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How old is too old for surgery, and why?

 

Many of us will have been in situations with older loved ones where a doctor says surgery is too risky given the patient’s advanced age. Why is it surgery becomes risky in the elderly, and is it based on chronological age or their health?

During surgery and anaesthesia, there are many changes in the body that occur in response to injury and trauma. This is known as the stress response to surgery.

The surgical stress response results in an increased secretion of hormones that promote the break down of carbohydrates, fats and proteins in the body to provide extra energy during and after surgery. The hormonal changes associated with the surgical stress response also activate the sympathetic nervous system.

The sympathetic nervous system is responsible for the “fight or flight” response and causes a rise in heart rate and blood pressure. The changes in the heart rate and blood pressure during surgery and anaesthesia create a state where the heart requires more oxygen, while the surgical stress response and anaesthesia often impedes the oxygen supply to the vital organs such as the heart and the brain. This is a result of less blood flow to the body organs during and after the operation.

Anaesthesia confers risks separate from the risks of surgery. These are mostly minor and easy to treat. But serious problems with the heart, lungs and other major organs are more likely during emergency surgery or in the presence of other health conditions. These factors may increase with chronological age, but frailty is the bigger factor for doctors in deciding whether a patient should undergo surgery and anaesthesia.

Frailty

Frailty is a state where a person is vulnerable due to decline in body function. This in turn reduces their ability to cope with acute and every day stressors.

In a frail person, there is an accumulation of defects in different organ systems of the body, causing them to function close to the threshold of failure. The organ systems near the threshold of failure are then unable to “bounce back” from an external or internal stressor.

An apparently small insult such as a simple fall can result in a significant and disproportionate reduction in reserve and function. The need to have surgery, and the condition that has caused a need for surgery, would often be considered a large insult in a frail person.

Although frailty is more common in older people, it’s not exclusive to older people. Most frail people have chronic health problems, and their frailty increases with the number of chronic health conditions. But most people with chronic health conditions are not frail.

There are certain health conditions that are more common in people who are frail, such as heart failure, chronic airways disease and chronic kidney disease.

How do we identify frailty and how does it affect health?

There are many different tools we can use to detect frailty. The Clinical Frailty Scale is one tool based on clinical features present in the patient and the Frailty Index is another tool based on the accumulation of deficits in the patient.

The Clinical Frailty Scale is a single descriptor of a person’s level of frailty using clinical judgement graded from one to nine. Level one is a very fit person; level four is “vulnerable” – where the person is not dependent on others for help with daily activities but does have symptoms that limit activities; and level nine is a terminally ill person.

It has been observed that people with a higher Clinical Frailty Scale were more likely to be older, female, have a degree of cognitive impairment and incontinence. The higher proportion of females will most likely reflect the longer life expectancy of women.

Frail people have a higher risk of recurrent falls and fractures and subsequent disability and reduced function. There have been many studies performed to examine how well frailty predicts outcomes after surgery.

In people who have surgery, frailty has been shown to be associated with a higher risk of surgical complications, a greater chance of requiring discharge to a residential care facility and a lower rate of survival. And the more frail the patient, the higher the risk the patient will require readmission after surgery, and the higher the risk of death.

The ConversationAs our population gets older and more frail people have surgery, this will become an important issue, and health care professionals in all areas will need to be more aware of it.

Juliana Kok, Clinical Lecturer and anaesthetist, University of Melbourne

This article was originally published on The Conversation. Read the original article.

A stitch in time: the fine art of suturing

 

Suturing is one of the oldest of medical arts. Its practice goes back at least 5,000 years, with evidence from mummies showing that Ancient Egyptians used plant fibres, hairs and tendons to sew up wounds. Today, basic suturing is something that all doctors are expected to master, and practically all GPs will have to perform at some stage.

The scariest part of learning how to suture, says Perth-based GP Dr Alison Soerensen, is when you’re presented with your very first patient.

“Up until then, you’ve practised on pig skin or pig trotters, but that’s not a perfect substitute for the real thing. ‘You’re my first one’ doesn’t necessarily go down well with the patient!” she laughs.

But Dr Soerensen says she was relatively lucky with her first experience, which involved a very elderly patient without too many concerns about cosmetic outcomes, and who had a very good relationship with the GP who was supervising the intervention.

“The GP said something like: ‘It’s her first time, but don’t worry, I won’t let her sew your foot to your elbow or anything’, and the patient was OK with it.”

Dr Soerensen says an easier first-time experience for med students might arise if they’re doing a surgical rotation, with the patient under general anaesthetic. The surgeon might do most of the suture and then let the student finish it.

“The advantage in that scenario is the patient is asleep and you’re not having the added pressure of them watching what you’re doing. And if you make a mistake it’s very easy for the surgeon to correct it.”

Dr Soerensen says that in many medical disciplines, “you’d struggle without some suturing skills”. A common issue is getting the skin edges to come together, which can be particularly difficult with elderly patients whose skin is fragile and tears easily. Scarring is not an issue with the actual intervention, but it’s a risk you should discuss with patients.

Another issue, says Dr Soerensen, is non-compliant patients. It could be an elderly patient with dementia who has cut her head in a fall and doesn’t understand the need to keep still during the intervention.

“Or, on the other end of the age scale, you’ve got the two-year-old with laceration. You might normally think about glueing, but then you’d worry the child might pick at it and you’d have an open wound again. So it’s a question of do you suture, and do you look at sedation to try and get a good result.”

Often the decision whether to suture or not can be a bit of a grey area, with different doctors having different opinions.

“You have to discuss it with the patient. For example, a lot of biopsies will heal fine by themselves, but you’ll get a little circular scar. Suturing might minimise the scar, but then you’ve got another needle going in. You have to talk to the patient to see what they want.”

Dr Soerensen says there’s a lot of variation among GPs as to how much suturing they do, although most would at least have one case per month.

“The more you do, the more confident you are, and that’s why you have GPs that essentially end up subspecialising in skin work, because it’s what they’re good at and they enjoy it. The more you do, the quicker you get, and the better results you get. Like everything else, there’s a learning curve.”

Want to sharpen your suturing skills? Sign up to doctorportal’s online Basic Suturing module to learn about wound assessment and cleaning, suturing technique and post-suturing wound care.

This one-hour course is designed for beginners and is accredited with ACEM, ACRRM, CICM and ANZCA.

How good are you at basic suturing?

 

Are you a junior medical officer looking for a refresher in basic suturing?  Are you up to date with your basic surgical skills? Suturing is an essential skill in the everyday practice of medicine. Although suturing technique is important, as a junior doctor you’re also expected to have a thorough understanding of wound management in general to effectively care for a patient with a laceration.

Whether in primary health or in an emergency environment,  junior doctors will encounter many types of wounds requiring closure. The decision to close a wound and the technique used are influenced by many factors, including location, depth and contamination of wound, age of patient and resources or time available.

Designed in response to feedback from junior doctors and accredited for CPD by ACRRM, ACEM, CICM and ANZCA, the Basic Suturing learning module will help doctors bolster their competence in the basic  techniques of minor surgery. Doctorportal Learning, in partnership with Osler, have created an easy to understand, well-structured module with step-by-step instructions and streaming video demonstrations of basic knot tying and suturing techniques for beginners. The module covers:

  • Wound assessment
  • Wound cleaning
  • Suturing technique
  • Post suturing wound care
  • Knowledge and assessment.

Click here for more information and add basic suturing to your skills.

The horror of waking up during surgery

 

The fear of waking up while you’re being operated upon is almost up there with the fear of being buried alive. But while the latter never happens any more, if it ever did, the former is more common than you might think. A newly published review reveals that accidental awareness during general anaesthesia (AAGA) may occur in one in every 800 interventions, depending on how you define the term. And some  level of responsiveness during surgery could happen in as many as one in 25 cases.

Waking up during surgery is often, understandably, a traumatic experience. Take the case of Sandra, who as a 12-year-old suffered an episode of AAGA during a routine orthodontic operation.

“Suddenly, I knew something had gone wrong,” Sandra wrote in the foreword to NAP5, a recent UK report on AAGA. “I could hear voices around me, and I realised with horror that I had woken up in the middle of the operation, but couldn’t move a muscle… while they fiddled, I frantically tried to decide whether I was about to die.”

Like many other victims of AAGA, Sandra suffered from PTSD-like symptoms for years after the event. She described nightmares in which “a Dr Who-style monster leapt on me and paralysed me.” The nightmares continued for more than 15 years before she realised the link: “I suddenly made the connection with feeling paralysed during the operation; after that I was freed of the nightmare and finally liberated from the more stressful aspects of the event.”

The account underlines a key factor in AAGA, which is the use of neuromuscular blocking agents as part of the anaesthetic mix. They paralyse the muscles, which means that if a patient wakes up for any reason, he or she cannot signal to the surgeon that anything is wrong. It can render AAGA a truly terrifying experience, during which patients can hear voices and equipment, and vainly try to move to alert staff as a feeling of dread and powerlessness sweeps over them.

The NAP5 report found that anaesthesia awareness was most common in obstetrics, and specifically in caesarian interventions. This could be because caesarians often require rapid induction of anaesthesia, with anaesthetists occasionally erring too greatly on the side of caution with doses that are too low.

Cardiothoracic surgeries also had a higher rate of AAGA, at around twice the rate of other surgeries.

Female gender, youth, obesity, a junior trainee anaesthetist and the use of neuromuscular blockades were found to be the key risk factors for AAGA.

Around 40% of victims of AAGA reported ongoing adverse effects, including nightmares, flashbacks and other PTSD-type symptoms.

The review authors say that although in many cases the cause of AAGA is obvious, involving technical failure or error, there remain cases where no rational explanation can be found. But although case reports of AAGA can make for harrowing reading, litigation is relatively rare. In the UK between 1995 and 2007, only 99 claims were made for intraoperative paralysis or brief awake paralysis.

When AAGA is reported, the authors recommend three stages of management: a meeting and interview with the patient; analysis of what went wrong; and follow-up interviews 24 hours and two weeks after the event.

It’s important that the interviewing clinician shows empathy, accepts the AAGA story as genuine, expresses regret, and offers psychological support to the patient.

You can read the review here.