Subinternship Surgery · Year 4 · from Subinternship Surgery
Case 3: Optimizing the High-Risk Elderly Patient
Patient Presentation
Demographics: 81-year-old female
Chief Complaint: Incarcerated umbilical hernia requiring repair
History of Present Illness: Mrs. Patterson presents with a 6-hour history of an irreducible umbilical hernia. The overlying skin is erythematous and she reports nausea. CT shows incarcerated omentum without bowel involvement or signs of strangulation. She requires semi-urgent surgical repair within 6-12 hours.
Past Medical History:
- COPD on home oxygen 2L (FEV1 45% predicted 6 months ago)
- Heart failure with reduced ejection fraction (EF 35%)
- Type 2 diabetes
- Chronic kidney disease stage 3b (GFR 38)
- BMI 34
- Lives in assisted living, uses walker
Medications:
- Tiotropium, budesonide/formoterol inhalers
- Carvedilol 12.5mg BID
- Furosemide 40mg daily
- Lisinopril 5mg daily
- Glipizide 5mg BID
- Metformin 500mg BID
Functional Status:
- Cannot climb one flight of stairs without stopping
- Limited to short distances with walker
- Requires assistance with bathing
- Functional capacity estimated at 2-3 METs
Clinical Questions
- What is this patient's RCRI score and overall operative risk?
RCRI Score:
- High-risk surgery: NO (umbilical hernia)
- Ischemic heart disease: NO (HFrEF without documented CAD)
- Heart failure: YES (+1)
- CVA/TIA: NO
- Insulin-dependent diabetes: NO
- Creatinine >2.0: NO (1.6 mg/dL)
RCRI Score: 1 point (0.9% MACE risk by RCRI)
However, RCRI underestimates risk in this patient:
- Poor functional capacity (<4 METs)
- Frailty indicators present
- Multiple comorbidities not captured by RCRI
- ACS NSQIP calculator would provide better estimate
- True perioperative mortality risk likely 5-10%
- How would you optimize her for surgery in the available time window?
6-12 Hour Optimization Protocol:
| System | Optimization | |--------|--------------| | Cardiac | Hold morning lisinopril; euvolemic fluid management; continue beta-blocker | | Pulmonary | Nebulizer treatments; incentive spirometry teaching; ensure inhalers given | | Renal | Judicious IV fluids; avoid nephrotoxins; check K+ | | Diabetes | Hold glipizide and metformin; check glucose; start insulin sliding scale | | Nutrition | NPO with IV dextrose if prolonged |
Not achievable in this timeframe:
- Smoking cessation benefit (needs 4-8 weeks)
- Significant nutritional optimization
- Pulmonary rehab
- The patient's daughter asks about the risks of surgery. How do you communicate this?
Risk Communication Framework:
"Mrs. Patterson has several medical conditions that increase the risks of surgery. However, the incarcerated hernia needs to be repaired to prevent it from becoming strangulated, which would be much more dangerous.
The main risks we're concerned about include:
- Breathing problems after surgery requiring longer oxygen support
- Heart strain or fluid buildup in her lungs
- Kidney function getting worse temporarily
- Wound healing problems given her diabetes
- The possibility of needing ICU care after surgery
We estimate her risk of a serious complication at approximately 20-30%, and her risk of not surviving the hospitalization at 5-10%. Without surgery, her risk is higher.
We will do everything to optimize her condition before surgery and monitor her closely afterward."
- What code status and goals of care discussion should occur before surgery?
Essential Elements:
- Confirm current code status and update as needed
- Discuss possibility of postoperative ICU admission
- Address intubation preferences if respiratory failure occurs
- Clarify acceptable outcomes and duration of intervention
- Document discussion clearly
- Consider palliative care consultation if high-risk
- Ensure healthcare proxy/POA identified
Clinical Image
Image: Anatomical diagram of abdominal wall hernia. Source: Wikimedia Commons. License: Public Domain.
Image Attribution: Hernia anatomy illustration. National Library of Medicine, Public Domain.
Summary Points
- RCRI components: High-risk surgery, ischemic heart disease, CHF, CVA, insulin-dependent diabetes, Cr >2.0
- Functional capacity: >4 METs reduces need for cardiac testing
- Aspirin for stents: Continue perioperatively unless bleeding risk prohibitive
- Bridging anticoagulation: Required for mechanical valves and high thromboembolic risk; stop warfarin 5 days before, bridge with LMWH
- Medication management: Continue beta-blockers and statins; hold ACE-I/ARBs, metformin, and SGLT2 inhibitors
- Elderly optimization: Focus on achievable goals within timeframe; honest risk communication; goals of care discussion essential
- Risk calculators: ACS NSQIP provides procedure-specific estimates; RCRI may underestimate risk in frail elderly