Ileus
Postsurgical ileus can cause profound clinical consequences in elderly patients. This complication is associated with delayed enteral feeding and malnutrition, increased length of hospital stay, and increased risk of pulmonary complications. Patients present with abdominal distension, nausea and vomiting, limited flatus, and a decreased presence of bowel sounds on auscultation. In cases of prolonged postsurgical ileus, consider pseudo-obstruction (Ogilvie’s syndrome) and mechanical obstruction.
Intravenous hydration and nutrition (in prolonged cases), assisted ambulation, and the avoidance of opiates remain the mainstays of treatment. Nasogastric tubes may provide symptomatic relief in patients with nausea and vomiting, but studies don’t support the use of this intervention to enhance resolution of the ileus. Many prokinetic agents have been examined for this use, including neostigmine and cisapride, but the results have been mixed, and the side effect profiles are generally unacceptable for elderly patients. Delay oral feeding until satisfactory bowel function has been restored.
Nutritional Care
An estimated 12%-50% of geriatric patients are found to be malnourished in the acute hospital setting. The adverse effects of malnutrition include delayed wound healing, greater risk of sepsis and wound infections, deterioration of functional status secondary to muscle wasting, and increased mortality.
Early identification of the patient’s feeding limitations is the key to preventing adverse outcomes. If a patient is restricted from oral or enteral feeding, parenteral nutrition should be started within 48 hours. When volitional food intake is permitted, the addition of canned nutritional supplements, fortified meals, and between-meal snacks may improve elderly patients’ energy and protein intake.
Initiate enteral feeding in patients for whom voluntary food intake is decreased. Parenteral nutrition may still be required until enteral feeding is established, however, and prescribed nutrients can be administered enterally. Because glucose tolerance diminishes with normal aging and may be further reduced in a state of acute illness, initiation of insulin therapy may be necessary in patients receiving either enteral or parenteral supplementation. Additionally, supplementation with a zinc-containing daily multivitamin has been shown to enhance immune function and prevent infections.
Respiratory Care
Respiratory function may be diminished in elderly patients due to age-related changes in the upper and lower respiratory tracts. Factors that contribute to an increased rate of pulmonary postoperative complications include diminished protective mechanisms like coughing and swallowing, decreased compliance of the chest wall and lung tissue, inadequate mucociliary transport, and a blunted ventilatory response to hypoxia and hypercapnia. Postoperative respiratory complications, including pneumonia, hypoxemia, hypoventilation, and atelectasis, occur in 2.1%-10.2% of elderly patients. These complications are associated with increased length of stay and a higher risk of long-term mortality.
Respiratory function may be preserved in the postoperative geriatric patient using a variety of measures. Effective pain control is essential in maintaining adequate lung volumes, and regional analgesia is associated with less-severe postoperative decreases in vital capacity and functional residual capacity (FRC). Once postoperative pain has been controlled, encourage the early resumption of physical activity (with appropriate assistance). Positioning patients in a seated position increases FRC and improves gas exchange in those recovering from abdominal procedures. Additionally, incentive spirometers, breathing exercises, and intermittent positive-pressure breathing may reduce the incidence of pulmonary complications after upper-abdominal operations, shortening the length of hospital stay.
Thromboembolic Disease
Fatal pulmonary embolism accounts for a large proportion of postoperative deaths in the elderly population. Between 20%-30% of patients undergoing general surgery without prophylaxis develop deep vein thrombosis, and the incidence is as high as 40% in those undergoing orthopedic surgeries, gynecologic cancer operations, and major neurosurgical procedures.
The Fifth American College of Chest Physicians Consensus Conference on Antithrombotic Therapy recommends the following postoperative interventions for older surgical patients:
