General principles of postoperative recovery

Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease. Sir William Osler (1849-1919) Introduction The outcomes for elderly patients are strongly correlated to the perioperative care offered when surgery is planned. Treatment tolerance may be impaired in many elderly patients, mostly when physical status is low (Braga et al. 2017); hence, the postoperative period, with prevention strategies for surgical and medical complications, is crucial in promoting a safe, rapid recovery. Before planning surgery, the healthcare team should be aware of comorbidities and functional reserve, and, in accordance with the prehabilitation principles (see Chapter 12), preoperative optimization of general medical conditions should be carried out whenever possible. The lack of adequate preoperative information and family involvement (see Chapter 10) has a detrimental impact on patient acceptance and compliance toward treatments proposed after surgery. Compared to younger patients, the elderly need a tailored postoperative care pathway, since their needs could be totally different, such as postoperative fluids, nutrition and physical therapy support. Even the ward setting should be planned to host elderly surgical patients; for example, an “unlimited access” policy should be adopted for caregivers to prevent disorientation and reduce the risk of delirium. All surgical tubes, catheters, drains and invasive monitoring devices should be removed as soon as possible. Prompt restoration of preoperative conditions, such as diet, preoperative medications and ambulation, should be encouraged. Malnutrition, prolonged bed rest and delirium are correlated with a higher risk of complications (above all pulmonary complications and urinary tract infections) and mortality in elderly patients; careful evaluation of the risk factors should be undertaken and strategies should be adopted to reduce postoperative events. Early mobilization, aggressive physical therapy and nutrition play a key role in this context, and also in preventing pressure ulcers and overall functional decline. The entire healthcare team should be involved in a collaborative approach towards elderly patients in order to tailor the optimal perioperative management pathway, which will ultimately influence their functional recovery.