatlentsbasalsobeenllnkeoto
lncreaseorlsko|postoperatlveoellrlum
31,80
anosurglcalslteln|ectlonswltbMPSA.
81,82
|nastuoyo|eloerly
surglcal patlents requlrlng |CU stay, prolongeo TUGT (<15 seconos) ano any |unctlonal oepenoence were
tbestrongestpreolctors|orrequlrlngpostoperatlveolscbargelnstltutlonallzatlon.
83
|naooltlon,preoperatlve
|unctlonalstatusstronglypreolctsbetterrecoveryanosborterrecoveryperloos|oractlvltleso|oallyllvlng
(ADL)anolnstrumentalactlvltleso|oallyllvlng(|ADL)|ollowlngmajoraboomlnalsurgery.
84
1. Assesspatlentsabllltytoper|ormoallyactlvltles(|unctlonalstatus).
ASSESSING BASELINE AND CURRENT FUNCTIONAL STATUS
IN AMBULATORY PATIENTS
Short Simple Screening Test for Functional Assessment
21,85
Asktbepatlenttbe|ollowlng|ourquestlons:
1. Can you get out of bed or chair yourself?
2. Can you dress and bathe yourself?
3. Can you make your own meals?
4. Can you do your own shopping?
Interpretation of Functional Screening Test
||NOtoanyo|tbesequestlons,moreln-oeptbevaluatlonsboulobeper|ormeo,
lncluolng|ullscreenlngo|ADLsano|ADLs.
Declts sboulo be oocumenteo ano may prompt perloperatlve lnterventlons (|or
eample,re|erraltooccupatlonaltberapyano/orpbyslcaltberapy)anoproactlve
olscbargeplannlng.
NOTL:Patlentsresponsesmaynotberellablelntbepresenceo|cognltlvelmpalrment
oroementla.
2. Document oeclts ln vlslon, bearlng, or swallowlng.
3. |nqulreaboutblstoryo||alls(Have you fallen in the past year?).
4. Lvaluatetbepatlent|orllmltatlonslngaltanomobllltyanooetermlnerlsk|or|alls.
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ASSESSING GAIT AND MOBILITY IMPAIRMENT AND
FALL RISK IN AMBULATORY PATIENTS
Timed Up and Go Test (TUGT)
86-88
Patlentssboulosltlnastanoaroarmcbalrwltballne10|eetlnlengtbln|ronto|tbecbalr.
Tbeysboulousestanoaro|ootwearanowalklngalosanosboulonotrecelveanyasslstance.
Havetbepatlentper|ormtbe|ollowlngcommanos:
1. Plse|romtbecbalr(l|posslble,wltboutuslngtbearmrests)
2. Walk to tbe llne on tbe Noor (10 |eet)
3. Turn
4. Peturntotbecbalr
5. Sltoownagaln
Interpretation of TUGT
Any person oemonstratlng ol|culty rlslng |rom tbe cbalr or requlrlng more tban 15
seconostocompletetbetestlsatblgbrlsk|or|alls.Consloerpreoperatlvere|erralto
pbyslcaltberapy|ormoreoetalleogaltassessment.
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SLCT|ON v. Fral l t y
Fralltylsasynoromeo|oecreaseopbyslologlcreserveanoreslstancetostressors,wblcbleavespatlentsmore
vulnerabletopoorbealtboutcomes,lncluolng|alls,worsenlngmobllltyanoADLolsablllty,bospltallzatlons,
anooeatb.|tlsacllnlcallyolstlnctentlty|romcomorbloltyanoolsablllty.
89,90
Altbougbanumbero|alternatlvemeasureso||ralltyelst,Frleoetal.proposeoawloely-recognlzeoano
operatlonal oenltlon
91
(sbownbelowano|ullyoutllneoln Appendix III),wblcbbasbeenvalloateo|oreloerly
surglcalpatlents.
89,92
Fralltybasbeensbowntolnoepenoentlypreolctblgberrateso|postoperatlveaoverse
events(lntermeolate|rallano|rallpatlentsbao2.06tlmesblgberooos[95C|,1.183.60]ano2.54tlmes
blgberooos[1.125.77]compareowltbnon-|rallpatlents,respectlvely),lncreaseolengtbo|stay(lntermeolate
|rallano|rallpatlentsbao44to53ano65to89longerbospltalstaystbannon-|rallpatlents),anoblgber
llkellboooo|olscbargetoaskllleoorasslsteo-llvlng|acllltylneloerlysurglcalpatlents(lntermeolate|rallano
|rallpatlentsbao3.16[1.009.99]ano20.48[5.5475.68]blgberooostbannon-|rallpatlents).
92
Poblnson et al. proposeo two otber oenltlons o| |rallty |or eloerly surglcal patlents. Tbe rst oenltlon
measures cognltlve lmpalrment (Mlnl-Cog >3), poor nutrltlon (serum albumln >3.3 g/oL), blstory o| |alls (<1
|alllntbeprevlous6montbs),anolowbematocrlt(<35).
78
Tbe secono oenltlon lncluoes tbe |actors |rom
tbe rst oenltlon, wltb tbe aooltlon o| |unctlonal lmpalrment (TUGT <15 seconos ano oepenoence ln any
ADL), ano comorblolty (Cbarlson lnoe score <3).
83
FRAILTY SCORE: OPERATIONAL DEFINITION
89

Criteria Definition
Sbrlnkage Unlntentlonal welgbt loss <10 pounos ln past year
Weakness Decreaseogrlpstrengtb
Lbaustlon Sel|-reporteopoorenergyanoenourance
Lowpbyslcalactlvlty Lowweeklyenergyepenolture
Slowness Slowwalklng
Interpretation of the Frailty Score
Tbepatlentrecelves1polnt|oreacbcrlterlonmet.
01=NotFrall
23=|ntermeolateFrall(Pre-|rall)
45=Frall
Frail patients are at much higher risk of adverse health outcomes.
Intermediate frail patients are at elevated risk (less than frail ones) but are also
at more than double the risk of becoming frail over three years.
SeeAppendix III |oramoreoetalleooescrlptlono|tbevalloateo|ralltyscore|orsurglcal
patlents.
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Sect l on v| . Nut rl t l onal St at us
Pateso|malnutrltlonwere|ounotobe5.8amongeloerlylnolvloualslntbecommunlty,13.8lnnurslng
bomes,38.7lnbospltals,ano50.5lnrebabllltatlon.
93
Poornutrltlonalstatuslsassoclateowltblncreaseorlsko|postoperatlveaoverseevents,mostlyln|ectlous
compllcatlons(|oreample,surglcalslteln|ectlons,pneumonla,urlnarytractln|ectlons,anosoon)anowouno
compllcatlons(|oreample,oeblscenceanoanastomotlcleaks),anolncreaseolengtbo|stay|orpatlents
unoergolngelectlvegastrolntestlnalsurgery.
94
1. Documentbelgbtanowelgbtanocalculatebooymasslnoe(8M|).
20,21
2. Measurebasellneserumalbumln,prealbumlnlevels.
20,21
3. |nqulreaboutunlntentlonalwelgbtlosslntbelastyear.
SCREENING FOR SEVERE NUTRITIONAL RISK
95
Risk Factors for Severe Nutritional Risk
8M|<18.5kg/m
2
Serumalbumln<3.0g/oL(wltbnoevloenceo|bepatlcorrenaloys|unctlon)
Unlntentlonalwelgbtloss>1015wltbln6montbs
Interpretation of Nutritional Screening
||YLStoanyabovecrlterlon,tbentbepatlentlsatseverenutrltlonalrlskanosboulo,
l||easlble,unoergoa|ullnutrltlonalassessmentbyaoletlclantooeslgnaperloperatlve
nutrltlonal plan to aooress oeclts.
4. Consloerpreoperatlvenutrltlonalsupport|orpatlentsatseverenutrltlonalrlsk(seeAppendix IV).
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Sect l on v| | . Meol cat l on Management
1. Pevlewanooocumenttbepatlentscomplete medication lists,lncluolnguseo|nonprescrlptlonagents
(over-tbe-counter, non-steroloal antl-lnNammatory orugs [NSA|Ds], vltamlns, eye orops, toplcal) ano
berbalprooucts.
96
NOTL:Patlentsresponsesmaynotberellablelntbepresenceo|cognltlvelmpalrmentoroementla.
2. |oentl|ymedications that should be discontinuedprlortoasurglcaloperatlonanomeolcatlonstbat
sboulobeavoloeo.Mlnlmlzeaoversee||ectso|meolcatlonstbrougboosereouctlonorsubstltutlons.
GUIDELINES FOR MODIFYING PERIOPERATIVE MEDICATIONS
Discontinue before surgery:
Nonessentlalmeolcatlonstbatlncreasesurglcalrlsksboulobeolscontlnueo.
96
Meolcatlonswltbpotentlal|ororuglnteractlonswltbanestbeslasboulobeolscontlnueoor
substltuteo.
96
See8eersCrlterla(seeAppendix V)|oraooltlonalllsto|meolcatlonstbatmayneeotobe
olscontlnueoperloperatlvely.
97
Herbalmeolcatlonssboulobestoppeoatleast7oaysbe|oreasurglcaloperatlonoueto
uncertalntyo|contents.
96
See Appendix VI |or more speclc recommenoatlons.
Continue perioperatively:
Meolcatlonswltbwltborawalpotentlal,lncluolngselectlveserotonlnreuptakelnblbltors
(SSP|s),trlcycllcantloepressants,benzoolazeplnes,antlpsycbotlcs,monoamlneoloase
lnblbltors(MAO|s),betablockers,clonlolne,statlns,anocortlcosterolos,sboulobe
contlnueo.
96
Anglotensln-convertlngenzymelnblbltorsanoanglotensln||receptorblockerssboulobe
contlnueounlesstbelronlylnolcatlonls|orbypertenslonanotbepatlentsblooopressurels
wellcontrolleo.
96
Additional considerations in patients at risk for postoperative delirium:
Avolostartlngnewprescrlptlons|orbenzoolazeplnesanoconsloerreouclng
benzoolazeplneswbenposslble.
33,34
Avoid using meperidine|ortreatmento|paln.
98
Lnsuretbatpalnlsaoequatelycontrolleo
toreoucerlsk|oroeveloplngpostoperatlveoellrlum.
35-38
Usecautlonwbenprescrlblngantlblstamlne H
1
antagonlsts(especiallydiphenhydramine/
Benadryl
)anootbermeolcatlonswltbstrongantlcbollnerglce||ects.
33,34
Nolncreaseorlskassoclateowltbneuroleptlcs(antlpsycbotlcs)anoolgoln.
33
Noconcluslveevloence|orH
2
antagonlsts,trlcycllcantloepressants,antl-Parklnson
meolcatlons,sterolos,NSA|Ds,anoantlmuscarlnlcs.
33
Forallotbercases:Lerclsecllnlcaljuogment.
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3. Consloerwblcbmedications should be startedpreoperatlvelytoreouceperloperatlverlskso|
aoverseevents(carolac,stroke,anosoon).
ACC/AHA GUIDELINES FOR PERIOPERATIVE
BETA BLOCKERS
21, 52
Summary of Recommendations on Beta Blockers
Indications:Tbeguloellnessupportaomlnlstratlono|betablockersto:
Patlentswboarealreaoyonbetablockers,partlcularlytbosewltblnoepenoent
carolaclnolcatlons|ortbesemeolcatlons(sucbasarrbytbmlaorblstoryo|myocarolal
ln|arctlon).
Patlentsunoergolnglntermeolaterlskorvascularsurgerywltbknowncoronaryartery
olseaseorwltbmultlplecllnlcalrlsk|actors|orlscbemlcbeartolsease.
Initiation and Titration:
||betablockersarelnolcateo,wben|easlble,tbeysboulobestarteoatleastoaystoweeks
be|oreelectlvesurgery,tltrateotoabeartrateo|6080beats/mlnutelntbeabsence
o|bypotenslon.Tltrateoratecontrolwltbbetablockerssboulocontlnueourlngtbe
lntraoperatlveanopostoperatlveperloos.
Discontinuation:
8etablockerssboulobetapereoo||slowlytomlnlmlzerlsko|wltborawal.
At the time of this writing, the current ACC/AHA guidelines state that routine administration of high-
dose beta-blockers in the absence of dose titration is not useful and may be harmful to patients not
currently taking beta-blockers who are undergoing noncardiac surgery.
SeeAppendix VII|or|ullrecommenoatlons.
INITIATION OF STATIN THERAPY
21, 52,99
Recommendation on Statins
Preoperatlvestatlnssboulobestarteoassoonasposslbleprlortoasurglcaloperatlon|or
patlentswbobaveknownvascularolsease,elevateolow-oensltyllpoprotelncbolesterol,or
lscbemlaontballlumtestlng.
Forpatlentsunoergolngnoncarolacsurgerywboarecurrentlytaklngstatlns,statlntberapy
sboulobecontlnueo.Statlnusemayalsobeconsloereo|orpatlentsunoergolngvascularano
lntermeolate-rlsksurglcaloperatlons.
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4. Aojustooseso|meolcatlons|orrenal function
Oloerpatlentsareatgreaterrlsk|orlmpalreorenal|unctlonanocbronlckloneyolsease.Slncemany
meolcatlonsarerenallycleareo,ltlscrltlcaltoaojustoosagestopreventaoversereactlons.Glomerular
ltratlon rate (GFP) ls accepteo as tbe best overall measure o| kloney |unctlon. Since the ratio of GFR
to serum creatinine decreases with increasing age, serum creatinine alone is an inadequate estimate of GFR in
older persons.SeveralequatlonstbattakeagelntoconsloeratlonbavebeenoevelopeotoestlmateGFP,
lncluolngtbe|ollowlng:
Cockcroft-Gault Formula
eGFP=
(140-Age)8ooyWelgbt[lnkg][0.85l||emale]
72 Serum Creatlnlne [ln mg ol]
Modification of Diet in Renal Disease (MDRD) Study Equation
eGFP=
175 Serum Creatlnlne[ln mg ol]
-1.154
Age
-0.203
[1.212l|black][0.742l||emale]
Tbese equatlons bave tbelr llmltatlons (|or eample, ln patlents wltb slgnlcant muscle wastlng ano ones
wltbraplolycbanglngkloney|unctlon).|ntbesecases,moreaccuratemeasureso|GFPcanbeobtalneo
wltb eogenous ltratlon markers.
100
Recommendations for Medications Regarding Renal Function
Meolcatlonstbatarerenallycleareosboulobaveoosagesaojusteobaseoontbepatlents
estlmateoGFP.
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5. Monltor|orpolypharmacyanopotentlalaoverselnteractlons.
Meolcatlonuselscommonamongtbeeloerly,lnasurveyo|natlonallysampleocommunltyowelllng
aoultsage5785years,81were|ounotobetaklngoneormoreprescrlptlonmeolcatlons,wblcbwas
blgbest(89.7)amongtbose7585yearsolo.Tbeuseo|nonprescrlptlonmeolcatlonswasalsocommon,
68o|tbeoloeraoultswereconcurrentlyuslngover-tbe-countermeolcatlons,oletarysupplements,or
botb wltb prescrlptlon meolcatlons. More tban bal| o| patlents, age 60 years ano oloer, useo ve or more
meolcatlonsanosupplementsano4were|ounotobeatrlsko|amajororug-oruglnteractlon.
101
Altbougb tbere ls no clear cuto|| polnt |or tbe number o| meolcatlons tbat oene polypbarmacy, tbe |ocus
sboulobeontbeuseo|suboptlmalorlnapproprlateprescrlptlonanononprescrlptlonmeolcatlonsano
potentlalorug-oruglnteractlons.Twostuoleso|ambulatoryeloerlylnolvloualsbave|ouno5560o|
patlentstaklngeltbersuboptlmalmeolcatlons,oroneswltboutapproprlatelnolcatlons.
96
Polypbarmacybasbeenassoclateowltblncreaseorlsko|cognltlvelmpalrment,morblolty,anomortallty,
aswellaspoorermeolcatloncompllance.Tberlsko|aoverseorugreactlonsalsolncreaseswltbgreater
numberso|meolcatlons,leaolngtomorebospltalaomlsslons.
102,103
Recommendations on Polypharmacy
Wbenposslble,nonessentlalmeolcatlonssboulobeolscontlnueoperloperatlvely,anotbe
aooltlono|newmeolcatlonssboulobekepttoamlnlmum.
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SLCT|ON v| | | . Patl ent Counsel l ng
Astuoyo|oeceaseolnolvloualswbowereage60yearsanooloer|ounotbatnearly30requlreooeclslon
maklngregarolngmeolcalcareneartbeenoo|ll|e,butlackeooeclslon-maklngcapaclty.Approlmatelytwo-
tblrosbaoaovanceolrectlves,anotbeselnolvloualsrecelveocarestronglyassoclateowltbtbelrpre|erences.
104
Wblletbenumbero|eloerlylnolvloualswltbaovanceolrectlvesbaslncreaseo,onestuoyo|oloerpatlents
unoergolngamajoroperatlon|ounotbataovanceolrectlveswererarelypresentlntbemeolcalcbartourlng
bospltallzatlon.
105
Altbougbpatlentso|tenbelleveotbattbelr|amlly,surrogates,anopbyslclanscoulorepresenttbelrwlsbes,
106
tbe|amllymembers,surrogates,anopbyslclanso|ten|alleotoaccuratelypreolcttbepatlentstreatment
pre|erences.
106-108
Fewpatlentsbaoeverolscusseotbelrpre|erenceswltbtbelr|amllymembersanotbelr
pbyslclans.
106
Forlncapacltateopatlents,pbyslclanso|tenrelyonbealtbcareprolestomakeeno-o|-ll|e
oeclslons|orpatlents,yetanumbero|stuolesbaveolscovereonegatlveemotlonale||ectsonnearlyone-tblro
o|surrogates,mostcommonlygulltanoooubtregarolngtbeoeclslons.
109
Patlents' epectatlons lnNuence tbelr treatment pre|erences. |n a survey o| patlents 60 years ano oloer wltb
llmlteoll|eepectancyouetocancer,congestlvebeart|allure,orcbronlcobstructlvepulmonaryolsease,
98.7o|patlentswoulounoergoalow-buroentreatmenttorestorecurrentbealtb(versusnotreatmentano
oylng).However,74.4woulo|orgotreatmentl|ltresulteolnsevere|unctlonallmpalrmentano88.8woulo
rejecttreatmentl|ltresulteolncognltlvelmpalrment.
110
Tbese nolngs stress tbe lmportance o| bavlng olscusslons between tbe pbyslclan ano tbe patlent to epllcltly
oetermlnetbepatlentspre|erencesanoepectatlons|romtbetreatment.|naooltlon,|amllymembersano
potentlaloeclslon-maklngsurrogatessboulobelnvolveolntbeconversatlons.
1. Lnsuretbattbepatlentbasanaovanceolrectlveanobasoeslgnateobealtbcareproy(orsurrogate
oeclslonmakers).Tbeseoocumentssboulobeplaceolntbemeolcalcbart.
Lampleslncluoe:
FlveWlsbesbyAglngwltbDlgnlty(www.agingwithdignity.org)
Ll|ecareAovanceDlrectlve(www.lifecaredirectives.com)
2. Dlscusswltbtbepatlenttbetreatmentgoalsanoplansanobe sure that the provider understands the patients
preferences and expectations.Dlscusslonso|tbepatlentspre|erencesanoepectatlonsanoensulngcbanges
sboulobeoocumenteolntbemeolcalrecoros.
3. Descrlbetbeepecteopostoperatlvecourseanoposslblecompllcatlonswltbtbepatlent. If relevant,
include discussion of possible functional decline and need for rehabilitation or nursing home care during the
informed consent process.
4. Determlne patlent's |amlly ano soclal support systems, wblcb are o| slgnlcant lmportance |or olscbarge
olsposltlon. || tbere ls concern o| an lnsu|clent |amlly/soclal support system, consloer preoperatlve
re|erraltoasoclalworker.
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Sect l on | X. Preoperat l ve Test l ng
Overtbepast|ewoecaoes,anumbero|stuolesbaveblgbllgbteotberelatlvelylowyleloo|routlnepreoperatlve
screenlnganotbeblgbaggregatecost|rombotbtbeolrectcosto|testsanotbesubsequentstuoles|orabnormal
results.Tbereportsbavesbowntbatmanyo|tbescreenlngtestsprooucelowrateso|abnormalvalueslnasymp-
tomatlcpatlents,areunllkelytocbangecllnlcalmanagement|ortbepatlentwltbabnormalvalues,oonotstrongly
preolctgooooraoverseoutcomes,oraresubjecttoacomblnatlono|tbesellmltatlon.
21,111-113
114,115
Tbestuolesbaverecommenoeoagalnstaroutlnebatteryo|preoperatlvescreenlngtests,
21,111,112,114-116
orones
baseoonagecrlterlaalone.
116,117
|nsteao,tbeyrecommenoselectlveolagnostlctestslnblgber-rlskpatlentpopula-
tlons, wblcb can be loentleo baseo on blstory ano pbyslcal eam, known comorbloltles, ano tbe type o| proce-
ouretobeper|ormeo.
21,111,112,115-118
Most bospltals bave speclc guloellnes |or wben preoperatlve tests sboulo be per|ormeo, sucb as wltbln 30 oays
o|tbeoperatlon.
20
Onestuoy,bowever,bassbowntbatnormallaboratorlesooneupto4montbsprlortoasur-
glcaloperatloncoulobeuseosa|elyaspreoperatlvetestsaslongasnosubstantlallntervalcbangelntbepatlents
cllnlcalstatusbasoccurreo.
112,118
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8aseoontbestuolesrevleweo,tbe|ollowlngrecommenoatlonsareprovloeo|orcommonpreoperatlvetests
wltblnolcatlons:
RECOMMENDED PREOPERATIVE TESTS FOR
ALL GERIATRIC SURGICAL PATIENTS
Preoperative
Tests Indications
Hemoglobin Peasonable|orall geriatric patients,especlallytbose>80years.
20,21
Pecommenoeo |or patlents unoergolng operatlons ln wblcb slgnlcant
blooolosslsantlclpateoanomayrequlretrans|uslon.
112,113
Pecommenoeo|orpatlentswltbblstoryorpbyslcaleamsuggestlng
severeanemla:
112,113
Hlstoryo|pro|ouno|atlgue,anemla,mallgnancy,carolovascular
olsease,renalolsease,orresplratoryolsease.
Oneam,restlngtacbycarolaorconjunctlvalpallor.
Renal Function
Tests
(8UN,Cr)
Pecommenoeo|orall geriatric patients,
20,21,112,113
especlallytbose
wbo:
Areunoergolngamajorsurglcaloperatlon(carolac,vascular,cbest,
oraboomen).
112,113
Haveolabetes,bypertenslon,carolovascularolsease,oruse
meolcatlonstbata||ectrenal|unctlon(ACLlnblbltors,NSA|DS).
Serum Albumin Peasonable|orall geriatric patients,
20,21,112
especlallytbosewbo:
Haveknownllverolsease,multlpleserlouscbronlclllnesses,ano
recentmajorlllness.
Areunoergolngamajorsurglcaloperatlon.
Llkelybavemalnutrltlon.
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SELECTED GERIATRIC SURGICAL PATIENTS
Preoperative
Tests Indications
White Blood Count
(W8C)
NOTPLCOMMLNDLD|orroutlnepreoperatlvescreenlng.
21,111,112
Pecommenoeo|orpatlentswltbsymptomssuggestlngln|ectlon,
knownorsuspecteomyeloproll|eratlveolsease(splenomegalyor
lympbaoenopatby),oratblgbrlsk|orleukopenla|romorugsorotber
knownolsease.
21,112
Maybelncluoeoasparto|acompleteblooocount.
21
Platelet Count NOTPLCOMMLNDLD|orroutlnepreoperatlvescreenlng.
21,111,112
Pecommeno|orpatlentswltbblstoryanopbyslcaleamsuggestlngblgb
llkellboooo|tbrombocytopenlaortbrombocytosls.
21,112
Hlstoryo|bleeolngoreasybrulslng,spontaneousbleeolng,or
unusualbleeolnglnprevloussurgerles.
Knownorsuspecteomyeloproll|eratlveolsease.
Pecenteposuretoorugsknowntocausetbrombocytopenla
(cbemotberapyagents).
Maybelncluoeoasparto|acompleteblooocount.
21
Coagulation Tests
(ProtbromblnTlme
[PT])anoPartlal
TbromboplastlnTlme
[PTT])
21,111,112
Pecommenoeo|orpatlentswltbblstoryo|bleeolngolsoroers,on
meolcatlonsa||ectlngcoagulatlon(|oreample,cbronlcantlblotlcs),on
war|arln,oronbemoolalysls.
21,111-113
Pecommenoeo |or patlents unoergolng speclc types o| operatlons
sucbasarterlalreconstructlon,carolacsurgery,canceroperatlons,
anooneslnwblcbsmallamountso|bleeolngcancauseoramatlc
compllcatlons(neurosurglcalorortbopeolcsplneproceoures).
21,113
PTsboulobecbecklnpatlentswltbmalnutrltlon,malabsorptlon,or
llverolsease.
21,111-113
Electrolytes
(Na,K,Cl,CO2)
21,111,112
Pecommenoeo |or patlents wltb basellne renal lnsu|clency, congestlve
beart|allure,tbosetaklngoluretlcs,olgoln,anglotensln-convertlng
enzyme(ACL)lnblbltors,orotbermeolcatlonstbatlncreasellkellbooo
o|abnormalresults.
21,112
Serum Glucose NOTPLCOMMLNDLD|orroutlnepreoperatlvescreenlng.
111-113
Pecommenoeo|orpatlentswltbknownorsuspecteoolabetes,or
obeslty
112
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Tableo|Contents
22
ACS NS Q| P

Preoperative
Tests Indications
Urinalysis NOTPLCOMMLNDLD|orroutlnepreoperatlvescreenlng.
21,112
Pecommenoeo|orpatlentswbo:
Haveslgnsanosymptomsconslstentwltburlnarytract
ln|ectlon.
21,112
Haveknownolabetes.
112
Unoergolngurogenltalsurgery.
113
Maybeoone|orsurgerleslnvolvlngprostbesls(beartvalvesorjolnt
replacement),
113
bowever,maynotbecoste||ectlve.
21
Chest Radiograph
(CXP)
111,113,119
113,119
Acutecarolopulmonaryolseaselssuspecteoontbebaslso|blstory
anopbyslcaleamlnatlon.Tblslncluoespatlentswbosmokeorbave
astbmaanoCOPD.
Areoloertbanage70wltbblstoryo|stablecbronlc
carolopulmonaryolseaseanowltboutarecentcbestraolograpb
wltblntbepast6montbs.
Mayrequlrean|CUstay,toestabllsbbasellneCXP.
Areunoergolngamajorsurglcaloperatlon,lncluolngaboomlnal,
tboraclc,carolac,someesopbageal,tbyroloectomy,otberbeaoano
neck,neurosurgery,anolympbnooeproceoures.
Electrocardiograms
(LCG)
NOTPLCOMMLNDLD|orroutlnepreoperatlvescreenlng,
speclcally |or patlents unoergolng low-rlsk proceoures l| tbey are
asymptomatlc.
52,112
21,52,112,113
Areunoergolnglntermeolaterlskorvascularsurgery.
Haveknownlscbemlcbeartolsease,prevlousmyocarolalln|arctlon,
carolacarrbytbmlas,perlpberalvascularolsease,cerebrovascular
olsease,compensateoorprlorbeart|allure,olabetes,renal
lnsu|clency, or resplratory olsease.
Lvloence|orage-baseocrlterlalnotberwlsebealtbylnolvlouals
lsmleo,butllkelyreasonablel|notunoergolnglow-rlsk
proceoure.
21,52,111-113,120-122
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Tableo|Contents
23
ACS NS Q| P

Preoperative
Tests Indications
Pulmonary Function
Tests (PFT)
21,72,113,123
Pecommenoeo|orpatlentsunoergolnglungresectlon.
21,72,124
Forpatlentsnotunoergolngtboraclcsurgery,PFTsarerecommenoeo
|orpatlentswbo:
54,123
Havepoorlycbaracterlzeooyspneaoreerclselntoleranceano
olagnostlcuncertalntyelstsbetweenacarolacorpulmonary
llmltatlonanoslmpleoeconoltlonlng.
Haveobstructlvelungolseasel|ltlsnotclear|romtbecllnlcal
evaluatlonl|patlentsareattbebestposslblebasellne.
Noninvasive Stress
Testing
NOT PLCOMMLNDLD |or routlne preoperatlve screenlng, speclcally
|orpatlentsunoergolnglntermeolaterlsksurglcaloperatlonswltb
nocllnlcalrlsk|actorsano|orpatlentsunoergolnglowrlsksurglcal
operatlons.
52
Peasonable|orpatlentswltbtbreeormorecllnlcalrlsk|actorsano
poor|unctlonalcapaclty(lesstban4MLTs)unoergolngvascular
surgery,or|orpatlentswltbatleastonetotwocllnlcalrlsk|actorsano
poor|unctlonalcapaclty(lesstban4MLTs)wborequlrelntermeolate
rlskorvascularsurgery,l|ltwlllcbangemanagement.
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Tableo|Contents
24
ACS NS Q| P

Appenol ces
APPLND| X|
PatlentsDeclslonMaklngCapaclty
APPLND| X||
CarolacLvaluatlon
APPLND| X|||
FralltyScore
APPLND| X|v
Pecommenoatlons|orPreoperatlveNutrltlonalSupport
APPLND| Xv
8eersCrlterla|orPotentlally|napproprlateMeolcatlonUselnOloerAoults
APPLND| Xv|
Pecommenoatlons|orPreoperatlveDlscontlnuatlono|HerbalMeolclnes/Supplements
APPLND| Xv||
ACC/AHAGuloellnes|orPerloperatlve8eta8lockers
Goto
Tableo|Contents
25
ACS NS Q| P

APPLND|X | . Pat l ent s Decl sl on Makl ng Capacl t y
LEGALLY RELEVANT CRITERIA FOR DECISION- MAKING CAPACITY
AND APPROACHES TO ASSESSMENT OF THE PATIENT
22
Criterion
Patients
Task
Physicians
Assessment
Approach
Questions for Clinical
Assessment
*
Comments
Communlcate
acbolce
Clearlylnolcate
pre|erreo
treatment
optlon
Askpatlent
tolnolcate
atreatment
cbolce
Haveyouoecloeowbetberto
|ollowyourooctors[ormy]
recommenoatlon|ortreatment?
Canyoutellmewbattbatoeclslonls?
[||nooeclslon]Wbatlsmaklnglt
baro|oryoutooecloe?
Frequentreversalso|cbolce
becauseo|psycblatrlcor
neurologlcconoltlonsmay
lnolcatelacko|capaclty
Unoerstano
tberelevant
ln|ormatlon
Grasptbe
|unoamental
meanlngo|
ln|ormatlon
communlcateo
bypbyslclan
Lncourage
patlentto
parapbrase
olscloseo
ln|ormatlon
regarolng
meolcal
conoltlonano
treatment
Pleasetellmelnyourownworos
wbatyourooctor[or|]toloyou
about:
Tbeproblemwltbyourbealtbnow
Tberecommenoeotreatment
Tbe posslble benets ano rlsks
(orolscom|orts)o|tbetreatment
Anyalternatlvetreatmentsano
tbelr rlsks ano benets
Tbe rlsks ano benets o| no
treatment
|n|ormatlontobeunoerstooo
lncluoesnatureo|patlents
conoltlon,natureanopurpose
o|proposeotreatment,
posslble benets ano rlsks o|
tbattreatment,anoalternatlve
approacbes(lncluolngno
treatment) ano tbelr benets ano
rlsks
Appreclate
tbesltuatlon
anolts
consequences
Acknowleoge
meolcal
conoltlon
anollkely
consequences
o|treatment
optlons
Askpatlentto
oescrlbevlews
o|meolcal
conoltlon,
proposeo
treatment,ano
llkelyoutcomes
Wbatooyoubellevelswrongwltb
yourbealtbnow?
Doyoubellevetbatyouneeo
someklnoo|treatment?
Wbatlstreatmentllkelytooo|or
you?
Wbatmakesyoubelleveltwlll
bavetbate||ect?
Wbatooyoubellevewlllbappenl|
youarenottreateo?
Wbyooyoutblnkyourooctor
bas[or|bave]recommenoeotbls
treatment?
Courtsbaverecognlzeotbat
patlentswbooonotacknowleoge
tbelrlllnesses(o|tenre|erreoto
aslacko|lnslgbt)cannotmake
vallooeclslonsabouttreatment
Deluslonsorpatbologlclevelso|
olstortlonoroenlalaretbemost
commoncauseso|lmpalrment
Peasonabout
treatment
optlons
Lngageln
aratlonal
processo|
manlpulatlng
tberelevant
ln|ormatlon
Askpatlent
tocompare
treatment
optlonsano
consequences
anotoo||er
reasons|or
selectlono|
optlon
Howoloyouoecloetoaccept
orrejecttberecommenoeo
treatment?
Wbatmakes[cbosenoptlon]
bettertban[alternatlveoptlon]?
Tblscrlterlon|ocusesontbe
processbywblcbaoeclslon
lsreacbeo,nottbeoutcome
o|tbepatlentscbolce,slnce
patlentsbavetberlgbttomake
unreasonablecbolces
*Patlentsresponsestotbesequestlonsneeonotbeverbal.
Peprlnteo|romNew England Journal of Medicine,vol357(18),AppelbaumPS.Assessmento|patlentscompetencetoconsenttotreatment,p1834-
1840,2007,wltbpermlsslon|romMassacbusettsMeolcalSoclety.
Goto
Tableo|Contents
26
ACS NS Q| P

APPLND| X | | . Carol ac Lval uat l on
ACTIVE CARDIAC CONDITIONS
Patients require evaluation and treatment before nonurgent,
noncardiac surgery (Class I, Level of Evidence B)
52
Condition Examples
Unstablecoronary
synoromes
Unstableorsevereanglna(CanaolanCarolovascularSoclety
class|||or|v)
Pecent M| (>30 oays)
Decompensateobeart
|allure
NewYorkHeartAssoclatlon|unctlonalclass|v
Worsenlngornew-onsetbeart|allure
Slgnlcant arrbytbmlas Hlgb-graoeA-vblock
Mobltz||A-vblock
Tblro-oegreeA-vbeartblock
Symptomatlcventrlculararrbytbmlas
Supraventrlcular arrbytbmlas (lncluolng atrlal brlllatlon) wltb
uncontrolleoventrlcularrate(HP>100bpmatrest)
Symptomatlcbraoycarola
Newlyrecognlzeoventrlculartacbycarola
Severevalvularolsease Severeaortlcstenosls(meanpressuregraolent>40mmHg,
aortlcvalvearea<1cm
2
,orsymptomatlc)
Symptomatlcmltralstenosls(progresslveoyspneaon
eertlon,eertlonpresyncope,orbeart|allure)
CARDIAC RISK STRATIFICATION FOR
NONCARDIAC SURGICAL PROCEDURES
(BASED ON REVISED CARDIAC RISK INDEX)
52
Risk Examples
Low(<1) Lnooscoplc proceoures, superclal proceoures, cataract
surgery,breastsurgery,ambulatorysurgery
|ntermeolate(1-5) |ntraperltonealanolntratboraclcsurgery,carolac
enoarterectomy,beaoanonecksurgery,ortbopaeolcsurgery,
prostatesurgery
vascular(>5) Aortlc/otbermajorvascularsurgery,perlpberalvascular
surgery
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Tableo|Contents
27
ACS NS Q| P

ESTIMATING ENERGY REQUIREMENTS
FOR VARIOUS ACTIVITIES
52
Metabolic Equivalents (METs)
Can you
1MLT
Takecareo|yoursel|?
Lat,oress,anousetbetollet?
Walklnooorsarounotbebouse?
Walkablockortwoonlevelgrounoat2to3mpb(3.2to4.8kpb)?
4MLTs

Dollgbtworkarounotbebousellkeoustlngorwasblngolsbes?
Cllmb a Nlgbt o| stalrs or walk up a blll?
Walkonlevelgrounoat4mpb(8.4kpb)?
Punasbortolstance?
Do beavy work arouno tbe bouse llke scrubblng Noors or ll|tlng or movlng
beavy|urnlture?
Partlclpatelnmooeraterecreatlonalactlvltyllkegol|,bowllng,oanclng,
ooublestennls,ortbrowlngabaseballor|ootball?
>10MLTs Partlclpatelnstrenuoussportsllkeswlmmlng,slnglestennls,|ootball,
basketball,orskllng?
CLINICAL RISK FACTORS FOR NONCARDIAC
SURGICAL PROCEDURES
52
Risk Factors
Hlstoryo|lscbemlcbeartolsease
Hlstoryo|compensateoorprlorbeart|allure
Hlstoryo|cerebrovascularolsease
Dlabetesmellltus
Penal lnsu|clency
Peprlnteo|romJournal of the American College of Cardiology,vol54(22),FlelscbmannKL,8eckman[A,8ullerCL,etal.,
2009ACCF/AHAFocuseoUpoateonPerloperatlve8eta8lockaoe,p2102-2128,2009,wltbpermlsslon|romLlsevler.
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Tableo|Contents
28
ACS NS Q| P

APPLND|X | | | . Fral l t y Score
FRAILTY SCORE
89,92
PATIENT RECEIVES ONE POINT FOR EACH CRITERION (05)
Frailty Criteria Definition
Welgbtloss Unlntentlonal welgbt loss <10 pounos ln tbe past year.
Decreaseogrlp
strengtb(Weakness)
Grlpstrengtblntbelowest20tbpercentllebygenoerano8M|.Tbreetrlalsare
per|ormeowltbabano-belooynamometeranotbeaveragevaluelsuseo.
Men
8M| KgForce
>24 >29
24.126 >30
26.128 >30
>28 >32
Women
8M| KgForce
>23 >17
23.126 >17.3
26.129 >18
>29 >21
Lbaustlon Fortbe|ollowlngtwostatements:
||elttbateverytblng|olowasane||ort.
|coulonotgetgolng.
Tbepatlentlsaskeo:Howo|tenlntbelastweekoloyou|eeltblsway?
0=rarelyornoneo|tbetlme(<1oay)
1=someorallttleo|tbetlme(12oays)
2=amooerateamounto|tbetlme(34oays)
3=mosto|tbetlme
Tbecrlterlonlsmetl|patlentanswers2or3toeltberstatement.
Lowpbyslcalactlvlty Weeklyenergyepenolture,oetermlneowltbtbesbortverslono|tbeMlnnesota
LelsureTlmeActlvltlesQuestlonnalre(seeTayloretal.
125
)lntbelowest20tb
percentllebygenoer:
Men:<383kcal/week.Women:<270kcal/week.
Sloweowalklng
speeo
Walklngspeeolntbelowest20tbpercentllebygenoeranobelgbt.Tlmels
measureo|oraolstanceo|15|eetatnormalpace.Tbeaverageo|tbreetrlalsls
useo.
Men
Helgbt Tlme
>173 cm <7 sec
>173cm <6 sec
Women
Helgbt Tlme
>159 cm <7 sec
>159cm <6 sec
Peprlnteo|romJournal of the American College of Surgeons,vol210(6),MakaryMA,SegevDL,PronovostP[,etal.Fralltyasapreolctoro|surglcal
outcomeslnoloerpatlents,901-908,2010,wltbpermlsslon|romLlsevler.
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Tableo|Contents
29
ACS NS Q| P

APPLND|X | v. Pecommenoat l ons | or Preoperat l ve
Nut rl t l onal Suppor t
PREOPERATIVE INTERVENTIONS FOR MALNUTRITION
ESPEN Recommendations
95,126
Usenutrltlonalsupportlnpatlentswltbseverenutrltlonalrlsk|or1014oaysprlortoa
majorsurglcaloperatlonevenl|tbeoperatlonbastobeoelayeo(GraoeA).
|nltlatenutrltlonalsupport(bytbeenteralroutel|posslble)wltboutoelay:
Lvenlnpatlentswltboutobvlousunoer-nutrltlon,l|ltlsantlclpateotbattbepatlent
wlllbeunabletoeat|ormoretban7oaysperloperatlvely(GraoeC).
|npatlentswbocannotmalntalnorallntakeabove60o|recommenoeolntake|or
moretban10oays(GraoeC).
Consloercomblnatlonwltbparenteralnutrltlonlnpatlentslnwbomtberelsanlnolcatlon
|ornutrltlonalsupportanolnwbomenergyneeoscannotbemet(<60o|calorlc
requlrement)vlatbeenteralroute(GraoeC).
Lncouragepatlentswbooonotmeettbelrenergyneeos|romnormal|ooototakeoral
nutrltlonalsupplementsourlngtbepreoperatlveperloo(GraoeC).
Aomlnlsterpreoperatlveenteralnutrltlonpre|erablybe|oreaomlsslontotbebospltal
(GraoeC).
Preoperatlveparenteralnutrltlonlslnolcateolnseverelyunoernourlsbeopatlentswbo
cannotbeaoequatelyorallyorenterally|eo|or710oayspreoperatlvely(GraoeA).
NOTL:Tbeenteralroutelspre|erreoecept|ortbe|ollowlngcontralnolcatlons:|ntestlnal
obstructlonsorlleus,severesbock,lntestlnallscbemla.
Other Recommendations
vltamlnsupplementatlon|oralcobol-relateomalnourlsbeopatlent:812ano|olate,
21
tblamlne.
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Tableo|Contents
30
ACS NS Q| P

APPLND|X v: 2012 8eers Crl t erl a | or Pot ent l al l y
| napproprl at e Meol cat l on Use l n Ol oer Aoul t s
2012 AGS BEERS CRITERIA FOR POTENTIALLY
INAPPROPRIATE MEDICATION USE IN OLDER ADULTS
97
Organ System/
Therapeutic
Category/Drug(s) Rationale Recommendation
Quality of
Evidence
Strength of
Recommendation
Anticholinergics (excludes TCAs)
Flrst-generatlon
antlblstamlnes(asslngleagent
orasparto|comblnatlon
prooucts)
8rompbenlramlne
Carblnoamlne
Cblorpbenlramlne
Clemastlne
Cyprobeptaolne
Debrompbenlramlne
Decblorpbenlramlne
Dlpbenbyoramlne(oral)
Doylamlne
Hyoroyzlne
Prometbazlne
Trlprollolne
Hlgblyantlcbollnerglc,clearancereouceo
wltbaovanceoage,anotoleranceoevelops
wbenuseoasbypnotlc,lncreaseorlsko|
con|uslon,orymoutb,constlpatlon,ano
otberantlcbollnerglce||ects/tolclty
Useo|olpbenbyoramlnelnspeclalsltuatlons
sucbasacutetreatmento|severeallerglc
reactlonmaybeapproprlate
Avolo Hyoroyzlne
ano
prometbazlne:
Hlgb
Allotbers:
Mooerate
Strong
Antl-Parklnsonagents
8enztroplne(oral)
Trlbeypbenloyl
Notrecommenoeo|orpreventlon
o|etrapyramloalsymptomswltb
antlpsycbotlcs,moree||ectlveagents
avallable|ortreatmento|Parklnsonolsease
Avolo Mooerate Strong
Antlspasmoolcs
8ellaoonnaalkalolos
Cllolnlum-cblorolazepoloe
Dlcyclomlne
Hyoscyamlne
Propantbellne
Scopolamlne
Hlgblyantlcbollnerglc,uncertaln
e||ectlveness
Avoloecept
lnsbort-term
palllatlvecare
tooecreaseoral
secretlons
Mooerate Strong
Antithrombotics
Dlpyrloamole,oralsbort-
actlng*(ooesnotapplytotbe
etenoeo-releasecomblnatlon
wltbasplrln)
Maycauseortbostatlcbypotenslon,more
e||ectlvealternatlvesavallable,|v|orm
acceptable|oruselncarolacstresstestlng
Tlcloplolne* Sa|er,e||ectlvealternatlvesavallable Avolo Mooerate Strong
Anti-Infective
Nltro|urantoln Potentlal|orpulmonarytolclty,sa|er
alternatlves avallable, lack o| e|cacy ln
patlentswltbCrCl<60mL/mlnoueto
lnaoequateorugconcentratlonlntbeurlne
Avolo|orlong-
termsuppresslon,
avololnpatlents
wltbCrCl<60mL/
mln
Mooerate Strong
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Tableo|Contents
31
ACS NS Q| P

97
Organ System/
Therapeutic
Quality of
Evidence
Strength of
Recommendation
Cardiovascular
Alpba1blockers
Doazosln
Prazosln
Terazosln
Hlgbrlsko|ortbostatlcbypotenslon,not
recommenoeoasroutlnetreatment|or
bypertenslon,alternatlveagentsbave
superlor rlsk/benet prole
Avolouseasan
antlbypertenslve
Mooerate Strong
Alpbablockers,central
Clonlolne
Guanabenz*
Guan|aclne*
Metbyloopa*
Peserplne(>0.1mg/oay)*
Hlgbrlsko|aoverseCNSe||ects,maycause
braoycarolaanoortbostatlcbypotenslon,
notrecommenoeoasroutlnetreatment|or
bypertenslon
Avoloclonlolne
as a rst-llne
antlbypertenslve
Avolootbersas
llsteo
Low Strong
Antlarrbytbmlcorugs
(Class|a,|c,|||)
Amlooarone
Do|etllloe
Droneoarone
Flecalnloe
|butllloe
Procalnamloe
Propa|enone
Qulnlolne
Sotalol
Datasuggesttbatratecontrolylelosbetter
balance o| benets ano barms tban rbytbm
control|ormostoloeraoults
Amlooaronelsassoclateowltbmultlple
tolcltles,lncluolngtbyroloolsease,
pulmonaryolsoroers,anoQTlnterval
prolongatlon
Avolo
antlarrbytbmlc
orugs as rst-llne
treatmento|atrlal
brlllatlon
Hlgb Strong
Dlsopyramloe* Dlsopyramloelsapotentnegatlvelnotrope
anotbere|oremaylnoucebeart|allureln
oloeraoults,stronglyantlcbollnerglc,otber
antlarrbytbmlcorugspre|erreo
Avolo Low Strong
Droneoarone Worseoutcomesbavebeenreporteoln
patlentstaklngoroneoaronewbobave
permanent atrlal brlllatlon or beart |allure
|ngeneral,ratecontrollspre|erreoover
rbytbm control |or atrlal brlllatlon
Avololnpatlents
wltbpermanent
atrlal brlllatlon or
beart|allure
Mooerate Strong
Dlgoln>0.125mg/oay |nbeart|allure,blgberoosagesassoclateo
wltb no aooltlonal benet ano may lncrease
rlsko|tolclty,oecreaseorenalclearance
mayleaotolncreaseorlsko|tolce||ects
Nl|eolplne,lmmeolate
release*
Potentlal|orbypotenslon,rlsko|
preclpltatlngmyocarolallscbemla
Avolo Hlgb Strong
Splronolactone>25mg/oay |nbeart|allure,tberlsko|byperkalemlals
blgberlnoloeraoultsl|taklng>25mg/oay
Avololnpatlents
wltbbeart|allure
orwltbaCrCl
<30mL/mln
Mooerate Strong
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Tableo|Contents
32
ACS NS Q| P

97
Organ System/
Therapeutic
Quality of
Evidence
Strength of
Recommendation
Central Nervous System
TertlaryTCAs,aloneorln
comblnatlon:
Amltrlptyllne
Cblorolazepoloe-
amltrlptyllne
Clomlpramlne
Doepln>6mg/oay
|mlpramlne
Perpbenazlne-amltrlptyllne
Trlmlpramlne
Hlgblyantlcbollnerglc,seoatlng,anocauses
ortbostatlc bypotenslon, tbe sa|ety prole o|
low-oose ooepln (>6 mg/oay) ls comparable
totbato|placebo
Avolo Hlgb Strong
Antlpsycbotlcs, rst-
(conventlonal)anosecono-
(atyplcal)generatlon
(seeTable First- and
Second-Generation
Antipsychotics below for
full list)
|ncreaseorlsko|cerebrovascularaccloent
(stroke)anomortalltylnpersonswltb
oementla
Avolouse|or
bebavloral
problemso|
oementlaunless
nonpbarmacologlc
optlonsbave|alleo
anopatlentlstbreat
tosel|orotbers
Mooerate Strong
Tblorloazlne
Mesorloazlne
Hlgblyantlcbollnerglcanogreaterrlsko|QT-
lntervalprolongatlon
8arblturates
Amobarbltal*
8utabarbltal*
8utalbltal
Mepbobarbltal*
Pentobarbltal*
Pbenobarbltal
Secobarbltal*
Hlgbrateo|pbyslcaloepenoence,tolerance
to sleep benets, greater rlsk o| overoose at
lowoosages
Avolo Hlgb Strong
8enzoolazeplnes
SHOPT-AND
|NTLPMLD|ATL-ACT|NG:
Alprazolam
Lstazolam
Lorazepam
Oazepam
Temazepam
Trlazolam
LONG-ACT|NG:
Cblorazepate
Cblorolazepoloe
Cblorolazepoloe-
amltrlptyllne
Cllolnlum-cblorolazepoloe
Clonazepam
Dlazepam
Flurazepam
Quazepam
Oloeraoultsbavelncreaseosensltlvltyto
benzoolazeplnesanooecreaseometabollsm
o|long-actlngagents,lngeneral,all
benzoolazeplneslncreaserlsko|cognltlve
lmpalrment,oellrlum,|alls,|ractures,ano
motorveblcleaccloentslnoloeraoults
Maybeapproprlate|orselzureolsoroers,
raploeyemovementsleepolsoroers,
benzoolazeplnewltborawal,etbanol
wltborawal,severegenerallzeoanlety
olsoroer,perlproceouralanestbesla,eno-o|-
ll|ecare
Avolo
benzoolazeplnes
(anytype)|or
treatment
o|lnsomnla,
agltatlon,or
oellrlum
Hlgb Strong
Goto
Tableo|Contents
33
ACS NS Q| P

97
Organ System/
Therapeutic
Quality of
Evidence
Strength of
Recommendation
Cbloralbyorate* Toleranceoccurswltbln10oaysanorlsk
outwelgbs tbe benets ln llgbt o| overoose
wltboosesonly3tlmestberecommenoeo
oose
Avolo Low Strong
Meprobamate Hlgbrateo|pbyslcaloepenoence,very
seoatlng
Nonbenzoolazeplnebypnotlcs
Lszoplclone
Zolploem
Zaleplon
8enzoolazeplne-receptoragonlststbat
baveaoverseeventsslmllartotbose
o|benzoolazeplneslnoloeraoults(|or
eample,oellrlum,|alls,|ractures),mlnlmal
lmprovementlnsleeplatencyanoouratlon
Avolocbronlcuse
(>90oays)
Mooerate Strong
Lrgotmesylates*
|sosuprlne*
Lack o| e|cacy Avolo Hlgb Strong
Endocrine
Anorogens
Metbyltestosterone*
Testosterone
Potentlal|orcarolacproblemsano
contralnolcateolnmenwltbprostatecancer
Avolounless
lnolcateo|or
mooerate
tosevere
bypogonaolsm
Mooerate Weak
Deslccateotbyrolo Concernsaboutcarolace||ects,sa|er
alternatlvesavallable
Avolo Low Strong
Lstrogenswltborwltbout
progestlns
Lvloenceo|carclnogenlcpotentlal(breast
anoenoometrlum),lacko|caroloprotectlve
e||ectanocognltlveprotectlonlnoloer
women
Lvloencetbatvaglnalestrogens|ortreatment
o|vaglnalorynesslssa|eanoe||ectlveln
womenwltbbreastcancer,especlallyat
oosageso|estraolol<25mcgtwlceweekly
Avolooralano
toplcalpatcb
Toplcalvaglnal
cream:Acceptable
touselow-oose
lntravaglnal
estrogen|ortbe
management
o|oyspareunla,
lowerurlnary
tractln|ectlons,
anootbervaglnal
symptoms
Oralano
patcb:Hlgb
Toplcal:
Mooerate
Oralanopatcb:
Strong
Toplcal:Weak
Growtbbormone |mpactonbooycomposltlonlssmallano
assoclateowltbeoema,artbralgla,carpal
tunnelsynorome,gynecomastla,lmpalreo
|astlngglucose
Avolo,ecept
asbormone
replacement
|ollowlngpltultary
glanoremoval
Hlgb Strong
|nsulln,sllolngscale Hlgberrlsko|bypoglycemlawltbout
lmprovementlnbyperglycemlamanagement
regarolesso|caresettlng
Megestrol Mlnlmale||ectonwelgbt,lncreasesrlsko|
tbrombotlceventsanoposslblyoeatbln
oloeraoults
Sul|onylureas,long-ouratlon
Cblorpropamloe
Glyburloe
Cblorpropamloe:Prolongeobal|-ll|elnoloer
aoults,cancauseprolongeobypoglycemla,
causesS|ADH
Glyburloe:blgberrlsko|severeprolongeo
bypoglycemlalnoloeraoults
Avolo Hlgb Strong
Goto
Tableo|Contents
34
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97
Organ System/
Therapeutic
Quality of
Evidence
Strength of
Recommendation
Gastrointestinal
Metoclopramloe Cancauseetrapyramloale||ectslncluolng
tarolveoysklnesla,rlskmaybe|urtber
lncreaseoln|ralloloeraoult.
Avolo,unless|or
gastroparesls.
Mooerate Strong
Mlneraloll,glvenorally Potentlal|orasplratlonanoaoversee||ects,
sa|eralternatlvesavallable
Trlmetbobenzamloe Oneo|tbeleaste||ectlveantlemetlcorugs,
cancauseetrapyramloalaoversee||ects
Pain Medications
Meperlolne Notane||ectlveoralanalgeslclnoosages
commonlyuseo,maycauseneurotolclty,
sa|eralternatlvesavallable
Avolo Hlgb Strong
NonCOX-selectlve
NSA|Ds,oral
Asplrln>325mg/oay
Dlclo|enac
DlNunlsal
Ltooolac
Fenopro|en
|bupro|en
Ketopro|en
Meclo|enamate
Me|enamlcaclo
Melolcam
Nabumetone
Naproen
Oaprozln
Plrolcam
Sullnoac
Tolmetln
|ncreasesrlsko|G|bleeolng/peptlculcer
olseaselnblgb-rlskgroups,lncluolng
tbose>75yearsoloortaklngoralor
parenteralcortlcosterolos,antlcoagulants,
orantlplateletagents,useo|protonpump
lnblbltorormlsoprostolreoucesbutooes
notellmlnaterlsk,upperG|ulcers,gross
bleeolng,orper|oratloncauseobyNSA|Ds
occurlnapprolmately1o|patlents
treateo|or36montbs,anolnabout24
o|patlentstreateo|or1year,tbesetrenos
contlnuewltblongerouratlono|use
Avolocbronlc
useunlessotber
alternatlvesare
note||ectlveano
patlentcantake
gastroprotectlve
agent(proton-
pumplnblbltoror
mlsoprostol)
Allotbers:
Mooerate
Strong
|noometbacln
Ketorolac,lncluoesparenteral
|ncreasesrlsko|G|bleeolng/peptlculcer
olseaselnblgb-rlskgroups(seeabovenon
COX-selectlveNSA|Ds)
O|alltbeNSA|Ds,lnoometbaclnbasmost
aoversee||ects
Avolo |noometbacln:
Mooerate
Ketorolac:
Hlgb
Strong
Pentazoclne* OploloanalgeslctbatcausesCNS
aoversee||ects,lncluolngcon|uslonano
balluclnatlons,morecommonlytbanotber
narcotlcorugs,lsalsoamleoagonlstano
antagonlst,sa|eralternatlvesavallable
Avolo Low Strong
Skeletalmusclerelaants
Carlsoproool
Cblorzoazone
Cyclobenzaprlne
Metaalone
Metbocarbamol
Orpbenaorlne
Mostmusclerelaantspoorlytolerateo
byoloeraoultsbecauseo|antlcbollnerglc
aoversee||ects,seoatlon,lncreaseorlsko|
|ractures,e||ectlvenessatoosagestolerateo
byoloeraoultslsquestlonable.
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Tableo|Contents
35
ACS NS Q| P

97
Organ System/
Therapeutic
Quality of
Evidence
Strength of
Recommendation
*Infrequently used drugs
/ZE^Ky
'/E^/^/,
d
Peprlnteo|romJournal of the American Geriatrics Society,vol60(4),TbeAmerlcanGerlatrlcsSoclety20128eersCrlterlaUpoateLpertPanel,
AmerlcanGerlatrlcsSocletyUpoateo8eersCrlterla|orPotentlally|napproprlateMeolcatlonUselnOloerAoults,p616-631,2012,wltbpermlsslon
|romTbeAmerlcanGerlatrlcsSoclety.
2012 AGS BEERS CRITERIA FOR POTENTIALLY INAPPROPRIATE
MEDICATIONS TO BE USED WITH CAUTION IN OLDER ADULTS
97
Drug(s) Rationale Recommendation
Quality of
Evidence
Strength of
Recommendation
Asplrln|orprlmarypreventlon
o|carolacevents
Lack o| evloence o| benet versus rlsk
ln lnolvlouals <80 years olo
Usewltbcautlonln
aoults <80 years olo
Low Weak
Dablgatran |ncreaseorlsko|bleeolngcompareo
wltb war|arln ln aoults <75 years olo,
lack o| evloence |or e|cacy ano sa|ety
lnpatlentswltbCrCl<30mL/mln
Usewltbcautlonln
orl|CrCl<30mL/mln
Mooerate Weak
Prasugrel |ncreaseorlsko|bleeolnglnoloer
aoults, rlsk may be o||set by benet ln
blgbest-rlskoloerpatlents(|oreample,
tbosewltbprlormyocarolalln|arctlon
orolabetes)
Usewltbcautlonln
Mooerate Weak
Antlpsycbotlcs
Carbamazeplne
Carboplatln
Clsplatln
Mlrtazaplne
SNP|s
SSP|s
TCAs
vlncrlstlne
MayeacerbateorcauseS|ADHor
byponatremla,neeotomonltorsoolum
levelcloselywbenstartlngorcbanglng
oosageslnoloeraoultsouetolncreaseo
rlsk
Usewltbcautlon Mooerate Strong
vasoollators Mayeacerbateeplsooeso|syncopeln
lnolvloualswltbblstoryo|syncope
Usewltbcautlon Mooerate Weak
Abbrevlatlons:CrCl,creatlnlneclearance,S|ADH,synoromeo|lnapproprlateantloluretlcbormonesecretlon,SSP|s,selectlveserotonlnreuptake
lnblbltors,SNP|s,serotonlnnoreplnepbrlnereuptakelnblbltors,TCAs,trlcycllcantloepressants.
Goto
Tableo|Contents
36
ACS NS Q| P

FIRST- AND SECOND- GENERATION ANTIPSYCHOTICS
97
First-Generation
(Conventional) Agents Second-Generation (Atypical) Agents
Cblorpromazlne
Flupbenazlne
Haloperlool
Loaplne
Mollnoone
Perpbenazlne
Plmozloe
Promazlne
Tblorloazlne
Tblotblene
TrlNuoperazlne
TrlNupromazlne
Arlplprazole
Asenaplne
Clozaplne
|loperloone
Lurasloone
Olanzaplne
Pallperloone
Quetlaplne
Plsperloone
Zlprasloone
Goto
Tableo|Contents
37
ACS NS Q| P

DRUGS WITH STRONG ANTICHOLINERGIC PROPERTIES
Antihistamines Anti-Parkinson Agents
8rompbenlramlne
Carblnoamlne
Cblorpbenlramlne
Clemastlne
Cyprobeptaolne
Dlmenbyorlnate
Dlpbenbyoramlne
Hyoroyzlne
Lorataolne
Mecllzlne
8enztroplne
Trlbeypbenloyl
Antidepressants Antipsychotics
Amltrlptyllne
Amoaplne
Clomlpramlne
Deslpramlne
Doepln
|mlpramlne
Nortrlptyllne
Paroetlne
Protrlptyllne
Trlmlpramlne
Cblorpromazlne
Clozaplne
Flupbenazlne
Loaplne
Olanzaplne
Perpbenazlne
Plmozloe
Procblorperazlne
Prometbazlne
Tblorloazlne
Tblotblene
TrlNuoperazlne
Antimuscarinics (Urinary Incontinence) Antispasmodics
Darl|enacln
Fesoteroolne
Flavoate
Oybutynln
Soll|enacln
Tolteroolne
Trosplum
Atroplneprooucts
8ellaoonnaalkalolos
Dlcyclomlne
Homatroplne
Hyoscyamlneprooucts
Loperamloe
Propantbellne
Scopolamlne
Skeletal Muscle Relaxants
Carlsoproool
Cyclobenzaprlne
Orpbenaorlne
Tlzanlolne
Peprlnteo|romJournal of the American Geriatrics Society,vol60(4),TbeAmerlcanGerlatrlcsSoclety20128eersCrlterlaUpoate
LpertPanel,AmerlcanGerlatrlcsSocletyUpoateo8eersCrlterla|orPotentlally|napproprlateMeolcatlonUselnOloerAoults,
p616-631,2012,wltbpermlsslon|romTbeAmerlcanGerlatrlcsSoclety.
Goto
Tableo|Contents
38
ACS NS Q| P

APPLND|X v| . Pecommenoat l ons | or Preoperat l ve
Dl scontl nuat l on o| Herbal Meol cl nes/ Suppl ement s
HERBAL MEDICINES/ SUPPLEMENTS:
CLINICALLY IMPORTANT EFFECTS AND
RECOMMENDATIONS FOR DISCONTINUATION
127
Herb
Relevant
Pharmacological
Effect Perioperative Concerns
Preoperative
Discontinuation
Lcblnacea Actlvatlono|cell-
meolateolmmunlty
Allerglcreactlon,oecreaseoe||ectlveness
o|lmmunosuppressants,potentlal|or
lmmunosuppresslonwltblong-termuse
Nooata
Lpbeora |ncreaseobeartrateano
blooopressuretbrougb
olrectanolnolrect
sympatbomlmetlce||ects
Plsko|myocarolallscbemlaanostroke|rom
tacbycarolaanobypertenslon,ventrlcular
arrbytbmlaswltbbalotbane,long-termuse
oepletesenoogenouscatecbolamlnesanomay
causelntraoperatlvebemooynamlclnstablllty,ll|e-
tbreatenlnglnteractlonwltbmonoamlneoloase
lnblbltors
Atleast24boursbe|ore
asurglcaloperatlon
Garllc |nblbltlono|platelet
aggregatlon(maybe
lrreverslble),lncreaseo
brlnolysls, equlvocal
antlbypertenslveactlvlty
Potentlaltolncreaserlsko|bleeolng,especlally
wbencomblneowltbotbermeolcatlonstbat
lnblbltplateletaggregatlon
Atleast7oaysbe|orea
surglcaloperatlon
Glnkgo |nblbltlono|platelet-
actlvatlng|actor
Potentlaltolncreaserlsko|bleeolng,especlally
wbencomblneowltbotbermeolcatlonstbat
lnblbltplateletaggregatlon
asurglcaloperatlon
Glnseng Lowersbloooglucose,
lnblbltlono|platelet
aggregatlon(maybe
lrreverslble),lncreaseo
PT-PTTlnanlmals,many
otberolversee||ects
Hypoglycemla,potentlaltolncreaserlsko|
bleeolng,potentlaltooecreaseantlcoagulatlon
e||ecto|war|arln
Atleast7oaysbe|orea
surglcaloperatlon
Kava Seoatlon,anlolysls Potentlaltolncreaseseoatlvee||ecto|
anestbetlcs,potentlal|oraoolctlon,tolerance,ano
wltborawala|terabstlnenceunstuoleo
asurglcaloperatlon
St.[obns
wort
|nblbltlono|
neurotransmltter
reuptake,monoamlne
oloaselnblbltlonls
unllkely
|nouctlono|cytocbromeP450enzymes,a||ectlng
cyclosporlne,war|arln,sterolos,protease
lnblbltors,anoposslblybenzoolazeplnes,
calclumcbannelblockers,anomanyotberorugs,
oecreaseoserumolgolnlevels
Atleast5oaysbe|orea
surglcaloperatlon
valerlan Seoatlon Potentlaltolncreaseseoatlvee||ecto|
anestbetlcs,benzoolazeplne-llkeacutewltborawal,
potentlaltolncreaseanestbetlcrequlrements
wltblong-termuse
Nooata
Peprlnteo|romJournal of the American Medical Association,vol286(2),Ang-LeeMKanoMoss[.HerbalMeolclnesanoPerloperatlveCare,p208-216,
2001,wltbpermlsslon|romTbeAmerlcanMeolcalAssoclatlon.
Goto
Tableo|Contents
39
ACS NS Q| P

APPLND|X v| | . ACC/AHA Gul oel l nes | or
Perl operat l ve 8et a 8l ockers
ACC/AHA GUIDELINES FOR PERIOPERATIVE BETA BLOCKERS
21, 52
Full Recommendations
52
Class I:
8etablockerssboulobecontlnueolnpatlentsunoergolngasurglcaloperatlonwboarerecelvlngbeta-blockersto
treatanglna,symptomatlcarrbytbmlas,bypertenslon,orotberACC/AHAClass|guloellnelnolcatlons.(Levelo|
evloenceC)
Class IIa:
8etablockerstltrateotobeartrateanoblooopressureareprobablyrecommenoeo|orpatlentsunoergolng
vascular surgery wbo are at blgb carolac rlsk owlng to coronary artery olsease or tbe nolng o| carolac lscbemla
onpreoperatlvetestlng.(Levelo|evloence8)
8etablockerstltrateotobeartrateanoblooopressurearereasonable|orpatlentslnwbompreoperatlve
assessment |or vascular surgery loentles blgb carolac rlsk, as oeneo by tbe presence o| more tban one
cllnlcalrlsk|actor(blstoryo|lscbemlcbeartolsease,blstoryo|compensateoorprlorbeart|allure,blstoryo|
cerebrovascular olsease, olabetes mellltus, renal lnsu|clency (>2 mg/oL). (Level o| evloence C)
8etablockerstltrateotobeartrateanoblooopressurearereasonable|orpatlentslnwbompreoperatlve
assessment loentles coronary artery olsease or blgb carolac rlsk, as oeneo by tbe presence o| more tban one
cllnlcalrlsk|actor,wboareunoergolnganlntermeolate-rlsksurglcaloperatlon.(Levelo|evloence8)
Class IIb:
Tbeuse|ulnesso|beta-blockerslsuncertaln|orpatlentswboareunoergolngeltberlntermeolate-rlskproceoures
or vascular surgery ln wbom preoperatlve assessment loentles a slngle cllnlcal rlsk |actor ln tbe absence o|
coronaryarteryolsease.(Levelo|evloenceC)
Tbeuse|ulnesso|beta-blockerslsuncertalnlnpatlentsunoergolngvascularsurgerywltbnocllnlcalrlsk|actors
wboarenotcurrentlytaklngbeta-blockers.(Levelo|evloence8)
Class III:
8eta-blockerssboulonotbeglventopatlentsunoergolngasurglcaloperatlonwbobaveabsolutecontralnolcatlons
tobeta-blockers.(Levelo|evloenceC)
Poutlneaomlnlstratlono|blgb-oosebeta-blockerslntbeabsenceo|oosetltratlonlsnotuse|ulanomaybebarm|ul
topatlentsnotcurrentlytaklngbeta-blockerswboareunoergolngnoncarolacsurgery.(Levelo|evloence8)
NOTL: Tbese |ocuseo upoates ln 2009 reNect new evloence tbat was elucloateo a|ter tbe publlcatlon o| tbe 2007 ACC/AHA 2007
GuloellnesonPerloperatlveCarolovascularLvaluatlonanoCare|orNoncarolacSurgery.MostnotablewastbePO|SL(PerlOperatlve
|Scbemlc Lvaluatlon) trlal, a large, ranoomlzeo-controlleo trlal o| eo blgber oose, etenoeo-release metoprolol starteo tbe oay
o| noncarolac surgery. Tbls stuoy conrmeo reouctlons ln tbe rates o| myocarolal ln|arctlon, carolac revascularlzatlon, ano cllnlcally
slgnlcant atrlal brlllatlon, tbls was o||set by lncreaseo rates o| oeatb, stroke, ano cllnlcally slgnlcant bypotenslon ano braoycarola.50
Tblsprompteotbeupoates,lncluolngtberecommenoatlonagalnstroutlnepreoperatlvelnltlatlono|blgb-oosebetablockerslnpatlents
notcurrentlytaklngtbem,especlallylntbeabsenceo|tltratlon.
Goto
Tableo|Contents
40
ACS NS Q| P

LXPLPT PANLL
Co-cbalrs:
NestorF.Lsnaola,MD,MPH,M8A,FACS
Department of Surgery, Medical University of South Carolina, Charleston, SC
American College of Surgeons, Chicago, IL
PonnleA.Posentbal,MD,MS,FACS
Department of Surgery, Yale School of Medicine, New Haven, CT
Veterans Affairs Connecticut Healthcare System, West Haven, CT
Members:
[amesW.Davls,[r.,MD,FACP
Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA
GeorgeW.Dracb,MD,FACS
Division of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
Lmllyv.A.Flnlayson,MD,MS,FACS
Department of Surgery, UCSF School of Medicine, San Francisco, CA
LvelynC.Granlerl,MD,MPH,MSLo
Division of Geriatric Medicine and Aging, Columbia University College of Physicians and Surgeons, New York, NY
MarkP.Katllc,MD,MMM,FACS
Department of Surgery, Sinai Hospital of Baltimore, Baltimore, MD
Cll||oroY.Ko,MD,MS,MSHS,FACS
Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
American College of Surgeons, Chicago, IL
SanobyaA.Lagoo-Deenaoayalan,MD,PbD,FACS
Department of Surgery, Duke University School of Medicine, Durham, NC
NancyL.Lunoebjerg,MPA
American Geriatrics Society, New York, NY
MartlnA.Makary,MD,MPH,FACS
Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
[.PatrlckOLeary,MD,FACS
'HDQV2IFHIRU&OLQLFDO$IIDLUV+HUEHUW:HUWKHLP&ROOHJHRI0HGLFLQH)ORULGD,QWHUQDWLRQDO8QLYHUVLW\0LDPL)/
WalterL.Po|abl||,MD,FACS
Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC
PeterPompel,MD,FACP
Department of Medicine, Stanford University School of Medicine, Stanford, CA
Goto
Tableo|Contents
41
ACS NS Q| P

KarenL.Plcbaros,8A
Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL
TbomasN.Poblnson,MD,MPH,FACS
Department of Surgery, University of Colorado at Denver School of Medicine, Aurora, CO
MarclaMcGoryPussell,MD
Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
[e||reyH.Sllversteln,MD,C|P
Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY
[ulleA.Sosa,MD,MA,FACS
Department of Surgery, Yale School of Medicine, New Haven, CT
LlsaM.Walke,MD
Department of Internal Medicine (Geriatrics), Yale School of Medicine, New Haven, CT
Veterans Affairs Connecticut Healthcare System, West Haven, CT
MlcbaelL.Zenllman,MD,FACS
Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
PLLPPLv|LWLPS
AGS Executive Committee
SbaronA.8rangman,MD,FACP,AGSF
Department of Medicine, SUNY Upstate Medical University, Syracuse, NY
[amesT.Pacala,MD,MS,AGSF
Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN
CatbyA.Alessl,MD,AGSF
Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
VA Greater Los Angeles Healthcare System, Sepulveda, CA
KeelaA.Herr,PbD,PN,FAAN,AGSF
Department of Nursing Services and Patient Care, University of Iowa Hospitals and Clinics, Iowa City, IA
8arbaraM.Pesnlck,PbD,CPNP,FAAN,FAANP
Department of Organizational Systems and Adult Health, University of Maryland School of Nursing, Baltimore, MD
AGS Clinical Practice and Models of Care Committee
MattbewK.McNabney,MD
Division of Geriatric Medicine and Gerontology, Johns Hopkins School of Medicine, Baltimore, MD
PaulL.Mulbausen,MD,MHS
Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
Goto
Tableo|Contents
42
ACS NS Q| P

TbeAmerlcanCollegeo|SurgeonsNatlonalSurglcalQuallty|mprovementProgram(ACSNSQ|P)anotbeAmerlcanGerlatrlcsSoclety
(AGS)8estPractlcesGuloellnesbavebeenoevelopeo|orqualltylmprovementpurposes.Tbeoocumentsmaybeoownloaoeoanoprlnteo
|orpersonalusebybealtbcarepro|esslonals,anomayalsobeuseolnqualltylmprovementlnltlatlvesorprograms.Tbeoocumentsmaynot
be olstrlbuteo |or prot wltbout tbe wrltten consent o| tbe Amerlcan College o| Surgeons ano tbe Amerlcan Gerlatrlcs Soclety.
Tbelntento|tbeACSNSQ|P/AGS8estPractlcesGuloellneslstoprovloebealtbcarepro|esslonalswltb
evloence-baseorecommenoatlonsregarolngtbepreventlon,olagnosls,ortreatmento|commonpostsurglcal
compllcatlons.Tbe8estPractlcesGuloellnesoonotlncluoeallpotentlaloptlons|orpreventlon,olagnosls,ano
treatment. Tbe responslble pbyslclan or bealtb care provloer must make tbe nal oeclslons regarolng patlent
careanotakelntoaccounttbepatlentslnolvloualcllnlcalpresentatlon.TbeACSNSQ|P/AGS8estPractlces
Guloellnes may be mooleo wltbout notlce.
Tbeoevelopmento|tbeACSNSQ|P/AGS8estPractlcesGuloellneswassupporteobytbeAmerlcan
GerlatrlcsSoclety,tbe[obnA.Hart|oroFounoatlon,anotbeAmerlcanCollegeo|Surgeons.
THL[ OHNA. HAPTFOPDFOUNDAT| ON: Founoeoln1929,tbe[obnA.Hart|oroFounoatlons
mlsslonlstolmprovetbebealtbo|oloerAmerlcans.TbeFounoatlonlsacommltteocbamplono|bealtbcare
tralnlng,researcb,anoservlcesystemlnnovatlonstbatwlllensuretbewell-belnganovltalltyo|oloeraoults.
Formoreln|ormatlon,pleasevlsltwww.jhartfound.org.
THLAMLP| CANGLP| ATP| CSSOC| LTY: Tbe Amerlcan Gerlatrlcs Soclety (AGS) ls a not-|or-prot
organlzatlono|moretban6,000bealtbpro|esslonalsoevoteotolmprovlngtbebealtb,lnoepenoence,ano
qualltyo|ll|eo|alloloerpeople.TbeSocletyprovloesleaoersblptobealtbcarepro|esslonals,pollcymakers,
anotbepubllcbylmplementlnganoaovocatlng|orprogramslnpatlentcare,researcb,pro|esslonalanopubllc
eoucatlon,anopubllcpollcy.Formoreln|ormatlon,pleasevlsltwww.americangeriatrics.org.
THLAMLP| CANCOLLLGLOFSUPGLONS: Tbe Amerlcan College o| Surgeons (ACS) ls a sclentlc
anoeoucatlonalorganlzatlono|surgeonstbatwas|ounoeoln1913tolmprovetbecareo|tbesurglcal
patlentanotosa|eguarostanoaroso|carelnanoptlmalanoetblcalpractlceenvlronment.ACSlsoeolcateo
to tbe etblcal ano competent practlce o| surgery. |ts acblevements bave slgnlcantly lnNuenceo tbe course
o|evloence-baseosurgerylnAmerlcaanobaveestabllsbeoACSasanlmportantaovocate|orallsurglcal
patlents.Formoreln|ormatlon,pleasevlsltwww.facs.org.
Goto
Tableo|Contents
43
ACS NS Q| P

PLFLPLNCLS
1. vlncentGK,velko||vA,U.S.Census8ureau.Tbenet|ouroecaoestbeoloerpopulatlonlntbeUnlteoStates:2010
to2050.Population estimates and projections P25-1138.[Wasblngton,DC:U.S.Dept.o|Commerce,Lconomlcsano
StatlstlcsAomlnlstratlon,U.S.Census8ureau,2010:bttp://purl.access.gpo.gov/GPO/LPS126599].
2. HobbsF,StoopsN.Demographic trends in the 20th century: [census 2000 special reports].Wasblngton,D.C.:U.S.Dept.
o|Commerce,LconomlcsanoStatlstlcsAomlnlstratlon,U.S.Census8ureau,2002.
3. DeFrancesC[,LucasCA,8ulevC,GoloslnsklyA.2006NatlonalHospltalDlscbargeSurvey.Natl Health Stat Report.
[uly30,2008,(5):1-20.
4. HallM[,DeFrancesC[,WllllamsSN,GoloslnsklyA,ScbwartzmanA.NatlonalHospltalDlscbargeSurvey:2007
summary.Natl Health Stat Report. October26,2010,(29):1-20,24.
5. CullenKA,HallM[,GoloslnsklyA.AmbulatorysurgerylntbeUnlteoStates,2006.Natl Health Stat Report. [anuary28,
2009,(11):1-25.
6. LtzlonlDA,Llu[H,OConnell[8,MaggaroMA,KoCY.Lloerlypatlentslnsurglcalworkloaos:Apopulatlon-baseo
analysls.Am Surg. November2003,69(11):961-965.
7. Plassman8L,LangaKM,FlsberGG,etal.Prevalenceo|cognltlvelmpalrmentwltboutoementlalntbeUnlteoStates.
Ann Intern Med. Marcb18,2008,148(6):427-434.
8. Plassman8L,LangaKM,FlsberGG,etal.Prevalenceo|oementlalntbeUnlteoStates:Tbeaglng,oemograpblcs,ano
memorystuoy.Neuroepidemiology. 2007,29(1-2):125-132.
9. CorraoaMM,8rookmeyerP,8erlauD,Paganlnl-HlllA,KawasCH.Prevalenceo|oementlaa|terage90:Pesults|rom
tbe90+stuoy.Neurology. [uly29,2008,71(5):337-343.
10. 8rookmeyerP,LvansDA,HebertL,etal.Natlonalestlmateso|tbeprevalenceo|AlzbelmersolseaselntbeUnlteo
States.Alzheimers & dementia: The journal of the Alzheimers Association. [anuary2011,7(1):61-73.
11. AnsalonlL,CatenaF,CbattatP,etal.Plsk|actorsanolncloenceo|postoperatlveoellrlumlneloerlypatlentsa|ter
electlveanoemergencysurgery.Br J Surg. February2010,97(2):273-280.
12. MarcantonloLP,GolomanL,MangloneCM,etal.Acllnlcalpreolctlonrule|oroellrluma|terelectlvenoncarolac
surgery.JAMA. [anuary12,1994,271(2):134-139.
13. PoblnsonTN,PaeburnCD,TranZv,AnglesLM,8rennerLA,MossM.Postoperatlveoellrlumlntbeeloerly:Plsk
|actorsanooutcomes.Ann Surg. [anuary2009,249(1):173-178.
14. Puoolpb[L,|nouyeSK,[onesPN,etal.Dellrlum:Anlnoepenoentpreolctoro||unctlonaloecllnea|tercarolac
surgery.J Am Geriatr Soc. Aprll2010,58(4):643-649.
15. Puoolpb[L,[onesPN,Levko||SL,etal.Derlvatlonanovalloatlono|apreoperatlvepreolctlonrule|oroellrluma|ter
carolacsurgery.Circulation. [anuary20,2009,119(2):229-236.
16. KnopmanDS,8oeve8F,PetersenPC.Lssentlalso|tbeproperolagnoseso|mllocognltlvelmpalrment,oementla,
anomajorsubtypeso|oementla.Mayo Clin Proc. October2003,78(10):1290-1308.
17. DelnerS,Sllversteln[H.Postoperatlveoellrlumanocognltlveoys|unctlon.Br J Anaesth. December2009,103Suppl
1:l41-46.
18. MonkTG,Weloon8C,GarvanCW,etal.Preolctorso|cognltlveoys|unctlona|termajornoncarolacsurgery.
Anesthesiology. [anuary2008,108(1):18-30.
19. 8orsonS,Scanlan[,8rusbM,vltallanoP,DokmakA.Tbemlnl-cog:acognltlvevltalslgnsmeasure|oroementla
screenlnglnmultl-llngualeloerly.Int J Geriatr Psychiatry. November2000,15(11):1021-1027.
20. McGoryML,KaoKK,SbekellePG,etal.Developlngqualltylnolcators|oreloerlysurglcalpatlents.Ann Surg. August
2009,250(2):338-347.
21. Woolger[M.Preoperatlvetestlnganomeolcatlonmanagement.Clin Geriatr Med. November2008,24(4):573-583,vll.
22. AppelbaumPS.Cllnlcalpractlce.Assessmento|patlentscompetencetoconsenttotreatment.N Engl J Med.
November1,2007,357(18):1834-1840.
Goto
Tableo|Contents
44
ACS NS Q| P

23. Ste||ensDC,FlsberGG,LangaKM,PotterGG,Plassman8L.Prevalenceo|oepresslonamongoloerAmerlcans:Tbe
Aglng,DemograpblcsanoMemoryStuoy.Int Psychogeriatr. October2009,21(5):879-888.
24. ColeMG,DenoukurlN.Plsk|actors|oroepresslonamongeloerlycommunltysubjects:asystematlcrevlewano
meta-analysls.Am J Psychiatry. [une2003,160(6):1147-1156.
25. 8lumentbal[A,LettHS,8abyakMA,etal.Depresslonasarlsk|actor|ormortalltya|tercoronaryarterybypass
surgery.Lancet. August23,2003,362(9384):604-609.
26. ContraoaP[,8oull|aroDA,HeklerL8,etal.Psycbosoclal|actorslnbeartsurgery:Presurglcalvulnerabllltyano
postsurglcalrecovery.Health Psychol. May2008,27(3):309-319.
27. HoPM,MasouolFA,Spertus[A,etal.Depresslonpreolctsmortallty|ollowlngcarolacvalvesurgery.Ann Thorac Surg.
Apr2005,79(4):1255-1259.
28. DeCosmoG,CongeooL,LalC,PrlmlerlP,DottarelllA,AcetoP.Preoperatlvepsycbologlcanooemograpblc
preolctorso|palnperceptlonanotramaoolconsumptlonuslnglntravenouspatlent-controlleoanalgesla.Clin J Pain.
[un2008,24(5):399-405.
29. Taenzer P, Melzack P, [eans ML. |nNuence o| psycbologlcal |actors on postoperatlve paln, mooo ano analgeslc
requlrements.Pain. Mar1986,24(3):331-342.
30. LlC,Frleoman8,ConwellY,FlscellaK.valloltyo|tbePatlentHealtbQuestlonnalre2(PHQ-2)lnloentl|ylngmajor
oepresslonlnoloerpeople.J Am Geriatr Soc. Apr2007,55(4):596-602.
31. DasguptaM,DumbrellAC.Preoperatlverlskassessment|oroellrluma|ternoncarolacsurgery:asystematlcrevlew.J
Am Geriatr Soc. Oct2006,54(10):1578-1589.
32. DemeureM[,FalnM[.Tbeeloerlysurglcalpatlentanopostoperatlveoellrlum.J Am Coll Surg. November
2006,203(5):752-757.
33. CleggA,Young[8.Wblcbmeolcatlonstoavololnpeopleatrlsko|oellrlum:Asystematlcrevlew.Age Ageing. [anuary
2011,40(1):23-29.
34. FllnnDP,DleblKM,Sey|rleoLS,MalanlPN.Preventlon,olagnosls,anomanagemento|postoperatlveoellrlumln
oloeraoults.J Am Coll Surg. August2009,209(2):261-268,qulz294.
35. LyncbLP,LazorMA,Gellls[L,Orav[,GolomanL,MarcantonloLP.Tbelmpacto|postoperatlvepalnontbe
oevelopmento|postoperatlveoellrlum.Anesth Analg. Aprll1998,86(4):781-785.
36. MorrlsonPS,Magazlner[,GllbertM,etal.Pelatlonsblpbetweenpalnanooploloanalgeslcsontbeoevelopmento|
oellrlum|ollowlngblp|racture.J Gerontol A Biol Sci Med Sci. [anuary2003,58(1):76-81.
37. vaurloLL,SanosLP,WangY,MullenLA,Leung[M.Postoperatlveoellrlum:Tbelmportanceo|palnanopaln
management.Anesth Analg. Aprll2006,102(4):1267-1273.
38. SleberFL.Postoperatlveoellrlumlntbeeloerlysurglcalpatlent.Anesthesiol Clin. Sep2009,27(3):451-464,tableo|
contents.
39. 8lazerDG,WuLT.Tbeeploemlologyo|substanceuseanoolsoroersamongmlooleageoanoeloerlycommunlty
aoults:Natlonalsurveyonoruguseanobealtb.Am J Geriatr Psychiatry. Marcb2009,17(3):237-245.
40. 8lazerDG,WuLT.Tbeeploemlologyo|at-rlskanoblngeorlnklngamongmloole-ageoanoeloerlycommunltyaoults:
NatlonalSurveyonDrugUseanoHealtb.Am J Psychiatry. October2009,166(10):1162-1169.
41. Natb8,LlY,Carroll[L,SzaboG,Tseng[F,SbabSA.Alcoboleposureasarlsk|actor|oraoverseoutcomesln
electlvesurgery.J Gastrointest Surg. November2010,14(11):1732-1741.
42. TonnesenH,KebletH.Preoperatlvealcobollsmanopostoperatlvemorblolty.Br J Surg. [uly1999,86(7):869-874.
43. HlnklnCH,CastellonSA,Dlckson-FubrmanL,DaumG,[a||e[,[arvlkL.Screenlng|ororuganoalcobolabuseamong
oloer aoults uslng a mooleo verslon o| tbe CAGL. Am J Addict. Fall2001,10(4):319-326.
44. 8eullens[,Aertgeerts8.Screenlng|oralcobolabuseanooepenoencelnoloerpeopleuslngDSMcrlterla:Arevlew.
Aging Ment Health. [anuary2004,8(1):76-82.
45. 8erks[,McCormlckP.Screenlng|oralcobolmlsuselneloerlyprlmarycarepatlents:Asystematlcllteraturerevlew.
Int Psychogeriatr. December2008,20(6):1090-1103.
46. McGratbA,CromeP,Crome|8.Substancemlsuselntbeoloerpopulatlon.Postgrad Med J. Aprll2005,81(954):228-
231.
Goto
Tableo|Contents
45
ACS NS Q| P

47. LeeTH,MarcantonloLP,MangloneCM,etal.Derlvatlonanoprospectlvevalloatlono|aslmplelnoe|orpreolctlon
o|carolacrlsko|majornoncarolacsurgery.Circulation. September7,1999,100(10):1043-1049.
48. DevereauP[,GolomanL,CookD[,GllbertK,LeslleK,GuyattGH.Perloperatlvecarolaceventslnpatlents
unoergolngnoncarolacsurgery:Arevlewo|tbemagnltuoeo|tbeproblem,tbepatbopbyslologyo|tbeeventsano
metboostoestlmateanocommunlcaterlsk.Cmaj. September13,2005,173(6):627-634.
49. LanoesbergG,8eattleWS,MosserlM,[a||eAS,Alpert[S.Perloperatlvemyocarolalln|arctlon.Circulation. [une9,
2009,119(22):2936-2944.
50. DevereauP[,YangH,Yusu|S,etal.L||ectso|etenoeo-releasemetoprololsucclnatelnpatlentsunoergolngnon-
carolacsurgery(PO|SLtrlal):Aranoomlseocontrolleotrlal.Lancet. May31,2008,371(9627):1839-1847.
51. DavenportDL,FerrarlsvA,HosokawaP,HenoersonWG,KburlSF,MentzerPM,[r.Multlvarlablepreolctorso|
postoperatlvecarolacaoverseeventsa|tergeneralanovascularsurgery:results|romtbepatlentsa|etylnsurgery
stuoy.J Am Coll Surg. [une2007,204(6):1199-1210.
52. FlelscbmannKL,8eckman[A,8ullerCL,etal.2009ACCF/AHA|ocuseoupoateonperloperatlvebetablockaoe.J
Am Coll Cardiol. November24,2009,54(22):2102-2128.
53. [obnsonPG,ArozullabAM,NeumayerL,HenoersonWG,HosokawaP,KburlSF.Multlvarlablepreolctorso|
postoperatlveresplratory|allurea|tergeneralanovascularsurgery:results|romtbepatlentsa|etylnsurgerystuoy.
J Am Coll Surg. [une2007,204(6):1188-1198.
54. Smetana GW, Lawrence vA, Cornell [L. Preoperatlve pulmonary rlsk stratlcatlon |or noncarolotboraclc surgery:
Systematlcrevlew|ortbeAmerlcanCollegeo|Pbyslclans.Ann Intern Med. Aprll18,2006,144(8):581-595.
55. QaseemA,Snowv,FlttermanN,etal.Plskassessment|oranostrateglestoreouceperloperatlvepulmonary
compllcatlons|orpatlentsunoergolngnoncarolotboraclcsurgery:Aguloellne|romtbeAmerlcanCollegeo|
Pbyslclans.Ann Intern Med. Aprll18,2006,144(8):575-580.
56. FlelscbmannKL,GolomanL,Young8,LeeTH.Assoclatlonbetweencarolacanononcarolaccompllcatlonslnpatlents
unoergolngnoncarolacsurgery:Outcomesanoe||ectsonlengtbo|stay.Am J Med. November2003,115(7):515-520.
57. LawrencevA,DbanoaP,HllsenbeckSG,PageCP.Plsko|pulmonarycompllcatlonsa|terelectlveaboomlnalsurgery.
Chest. September1996,110(3):744-750.
58. LawrencevA,HllsenbeckSG,MulrowCD,DbanoaP,Sapp[,PageCP.|ncloenceanobospltalstay|orcarolacano
pulmonarycompllcatlonsa|teraboomlnalsurgery.J Gen Intern Med. December1995,10(12):671-678.
59. Dlmlck[8,CbenSL,TaberlPA,HenoersonWG,KburlSF,CampbellDA,[r.Hospltalcostsassoclateowltbsurglcal
compllcatlons:Areport|romtbeprlvate-sectorNatlonalSurglcalQuallty|mprovementProgram.J Am Coll Surg.
October2004,199(4):531-537.
60. Manku K, 8accbettl P, Leung [M. Prognostlc slgnlcance o| postoperatlve ln-bospltal compllcatlons ln eloerly patlents.
|.Long-termsurvlval.Anesth Analg. February2003,96(2):583-589.
61. Poberts[,LawrencevA,LsnaolaNF.ACSNSQ|P8estPractlcesGuloellnes:Preventlono|PostoperatlvePulmonary
Compllcatlons.Cblcago:AmerlcanCollegeo|Surgeons,2010.
62. McAllsterFA,8ertscbK,Man[,8raoley[,[ackaM.|ncloenceo|anorlsk|actors|orpulmonarycompllcatlonsa|ter
nontboraclcsurgery.Am J Respir Crit Care Med. Marcb1,2005,171(5):514-517.
63. ArozullabAM,Daley[,HenoersonWG,KburlSF.Multl|actorlalrlsklnoe|orpreolctlngpostoperatlveresplratory
|allurelnmena|termajornoncarolacsurgery.TbeNatlonalveteransAomlnlstratlonSurglcalQuallty|mprovement
Program.Ann Surg. August2000,232(2):242-253.
64. ArozullabAM,KburlSF,HenoersonWG,Daley[.Developmentanovalloatlono|amultl|actorlalrlsklnoe
|orpreolctlngpostoperatlvepneumonlaa|termajornoncarolacsurgery.Ann Intern Med. November20,
2001,135(10):847-857.
65. GuptaPM,Parvlzl[,HanssenAD,GayPC.Postoperatlvecompllcatlonslnpatlentswltbobstructlvesleepapnea
synoromeunoergolngblporkneereplacement:Acase-controlstuoy.Mayo Clin Proc. September2001,76(9):897-905.
66. LalHC,WangKY,LeeWL,TlngCT,LluT[.Severepulmonarybypertensloncompllcatespostoperatlveoutcomeo|
non-carolacsurgery.Br J Anaesth. August2007,99(2):184-190.
Goto
Tableo|Contents
46
ACS NS Q| P

67. PamakrlsbnaG,Sprung[,Pavl8S,CbanorasekaranK,McGoonMD.|mpacto|pulmonarybypertenslonontbe
outcomeso|noncarolacsurgery:Preolctorso|perloperatlvemorbloltyanomortallty.J Am Coll Cardiol. May17,
2005,45(10):1691-1699.
68. SmetanaGW.Postoperatlvepulmonarycompllcatlons:anupoateonrlskassessmentanoreouctlon.Cleve Clin J Med.
November2009,76Suppl4:S60-65.
69. O8rlenMM,GonzalesP,SbroyerAL,etal.Mooestserumcreatlnlneelevatlona||ectsaoverseoutcomea|ter
generalsurgery.Kidney Int. August2002,62(2):585-592.
70. 8ergH,Poeo[,vlby-Mogensen[,etal.Pesloualneuromuscularblocklsarlsk|actor|orpostoperatlvepulmonary
compllcatlons.Aprospectlve,ranoomlseo,anobllnoeostuoyo|postoperatlvepulmonarycompllcatlonsa|ter
atracurlum,vecuronlumanopancuronlum.Acta Anaesthesiol Scand. October1997,41(9):1095-1103.
71. DoylePL.Assesslnganomool|ylngtberlsko|postoperatlvepulmonarycompllcatlons.Chest. May1999,115(5
Suppl):77S-81S.
72. SmetanaGW.Preoperatlvepulmonaryassessmento|tbeoloeraoult.Clin Geriatr Med. February2003,19(1):35-55.
73. MollerAM,vlllebroN,PeoersenT,TonnesenH.L||ecto|preoperatlvesmoklnglnterventlononpostoperatlve
compllcatlons:Aranoomlseocllnlcaltrlal.Lancet. [an122002,359(9301):114-117.
74. 8lumanLG,MoscaL,NewmanN,SlmonDG.Preoperatlvesmoklngbabltsanopostoperatlvepulmonary
compllcatlons.Chest. Aprll1998,113(4):883-889.
75. LlnostromD,SaorAzoolO,WlaolsA,etal.L||ectso|aperloperatlvesmoklngcessatlonlnterventlonon
postoperatlvecompllcatlons:Aranoomlzeotrlal.Ann Surg. November2008,248(5):739-745.
76. MyersK,HajekP,HlnosC,McPobbleH.Stopplngsmoklngsbortlybe|oresurgeryanopostoperatlvecompllcatlons:
Asystematlcrevlewanometa-analysls.Arch Intern Med. [une13,2011,171(11):983-989.
77. HulzebosLH,HeloersP[,FavleN[,De8lePA,8ruteloelaPlvlereA,vanMeeterenNL.Preoperatlvelntenslve
lnsplratorymuscletralnlngtopreventpostoperatlvepulmonarycompllcatlonslnblgb-rlskpatlentsunoergolng
CA8Gsurgery:Aranoomlzeocllnlcaltrlal.JAMA. October18,2006,296(15):1851-1857.
78. Poblnson TN, Llseman 8, Wallace [|, et al. Peoenlng gerlatrlc preoperatlve assessment uslng |rallty, olsablllty ano co-
morblolty.Ann Surg. September2009,250(3):449-455.
79. HamelM8,HenoersonWG,KburlSF,Daley[.Surglcaloutcomes|orpatlentsageo80anooloer:morbloltyano
mortallty|rommajornoncarolacsurgery.J Am Geriatr Soc. Marcb2005,53(3):424-429.
80. 8rouquetA,CuoennecT,8enolstS,etal.|mpalreomoblllty,ASAstatusanoaomlnlstratlono|tramaoolarerlsk
|actors|orpostoperatlveoellrlumlnpatlentsageo75yearsormorea|termajoraboomlnalsurgery.Ann Surg. Aprll
2010,251(4):759-765.
81. CbenTY,AnoersonD[,CbopraT,CbolY,ScbmaoerKL,KayeKS.Poor|unctlonalstatuslsanlnoepenoentpreolctor
o|surglcalslteln|ectlonsouetometblclllln-reslstantStapbylococcusaureuslnoloeraoults.J Am Geriatr Soc. Marcb
2010,58(3):527-532.
82. AnoersonD[,CbenLF,ScbmaoerKL,etal.Poor|unctlonalstatusasarlsk|actor|orsurglcalslteln|ectlonoueto
metblclllln-reslstantStapbylococcusaureus.Infect Control Hosp Epidemiol. September2008,29(9):832-839.
83. PoblnsonTN,Wallace[|,WuDS,etal.Accumulateo|ralltycbaracterlstlcspreolctpostoperatlveolscbarge
lnstltutlonallzatlonlntbegerlatrlcpatlent.J Am Coll Surg. [uly2011,213(1):37-42,olscusslon42-34.
84. LawrencevA,HazuoaHP,Cornell[L,etal.Functlonallnoepenoencea|termajoraboomlnalsurgerylntbeeloerly.J
Am Coll Surg. November2004,199(5):762-772.
85. LacbsMS,FelnstelnAP,CooneyLM,[r.,etal.Aslmpleproceoure|orgeneralscreenlng|or|unctlonalolsabllltyln
eloerlypatlents.Ann Intern Med. May11990,112(9):699-706.
86. Summaryo|tbeUpoateoAmerlcanGerlatrlcsSoclety/8rltlsbGerlatrlcsSocletycllnlcalpractlceguloellne|or
preventlono||allslnoloerpersons.J Am Geriatr Soc. [anuary2011,59(1):148-157.
87. GunterK8,WblteKN,HayesWC,SnowCM.Functlonalmobllltyolscrlmlnatesnon|allers|romone-tlmeano
|requent|allers.J Gerontol A Biol Sci Med Sci. November2000,55(11):M672-676.
88. PooslaoloD,PlcbarosonS.TbetlmeoUp&Go:Atesto|baslc|unctlonalmoblllty|or|ralleloerlypersons.J Am
Geriatr Soc. February1991,39(2):142-148.
Goto
Tableo|Contents
47
ACS NS Q| P

89. FrleoLP,TangenCM,Walston[,etal.Fralltylnoloeraoults:evloence|orapbenotype.J Gerontol A Biol Sci Med Sci.
Marcb2001,56(3):M146-156.
90. FrleoLP,FerrucclL,Darer[,Wllllamson[D,AnoersonG.Untangllngtbeconceptso|olsablllty,|rallty,ano
comorblolty:lmpllcatlons|orlmproveotargetlnganocare.J Gerontol A Biol Sci Med Sci. Marcb2004,59(3):255-263.
91. 8ergmanH,FerrucclL,Guralnlk[,etal.Frallty:anemerglngresearcbanocllnlcalparaolgm:|ssuesanocontroversles.
J Gerontol A Biol Sci Med Sci. [uly2007,62(7):731-737.
92. MakaryMA,SegevDL,PronovostP[,etal.Fralltyasapreolctoro|surglcaloutcomeslnoloerpatlents.J Am Coll Surg.
[une2010,210(6):901-908.
93. KalserM[,8auer[M,PamscbC,etal.Frequencyo|malnutrltlonlnoloeraoults:Amultlnatlonalperspectlveuslng
tbemlnlnutrltlonalassessment.J Am Geriatr Soc. September2010,58(9):1734-1738.
94. ScblesserM,Klrcbbo||P,MullerMK,Scba|erM,ClavlenPA.Tbecorrelatlono|nutrltlonrlsklnoe,nutrltlonrlsk
score,anoblolmpeoanceanalyslswltbpostoperatlvecompllcatlonslnpatlentsunoergolnggastrolntestlnalsurgery.
Surgery. May2009,145(5):519-526.
95. WelmannA,8ragaM,HarsanylL,etal.LSPLNGuloellnesonLnteralNutrltlon:Surgerylncluolngorgan
transplantatlon.Clin Nutr. Aprll2006,25(2):224-244.
96. WblnneyC.Perloperatlvemeolcatlonmanagement:Generalprlnclplesanopractlcalappllcatlons.Cleve Clin J Med.
November2009,76Suppl4:S126-132.
97. AmerlcanGerlatrlcsSocletyUpoateo8eersCrlterla|orPotentlally|napproprlateMeolcatlonUselnOloerAoults.J
Am Geriatr Soc. February29,2012.
98. FongHK,SanosLP,Leung[M.Tberoleo|postoperatlveanalgeslalnoellrlumanocognltlveoecllnelneloerly
patlents:Asystematlcrevlew.Anesth Analg. Aprll2006,102(4):1255-1266.
99. 8lccaro8M,Sear[W,FoeP.Statlntberapy:Apotentlallyuse|ulperl-operatlvelnterventlonlnpatlentswltb
carolovascularolsease.Anaesthesia. November2005,60(11):1106-1114.
100. Stevens LA, Coresb [, Greene T, Levey AS. Assesslng kloney |unctlon: Measureo ano estlmateo glomerular ltratlon
rate.N Engl J Med. [une8,2006,354(23):2473-2483.
101. QatoDM,AleanoerGC,ContlPM,[obnsonM,ScbummP,LlnoauST.Useo|prescrlptlonanoover-tbe-
countermeolcatlonsanooletarysupplementsamongoloeraoultslntbeUnlteoStates.JAMA. December24,
2008,300(24):2867-2878.
102. Hajjar LP, Caero AC, Hanlon [T. Polypbarmacy ln eloerly patlents. Am J Geriatr Pharmacother. December
2007,5(4):345-351.
103. 8arnettSP.Polypbarmacyanoperloperatlvemeolcatlonslntbeeloerly.Anesthesiol Clin. September2009,27(3):377-
389.
104. SllvelraM[,KlmSY,LangaKM.Aovanceolrectlvesanooutcomeso|surrogateoeclslonmaklngbe|oreoeatb.N Engl J
Med. Aprll1,2010,362(13):1211-1218.
105. YangAD,8entremD[,PappasSG,etal.Aovanceolrectlveuseamongpatlentsunoergolngblgb-rlskoperatlons.
American journal of surgery. [uly2004,188(1):98-101.
106. SecklerA8,MelerDL,MulvlblllM,Parls8L.Substltuteojuogment:Howaccurateareproypreolctlons?Ann Intern
Med. [uly15,1991,115(2):92-98.
107. SbalowltzD|,Garrett-MayerL,WenolerD.Tbeaccuracyo|surrogateoeclslonmakers:Asystematlcrevlew.Arch
Intern Med. Marcb13,2006,166(5):493-497.
108. MattlmoreT[,WengerNS,DesblensNA,etal.Surrogateanopbyslclanunoerstanolngo|patlentspre|erences|or
llvlngpermanentlylnanurslngbome.J Am Geriatr Soc. [uly1997,45(7):818-824.
109. WenolerD,PloA.Systematlcrevlew:tbee||ectonsurrogateso|maklngtreatmentoeclslons|orotbers.Ann Intern
Med. Marcb1,2011,154(5):336-346.
110. FrleoTP,8raoleyLH,TowlevP,AlloreH.Unoerstanolngtbetreatmentpre|erenceso|serlouslylllpatlents.N Engl J
Med. Aprll4,2002,346(14):1061-1066.
111. Munro[,8ootbA,Nlcboll[.Poutlnepreoperatlvetestlng:Asystematlcrevlewo|tbeevloence.Health Technol Assess.
1997,1(12):l-lv,1-62.
Goto
Tableo|Contents
48
ACS NS Q| P

112. SmetanaGW,MacpbersonDS.Tbecaseagalnstroutlnepreoperatlvelaboratorytestlng.Med Clin North Am. [anuary
2003,87(1):7-40.
113. Natlonal|nstltute|orCllnlcalLcellence(N|CL).Preoperatlvetests:Tbeuseo|routlnepreoperatlvetests|or
electlvesurgery.Lonoon:NatlonalCollaboratlngCentre|orAcuteCare,2003.
114. Turnbull[M,8uckC.Tbevalueo|preoperatlvescreenlnglnvestlgatlonslnotberwlsebealtbylnolvlouals.Arch Intern
Med. [une1987,147(6):1101-1105.
115. KaplanL8,SbelnerL8,8oeckmannA[,etal.Tbeuse|ulnesso|preoperatlvelaboratoryscreenlng.JAMA. [une28,
1985,253(24):3576-3581.
116. DzanklcS,PastorD,GonzalezC,Leung[M.Tbeprevalenceanopreolctlvevalueo|abnormalpreoperatlve
laboratorytestslneloerlysurglcalpatlents.Anesth Analg. August2001,93(2):301-308,302nocontentspage.
117. HepnerDL.Tberoleo|testlnglntbepreoperatlveevaluatlon.Cleve Clin J Med. November2009,76Suppl4:S22-27.
118. MacpbersonDS,SnowP,Lo|grenPP.Preoperatlvescreenlng:valueo|prevloustests.Ann Intern Med. December15,
1990,113(12):969-973.
119. MacMabonH,KbanAP,MobammeoTL,etal.ACPApproprlatenessCrlterlaroutlneaomlsslonanopreoperatlve
cbestraolograpby.Peston(vA):AmerlcanCollegeo|Paolology(ACP),2008:5.
120. LluLL,DzanklcS,Leung[M.Preoperatlveelectrocarologramabnormalltlesoonotpreolctpostoperatlvecarolac
compllcatlonslngerlatrlcsurglcalpatlents.J Am Geriatr Soc. [uly2002,50(7):1186-1191.
121. vanKlelWA,8rysonGL,YangH,KalkmanC[,WellsGA,8eattleWS.Tbevalueo|routlnepreoperatlve
electrocarolograpbylnpreolctlngmyocarolalln|arctlona|ternoncarolacsurgery.Ann Surg. August2007,246(2):165-
170.
122. CorrellD[,HepnerDL,CbangC,TsenL,HeveloneND,8aoerAM.Preoperatlveelectrocarolograms:Patlent|actors
preolctlveo|abnormalltles.Anesthesiology. [une2009,110(6):1217-1222.
123. QaseemT.Plskassessment|oranostrateglestoreouceperloperatlvepulmonarycompllcatlons.Ann Intern Med.
October3,2006,145(7):553,autborreply553.
124. Collce GL, Sba|azano S, Grl|n [P, Keenan P, 8olllger CT. Pbyslologlc evaluatlon o| tbe patlent wltb lung cancer
belngconsloereo|orresectlonalsurgery:ACCPevloenceo-baseocllnlcalpractlceguloellnes(2noeoltlon).Chest.
September2007,132(3Suppl):161S-177S.
125. TaylorHL,[acobsDP,[r.,Scbucker8,Knuosen[,LeonAS,DebackerG.Aquestlonnalre|ortbeassessmento|lelsure
tlmepbyslcalactlvltles.J Chronic Dis. 1978,31(12):741-755.
126. 8ragaM,LjungqvlstO,SoetersP,FearonK,WelmannA,8ozzettlF.LSPLNGuloellnesonParenteralNutrltlon:
Surgery.Clin Nutr. August2009,28(4):378-386.
127. Ang-LeeMK,Moss[,YuanCS.Herbalmeolclnesanoperloperatlvecare.JAMA. [uly112001,286(2):208-216.
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RISK FACTORS FOR POSTOPERATIVE DELIRIUM

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SCREENING FOR ALCOHOL AND SUBSTANCE ABUSE

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Surgical Procedure-Related Factors

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