ASA 2006: WHATS NEW IN GERIATRIC ANESTHESIA

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Title: ASA 2006: WHATS NEW IN GERIATRIC ANESTHESIA

1
ASA 2006 WHATS NEW IN GERIATRIC ANESTHESIA

Raymond C. Roy PhD MD
Professor Chair of Anesthesiology
Wake Forest University School of Medicine
Winston-Salem NC USA 27157-1009
rroy_at_wfubmc.edu

2
Present a reasonable way not the one right
way to handle clinical situations

Applying conclusions from chronic disease
management studies to acute perioperative
management
Too few studies addressing how well they
translate
Applying conclusions from studies on higher risk
patients to
lower risk patients or
higher risk patients for low risk surgery
Greater overall population benefit versus
Increase of adverse events in low risk
population

3
Encourage medical anesthesia

Minimal interference with medical management
Discontinue as few drugs as possible
perioperatively
Light anesthesia
Lower doses of inhaled agents
Aggressive pain control preemptive analgesia
Regional or combined regional/general when
possible
Bridge (ORPACUpost-PACU) rather than silo
Pain cardiovascular and metabolic control
Aggressive use of medical drugs
Cardiovascular control
Medical drugs anesthetic drugs volume
administration
Metabolic control
Insulin infusions glitazones K Mg

4
4 PROBLEMS COMMON IN THE ELDERLY

HYPERTENSION
DIASTOLIC DYSFUNCTION
TYPE 2 DIABETES MELLITUS
CORONARY HEART DISEASE

5
Changes in BP with Normal Aging Franklin SS et
al Circulation 1997 96308-15
6
Hypertension 3 Stages7th Report of Joint
National Committee on Prevention Detection and
Treatment of High Blood Pressure (JNC-7)Mean of
2 measured readings 2 clinic visits seated
quietly for 5 min auscultatory method BP cuff
bladder encircles 80 armChobanian. JAMA
20032892560
7
Prevalence () of Stage 2 Hypertension in
MenLloyd-Jones JAMA 2005 294466

SP increases with increasing age
LV mass increases with increasing SP
DP increases with increasing age
DP decreases with increasing age 55
Key to explanation is reflected aortic wave

8
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9
HYPERTENSION

72-yr-old 85 kg man inguinal hernia repair
Meds lisinopril atenolol aspirin statin
BP 200/90 immediately preoperatively
Postpone to control BP What if BP 220/105

10
Postpone to control BP What if BP 220/105

Pro (risk averse)
Philosophy Not in best medical condition
Perioperative hemodynamic instability
Create need-to-rescue events if proceed
Con (risk tolerant)
Basing decision on inaccurate single BP
measurement
Outcome data do not support delay
Perceived risks overestimated easily managed
Control requires 1-2 months impractical

11
HYPERTENSION

72-yr-old 85 kg man inguinal hernia repair
Meds lisinopril atenolol aspirin statin
BP 200/90 immediately preoperatively
Is this high BP measurement iatrogenic
Is high BP a green yellow or red light
Treat this BP before induction
What BP is too low in hypertensive patients
Which antihypertensive agents should be
discontinued prior to surgery

12
Is High BP Measurement Iatrogenic

Deliberate loose control by PCP
Tight control in elderly leads to side effects
complications decreased compliance
White coat hypertension
Withholding of anti-hypertensive medication by
anesthesiologists
Inaccurate BP measurement

13
Inaccurate BP Measurement

Automated devices (Jones et al JAMA 2003
2891027-30)
AAMI validation not required by FDA questioned
Association for Advancement of Medical
Instrumentation
Mean rather than measurements exceeding limits
Systolic and diastolic derived from mean
Error greatest in elderly Diastolic
overestimated
BP cuff bladder
Problem increasing with obese elderly

14
STAGE 2 HYPERTENSION RED YELLOW OR GREEN
LIGHT

RED stop
Cancel surgery
Medical treatment
End-organ disease
BP itself
YELLOW proceed with caution
Co-morbidity control
Perioperative BP control
GREEN go
Perioperative BP control

15
Stage 2 Hypertension Green LightGreen light.
Go

Hypertension is never a green light in patients
65 yrs of age

16
Stage 2 Hypertension Yellow LightProceed with
caution

Hypertension per se minor risk factor
American College of Cardiology
American Heart Association
JNC-7 eliminated Stage 3 classification in 2003
JNC-6 Stage 3 Systolic 180 or diastolic 110
mm Hg
Meta-analysis
Howell Sear Foëx Br J Anaesth 200492570

17
Howell Sear Foëx RecommendationsBr J Anaesth
200492570-83

anaesthesia and surgery should not be cancelled
on the grounds of elevated preoperative arterial
pressure
attention should be paid to the presence of
target organ damage such as coronary artery
disease

18
Howell Sear Foëx RecommendationsBr J Anaesth
200492570-83

intraoperative arterial pressure should be
maintained within 20 of best estimate of
preoperative arterial pressure especially in
patients with markedly elevated preoperative
pressures
Best estimate of preoperative arterial
pressure
Auscultatory (Hg manometer)
Office clinic and hospital records
Does not apply to aortic dissection
Systolic

19
Stage 2 Hypertension Yellow LightProceed with
caution

Preoperative hypertension remain wary Yes
cancel surgery No
Spahn DR Priebe H-J
Br J Anaesth 2004 92461-4 Editorial

20
Stage 2 Hypertension Yellow LightProceed with
caution

Manage comorbidities to avoid
Myocardial ischemia
Congestive heart failure
Expect hemodynamic instability
Hypotension on induction
Hypertension on emergence in PACU
postoperatively

21
Stage 2 Hypertension Red LightRed light.
Stop

high BP measurement
recent change in coronary heart disease signs
symptoms
decompensated congestive heart failure
Really high BP

22
Really High Blood PressureElliott WJ
Progress in Cardiovascular Disease 2006 48316-25

Hypertensive emergency stop
Signs symptoms acute target-organ damage
Hypertensive urgency controversy
Signs or history chronic target-organ damage
Hypertensive situation proceed
Untreated or poorly treated Stage 2 hypertension

23
Hypertensive Urgency Elliott WJ Progress in
Cardiovascular Disease 2006 48316-25

Treating physician feels that it would be unsafe
to leave such a patient without lowering the BP.
There is very limited evidence in the medical
literature that this feeling is in fact true
and even less evidence to support BP lowering in
this setting.

24
Really High Blood Pressure

My feeling really high auscultatory BP
measurement
Normal mental status no acute ECG changes no
increased dyspnea JVD S3 S4 or rales.
Systolic 180 or diastolic 110 mm Hg
tachycardia
Old JNC-6 Stage 3 tachycardia
Isolated systolic 220 mm Hg
20 above old JNC-6 Stage 3
Systolic 200 mm Hg and diastolic 120 mm Hg
Combined really high systolic and diastolic
10 above old JNC-6 Stage 3

25
Treat BP before induction

Controversies with biased answers
Anesthetic agents versus medical drugs
I prefer medical drugs
End-point if use medical drugs
I use HR
Shorter- versus longer-acting agents
e.g. labetalol versus esmolol
I use longer-acting for most elective cases
I use shorter-acting for longer complex cases

26
What BP is too Low

Diastolic pressure end-organ issues
Heart primary concern
Only organ whose perfusion occurs primarily
during diastole
If take care of the heart the other organs will
take care of themselves
Ed Lowenstein MD
Kidneys second order concern
Acute renal decompensation
Brain distant third order concern
Embolic strokes hemorrhagic hypotensive
strokes

27
Diastolic Pressure Coronary Heart
DiseaseMesserli FH et al Ann Intern Med
2006144884 - 893

22776 patients
Chronic treatment
J-shaped relationship for all-cause death DP
Nadir DP 84 mm Hg
MI/stroke ratio constant at DP above nadir
MI/stroke ratio increases with decreasing DP
below nadir i.e more MIs

28
Appropriate Blood Pressure for Patients with
Contrast Nephropathy
Palmer N Engl J Med 2002 348491
29
Suggested Pressure Minimums

Goal Rule of 70s
70 yrs
DP 70 mm Hg
PP
HR 70 bpm
If A-line phenylephrine infusion consider
co-infusion NTG to create the best arterial wave
form (equivalent to timing IABP)
Pauca AL et al Heart 2005 911428-32

30
Which antihypertensive agents should be
discontinued prior to surgery

ACE-I and ARBs
Beta blockers
Calcium channel blockers
Diuretics

31
Which antihypertensive agents should be
discontinued prior to surgery

ASA Panel Highs and Lows of Blood Pressure
When Does It Really Matter
10/15 Drs. Barnett Communale Groban Prielipp
Key comorbidities
Congestive heart failure
More likely to continue ABCD
Coronary heart disease
More likely to continue only BC

32
Comfere T et al Angiotensin system inhibitors
in a general surgical population.Anesth Analg
2005 100636-44

N267
2 groups ACE-I/ARB
10 hrs
Significant incidence of hypotension on
induction
BUT

33
Comfere T et al Angiotensin system inhibitors
in a general surgical population.Anesth Analg
2005 100636-44

This hypotension responded to conventional
therapy i.e. no refractory hypotension and
thus seemed to be of little clinical consequence
withholding should be considered for patients
who may be especially prone to hypotension-induced
complications (e.g. severe aortic stenosis).
No in cardiac events
Induction doses essentially same in both groups
Midazolam 2 mg Propofol 150 mg Fentanyl 150 µg
Arguably high doses for this age group

34
HYPERTENSION

72-yr-old 85 kg man inguinal hernia repair
Meds lisinopril atenolol aspirin statin
BP 200/90 immediately preoperatively
Is this high BP measurement iatrogenic
Auscultatory BP 183/86 HR 62 ACE-I held
anxious
Is high BP a green yellow or red light -
yellow
Treat this BP before induction
Midazolam 0.5 mg 164/82 Labetalol 10 mg 135/75
Induction fentanyl 50 µg propofol 50 mg
lidocaine 75 mg
What BP is too low in hypertensive patients
Single dose of ephedrine 5 mg for diastolic 65 mm
Hg

35
MAJOR TOPICS - PATIENTS PRESENTING WITH

HYPERTENSION
DIASTOLIC DYSFUNCTION
TYPE 2 DIABETES MELLITUS
CORONARY HEART DISEASE

36
DIASTOLIC DYSFUNCTION

75-yr-old 80 kg woman for THR History of CHF
Echo EF 65 normal valvular function LA
enlargment thickened LV normal LV volume
Meds spironolactone verapamil enalapril
Diastolic dysfunction
Perioperative concerns

37
DIASTOLIC DYSFUNCTION vs AGERedfield et al
JAMA 2003 289194

Impaired LV filling at normal LA pressure
Concentric LV hypertrophy
LV ejection fraction 50
LA enlargement

38
LEFT VENTRICULAR FILLING

Rapid filling phase (suction from LV
relaxation)
Young adult 90 Elderly
Slow passive filling phase
Up to 50 in elderly
Maintain preload diastolic filling time
Backs up if overload reduce duration of
diastole (tachycardia) increase LVEDP
(myocardial ischemia hypertension)
Atrial systole
Up to 50 in elderly
Preserve sinus rhythm

39
Diagnosis of Diastolic Dysfunction

Abnormal diastolic heart sounds (S3 S4 gallops)
Specificity 80 sensitivity
Left ventricular hypertrophy
Normal ejection fraction ( 50)
Elevated B-type natriuretic peptide (BNP)
Enlarged left atrium
Increased diastolic filling pressure
Echocardiographic measures

40
B-type Natriuretic Peptide Plasma LevelsMaisel.
N Engl J Med 2002 347163

A-type natriuretic peptide - secreted by atria
when chamber dilates
B-type natriuretic peptide (BNP) - secreted by
ventricles when increased end-diastolic pressure
and volume expansion

41
Left Ventricular Heart Failure

Systolic heart failure
Diastolic heart failure 40
a.k.a. heart failure with preserved systolic
function
flash pulmonary edema
Rapid fluid administration
Routine fluid administration during
decompensation
Tachycardia
Myocardial ischemia
Hypertension
Loss of atrial kick

42
DIASTOLIC DYSFUNCTION

75-yr-old 80 kg woman for THR History of CHF
Echo EF 65 normal valvular function LA
enlargment thickened LV nl LV vol
Meds spironolactone verapamil enalapril
Diastolic dysfunction Yes
Perioperative concerns
Received enalapril BP on induction
Tight fluid management
Avoid tachycardia hypertension myocardial
ischemia
Preserve sinus rhythm

43
MAJOR TOPICS - PATIENTS PRESENTING WITH

HYPERTENSION
DIASTOLIC DYSFUNCTION
TYPE 2 DIABETES MELLITUS
CORONARY HEART DISEASE

44
Diabetes Mellitus New Terminology

American Diabetes Association (1997)
Eliminated terms
Insulin-dependent DM
Non-insulin-dependent DM
Re-classified Diabetes Mellitus
Type I absolute lack of insulin
Type 2 insulin present
Impaired secretion
Insulin resistance

45
Type 2 DM 10 Year Progression

Insulin resistance in muscle cells
Hyperinsulinemia
Decline in pancreatic function
Hyperglycemia (ß-cell function
Type 2 DM
20 of 75 year olds
Coronary heart disease equivalent
Rate of 1st MI in patient with type 2 DM rate
of 2nd MI in patient with CAD without DM

46
Oral Hypoglycemic Agent IssuesGu
Anesthesiology 2003 981359

Sulfonylureas discontinue
Predispose to myocardial ischemia
Metformin discontinue
Lactic acidosis
Thiazolidinediones (glitazones) continue
Actos Avandia
Sensitize response to insulin better
intraoperative control
Kersten et al Anesthesiology 2005 103677-8

47
Kersten Warltier Pagel Aggressive control of
intra-operative glucose concentration.Anesthesiol
ogy 2005 103677-8 (Editorial)

Stated strong evidence exists to indicate
hyperglycemia alone with or without diabetes
contributes to morbidity and mortality in
patients at risk for myocardial ischemia and
reperfusion injury
Speculated thiazolidinedione insulin
sensitizing agents may improve patient outcome by
enhancing degree to which tight control of blood
glucose concentrations may be achieved with
exogenous insulin. Actos Avandia

48
Type 2 Diabetes MellitusTight Control of
GlucoseGu. Anesthesiology 2003 981359

Perioperative insulin infusions
Glucose 80-150 mg/dl intraop
Glucose 80-110 mg/dl postop
Reduces ICU mortality by 40
Improves outcome from acute MI
Decreases infections

49
Ouattara et al Poor intraoperative blood
glucose control is associated with a worsened
hospital outcome after cardiac surgery in
diabetic patients. Anesthesiology 2005
103687-94.

Attempted tight glycemic control in all patients
18 insulin resistance poor control
Morbidity
Poor control 37 (odds ratio 7.2)
Tight control 10
Could not predict poor control preop
Identifies vs. responsible for higher risk

50
INTRAOPERATIVE BLOOD GLUCOSE CONCENTRATIONS IN
DIABETIC CARDIAC SURGERY PATIENTS WITH SAME
INSULIN REGIMEN
Ouattara et al Anesthesiology 2005 103687-94
51
IN-HOSPITAL MORBIDITY VERSUS INTRAOPERATIVE
GLUCOSE CONTROL
Ouattara et al Anesthesiology 2005 103687-94
52
TYPE 2 DIABETES MELLITUS

70-yr-old woman for colon resection. Type 2 DM.
Preop blood glucose 185 mg/dL. Medications
metformin (Glucophage) rosiglitazone (Avandia).
Discontinue oral hypoglycemic agents
Stop metformin continue glitazone
Treat blood glucose
Insulin infusion (1-3 units/hr) - encouraged
Sliding scale - discouraged

53
MAJOR TOPICS - PATIENTS PRESENTING WITH

HYPERTENSION
DIASTOLIC DYSFUNCTION
TYPE 2 DIABETES MELLITUS
CORONARY HEART DISEASE

54
CORONARY HEART DISEASE

68-yr-old man for repair of retinal detachment.
ECG ST depression in II and V5 during emergence
Should he have received ß-blockers in
perioperative period
What is significance of the ST depression
Is this patient suffering a perioperative
myocardial infarction

55
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56
CLINICAL RISK FACTORS

Age 70 yrs
Angina
Past MI
CHF

Past CVA
DM
CRI
COPD

57
MI AFTER AAA SURGERYKertai et al.
Anesthesiology 2004 1004-7
58
Conclusions for High Risk Patients

Clear benefit to ß-blockers
pre-/intra-/post-op
targets Rule of 70s
esmolol boluses intra-op insufficient
Statins pre-/post-op

59
REVISED CARDIAC RISK INDEX

RCRI - one point each for
High risk surgery
Intrathoracic intraperitoneal suprainguinal
vascular
Ischemic heart disease
Cerebrovascular disease
Renal insufficiency
Diabetes mellitus
Lindenauer et al N Engl J Med 2005 353349-61

60
Adjusted Odds Ratio for Death Associated with
Perioperative ß-Blockade in Patients Undergoing
Major Noncardiac Surgery
RCRI Revised Cardiac Risk Index
Lindenauer et al N Engl J Med 2005 353349-61
61
Conclusions for Low Risk Patients

ß-blocker controversy
No benefit Juul AHA Abstract 2004
921 diabetic patients non-cardiac surgery
metoprolol
Harm Lindenauer et al N Engl J Med 2005
353349-61 ( 600000 patients)
2 ongoing randomized trials (results in 4 yrs)
POISE Perioperative Ischemic Evaluation
10000 patients
DECREASE IV 6000 patients
Recommend still yes to ß-blockers
Poldermans Boersma N Engl J Med 2005 353412-4
(Editorial)

62
ESC/ACC Criteria for Acute Evolving or Recent
Myocardial Infarction

Either one of
Typical rise and fall of biochemical markers of
myocardial necrosis (e.g. troponin CK-MB) with
at least one of following
Ischemic symptoms
Development of Q-waves on the ECG
ST changes indicative of ischemia (ST or )
Coronary artery intervention
Pathologic findings of acute MI

63
Does ST Depression Mean Myocardial
InfarctionPriebe H-J Br J Anaesth 2004
939-20

Although ST-segment depression usually reflects
subendocardial ischaemia and is often regarded as
reversible injury it is not inconsistent with a
myocardial infarction. Especially elderly
patients may present with myocardial infarction
without ST-segment elevation.

64
Pre- and Postoperative Troponin
DeterminationsHowell SJ Sear JW Br J Anaesth
2004 933-8

It now seems reasonable to ask if patients with
one or more risk factors for cardiovascular
disease who undergo surgery should have pre-
and postoperative measurements of cardiac
troponin and should receive cardiovascular
secondary prevention if any postoperative
elevation is detected.

65
EFFECT OF ß-BLOCKERS ON TROPONIN RELEASE DURING
MAJOR NONCARDIAC SURGERY IN PATIENTS WITH
ISCHEMIC HEART DISEASE

Elevated troponin I
Atenolol - 22 (9/40)
No atenolol 42 (8/19)
troponin I detected during surgery
Zaugg Anesthesiology 1999 911674

66
DEATH BY 42 DAYS () VS TROPONIN I RELEASE IN
PATIENTS WITHOUT ST ELEVATIONS
67
CORONARY HEART DISEASE

68-yr-old man for repair of retinal detachment.
ECG ST depression in II and V5 during emergence
Should he have received ß-blockers in
perioperative period - yes
What is significance of the ST depression
Myocardial ischemia or myocardial infarction
Is this patient suffering a perioperative
myocardial infarction
Maybe! Draw troponin levels if ST depression
persists beyond several minutes. Observe for
evolution of signs and symptoms of myocardial
infarction

68
HYPERTENSION