ANESTHETIC MANAGEMENT OF THE ELDERLY PATIENT

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ANESTHETIC MANAGEMENT OF THE ELDERLY PATIENT

• Raymond C. Roy, PhD, MD
• Professor Chair of Anesthesiology
• Wake Forest University Health Sciences
• Winston-Salem, NC 27157-1009
• rroy_at_wfubmc.edu

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ONE VIEW OF AGING

• Because modern humans, unlike feral animals,
  have learned how to escape death long after
  reproductive success, we have revealed a process
  that, teleologically, was never intended for us
  to experience.
• Leonard Hayflick

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LIFE SPANGuinness Book of Records

• Oldest man - 120 yrs 237 days
• Oldest woman - 122 yrs 164 days

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LIFE EXPECTANCYat birth USA 1997

• WOMEN
• Caucasian 79.9
• African-American 74.7
• MEN
• Caucasian 74.3
• African-American 67.2

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OLDEST SURGICAL PATIENTOliver. Br J Anaesth
2000 84260

• 113 y/o woman
• Femoral fracture
• General
• CVP, no arterial-line
• Extubation in ICU 5 h postop
• Hospital discharge POD 23

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ANESTHETIC FREQUENCYAdministrations/100 people
(FRANCE)Clergue. Anesthesiology 1999911509

• WOMEN
• 35-44 yrs 13.2
• 75-84 yrs 23.6
• MEN
• 35-44 yrs 8.9
• 75-84 yrs 30.2

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AGE AND ANESTHESIA AND SURGICAL OUTCOME

• WITH ADVANCING AGE
• MORTALITY MORBIDITY INCREASE
• STEEP INCREASE gt 75 yrs
• CAUSE DISEASE or AGE?
• DISEASE gt AGE if lt 85 yrs
• AGE APPROACHES DISEASE gt 85 yrs (age of natural
  death)

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VASCULAR SURGERYMORTALITY vs AGEFleisher.
Anesth Analg 1999 89849
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PERIOPERATIVE COMPLICATION RATES IN MEDICARE
PATIENTS

• INTERMEDIATE RISK - 42
• Silber Anesthesiology 2000 93152 - 217,440
  general orthopedic surgery patients
• LOW RISK - 3
• Schein N Engl J Med 2000 342168 - 18,901
  cataract surgery patients

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ANESTHETIC CONCERNS IN OLDER PATIENTS

• ROUTINE PREOPERATIVE TESTS
• BETA-ADRENERGIC BLOCKADE
• PRE-OXYGENATION
• PROPOFOL INDUCTIONS

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ANESTHETIC CONCERNS IN OLDER PATIENTS

• SHORTER-ACTING RELAXANTS
• MINIMUM DIASTOLIC PRESSURE
• TRANSFUSION TRIGGER
• EMERGENCE TIME

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ANESTHETIC CONCERNS IN OLDER PATIENTS

• REGIONAL vs. GENERAL
• SEDATION DURING SPINAL/EPIDURAL
• POSTOPERATIVE ANALGESIA

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WHY PREOP TESTING?

• SCREENING - NO
• TREATMENT EFFECTIVENESS - YES
• BASELINE MAYBE
• RISK ASSESSMENT - YES

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PREVALENCE OF ABNORMAL PREOPERATIVE TESTS IN 544
CONSECUTIVE NONCARDIAC SURGICAL PATIENTS gt 69
YEARS? Dzankic. Anesth Analg 2001 93301

• Creatinine gt 1.5 mg/dL 12
• Hemoglobin lt 10 mg/dL 10
• Glucose gt 200 mg/dL 7
• K lt 3.5 mEq/L 5
• K gt 5.0 mEq/L 4
• Platelets lt 115,000/ml 2

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VALUE OF PREOPERATIVE TESTING BEFORE CATARACT
(LOW RISK) SURGERY Schein. N Engl J Med 2000
342168
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VALUE OF PREOPERATIVE TESTING BEFORE CATARACT
(LOW RISK) SURGERY Schein. N Engl J Med 2000
342168

• Tests should be ordered only when the history or
  a finding on a physical examination would have
  indicated the need for the test even if surgery
  had not been planned.

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OUTCOMES OF PATIENTS WITH NO LABORATORY
ASSESSMENT FOR INTERMEDIATE RISKSURGERY N
1,044Narr. Mayo Clin Proc 1997 72505

• Patients assessed by history and physical
  examination safely undergo operation with
  tests drawn only as indicated intraoperatively
  and postoperatively.

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NO NON-INVASIVE OR INVASIVE CARDIAC TESTING FOR
INTERMEDIATE RISK SURGERY

• MODERATE FUNCTIONAL CAPACITY INTERMEDIATE
  CLINICAL PREDICTORS
• OR
• POOR FUNCTIONAL CAPACITY MINOR CLINICAL
  PREDICTORS
• J Am Coll Cardiol 1996 27910

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INTERMEDIATE RISK NONCARDIAC SURGERY(Mortality gt
1, lt 5)

• CAROTID
• HEAD NECK
• INTRAPERITONEAL
• INTRATHORACIC
• ORTHOPEDIC
• PROSTATE

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MINOR CLINICAL PREDICTORS

• ADVANCED AGE
• ABNORMAL ECG
• NON-SINUS RHYTHM
• LOW FUNCTIONAL CAPACITY
• STROKE HISTORY
• UNCONTROLLED BP

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INTERMEDIATE CLINICAL PREDICTORS

• MILD STABLE ANGINA
• PRIOR MI
• COMPENSATED CHF
• PRIOR CHF
• DIABETES MELLITUS

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FUNCTIONAL CAPACITY

• MET METABOLIC EQUIVALENT O2 CONSUMPTION OF 70
  kg, 40 y/o MAN IN RESTING STATE
• gt 7 METs - excellent
• 4-7 METs - moderate
• lt 4 METs - poor
• J Am Coll Cardiol 1996 27910-48

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ESTIMATED ENERGY REQUIREMENTS FOR ADL

• 1 MET -------------------------gt 4 METs
• eat, dress, use toilet
• walk indoors around house
• walk 1-2 blocks on level ground
• light house work

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ESTIMATED ENERGY REQUIREMENTS for ADL

• 4 METs -------------------gt 10 METs
• climb flight of stairs, walk up a hill
• walk briskly on level ground
• run a short distance
• do heavy house work
• golf, bowling, dancing, doubles tennis

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IS ROUTINE LABORATORY TESTING INDICATED FOR OLDER
PATIENTS?Fleisher. Anesth Analg 2001 93249

• There is insufficient evidence either to
  advocate routinely performing any given test or
  to clearly define preoperative tests that are
  without value.

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MORE PREOPERATIVE ASSESSMENT BY PHYSICIANS LESS
LABORATORY TESTSRoizen. N Engl Med 2000 342204

• Without changes to the system to increase
  preoperative clinical assessment by physicians,
  we may see poorer patient outcomes and higher
  long term costs.

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IS ROUTINE PREOPERATIVE TESTING IN THE ELDERLY
INDICATED?

• NO, IF
• FOLLOWED BY PRIMARY CARE MD
• GOOD H P WITH NO RED FLAGS
• MODERATE FUNCTIONAL STATUS INTERMEDIATE SURGERY
• OR
• POOR BUT STABLE FUNCTIONAL STATUS LOW RISK
  SURGERY

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LEAST USEFUL ROUTINE PREOPERATIVE TESTS IN OLDER
PATIENTS

• CHEST X-RAY
• PT and PTT in patients not receiving heparin or
  warfarin
• LIVER FUNCTION TESTS

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BETA-ADRENERGIC-BLOCKING DRUGS. INCREDIBLY
USEFUL, INCREDIBLY UNDERUTILIZED

• DAVID C. WARLTIER, MD, PhD
• EDITORIAL
• Anesthesiology 1998 882-5

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PERIOPERATIVE MYOCARDIAL ISCHEMIAWallace.
Anesthesiology 1998 887
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BETA-ADRENERGIC BLOCKADE

• THERAPEUTIC TARGET
• PROVEN INDICATIONS TO ADD
• PROVEN INDICATIONS TO MAINTAIN
• UNCLEAR INDICATIONS
• POSSIBLE ANESTHETIC BENEFITS

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PERIOPERATIVEBETA-BLOCKADETHERAPEUTIC TARGET

• HEART RATE 55 65 bpm
• SYSTOLIC BP gt100 mm Hg
• BEFORE, DURING, AFTER SURGERY

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ADDING PERIOPERATIVEBETA-BLOCKADE PROVEN
INDICATIONSAuerbach. JAMA 2002 2871435

• HIGH RISK 3 MAJOR CRITERIA
• INTERMEDIATE RISK ANY 2 MINOR OR 1-2 MAJOR
  CRITERIA

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CARDIAC RISK INDEXMAJOR CRITERIAAuerbach. JAMA
20022871435

• HIGH RISK SURGERY
• ISCHEMIC HEART DISEASE
• TIA, CVA
• IDDM
• CREATININE gt 2.0

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CARDIAC RISK INDEXMINOR CRITERIAAuerbach. JAMA
20022871435

• gt 64 yrs
• HYPERTENSION
• CURRENT SMOKER
• ELEVATED CHOLESTEROL
• NIDDM

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MAINTAINING PERIOPERATIVEBETA-BLOCKADE PROVEN
INDICATION

• CHRONIC BETA-BLOCKER THERAPY

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PERIOPERATIVEBETA-BLOCKADE UNCLEAR INDICATIONS

• ADDITIONAL DOSE WHEN AT TARGET
• AORTIC STENOSIS
• CONGESTIVE HEART FAILURE
• REGIONAL ANESTHESIA
• NON-SELECTIVE vs BETA-1 SELECTIVE
• LOW RISK PATIENTS

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PRACTICE vs EVIDENCED-BASED BETA-BLOCKADEWrong
Answers from ABA Oral Examinees

• DID NOT ADD IN PREOP CLINIC
• USED HR 80 AS TARGET INTRAOP
• DID NOT ORDER POSTOP (7 days)
• ASSUMED ESMOLOL-BOLUS LONG-ACTING PRE-, INTRA-,
  POSTOP
• (REACTIVE vs PROPHYLACTIC)

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PERIOPERATIVE MYOCARDIAL INFARCTIONS

• MOST OCCUR ON DAY OF SURGERY
• CARDIAC TROPONIN I LOWER IN BETA-BLOCKED PATIENTS
• Zaugg. Anesthesiology 1999 911674

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FREQUENCY OF NEW T-WAVE CHANGES IN PACU?

• Breslow. Anesthesiology 1986 64 398
• 18 of 394 consecutive patients
• Young old, regional general
• 46 flattening 25 - inversion
• No S/S of myocardial ischemia

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FREQUENCY OF NEW T-WAVE CHANGES IN PACU?

• Ashton. J Am Geriatr Soc 1991 39 575
• 21 of 206 TURP patients
• No S/S of myocardial ischemia
• No elevations of CK-MB

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SIGNIFICANCE OF T-WAVE CHANGES IN PACU?

• OCCUR IN PATIENTS WITHOUT CAD
• ELDERLY - NON-TEXTBOOK SIGNS SYMPTOMS OF
  ISCHEMIA
• NO WORKUP IF NO OTHER SOFT SIGNS
• WORKUP IF ANY RHYTHM OR HEMODYMAMIC CHANGE

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PERIOPERATIVEBETA-BLOCKADE POSSIBLEANESTHESTIC
BENEFITSSecondary ObservationsZaugg.
Anesthesiology 1999 911674

• DECREASED ANESTHETIC REQUIREMENTS
• FASTER EMERGENCE
• DECREASED ANALGESIC REQUIREMENTS

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WHY IS PREOXYGENATION MORE IMPORTANT IN OLDER
THAN YOUNGER PATIENTS?

• FASTER DESATURATION
• SLOWER ONSET OF RELAXANTS
• HIGHER INCIDENCE OF CAD

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DESATURATION TIME (sec) to SpO2 90Benumof.
Anesthesiology 1999 91 603
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DESATURATION TIME (sec) to SpO2 95Baraka.
Anesthesiology 1999 91 612
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SUCCINYLCHOLINE AGING1 mg/kgKoscielniak-Nelson
. Anesthesiology 1993 79229
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VECURONIUM AGING0.1 mg/kgKoscielniak-Nelson.
Anesthesiology 1993 79229
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BEST WAY TO PRE-OXYGENATE OLDER
PATIENTS? Benumof. Anesthesiology 1999 91
603 Baraka. Anesthesiology 1999 91 612

• 8 DEEP BREATHS in 60 s
• at 10 L/min O2 flow rate

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PROPOFOL INDUCTIONS 25 81 YRSSchnider.
Anesthesiology 1999 901502

• DOSE
• 2 mg/kg lt 65 yrs, 1 mg/kg gt 64 yrs
• Injection time 13 24 s
• LOSS OF CONSCIOUSNESS
• Young old 40 s
• RETURN OF CONSCIOUSNESS
• 30 yrs 6 min, 75 yrs 10 min

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PROPOFOL INDUCTIONS 20 84 YRSKazama.
Anesthesiology 1999 901517

• HALF-TIME FOR NADIR IN BP
• 20 29 yrs 5.7 min
• 70 85 yrs 10.2 min

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PROPOFOL INDUCTIONS gt 65 YRSHabib. Br J Anaesth
2002 88430

• INDUCTION
• GLYCOPYRROLATE
• PROPOFOL 1 mg/kg
• ALFENTANIL 10 µg/kg or
• REMIFENTANIL 0.5 µg/kg 0.1 µg/kg/min
• SYSTOLIC BP
• lt 100 mm Hg 50
• lt 80 mm Hg 8

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PROPOFOL INDUCTIONSgt 65 YRS

• BOLUS DOSE (lt 30 s)
• No concurrent drugs 1.5 mg/kg
• Concurrent drugs 1.0 mg/kg
• HYPOTENSION
• Continues for 10 min after injection
• SLOWER INJECTION (12 min)
• Less hypotension, LOC with lt 1.0 mg/kg

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ANESTHETIC INDUCTIONgt 65 yrs

• MASK
• DECREASED AIRWAY REFLEXES IN ELDERLY
• BP STABILITY MASK gt IV INDUCTIONS
• Kirkbride et al. Br J Anaesth 200187166P
• SEVOFLURANE NOT JUST FOR KIDS

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SHORTER-ACTING NEUROMUSCULAR BLOCKING AGENTS

• Prefer ROCURONIUM or CISATRACURIUM to VECURONIUM
  or PANCURONIUM in elderly patients
• EVIDENCED-BASED STUDIES
• THEORETICAL REASONS

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SHORTER gt LONGER-ACTING NEUROMUSCULAR BLOCKERS

• EVIDENCED-BASED
• SHORTER PACU STAYS
• Ballantyne. Anesth Analg 1997 85476
• FEWER POSTOP PULMONARY COMPLICATIONS
• Berg. Acta Anaesth Scand 1997 411095
• PROLONGED ACTION IF HYPOTHERMIC
• Caldwell. Anesthesiology 2000 9284

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INTRAOPERATIVE HYPOTHERMIAWho Is at Risk?

• Diabetic Neuropathy
• Kitamura. Anesthesiology 2000 92 1131
• High spinal
• Core T (oC) 34.37 0.15 (T dermatome)
• Frank. Anesthesiology 2000 92 1330
• Advanced age
• Core T (oC) 36.72 0.03 (age in yrs)
• Frank. Anesthesiology 2000 92 1330

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EFFECT OF HYPOTHERMIA ON TIME TO 25 RECOVERY
Vecuronium 0.1 mg/kg Caldwell.
Anesthesiology 2000 92 84
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SHORTER gt LONGER-ACTING NEUROMUSCULAR BLOCKERS

• THEORETICAL
• DECREASED RENAL FUNCTION
• DOSING mg/kg IN OBESE

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OLD OBESE (BMI gt 29.9)Flegal. JAMA 2002
2881723

• 1990 2000
• MEN
• 60-69 yrs 24.8 38.1
• 70-79 20.0 28.9
• 80 8.0 9.6
• WOMEN
• 60-69 yrs 29.8 42.5
• 70-79 25.0 31.9
• 80 15.1 19.5

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MINIMUM DIASTOLIC PRESSURE

• WHEN TREATING SYSTOLIC HYPERTENSION, KEEP
  DIASTOLIC PRESURE
• WITHIN 10 BASELINE
• GREATER THAN 60 mm Mg

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TRANSFUSION TRIGGER

• HCT 30-33
• ELDERLY
• MYOCARDIAL ISCHEMIA
• Wu. N Engl J Med 20023451230

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ELDERLY TAKE LONGER TO EMERGE THAN YOUNGER
PATIENTS

• LOWER MACawake
• HIGHER PAIN THRESHOLD
• HYPOTHERMIA MORE LIKELY
• EMERGENCE HYPERTENSION
• RELUCTANCE TO TURN OFF VAPORIZER
• LONGER DURATIONS OF ACTION
• RELATIVE DRUG OVERDOSES

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ALVEOLAR CONCENTRATIONS UNDERESTIMATE BRAIN
CONCENTRATIONS DURING EMERGENCE FROM ISFLURANE
Lockhart. Anesthesiology 1991 74 575
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REGIONAL VS GENERAL

• MORTALITY MORBIDITY
• REGIONAL GENERAL
• STUDIES (Christopherson Bode)
• BP, HR TIGHTLY CONTROLLED
• HARDER TO CONTROL IN G/A GROUP
• REGIONAL lt GENERAL
• REAL WORLD
• BP, HR NOT TIGHTLY CONTROLLED
• Rogers et al. Br Med J 20003211493

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DOES EPIDURAL ANESTHESIA REDUCE MAC? Yes, by
50! Hodgson. Anesthesiology 1999 91 1687
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DOES EPIDURAL ANESTHESIA REDUCE MAC-BIS50? Yes,
by 34! Hodgson. Anesthesiology 2001 94
799
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DOES SPINAL OR EPIDURAL ANESTHESIA AFFECT
SEDATIVE REQUIREMENTS? YES!

• Sedation, sleep, and lower BIS scores in patients
  during spinal anesthesia without iv sedation
• Pollock. Anesthesiology 2000 93 728
• Gentili. Br J Anaesth 1998 93 970

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DOES SPINAL OR EPIDURAL ANESTHESIA AFFECT
SEDATIVE REQUIREMENTS? YES!

• 30 50 DECREASE IN DOSE OF MIDAZOLAM,
  THIOPENTAL, OR PROPOFOL TO PRODUCE LOC DURING
  SPINAL OR EPIDURAL
• Tverskoy. J Clin Anesth 1994 6 487
• Ben-David. Anesth Analg 1995 81 525
• Tverskoy. Reg Anesth 1996 21 209

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IS SEDATION ROUTINELY REQUIRED IN ELDERLY
PATIENTS DURING SPINAL OR EPIDURAL ANESTHESIA?

• DECREASED SEDATIVE REQUIREMENTS
• Age, spinal or epidural
• SYNERGISTIC DRUG INTERACTIONS
• Easy to overdose
• INADEQUATE BLOCK
• Increased cardiac complications
• ENDPOINT IF WILL SLEEP ANYWAY?

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POSTOPERATIVE TITRATION OF INTRAVENOUS MORPHINE
IN THE ELDERLY PATIENT Abrun. Anesthesiology
2002 9617

• Bolus q 5 min to VAS 30 mm
• 2 mg if lt60 kg 3 mg if gt 60 kg
• Total mg/kg dose young old
• Young (lt 70, mean 45) vs Old (gt 70, mean 76)
• Morbidity young old
• adverse opioid effects, sedation, stopped
  titrations

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AGE IS NOT AN IMPEDIMENT TO EFFECTIVE USE OF
PCAGagliese. Anesthesiology 2000 93601

• RELIEF young old
• TOTAL DOSE old lt young

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PREEMPTIVE ANALGESIAPREVENT SPINAL CORD WINDUP

• PERIPHERAL NERVE BLOCKS
• NMDA ANTAGONISTS
• ketamine 0.15 mg/kg Mg 30 mg/kg methadone
  dextromethorphan
• SYSTEMIC LIDOCAINE
• NSAIDs COX-2 INHIBITORS

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SYSTEMIC LOCAL ANESTHETICS

• IV -gt DECREASED POSTOP PAIN
• Koppert, et al. Perioperative intravenous
  lidocaine reduces postoperative morphine
  consumption after abdominal surgery.
  Anesthesiology 2001 95 A-855
• Groudine, et al. Intravenous lidocaine speeds
  the return of bowel function, decreases
  postoperative pain, and shortens hospital stay in
  patients undergoing radical retropubic
  prostatectomy. Anesth Analg 1998 86 235-9.

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A DOZEN WAYS TO IMPROVE ANESTHESIA IN OLDER
PATIENTS

• H P gt PREOP TESTING gt CXR, PT, PTT
• BETA-BLOCKERS TO HR 55-65
• TIMELY ANTIBIOTIC ADMINISTRATION
• PRE-OXYGENATE 8 DB/60 sec
• LOWER PROPOFOL DOSES
• SHORTER-ACTING MUSCLE RELAXANTS

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A DOZEN WAYS TO IMPROVE ANESTHESIA IN OLDER
PATIENTS

• HIGHER FIO2s CONSIDER 100
• TRANSFUSION TRIGGER HCT 30
• LOWER BRAIN CONCENTRATIONS AT EMERGENCE
• REDUCE POSTOP OPIOID REQUIREMENTS
• REDUCE SEDATIVE DOSES DURING SPINAL OR EPIDURAL
• JOIN SAGA

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SOCIETY FOR THE ADVANCEMENT OF GERIATRIC
ANESTHESIA (SAGA)

• Educational Scientific Exhibit 14
• Offspring of ASA Committee
• Alec Rooke, MD, President
• Rooke_at_u.washington.edu