Special Needs Population: Care of the Geriatric Patient Population in the Perioperative Setting

Effects of surgery on survival of patients aged 75 years or older with Merkel cell carcinoma

Objective

To investigate whether surgery improves prognosis in elderly patients with Merkel cell carcinoma (MCC).

Materials/Methods

Data of all patients with MCC diagnosed between 2004 and 2015 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Differences in baseline characteristics were analyzed among the age groups (75–80, 80–85, and ≥85 years). Multivariate Cox proportional hazards analysis was used to assess the effects of each variable on patient outcomes. The Kaplan–Meier curves were employed to evaluate MCC overall survival (OS) and MCC‐specific survival (MSS).

Results

A total of 1156 of patients with MCC met the inclusion and exclusion criteria. The surgery rate decreased with age (75–80, 80–85, and ≥85 years were 93.3%, 91.1%, and 88.7%, respectively; p = 0.082). Multivariate Cox proportional hazards analysis showed that the OS of patients in the 80–85 years group (hazard ratio [HR] = 1.39; 95% confidence interval [CI] = 1.14–1.70; p = 0.001) and the ≥85 years group (HR = 2.18; 95% CI = 1.80–2.63; p < 0.0001) was worse than that in the 75–80 years group. Compared with the non‐surgery groups, the HR for the surgery group was 0.75 for OS (95% CI = 0.56–1.00; p = 0.048) and 0.73 for MSS (95% CI = 0.48–1.10; p = 0.130). Subgroup analyses showed that patients aged ≥85 years undergoing surgery had better OS (HR = 0.65; 95% CI = 0.45–0.95; p = 0.024).

Conclusions

MCC patients aged 75 years and older would benefit from surgical resection. However, surgical resection should be performed cautiously, and larger prospective clinical trials are needed to further verify these findings.

Factors predictive of topographical accuracy in spine level localization

BACKGROUND

Pre-operative spine level localization by palpation of anatomical landmarks (ribs, spinous processes) in posterior approaches for surgeries from T4 to L2 is often inaccurate. This can lead to ineffective utilization of procedural time, increased radiation dose, potentially longer skin incision and wrong level surgery. Factors affecting topographical accuracy includes body mass index (BMI) of the patient, congenital or acquired deformity and knowledge of topographical anatomy.

METHODS

All patients had the presumed location of their pathology marked on the skin using anatomical landmarks prior to application of the Target Tape^® (Vancouver, BC, Canada) and verification using an anterior-posterior radiograph. Potential factors predictive of accurate pre-operative spine level localization such as age, gender, BMI, palpable deformity, pathology related interspinous distance (ISPD) and pathology related skin to spinous process distance were evaluated.

RESULTS

A prospective study was performed with 30 consecutive patients undergoing posterior spine surgery (T4 to L2). Accuracy of pathology related spine level localization using anatomical landmarks was only 40%. Pathology related ISPDs of more than 10 mm and palpable deformity was significantly correlated with successful determination of spine levels using anatomical landmarks.

CONCLUSIONS

This study showed that poor spine level localization using anatomical landmarks was associated with pathology related ISPDs of less than 10 mm. Conversely, patients with palpable spinal deformity have their levels easily localized.

The Impact of Comorbidity on Surgical Outcomes in Older Adults with Cancer

OBJECTIVES

To provide an overview of the impact of comorbidity on surgical outcomes and postoperative geriatric events in older adults with cancer, and review key components of quality perioperative nursing care of older adults with cancer.

DATA SOURCES

Journal articles, research reports, state of the science papers, position papers, and clinical guidelines from professional organizations.

CONCLUSION

The high prevalence of multiple comorbidities and the associated burden of geriatric events in older adults after cancer surgery have a substantial impact on surgical outcomes, quality of life, and health care costs. Practical and efficient models of comprehensive assessment, prevention, and management of postoperative geriatric events and comorbid conditions are needed to improve surgical outcomes for this vulnerable cancer population.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses practicing in clinical and research settings have a responsibility to arm themselves with evidence-based knowledge and resources to improve the perioperative care of older adults with cancer.

Incorporating Age-Specific Plans of Care to Achieve Optimal Perioperative Outcomes

When developing a nursing plan of care, a perioperative nurse identifies nursing diagnoses during the preoperative patient assessment. The ability to identify age-specific outcomes (ie, infant/child, adolescent, adult, elderly adult) in addition to those that are universally applicable is a major responsibility of the perioperative RN. Having an individualized plan of care is one of the best ways to determine whether desired patient outcomes have been successfully attained. Nursing care plans address intraoperative and postoperative risks and allow for a smooth transfer of care throughout the perioperative experience. A good nursing care plan also includes education for the patient and his or her caregiver. Within an overall plan of care, the use of methods such as a concept or mind map can visually demonstrate the relationships between systems, nursing diagnoses, nursing interventions, and desirable outcomes.