Is routine preoperative hemodynamic evaluation of nonagenarians necessary?
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Published on: August 1, 2018
L L Schrader1, M A McMillen, C B Watson
1Department of Surgery, Bridgeport Hospital, Connecticut 06610.
Insights
Elderly surgical patients often receive invasive hemodynamic monitoring, but this study found low complication rates without it. Advanced age alone may not necessitate Swan-Ganz catheterization for major surgeries in non-agenarians.
Area of Science:
- Geriatric Surgery
- Cardiovascular Medicine
- Anesthesiology
Background:
- Co-morbid cardiac disease affects up to 66% of elderly surgical patients.
- Advanced age often prompts invasive hemodynamic monitoring (e.g., Swan-Ganz catheterization) regardless of clinical cardiac status.
- Evidence supporting routine hemodynamic evaluation and intervention in elderly surgical patients is limited.
Purpose of the Study:
- To evaluate the necessity of preoperative Swan-Ganz catheterization and hemodynamic monitoring in non-agenarian patients undergoing major general surgical and orthopedic procedures.
- To assess complication rates and survival in elderly surgical patients who did not undergo routine invasive hemodynamic monitoring.
Main Methods:
- Retrospective review of 51 major general surgical and orthopedic procedures performed on 46 patients (non-agenarians) between July 1987 and December 1988.
- Patients did not receive preoperative Swan-Ganz catheterization or hemodynamic evaluation.
- Data collected included procedure type, anesthesia, complications, and mortality.
Main Results:
- No patients underwent preoperative Swan-Ganz catheterization or hemodynamic evaluation.
- Seven out of 51 patients (14%) experienced major complications; 16 (31%) experienced minor complications.
- Thirty-day mortality was 0%, and 6-month survival was 92%. Only one complication was potentially preventable with intensive monitoring.
Conclusions:
- Routine Swan-Ganz catheterization and intensive hemodynamic monitoring may not be necessary for all elderly surgical patients undergoing major non-agenarian procedures.
- Advanced age alone does not appear to significantly increase surgical risk in the absence of invasive monitoring.
- Further research is needed to define specific indications for hemodynamic monitoring in this patient population.
Abstract:
An Incidence of co-morbid cardiac disease in the elderly surgical patient as high as 66% has been previously reported. Even in the absence of clinically significant cardiac disease, advanced age alone is often considered sufficient indication for Swan-Ganz placement, hemodynamic evaluation, adjustment of fluid states, and inotropic support. Yet data clearly documenting the need for this evaluation and therapy are difficult to obtain. All major general surgical and orthopedic operations in non-agenarians were reviewed in our institution from July 1, 1987 through December 31, 1988. Fifty-one procedures were performed on 46 patients. None of these patients had preoperative Swan-Ganz catheterization or hemodynamic evaluation. Eighteen general surgical, 30 orthopedic, 2 neurosurgical, and 1 gynecological procedures were performed. Forty-three were performed under general anesthesia, 7 under spinal anesthesia, and 1 with local anesthesia. Seven out of 51 patients (14%) experienced major complications, and 16 out of 51 (31%) experienced minor complications. Thirty-day mortality was 0%, and 6-month survival was 92%. Only one complication occurred within 48 hours of surgery that might possibly have been prevented with hemodynamic evaluation, adjustment of fluid status, inotropic support, and intensive care unit monitoring.
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