A med­i­cal spe­cialty that aids in post-op­er­a­tive re­cov­ery is of par­tic­u­lar ben­e­fit to the frail.

New Zealand Listener - - CONTENTS - by Ruth Ni­chol

A med­i­cal spe­cialty that aids in post-op­er­a­tive re­cov­ery is of par­tic­u­lar ben­e­fit to the frail.

Not all elderly peo­ple are frail, but the preva­lence of frailty in­creases with age – and that’s bad news for the in­creas­ing num­ber of New ­Zealan­ders hav­ing surgery later in life. Ac­cord­ing to Christchurch ­anaes­thetist Dick On­g­ley, be­ing both old and frail means you’re more likely to ­ex­pe­ri­ence com­pli­ca­tions in the first few weeks after surgery, in­clud­ing con­fu­sion, chest in­fec­tions, falls and – in some cases – death.

“Med­i­cal pro­fes­sion­als have started to recog­nise that there is this ­geri­atric syn­drome that sig­ni­fies a per­son is hav­ing a change in their phys­i­cal health and that they might not do as well from surgery as hoped.” Al­though most of us as­sume the worst is over when an older rel­a­tive

emerges from the op­er­at­ing theatre, the dan­ger pe­riod is re­ally just be­gin­ning. “When you have surgery, it sets up a big in­flam­ma­tory re­sponse in the body, which we call the ­sur­gi­cal in­sult – some peo­ple equate it to trauma. The longer you spend on the op­er­at­ing ta­ble, the big­ger the in­sult.”

There’s grow­ing ev­i­dence that the ef­fects of sur­gi­cal in­sult can last as long as a year. For over 65s, who are more likely to have both elec­tive and emer­gency surgery, that can mean a longer re­cov­ery time. Even if they do tech­ni­cally re­cover, they might not be able to re­turn to the ac­tiv­i­ties they en­joyed be­fore their op­er­a­tion, or they might need a higher level of care than pre­vi­ously.

The good news is that a rel­a­tively new med­i­cal spe­cialty, pe­ri­op­er­a­tive medicine, can im­prove the re­cov­ery of high-risk sur­gi­cal pa­tients. On­g­ley is help­ing to de­velop it in New ­Zealand and Aus­tralia. Pe­ri­op­er­a­tive medicine cov­ers the care of pa­tients from the time they first con­tem­plate surgery through to their full re­cov­ery at home. The goal is to make surgery more ef­fi­cient and ef­fec­tive.

On­g­ley, who is a mem­ber of the pe­ri­op­er­a­tive special in­ter­est group run by the Aus­tralian and New Zealand Col­lege of Anaes­thetists, says pe­ri­op­er­a­tive teams in­clude not just anaes­thetists but also GPs, sur­geons, geri­a­tri­cians, phys­io­ther­a­pists and oc­cu­pa­tional ther­a­pists.

“It’s a col­lab­o­ra­tive game and it’s about com­mu­ni­ca­tion. It’s about us hav­ing frank con­ver­sa­tions with pa­tients, and it’s also about hav­ing con­ver­sa­tions with each other to pro­duce bet­ter out­comes for pa­tients.”

Anaes­thetists have be­come in­volved in ­peri­op­er­a­tive medicine be­cause, un­like most med­i­cal spe­cial­ists, they have to un­der­stand how all the or­gans in the body work and in­ter­act. Their job in the pe­ri­op­er­a­tive team is to as­sess the risks pre­sented by surgery and to rec­om­mend ways to min­imise them to get the best pos­si­ble out­come.

That can in­clude the pa­tient pre­par­ing for surgery by ­stop­ping smok­ing, eat­ing bet­ter and ex­er­cis­ing more. For peo­ple with med­i­cal con­di­tions such as high blood pres­sure, di­a­betes or heart dis­ease, their GP needs to make sure the drugs they’re on are do­ing what they’re sup­posed to.

“There’s no point in find­ing out at the 11th hour that we failed to con­trol Mrs W’s blood pres­sure when we had months to do it.”

In some cases, an anaes­thetist may rec­om­mend a dif­fer­ent op­er­a­tion, or an al­ter­na­tive to surgery, such as ­pre­scrib­ing more-ef­fec­tive ­painkillers for an elderly per­son rather than do­ing a hip re­place­ment.

Age and frailty are known risk ­fac­tors for post-sur­gi­cal ­com­pli­ca­tions. Signs of frailty can in­clude weak­ness, weight loss, ex­haus­tion and a slow walk­ing speed. On­g­ley is in­volved in a study at Auckland City Hos­pi­tal to iden­tify which symp­toms of frailty present the most risk.

But younger pa­tients with ­con­di­tions such as di­a­betes or those who smoke, eat badly or do lit­tle ­ex­er­cise are also more likely to ­ex­pe­ri­ence com­pli­ca­tions fol­low­ing surgery.

Some over­seas doc­tors use the term “fu­tile surgery” to de­scribe op­er­a­tions car­ried out on high-risk pa­tients. On­g­ley prefers to talk about “low-ben­e­fit surgery”. He says that al­though an op­er­a­tion may ul­ti­mately be un­suc­cess­ful, few sur­geons would per­form surgery if they thought it had no chance of suc­ceed­ing.

The goal of pe­ri­op­er­a­tive medicine is not to stop high-risk pa­tients from hav­ing surgery but to make sure they get as much ben­e­fit from it as pos­si­ble.

“It’s not a cost-cut­ting ex­er­cise. Re­duc­ing the com­pli­ca­tions will have ben­e­fits to the cof­fers of the ­hos­pi­tal, but it’s also go­ing to ben­e­fit the pa­tient, their fam­ily and their ­med­i­cal team.”

“Surgery sets up a big in­flam­ma­tory re­sponse in the body, which we call the sur­gi­cal in­sult.”

Dick On­g­ley: a lo­cal pi­o­neer of pe­ri­op­er­a­tive medicine.

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