Makindo Medical Notes

Older surgical patients are at high risk of complications, delirium, and functional decline. Geriatricians play a key role in surgical liaison, optimising health before, during, and after surgery, and supporting decision-making around escalation and ceilings of care.

Common Peri-operative Issues in Older Patients 🧩

• Delirium risk (pre-existing cognitive impairment, infection, dehydration) → prevent with orientation, sensory aids, sleep protection, early mobilisation, opioid-sparing analgesia. 🧠
• Medication pitfalls (recent DOAC/warfarin timing, SGLT2 inhibitors → euDKA risk, anticholinergics/opioids → retention/delirium) → reconcile, stop/bridge appropriately, check ketones if SGLT2 used. 💊
• Haemodynamic instability & AKI (vasoplegia, anaemia, sepsis, ACE-I/ARB) → balanced fluids, MAP ≥65, early lactate, avoid nephrotoxins, monitor U&Es/urine output. 🩸
• Malnutrition & sarcopenia → early dietetics, protein targets (≈1.2–1.5 g/kg/day if feasible), “prehab” where time allows, vitamin D/calcium if indicated. 🍽️
• Respiratory complications (atelectasis, pneumonia) → incentive spirometry, chest physio, early sitting/walking, treat OSA optimally. 🫁
• VTE & bleeding balance → procedure-specific LMWH timing, mechanical prophylaxis, careful restart of anticoagulants post-op. 🧵
• Pain management → regional blocks (e.g., fascia-iliaca for #NOF), regular paracetamol, reduce deliriogenic opioids/benzodiazepines. ⚕️
• Urinary & bowel dysfunction → avoid unnecessary catheters, treat retention/constipation proactively, early TWOC plans. 🚽
• Pressure damage & deconditioning → pressure care, falls prevention, day-1 physio, clear mobility goals. 🛏️➡️🚶
• Communication & capacity → MCA 2005 assessments, ReSPECT/TEP, shared decisions with patient/family; document clearly. 🗣️

Quality & Safety: What to Aim For 📈

• Timely senior review (ED/acute floor) and early antibiotics for sepsis (ideally within 1 hour). ⏱️
• Risk stratification (e.g., NELA for emergency laparotomy; frailty score such as Rockwood CFS) to guide level of care. 📊
• Appropriate imaging & labs (CT where indicated, lactate, ABG, U&Es) before theatre when it won’t delay life-saving surgery. 🧪
• Consultant presence for high-risk surgery and a clear plan for post-op critical care (HDU/ICU) when predicted mortality is high. 🧑‍⚕️
• Delirium prevention bundle (4AT screening, orientation, sleep hygiene, glasses/hearing aids, avoid deliriogenic drugs). 🧠
• Opioid-sparing analgesia with regional techniques where feasible; regular laxatives and anti-emetics. 🌿
• VTE prophylaxis (mechanical + pharmacological) with correct timing around neuraxial anaesthesia. 🦵
• Early mobilisation, early feeding (ERAS principles) and documented daily goals. 🍲🚶
• Clear escalation/ceiling-of-care (ReSPECT/TEP) and realistic discharge planning from day 1. 📝

What is NELA? 🇬🇧

NELA is the National Emergency Laparotomy Audit—the UK programme that measures and improves care for adults undergoing emergency laparotomy. It tracks key process measures (e.g., time to CT/theatre, pre-op risk documentation, consultant presence, lactate measurement, critical-care admission) and outcomes (e.g., risk-adjusted mortality, length of stay, returns to theatre). Teams use NELA data to benchmark performance and drive system changes: earlier senior decision-making, better sepsis bundles, appropriate critical-care use, and robust pathways for older/frail patients.

Silver Trauma — Older Adults with Low-Energy Trauma 🥈🤕

• Definition & Risk: “Silver trauma” refers to trauma in older adults—often low-energy mechanisms (simple fall from standing)—that cause disproportionately severe injury due to frailty, osteoporosis, anticoagulation and reduced physiological reserve. Mortality and missed injury are higher despite innocuous histories. 🧓➡️⚠️
• Initial Priorities: Senior-led assessment using an adapted ATLS approach; low threshold for pan-scan CT (head/cervical spine/chest/abdomen/pelvis) when on anticoagulants/antiplatelets or with any head strike, even if GCS 15. Check drug list early (DOAC/warfarin, antiplatelets, opioids, sedatives). 📟🩻
• Anticoagulation & Bleeding: Document last dose; send coagulation profile and anti-Xa if available. Consider reversal pathways (vitamin K ± PCC for warfarin; 4-factor PCC or specific antidotes where available for DOACs; platelet transfusion rarely for isolated antiplatelet use). Balance VTE risk—mechanical prophylaxis early, pharmacological once haemostasis secure. 💉🩸
• Hidden Injuries to Seek: Subdural/SAH, odontoid and C-spine fractures, rib fractures with flail/contusions, sternal fractures, solid organ injury without tenderness, pelvic and acetabular fractures, vertebral compression/burst fractures, and retroperitoneal bleeding. Maintain a low threshold for pelvic binders where suspicious. 🔍
• Pain & Delirium: Use regional techniques (e.g., Fascia Iliaca Compartment Block for hip/femur; serratus/erector spinae blocks for rib fractures) to minimise opioids and delirium; apply a delirium prevention bundle (4AT screening, orientation, sleep protection, hearing/vision aids, avoid anticholinergics/benzodiazepines). 🧠🌿
• Frailty & CGA: Screen frailty (Rockwood CFS), falls risks, and osteoporosis; initiate Comprehensive Geriatric Assessment in ED or on the trauma ward (meds optimisation, nutrition, bone health, rehabilitation plan, pressure care). Link with ortho-geriatrics/acute frailty teams early. 🧩
• Safeguarding & Causes: Evaluate for syncope (arrhythmia, orthostatic hypotension), infection, hypoglycaemia, stroke/TIA; screen for domestic circumstances, carer strain, and neglect. Plan secondary prevention (vitamin D/calcium, bisphosphonates if appropriate, strength/balance rehab). 🛡️
• Disposition & Escalation: Consider need for HDU/ICU if rib fractures, chest injury, head injury on anticoagulants, or high frailty. Document ceilings of care (ReSPECT/TEP) and involve family early; communicate realistic goals. 🏥
• Quality Indicators (Trauma): Senior decision within 60–90 min; timely CT imaging; analgesia within 30 min; regional block within 2–4 h for hip/rib injuries; early physio and mobilisation; medication reconciliation and anticoagulant plan documented; discharge with falls/osteoporosis interventions. 📈

Fast Teaching Pearls 🎓

• Frailty ≠ futility: it changes the pathway (CGA, delirium bundle, nutrition, escalation), not entitlement to high-quality, senior-led care. 🌱
• Silver trauma hides in plain sight: low-energy fall + anticoagulant + headache or chest wall pain → scan early and block early. 🧲
• Document risk, capacity, and plan: NELA (for laparotomy), frailty score, reversal strategy, VTE plan, and level of post-op/trauma care—before knife-to-skin or transfer. 🖊️
• Think physiology: preload/afterload, oxygen delivery, and the inflammatory response drive outcomes more than any single “magic” drug. ❤️‍🔥

Surgical Liaison — Perioperative Care in Older Patients (UK)

• Case 1 — Emergency laparotomy in a frail anticoagulated patient 🚑: An 84-year-old with CFS 6, AF on apixaban, CKD-3 and suspected perforated diverticulitis arrives septic with peritonism and lactate 5.2; priorities are rapid balanced-fluid resuscitation, early broad-spectrum antibiotics, NELA risk stratification and time-to-theatre (<6 h) with capacity/ReSPECT discussion under MCA 2005, check last DOAC dose and renal function, consider 4-factor PCC (off-label) and tranexamic acid if surgery cannot wait, avoid neuraxial until anticoagulant effect has waned, plan post-op critical care, and mitigate delirium with opioid-sparing analgesia, early mobilisation, and sensory aids while monitoring for post-op AKI and ileus.
• Case 2 — Hip fracture co-managed with orthogeriatrics 🦴: An 88-year-old with moderate dementia, T2DM on an SGLT2 inhibitor, and a systolic murmur has an extracapsular #NOF; deliver CGA on admission, provide fascia-iliaca block to minimise opioids, stop SGLT2 (risk euDKA) and check ketones, correct fluids/electrolytes, proceed to surgery within 36 h, document best-interests if no capacity, ensure pressure-area care and dose-adjusted LMWH around neuraxial timing, then prevent delirium with orientation, regular paracetamol, bowel/urinary protocols and early mobilisation; start bone health and falls interventions before discharge and prioritise early protein/calories to counter catabolic stress and sarcopenia.
• Case 3 — Elective colorectal resection with severe aortic stenosis & malnutrition 🫀🍽️: A 79-year-old with IDA (ferritin 9 µg/L), BMI 17 and loud ejection systolic murmur is listed for right hemicolectomy; optimise via “prehab” (IV iron, dietitian-led high-protein supplementation, inspiratory muscle training, functional conditioning), obtain urgent echo and discuss with anaesthesia/cardiology (severe symptomatic AS → consider valve strategy; if not feasible, plan enhanced monitoring, slow induction, maintain preload/afterload and sinus rhythm), continue statin, hold ACE-I morning of surgery if hypotension-prone, manage VTE prophylaxis and peri-op glucose, use CPET or functional surrogates for risk communication, document shared decisions, and book HDU/ICU post-op.

Silver Trauma — 2 Clinical Cases 🥈🤕

• Case 1 — Anticoagulated fall with rib fractures & occult haemothorax: An 82-year-old on apixaban for AF falls from standing onto the left side; vitals: RR 22, SpO₂ 92% on air, BP 132/68, GCS 15, chest wall tenderness with crepitus; CXR suggests lower-zone opacification and CT trauma confirms 6th–8th rib fractures with a small haemothorax and pulmonary contusion. Management: senior-led trauma review; early high-flow nasal oxygen, aggressive analgesia with a serratus anterior plane block to minimise opioids and delirium; apixaban withheld, tranexamic acid given, haemostasis monitored with serial Hb; consider chest drain if haemothorax enlarges or respiratory mechanics worsen; start incentive spirometry, physio, and VTE prophylaxis (mechanical initially, LMWH when bleeding risk acceptable); CGA including falls/osteoporosis assessment before discharge.
• Case 2 — Head strike on clopidogrel with delayed subdural: A 79-year-old with CFS 5 and IHD on clopidogrel trips over a rug, brief head strike, no LOC; initial exam normal and GCS 15, but family report increasing confusion that evening; CT head shows an acute-on-chronic subdural haematoma with 6 mm midline shift. Management: urgent neurosurgical discussion; reverse antiplatelet effect pragmatically (local protocol—platelets seldom indicated unless peri-operative or severe), maintain SBP 140–160 to optimise CPP, elevate head 30°, normocapnia and normoglycaemia, avoid sedatives; consent/best-interests discussion under MCA 2005 with ReSPECT/TEP review; proceed to burr-hole evacuation if indicated; post-op delirium prevention (4AT screening, orientation, hearing/vision aids) and early mobilisation; secondary prevention plan (home hazards, strength/balance rehab, bone health) and clear anticoagulant/antiplatelet restart strategy.