An 86-year-old man with severe Alzheimer's disease is scheduled to undergo a left carotid endarterectomy. The patient is on the medical service recovering from a fall sustained during a syncopal episode. His other past medical history is significant for pharyngeal dysmotility and reflux disease. He has no known coronary artery disease. In the evaluation of that episode, it was determined that he had a 99% stenosis of his left internal carotid artery and a 100% occlusion of his right internal and external. This was thought to be the cause of his syncope. The patient is moderately demented and is fed soft solids and thick liquids with the help of an aide. In speaking with the anesthesia team, you learn that the patient cannot have the procedure done under a cervical plexus block due to his dementia and he will therefore require a general anesthetic. In discussing the risks of the procedure with the patient's daughter (his health proxy), a serious postoperative complication that this patient is at especially high risk for is
A. aspiration pneumonitis
B. deep venous thrombosis
C. delirium
D. myocardial infarction
E. need for a tracheostomy
A. aspiration pneumonitis
The correct answer is A. For the elderly, the risks of surgery and anesthesia are often heightened and much of this increased risk stems for comorbid conditions more present in the elderly. This patient is a high aspiration risk even while awake. After general anesthesia however, his risk is dramatically elevated such that aspiration of significant quantities of stomach contents are possible leading to pneumonitis. If the pneumonitis progressed to pneumonia, a patient such as this, debilitated and moderately demented, would certainly need a tracheostomy (choice E). The patient's risk however is for the aspiration, not necessarily the pneumonia or prolonged intubation.
All postoperative patients are at risk for deep venous thrombosis (choice B). This patient's risk is no greater because of his comorbid conditions and his surgical procedure is at the low risk end of the spectrum since his ambulation should not be limited by the incision in his neck.
Delirium (choice C) is certainly troublesome for the patient and family, but is not serious. Elderly patients are more likely to be confused in hospital settings (so-called sundowning) as well as postoperatively. This patient is at high risk for both given his dementia but again, these concerns are not serious compared to the possibility of aspiration. The aspiration can be guarded against, the delirium cannot.
This patient is at low-risk for a perioperative myocardial infarction (choice D) based upon American Heart Association stratification guidelines that all medical house officers carry in their jacket pockets. The surgical procedure is classified as low risk. Given the patient's lack of prior coronary history, he is also classified