Frail 89-year-old for emergency laparotomy89-year-old woman, 48 kg, for emergency laparotomy for perforated sigmoid diverticulitis with faecal peritonitis

The patient

The examiner asks

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1. Consider

   What are the key issues?

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   • An 89-year-old frail woman with mild cognitive impairment, for emergency laparotomy with faecal peritonitis. Patient
   • At 89, frail and cognitively impaired, she risks delirium, death and losing her independence.
   • She is septic now: fever, tachycardia, low pressure and fast breathing. Disease
   • Temazepam and oxybutynin add delirium risk; furosemide may have dried her out.
   • Emergency surgery can't wait long, but operating must still match her goals. Surgery

2. Prepare

   How will you prepare her in the time you have?

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   • Frailty scored on the Clinical Frailty Scale, which takes about a minute. Patient
   • The NSQIP calculator estimates her risk, including geriatric outcomes, to guide the conversation.
   • A shared decision with her and her family: what does she want surgery to achieve? After surgery
   • Resuscitation status and ceilings of care agreed and written down before theatre.
   • Her delirium risk is recorded and shared: age, ASA over 2, cognitive impairment. Patient
   • If she is hypoperfused, crystalloid 30 mL/kg within 3 hours in small boluses, reassessed often; antibiotics now. Disease

3. Plan

   How will you anaesthetise her?

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   • Arterial line, then a reduced induction; propofol over 1.5 mg/kg drops older patients' pressure severely. Patient
   • Rapid sequence for her peritonitis, with rocuronium 1.2 mg/kg. Airway
   • Processed EEG to guide her depth, which may reduce delirium. Patient
   • Active warming; in the elderly, cold adds ischaemia, wound infection and bleeding.
   • No benzodiazepines, anticholinergics or pethidine for her.
   • Multimodal, opioid-sparing analgesia; both pain and opioids drive delirium. After surgery
   • HDU or ICU afterwards, with geriatric review.

4. Crisis

   On the first night she is agitated, pulling at her lines and shouting. BP 150/90, HR 118, SpO2 89% on 2 L, temperature 38.2°C. What do you do?

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   • Likely hyperactive delirium; I confirm it with the Confusion Assessment Method. Crisis
   • Cause first: her saturation of 89% needs more oxygen and a chest examination.
   • Then pain, a full bladder, sepsis or an anastomotic problem, glucose and her drug chart.
   • Non-drug measures: family at the bedside, glasses and hearing aids, reorientation, unneeded lines out.
   • Low-dose haloperidol only if she is a danger and other measures fail; no benzodiazepines.
   • Geriatrician co-manages her, and her family is kept informed. After surgery