Bei der Vorbereitung des Patienten auf Operationen wachsen dem Hausarzt wichtige Aufgaben zu, die gerade beim Älteren auf der langjährigen Kenntnis und vertrauensvollen Beziehung beruhen. Denn nach dem Alter ist der verlässlichste Risikoindikator der nach ASA (American Society of Anesthesiologists) eingeschätzte Allgemeinzustand und die Größe des Eingriffs. Sinnvolle Maßnahmen des Hausarztes umfassen zum Beispiel die Einstellung eines Hypertonus, Verbesserung des Ernährungszustands, Durchführung von Atemgymnastik und Mobilisierung des Patienten sowie eine adäquate Flüssigkeitszufuhr. Wichtig ist die Übermittlung der Dauerdiagnosen und Medikamente an den Operateur oder Narkosearzt. Im Rahmen eines geriatrischen Assessments empfiehlt sich die Durchführung eines Minimal mental status vor stationären Eingriffen, da kognitive postoperative Störungen häufig sind. Die meisten Komplikationen treten erst nach dem Eingriff auf: einerseits weil der Patient während der Narkose in sicheren Händen ist, andererseits, weil gewisse pathophysiologische Bedingungen eine gewisse Latenzperiode aufweisen.
For the patient facing an operation, the family doctor has a number of important tasks to perform, which, in particular in the elderly, are validated by years of familiarity with the patient and a trusting relationship. For, the second most reliable risk indicator after age is the ASA- (American Society of Anesthesiologists) based general state of health of the patient and the severity of the surgery. Useful tasks for the family doctor include control of hypertension, improvement of nutritional sate, initiation of respiratory training, mobilization of the patient, and ensuring adequate fluid intake. Also of importance is the provision of the surgeon or anaesthetist with relevant information on the long-term diagnoses and drug use. Within the framework of a geriatric assessment, it is to be recommended that a minimal mental status test be performed prior to inpatient operations, since postoperative cognitive disturbances are common. Most complications occur after the surgery, in the first place since during the operation the patient is in reliable hands, and secondly since some pathophysiological conditions are associated with a certain latency period.
Key Words
preoperative preparation - geriatric patient - family doctor - geriatric assessment - postoperative disorders
Literatur
-
1
Abbas S, Booth M.
Major abdominal surgery in octogenarians.
N Z Med J.
2003;
116
U402
-
2
Agnoletti V, Ansaloni L, Catena F. et al. .
Postoperative Delirium after elective and emergency surgery: analysis and checking of risk factors. A study protocol.
BMC Surg.
2005;
5
12
-
3
Akoh JA, Mathew AM, Chalmers JW. et al. .
Audit of major gastrointestinal surgery in patients aged 80 years or over.
J R Coll Surg Edinb.
1994;
39
208-213
-
4
Alexander KP, Anstrom KJ, Muhlbaier LH. et al. .
Outcomes of cardiac surgery in patients > or = 80 years: results from the National Cardiovascular Network.
J Am Coll Cardiol.
2000;
35
731-738
-
5
Altemeyer KH, Schultz M, Mehrke HH, Heinz E, Dick W.
Präoperative Befunderhebung durch eine Anaesthesieambulanz - Auswertung der Ergebnisse bei 2500 Patienten.
Anaesthesiologie und Intensivmedizin.
1984;
1
1-7
-
6
Arenal JJ, Bengoechea-Beeby M.
Mortality associated with emergency abdominal surgery in the elderly.
Can J Surg.
2003;
46
111-116
-
7
Arne J, Descoins P, Fusciardi J. et al. .
Preoperative assessment for difficult intubation in general and ENT surgery: predictive value of a clinical multivariate risk index.
Br J Anaesth.
1998;
80
140-146
-
8
Audisio RA, Ramesh H, Longo WE. et al. .
Preoperative assessment of surgical risk in oncogeriatric patients.
Oncologist.
2005;
10
262-268
-
9
Beaupre LA, Jones CA, Saunders LD. et al. .
Best practices for elderly hip fracture patients. A systematic overview of the evidence.
J Gen Intern Med.
2005;
20
1019-1025
-
10
Berggren D, Gustafson Y, Erikson B. et al. .
Postoperative confusion after anesthesia in elderly patients with femoral neck fractures.
Anesth Analg.
1987;
66
497-504
-
11
Bertrand YM, Boelens D, Collin L. et al. .
Preoperative assessment in geriatric patients for elective surgery.
Acta Anaesthesiol Belg.
1984;
35
155-165
-
12
Bosshardt TL.
Outcomes of ostomy procedures in patients aged 70 years and older.
Arch Surg.
2003;
138
1077-1082
-
13
Bridgewater B, Neve H, Moat N. et al. .
Predicting operative risk for coronary artery surgery in the United Kingdom: a comparison of various risk prediction algorithms.
Heart.
1998;
79
350-355
-
14
Bufalari A, Ferri M, Cao P. et al. .
Surgical care in octogenarians.
Br J Surg.
1996;
83
1783-1787
-
15
Bufalari A, Giustozzi G, Burattini MF. et al. .
Rectal cancer surgery in the elderly: a multivariate analysis of outcome risk factors.
J Surg Oncol.
2006;
93
173-180
-
16
Campell IT, Gosling P.
Preoperative biochemical screening.
BMJ.
1988;
297
803-804
-
17
Carliner NH, Fisher ML, Plotnick GD. et al. .
The preoperative electrocardiogram as an indicator of risk in major non-cardiac surgery.
Can J Cardiol.
1986;
2
134-137
-
18
Chahal R, Sundaram SK, Iddenden R. et al. .
A study of the morbidity, mortality and long-term survival following radical cystectomy and radical radiotherapy in the treatment of invasive bladder cancer in Yorkshire.
Eur Urol.
2003;
43
246-257
-
19
Charpak Y, Blery C, Chastang C. et al. .
Prospective assessment of a protocol for selective ordering of preoperative chest X-rays.
Can J Anaesth.
1988;
35
259-264
-
20
Clemency MV, Thompson NJ.
Do not resuscitate orders in the perioperative period: patient perspectives.
Anesth Analg.
1997;
84
859-864
-
21
Collins KJ, Dore C, Exton-Smith AN. et al. .
Accidental hypothermin and impaired temperature homoeostasis in the elderly.
British Medical Journal.
1977;
1
353-356
-
22
Cook TM, Day CJ.
Hospital mortality after urgent and emergency laparotomy in patients aged 65 yr and over. Risk and prediction of risk using multiple logistic regression analysis.
Br J Anaesth.
1998;
80
776-781
-
23
Davies FM, Woolner DF, Frampton C. et al. .
Prospective multi-centre trial of mortality following general or spinal anesthesia for hip fracture surgery in the elderly.
Br J Anaesth.
1987;
59
1080-1088
-
24
Desmeules H, Fournier L, Trembley PR.
Systemic changes in the elderly patients and their anaesthetic implications.
Can Anaesthh Soc.
1985;
32
184-187
-
25
Djokovic JL, Whyte J.
Prediction of surgery and anesthesia in patients over 80.
Jama.
1979;
242
2301-2306
-
26
Dodson ME.
Aspects of anaesthesia in the elderly.
Br J Hosp Med.
1987;
2
114-120
-
27
Donati A, Ruzzi M, Adrario E. et al. .
A new and feasible model for predicting operative risk.
Br J Anaesth.
2004;
93
393-399
-
28
Dundar Y, Boland A, Strobl J. et al. .
Newer hypnotic drugs for the short-term management of insomnia: a systematic review and economic evaluation.
Health Technol Assess.
2004;
8
1-125
-
29
Fortescue EB, Kahn K, Bates DW.
Prediction rules for complications in coronary bypass surgery: a comparison and methodological critique.
Med Care.
2000;
38
820-835
-
30
Fritsche P.
Risikosteigerung durch pathologische Veränderungen im oberen Respirationstrakt.
Anaest Intensivmed.
1985;
1
7-12
-
31
Fukuse T, Satoda N, Hijiya K, Fujinaga T.
Importance of a comprehensive geriatric assessment in prediction of complications following thoracic surgery in elderly patients.
Chest.
2005;
127
886-891
-
32
Gatti G, Cardu G, Lusa AM, Pugliese P.
Predictors of postoperative complications in high-risk octogenarians undergoing cardiac operations.
Ann Thorac Surg.
2002;
74
671-677
-
33
Gehlot A, Mullany CJ, Ilstrup D. et al. .
Aortic valve replacement in patients aged eighty years and older: early and long-term results.
J Thorac Cardiovasc Surg.
1996;
111
1026-1036
-
34
Gottschalk A, Schulte EJ Am.
Limitations of anesthesia. Risks and older patients in daily practice.
Internist.
2005;
46
457-465
-
35
Hamel MB, Davis RB, Teno JM. et al. .
Older age, aggressiveness of care, and survival for seriously ill, hospitalized adults. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.
Ann Intern Med1.
1999;
131
721-728
-
36
Hartung HJ, Osswald PM, Roller G, Lutz H.
Kreislaufkomplikationen bei Hypertonikern während der perioperativen Phase.
Anaesth Intensivther Notfallmed.
1983;
18
196-198
-
37
Hosking MP, Warner MA, Lobdell CM. et al. .
Outcomes of surgery in patients 90 years of age and older.
JAMA.
1989;
261
1909-1915
-
38
Jin F, Chung F.
Minimizing perioperative adverse events in the elderly.
Br J Anaesth.
2001;
87
608-624
-
39
Kaplan EB, Sheiner LB, Boeckmann AJ. et al. .
The usefulness of preoperative laboratory screening.
Jama.
1985;
253
3576-3581
-
40
Khuri SF, Daley J, Henderson W. et al. .
The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care.
J Am Coll Surg.
1995;
180
519-531
-
41
Kojima Y, Narita M.
Postoperative outcome among elderly patients after general anesthesia.
Acta Anaesthesiol Scand.
2006;
50
19-25
-
42 Langley J, Adams G. Insulin-based regimens decrease mortality rates in critically ill patients: a systematic review. Diabetes Metab Res Rev 2006
-
43
Lenze EJ, Munin MC, Dew MA. et al. .
Adverse effects of depression and cognitive impairment on rehabilitation participation and recovery from hip fracture.
Int J Geriatr Psychiatry.
2004;
19
472-478
-
44
Lenze EJ, Munin MC, Dew MA. et al. .
Adverse effects of depression and cognitive impairment on rehabilitation participation and recovery from hip fracture.
Int J Geriatr Psychiatry.
2004;
19
472-478
-
45
Leung JM, Dzankic S.
Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients.
J Am Geriatr Soc.
2001;
49
1080-1085
-
46
Leveson SH.
Surgical deaths.
Br Med J.
1988;
296
3-4
-
47
Lewis AM, Khoury GA.
Resection for colorectal cancer in the very old: are the risks too high?.
Br Med J.
1988;
296
459-461
-
48
Luciani N, Nasso G, D'Alessandro C. et al. .
Heart surgery interventions in chronic dialysis patients: short- and long-term results.
Ital Heart J Suppl.
2002;
3
746-752
-
49
Luijpen MW, Scherder EJ, Someren EJ Van. et al. .
Non-pharmacological interventions in cognitively impaired and demented patients - a comparison with cholinesterase inhibitors.
Rev Neurosci.
2003;
14
343-368
-
50
Manchikanti L, Colliver JA, Marrero TC.
Assessment of age-related acid aspiration risk factors in pediatric, adult and geriatric patients.
Anaesth Analg.
1985;
64
11-17
-
51
Mann RA, Bisset WI.
Anaesthesia for lower limb amputation. A comparison of spinal analgesia and general anaesthesia in the elderly.
Anaesthesia.
1983;
38
1185-1191
-
52
Marcantonio ER, Flacker JM, Wright RJ, Resnick NM.
Reducing delirium after hip fracture: a randomized trial.
J Am Geriatr.
2001;
49
516-522
-
53
Margenthaler JA, Longo WE, Virgo KS. et al. .
Risk factors for adverse outcomes after the surgical treatment of appendicitis in adults.
Ann Surg.
2003;
238
59-66
-
54
McCulloch P, Ward J, Tekkis PP.
Mortality and morbidity in gastro-oesophageal cancer surgery: initial results of ASCOT multicentre prospective cohort study.
BMJ.
2003;
327
1192-1197
-
55
McCusker J, Cole M, Dendukuri N. et al. .
Delirium in older medical inpatients and subsequent cognitive and functional status: a prospective study.
CMAJ.
2001;
165
575-583
-
56
McKenzie PJ, Wishart HY, Gray I, Smith G.
Effects of anaesthetic technique on deep vein thrombosis. A comparison of subarachnoid and general aneasthesia.
Br J Anaesth.
1984;
57
853-857
-
57
Mehta RH, Grab JD, O'Brien SM. et al. .
Bedside tool for predicting the risk of postoperative dialysis in patients undergoing cardiac surgery.
Circulation.
2006;
114
2208-2216
-
58
Neary WD, Foy C, Heather BP, Earnshaw JJ.
Identifying high-risk patients undergoing urgent and emergency surgery.
Ann R Coll Surg Engl.
2006;
88
151-156
-
59
Nilsdotter AK, Lohmander LS.
Age and waiting time as predictors of outcome after total hip replacement for osteoarthritis.
Rheumatology (Oxford).
2002;
41
1261-1267
-
60
Okita Y, Ando M, Minatoya K. et al. .
Early and long-term results of surgery for aneurysms of the thoracic aorta in septuagenarians and octogenarians.
Eur J Cardiothorac Surg.
1999;
16
317-323
-
61
Osswald PM, Hartung HJ, Bender HJ. et al. .
Zeitpunkt und Häufigkeit perioperativer Herz-Kreislaufkomplikationen bei geriatrischen Patienten.
Anaesth Intensivther Notfallmed.
1983;
18
193-195
-
62
Parker MJ, Handoll HH, Griffiths R.
Anaesthesia for hip fracture surgery in adults.
Cochrane Database Syst Rev.
2004;
18
-
63
Pereira ED, Fernandes AL, da AM Silva. et al. .
Prospective assessment of the risk of postoperative pulmonary complications in patients submitted to upper abdominal surgery.
Sao Paulo Med J.
1999;
117
151-160
-
64
Rabkin SW, Horne JM.
Preoperative electrocardiography: effects of new abnormalities on clinical decision.
Can Med Assoc J.
1983;
128
146-147
-
65
Rao TKD, Jacobs KH, El-Etr AA.
Reinfaction following anesthesia in patients with myocardial infarction.
Anesthesiology.
1983;
59
499-505
-
66
Roche JJ, Wenn RT, Sahota O, Moran CG.
Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study.
BMJ.
;
2005;
331
1374
-
67
Roizen MF, Kaplan EB, Schreider BD. et al. .
The relative roles of the history and physical examination and laboratory testing in preoperative evaluation for outpatient surgery: The „Starling Curve” of preoperative laboratory testing.
Anesthesiol Clin North Am.
1987;
5
15-34
-
68 Sandholzer H. Die präoperative Vorbereitung des geriatrischen Patienten. In: Fischer CG. Hausärztliche Geriatrie. Berlin Heidelberg New York: Springer 1990
-
69
Seymour DG, Pringle R, MacLennan WJ.
The role of the routine preoperative electrocardiogram in the elderly patient.
Age Ageing.
1983;
12
97-104
-
70
Shapira OM, Kelleher RM, Zelingher J. et al. .
Prognosis and quality of life after valve surgery in patients older than 75 years.
Chest.
1997;
112
885-894
-
71
Silber JH, Rosenbaum PR, Trudeau ME. et al. .
Preoperative antibiotics and mortality in the elderly.
Ann Surg.
2005;
242
107-114
-
72
Suan C, Perez-Torres C, Herrera A.
Postoperative mortality in a general hospital.
Rev Esp Anestesiol Reanim.
1997;
44
267-272
-
73
Sundt TM, Bailey MS, Moon MR. et al. .
Quality of life after aortic valve replacement at the age of > 80 years.
Circulation.
2000;
102
III70-III74
-
74
Taborski U, Müller N.
Die präoperative Eigenblutspende: Der Allgemeinarzt als Mittler zwischen Patient und Klinik.
Z Allg Med.
1988;
64
742-746
-
75
Turnbull JM, Buck C.
The value of preoperative screening investigations in otherwise healthy individuals.
Arch Int Med.
1987;
147
1101-1105
-
76
Turrentine FE, Wang H, Simpson VB, Jones RS.
Surgical risk factors, morbidity, and mortality in elderly patients.
J Am Coll Surg.
2006;
203
865-877
-
77
Ungern-Sternberg BS, Regli A, Reber A, Schneider MC.
Effect of obesity and thoracic epidural analgesia on perioperative spirometry.
Br J Anaesth.
2005;
94
121-127
-
78
Warner MA, Hosking MP, Lobdell CM. et al. .
Surgical procedures among those > 90 years of age.
Ann Surg.
1988;
207
380-386
-
79
Warner MA, Hosking MP, Lobdell CM. et al. .
Effects of referral bias on surgical outcomes: a population-based study of surgical patients 90 years of age or older.
Mayo Clin Proc.
1990;
95
1185-1191
-
80
Warner MA, Saletel RA, Schroeder DR. et al. .
Outcomes of anesthesia and surgery in people 100 years of age and older.
J Am Geriatr Soc.
1998;
46
988-993
-
81
Wickström I, Holmberg I, Stefansson T.
Survical of female geriatric patients after hip fracture surgery. A comparison of 5 anesthetic methods.
Acta Anesthesiol Scand.
1982;
26
607-614
-
82
Yilmazlar T, Guner O, Yilmazlar A.
Criteria to consider when assessing the mortality risk in geriatric surgery.
Int Surg.
2006;
91
72-76
-
83
Zakriya KJ, Christmas C, Wenz JF. et al. .
Preoperative factors associated with postoperative change in confusion assessment method score in hip fracture patients.
Anesth Analg.
2002;
94
1628-32
Korrespondenz
Dr. med. Thomas Karg
Professur für Allgemeinmedizin, Justus-Liebig-Universität Gießen
Gaffkystraße 11c
35392 Gießen
