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GERIATRICS

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GERIATRICS. Donna Nyght, CRNA. GERIATRIC POPULATION. Growing faster than any other age group ... New agents good for geriatrics. Less metabolism. Low blood solubility ... – PowerPoint PPT presentation

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Title: GERIATRICS


1
GERIATRICS
  • Donna Nyght, CRNA

2
GERIATRIC POPULATION
  • Growing faster than any other age group
  • In 2000, 50 million Americans gt70
  • 13 of general population

3
PATIENTS OVER AGE 65
  • Over half will have at least 1 surgery
    anesthetic before dying
  • Aging process concomitant diseases increase
    risk of morbidity mortality
  • Emergency surgery increases risk even more

4
ANATOMIC PHYSILOGIC CHANGES
  • Structural changes in cells organs
  • Cell division fails
  • Organ function shows linear decline with age
  • Body fat increases
  • Blood volume decreases
  • Loss of protective reflexes
  • Inability to retain body heat
  • Reduced lean body mass
  • Loss of skin elasticity
  • Loss of collagen
  • Intracellular water decreases

5
Human Organ Function Declines with Age
  • Linear decline
  • After age 30, lose 1 per year functional
    capacity
  • 60 y/o has 30 less function of any given organ
    system than a 30 y/o
  • Healthy 30 y/o has 4-10 times the necessary organ
    function

6
Administration of Anesthesia
  • Body composition change has huge impact on pt.
    care
  • Loss of skeletal muscle
  • Blood volume reduced 20-30
  • Body fat increases, so increase in lipid storage
  • Prolonged effect of anesthetic

7
Hypothermia
  • Highly susceptible to decreases in temperature
  • BMR declines with age
  • Lack of autonomic peripheral vasoconstriction
  • Shivering in PACU
  • Postop protein catabolism

8
Positioning
  • Decreased range of motion
  • Prevent trauma
  • Use of padding

9
Skin
  • More sensitive to damage
  • Tape
  • Monitoring devices
  • Collagen loss
  • Elasticity of tissue decreases

10
Airway
  • Protective airway reflexes diminish
  • Difficult mask fit
  • Limited range of motion

11
Cardiovascular
  • Cardiac output reduced
  • Impaired myocardial function
  • Prolonged circulation time
  • Delayed onset of drug effects
  • Decreased organ perfusion
  • Anesthetics cause myocardial depression and
    hypotension
  • Higher incidence of CHF

12
Cardiovascular
  • Myocardial fiber atrophy
  • Arterial vasculature loses elasticity
  • LVH
  • Increased peripheral vascular resistance
  • Systemic hypertension
  • CAD

13
Cardiovascular
  • Myocardium becomes thicker and stiffer in aging
    heart
  • Atrial contraction becomes more important
  • Loss of atrial contraction causes drop in
    systolic pressure
  • Decreased response to adrenergic drugs

14
Pulmonary
  • Generalized reduction of elasticity
  • Decrease in lung compliance
  • Ventilation-perfusion mismatch
  • Increased physiologic shunt
  • Oxygen exchange diminished at alveoli

15
Pulmonary
  • Loss of skeletal muscle elasticity around alveoli
    and lung ducts
  • Alveoli more distended at rest and less
    distensible during inspiration
  • Closing volume increases

16
Pulmonary
  • Deterioration of intervertebral discs
  • Loss of height
  • ? total lung capacity
  • Chest expansion restricted
  • ? stiffness of thoracic cage
  • Progressive dorsal kyphosis

17
Pulmonary
  • Surface area of alveoli ?
  • Thickening of alveolicapillary membrane
  • ? capillary blood flow
  • PaO2 ? with age
  • PaO2 - 100 - (0.4 age yrs mm Hg)

18
Nervous System
  • ? CNS activity
  • Neuronal density decreased
  • ? cerebral metabolic oxygen consumption
  • Blood flow ?
  • Neurotransmitter receptor sites ?
  • Conduction velocity slows in peripheral nerves
  • Reduced number of fibers in spinal cord tracts

19
Nervous System
  • Cognitive loss questionable
  • Target organ for anesthetic agents
  • Reduced requirements
  • Required MAC of inhalation agent ?
  • ? locals, narcotics, barbiturates,
    benzodiazepines, etc.

20
Renal System
  • GFR ? 6-8 per decade
  • Renal blood flow ? 1-2 after age 25
  • Reduced cardiac output
  • Size of renal vascular bed diminished

21
Renal System
  • Impaired drug elimination
  • Decreased ability to concentrate urine
  • More susceptible to fluid overload
  • ? ability to conserve water

22
Hepatobiliary System
  • ? blood flow
  • Reduced plasma drug clearance

23
Endocrine System
  • Pancreatic function ?
  • Higher incidence of diabetes
  • Impaired ability to metabolize glucose

24
Pharmacokinetics
  • What the body does to the drug
  • Drug absorption
  • Tissue distribution
  • Metabolism
  • Elimination

25
Pharmacokinetics
  • Contracted vascular volume?high initial plasma
    concentration
  • ? protein binding?availability of free drug
    increased
  • ? total body adipose tissue?prolonged action of
    lipid-soluble drugs
  • ? renal and hepatic blood flow?prolonged action
    of drugs dependent on kidney and liver
    elimination

26
Pharmacodynamics
  • What the drug does to the body
  • Concentration of drug at site of action
  • Intensity of effect
  • Well documented that dose/MAC of anesthetic
    agents ?

27
Pharmacodynamics
  • ? barbiturate (pentothal) dose 30-40
  • Decrease propofol dose
  • More pronounced hypotension
  • MAC of inhalation agents ?
  • 4 ? per decade after age 40
  • New agents good for geriatrics
  • Less metabolism
  • Low blood solubility
  • Less depression of myocardium

28
Pharmacodynamics
  • Hepatic clearance reduced
  • ? half-life and duration of narcotics
  • ? half-life and duration of nondepolarizing
    muscle relaxants
  • Prolonged effect of succinylcholine

29
Anesthetic Management
  • Consider anatomic and physiologic changes
  • Need for adjustment of drug dosages
  • Multiple disease processes

30
History
  • Extremely important!
  • Need for information from family and other
    caregivers

31
Patient Assessment
  • Thorough history and physical exam
  • Common coexisting diseases
  • Hypertension
  • Diabetes mellitus
  • Coronary artery disease
  • Chronic obstructive pulmonary disease
  • Rheumatoid arthritis
  • Osteoarthritis

32
Patient Assessment
  • Complete list of medications
  • Look for drugs that prolong bleeding times
  • Antihypertensive agents
  • Careful assessment of allergies vs. side effects
    of drugs

33
Patient Assessment
  • Lab results
  • Xrays
  • ECG
  • Other tests

34
Premedication
  • Lower versed dose
  • Lower narcotic dose
  • TITRATE!!!!

35
Anesthetic Technique
  • Choice of anesthetic technique based on
  • Organ system function
  • Effect of medications
  • Surgical requirements
  • Needs and susceptibilities of patient
  • Hypotension
  • Delayed drug clearance

36
Monitoring
  • Standard noninvasive monitors
  • Debate about more aggressive use of invasive
    monitors in elderly

37
Postanesthesia Recovery
  • Cardiac and pulmonary complications are most
    common
  • ? incidence of regurgitation and aspiration
  • Longer duration of drugs
  • More likely to develop CHF
  • Unable to tolerate heat loss
  • More likely to be confused and combative
  • Increased risk of morbidity and mortality

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