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Anesthetic Management of the Elderly Patient

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Title: Anesthetic Management of the Elderly Patient


1
Anesthetic Management of the Elderly Patient
  • Raymond C. Roy, PhD, MD
  • Professor Chair of Anesthesiology
  • Wake Forest University Health Sciences
  • Winston-Salem, NC, USA 27157-1009

http//www.wfubmc.edu/anesthesia Education
Annual Meeting American Society of
Anesthesiologists
2
Hayflicks 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.

3
Older Americans
  • 2000 2030
  • gt 65 yrs 12.4 19.6
  • 35 mil 71 mil
  • gt 80 yrs 9.3 mil 19.5 mil

4
(No Transcript)
5
The Oldest..
  • MAN 120 yrs
  • WOMAN 122
  • Guinness Book of Records
  • GENERAL ANESTHETIC 113
  • Br J Anaesth 2000 84260

6
Life Expectancy at birth USA - 1997
  • WOMEN Caucasian 79.9 yrs
  • African-American 74.7
  • MEN Caucasian 74.3
  • African-American 67.2

7
Life Expectancy, Life Span, Maximum Length of
Life
  • Maximum Length of Life gt 120 yrs
  • Life Span 85-100
  • Natural death (no trauma or disease)
  • Life Expectancy (USA) 67-80
  • Premature death (trauma, disease)

8
Oldest Surgical Patient? Oliver. Br J Anaesth
2000 84260
  • Woman, 113 yrs, femoral fracture
  • General anesthesia
  • CVP, no arterial-line
  • Extubation in ICU after 5h
  • Hospital discharge POD 23

9
Anesthetics per 100 Population? Clergue.
Anesthesiology 1999 911509 (France)
Ages (yrs) Men Women
35 44 8.9 13.2
55 - 64 17.7 14.6
75 - 84 30.2 23.6
10
Vascular Surgery Mortality vs Age Fleisher.
Anesth Analg 1999 89849
11
Perioperative Complication Rates in Medicare
Patients
  • Intermediate Risk Surgery - 42
  • Silber, Anesthesiology 2000 93152
  • 217,440 general orthopedic surgery
  • Low Risk Surgery - 3
  • Schein, N Engl J Med 2000 342168
  • 18,901 cataract surgery

12
Age Perioperative Outcome
  • With advancing age
  • More surgery
  • Morbidity increases
  • Mortality increases
  • Cause - disease vs age ?
  • Disease gt age when lt 85 yrs
  • Age may disease when gt 85 yrs
  • Increase ASA PS when gt 85 yrs

13
Preoperative Considerations
  • Preoperative Assessment
  • No routine preoperative testing
  • Statin myopathic syndromes
  • Diastolic dysfunction
  • Diabetes Mellitus
  • Tighter glucose control with insulin
  • Stop oral hypoglycemic agents

14
Why Obtain Preoperative Tests?
  • Screening NO with one exception
  • Urinalysis if hip surgery or acutely ill
  • Cook Rooke, Anesth Analg 2003 961823
  • Treatment effectiveness - YES
  • Baseline MAYBE, but overused
  • Risk Assessment - YES

15
Value of Preoperative Testing Before Low Risk
Surgery Schein. N Engl J Med 2000 342168
16
Value of Preoperative Testing Before 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.

17
Intermediate Risk Noncardiac Surgery (Mortality gt
1, lt 5)
  • CAROTID
  • HEAD NECK
  • INTRAPERITONEAL
  • INTRATHORACIC
  • ORTHOPEDIC
  • PROSTATE

18
Preoperative Tests - Prevalence of Abnormal
Results 544 consecutive intermediate risk
non-cardiac surgical patients gt 69 yrs - 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

19
Outcomes of Patients with No Laboratory
Assessment for Intermediate Risk Surgery N
1,044 Narr. Mayo Clin Proc 1997 72505
  • Patients assessed by history and physical
    examination safely undergo operation with
    tests drawn only as indicated intraoperatively
    and postoperatively.

20
Is ROUTINE Preoperative Testing Indicated?
  • NO (my opinion), IF
  • FOLLOWED BY PRIMARY CARE MD
  • RELIABLE SYSTEM TO OBTAIN H P
  • NO RED FLAGS IN H P
  • MODERATE FUNCTIONAL STATUS INTERMEDIATE RISK
    SURGERY OR
  • POOR BUT STABLE FUNCTIONAL STATUS LOW RISK
    SURGERY

21
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

22
INTERMEDIATE CLINICAL PREDICTORS
  • MILD STABLE ANGINA
  • PRIOR MI
  • COMPENSATED CHF
  • PRIOR CHF
  • DIABETES MELLITUS

23
FUNCTIONAL CAPACITY
  • MET metabolic equivalent O2 consumption of 70
    kg, 40 yr old man in resting state
  • gt 7 METs - excellent
  • 4-7 METs - moderate
  • lt 4 METs - poor
  • J Am Coll Cardiol 1996 27910-48

24
Estimated Energy Requirements for Activities of
Daily Living - 1
  • 1 MET -------------------------gt 4 METs
  • eat, dress, use toilet
  • walk indoors around house
  • walk 1-2 blocks on level ground
  • light house work

25
Estimated Energy Requirements for Activities of
Daily Living - 2
  • 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

26
Most Difficult ROUTINE Preoperative Tests to
Justify
  • Chest X-ray
  • PT and aPTT (if no heparin or warfarin)
  • Liver Function Tests

27
4 Statin Myopathic Syndromes Thompson. JAMA 2003
2891681
  • STATIN MYOPATHY
  • Any muscle complaint with onset coincident with
    start of statin therapy
  • MYALGIA with normal CK
  • MYOSITIS with elevated CK
  • RHABDOMYOLYSIS

28
of Older Patients with Diastolic Dysfunction
29
Diabetes Mellitus 8.7 of Elderly
  • Ischemic heart disease
  • Problems with all oral hypoglycemic agents
  • More infections pulmonary, wound
  • Decreased pulmonary function
  • Decreased response to hypoxia
  • Prolonged response to vecuronium

30
Problems with Oral Hypoglycemic Agents Gu.
Anesthesiology 2003 981359
  • Sulfonylureas myocardial ischemia
  • Interfere with K-ATP channels
  • Prevent ischemic preconditioning
  • Eliminate ECG benefit of warm-up
  • Eliminate functional benefit of warm-up
  • Worsen dipyridamole-induced ischemia
  • Metformin lactic acidosis

31
Diabetes Mellitus Tight Control of Glucose Gu.
Anesthesiology 2003 981359
  • Insulin infusions to maintain glucose
  • 80-150 mg/dl intraoperatively
  • 80-110 mg/dl postoperatively
  • Reduce ICU mortality by 40
  • Improve outcome from acute MI
  • Decrease infections

32
Beta-adrenergic Blocking Agents Perioperative
Administration
  • Reduces myocardial ischemia
  • Reduces myocardial infarction
  • Secondary Observations
  • Zaugg. Anesthesiology 1999 911674
  • Decrease anesthetic administration
  • Enable faster emergence
  • Decrease post-op analgesic requirement

33
Perioperative Myocardial Ischemia Wallace.
Anesthesiology 1998 887
MYOCARDIAL ISCHEMIA ATENOLOL (N 99) PLACEBO (N 101)
POD 0 - 2 17 34 p 0.008
POD 0 - 7 24 39 p 0.029
34
Perioperative Beta-Blockade - Therapeutic Target
Auerbach. JAMA 2002 2871435
  • HEART RATE 55 65 bpm
  • SYSTOLIC gt100 mm Hg
  • Before, during, and after surgery

35
Actual Practice versus Evidenced-based
Beta-blockade Wrong 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)

36
General Anesthesia
  • Anesthetic depth
  • Neuromuscular blocking agents
  • Diastolic pressure
  • Transfusion trigger
  • Regional vs general anesthesia

37
MAC Age Nickalls. Br J Anaesth 2003 91170
38
Nitrous Oxide MAC Age Nickalls. Br J Anaesth
2003 91170
39
End-tidal Isoflurane to Provide MAC with N2O in
80 Year Olds Nickalls. Br J Anaesth 2003 91170
40
Most of Us Overdose Elderly
  • Gas monitors
  • Assume patient is 40 yrs old
  • Do not know what other drugs given
  • Do not know opioids epidurals lower MAC
  • Underestimate brain concentration on emergence
  • BIS Index 55-60 with beta-blockers better than
    BIS Index 35-45

41
End-tidal Concentrations Under-estimate Brain
Concentrations During Emergence from
Isoflurane Lockhart. Anesthesiology 1991 74575
42
PROPOFOL INDUCTIONS IN 25 81 YR-OLDS Schnider.
Anesthesiology 1999 901502
  • Propofol 2 mg/kg lt 65 yrs 1 mg/kg gt 65 yrs
  • Injection time 13-24 s
  • Loss of consciousness
  • Young old 40 s
  • Return of consciousness
  • 30 yrs 5 min, 75 yrs 10 min

43
PROPOFOL INDUCTIONS 20 84 YRS Kazama.
Anesthesiology 1999 901517
  • HALF-TIME FOR NADIR IN BP
  • 20 29 yrs 5.7 min
  • 70 85 yrs 10.2 min

44
PROPOFOL INDUCTIONS gt 65 YRS Habib. Br J Anaesth
2002 88430
  • Glycopyrrolate, propofol 1 mg/kg, and either
    alfentanil 10 µg/kg or remifentanil 0.5 µg/kg
    0.1 µg/kg/min
  • SBP lt 100 mmHg 50, lt 80 mmHg 8

45
RECOMMENDED PROPOFOL DOSE FOR INDUCTION IF gt 65
yrs old
  • IF BOLUS (lt 30 s)
  • No concurrent drugs 1.0-1.5 mg/kg
  • Concurrent drugs 0.5-1.0 mg/kg
  • HYPOTENSION
  • Continues for 10 min after injection
  • Fentanyl peak 6-8 min, midazolam peak 5 min
  • PREFER SLOWER INJECTION (1 min)
  • Less hypotension if slow with lt 1.0 mg/kg

46
Elderly Take Longer to Emerge Than Younger
Patients
  • Lower MACawake and higher pain threshold
  • Hypothermia more likely
  • Emergence hypertension treated as light
    anesthesia
  • Reluctance to turn off vaporizer
  • Longer durations of action for drugs in elderly
  • Relative drug overdoses
  • Synergistic drug interactions

47
Neuromuscular Blocking Agents in the Elderly - 1
  • Same initial dose as in younger
  • Longer onset times with
  • Advanced age
  • Vecuronium vs rocuronium
  • Tullock. Anesth Analg 1990 7086
  • Esmolol
  • Szmuk. Anesth Analg 2000 901217

48
Onset Time (sec) Increases with Advancing Age
Koscielniak-Nelson. Anesthesiology 1993 79229
49
Neuromuscular Blocking Agents in the Elderly - 2
  • Longer duration (except cisatracurium)
  • Advanced age
  • Intraoperative hypothermia (34.7o C)
  • Diabetes mellitus (8.7 of elderly)
  • Obesity dosing mg/kg

50
Obesity in Older Men with BMI gt 29.2 Flegal.
JAMA 2002 2881723
51
Obesity in Older Women with BMI gt 29.2 Flegal.
JAMA 2002 2881723
52
Times to Reappearance of T1, T2, T3, T4 after
Vecuronium 0.1 mg/kg in Patients with Diabetes
Mellitus Saito. Br J Anaesth 2003 90480
53
Effect of Hypothermia on Time-to-25-Recovery
from Vecuronium 0.1 mg/kg Caldwell.
Anesthesiology 2000 92 84
54
Rocuronium gt Vecuronium gt Pancuronium (My
Practice)
  • Fastest onset
  • Shortest duration
  • Least inter-patient variability
  • Easiest to reverse
  • Shortest PACU length of stay
  • Fewest post-op pulmonary complications
  • Cisatracurium gt rocuronium if renal
    insufficiency

55
Transfusion Trigger for Elderly Hgb 10 g/dl or
Hct 0.30
  • Ischemic Heart Disease
  • Especially if reversible ischemia, unstable
    angina, recent infarction or dysfunction
  • Pulmonary Disease
  • Intra-thoracic or intra-abdominal surgery
  • Leukocyte-reduced
  • Walsh, McClelland, Br J Anaesth 2003 719

56
Minimum Diastolic Pressure Pauca Abstract ASA 2003
  • When treating systolic pressure (SP), pay
    attention to diastolic pressure (DP)
  • To maintain coronary perfusion, keep
  • DP at least 2/3rd SP
  • DP greater than Pulse Pressure
  • DP at least 60 mmHg

57
Regional vs General Anesthesia Mortality
Morbidity
  • REGIONAL GENERAL
  • BP, HR tightly controlled in studies
  • More interventions to control BP, HR in general
    anesthesia group
  • REGIONAL lt GENERAL
  • Real world , BP, HR not tightly controlled
  • Included combined regional-general in regional
    group
  • Rogers et al. Br Med J 20003211493

58
Postoperative Considerations
  • Postoperative Analgesia
  • Postoperative Delirium

59
Postoperative Titration of Intravenous Morphine
in Elderly Patients Abrun. Anesthesiology 2002
9617
  • Bolus q 5 min to VAS 30 (max 100)
  • 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

60
Age is not an Impediment to Effective Use of PCA
Gagliese. Anesthesiology 2000 93601
  • Initial Dose for Pain Relief
  • young old
  • Total Dose
  • old lt young

61
Postoperative Delirium in 5-50 That Appears on
PODs 1-3 Cook. Anesth Analg 2003 961823
  • Cellular proteins altered by potent inhaled
    agents
  • Central cholinergic insufficiency, Microemboli
  • Preexisting subclinical dementia, Hypoxia
  • Fever, Infection (UTI, sinusitis, pneumonia)
  • Electrolyte abnormalities, Anemia, Pain
  • Sleep deprivation, Unfamiliar environment

62
Ten Ways to Improve Anesthesia in Older Patients
  1. H P gt Pre-op Testing gt CXR, PT, PTT
  2. Beta-blockers pre-. intra-, post-op
  3. Timely antibiotic administration
  4. Lower doses of inhaled iv agents
  5. Rocuronium or cisatracurium

63
Ten Ways to Improve Anesthesia in Older Patients
  • 6. Higher FIO2 intra-, post-op
  • 7. Transfusion trigger Hct .30
  • 8. Diastolic pressure 60 mmHg
  • 9. Blood glucose - periop 80-150 mg/dl
  • 10. Reduce post-op opioid requirements
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