Anesthesia for elderly

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Anesthesia for elderly

  1. 1. Anesthetic Management ofthe 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. 2. Hayflick’s 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. 3. # Older Americans 2000 2030 > 65 yrs 12.4% 19.6% 35 mil 71 mil > 80 yrs 9.3 mil 19.5 mil
  4. 4. The Oldest…..• MAN 120 yrs• WOMAN 122 – Guinness Book of Records• GENERAL ANESTHETIC 113 – Br J Anaesth 2000; 84:260
  5. 5. Life Expectancy at birthUSA - 1997WOMEN Caucasian 79.9 yrs African-American 74.7MEN Caucasian 74.3 African-American 67.2
  6. 6. Life Expectancy, Life Span, & Maximum Length of Life• Maximum Length of Life > 120 yrs• Life Span 85-100 – Natural death (no trauma or disease)• Life Expectancy (USA) 67-80 – Premature death (trauma, disease)
  7. 7. Oldest Surgical Patient?Oliver. Br J Anaesth 2000; 84:260 • Woman, 113 yrs, femoral fracture • General anesthesia • CVP, no arterial-line • Extubation in ICU after 5h • Hospital discharge POD 23
  8. 8. # Anesthetics per 100 Population?Clergue. Anesthesiology 1999; 91:1509 (France) Ages (yrs) Men Women 35 – 44 8.9 13.2 55 - 64 17.7 14.6 75 - 84 30.2 23.6
  9. 9. Vascular Surgery – Mortality vs AgeFleisher. Anesth Analg 1999; 89:849 25% 20% 15% aortic 10% infrainquinal 5% 0% <65 66-70 71-75 76-80 81-85 >85 yrs
  10. 10. Perioperative ComplicationRates in Medicare Patients• Intermediate Risk Surgery - 42% – Silber, Anesthesiology 2000; 93:152 – 217,440 general & orthopedic surgery• Low Risk Surgery - 3% – Schein, N Engl J Med 2000; 342:168 – 18,901 cataract surgery
  11. 11. Age & Perioperative Outcome • With advancing age – More surgery – Morbidity increases – Mortality increases • Cause - disease vs age ? – Disease > age when < 85 yrs – Age may = disease when > 85 yrs – Increase ASA PS when > 85 yrs
  12. 12. Preoperative Considerations• Preoperative Assessment – No routine preoperative testing – Statin myopathic syndromes – Diastolic dysfunction• Diabetes Mellitus – Tighter glucose control with insulin – Stop oral hypoglycemic agents
  13. 13. Why Obtain Preoperative Tests?• Screening – NO with one exception – Urinalysis if hip surgery or acutely ill – Cook & Rooke, Anesth Analg 2003; 96:1823• Treatment effectiveness - YES• Baseline – MAYBE, but overused• Risk Assessment - YES
  14. 14. Value of Preoperative TestingBefore Low Risk SurgerySchein. N Engl J Med 2000; 342:168 Rate/100 Untested TestedMedical Event: Intraop 1.87 1.94 Postop .92 .94Unplanned Hospitalization .34 .29Death .02 .01Total 3.13 3.13
  15. 15. Value of Preoperative TestingBefore Low Risk SurgerySchein. N Engl J Med 2000; 342:168“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.”
  16. 16. Intermediate Risk NoncardiacSurgery (Mortality > 1%, < 5%) CAROTID HEAD & NECK INTRAPERITONEAL INTRATHORACIC ORTHOPEDIC PROSTATE
  17. 17. Preoperative Tests - Prevalence ofAbnormal Results544 consecutive intermediate risk non-cardiac surgicalpatients > 69 yrs - Dzankic. Anesth Analg 2001; 93:301 Creatinine > 1.5 mg/dL 12% Hemoglobin < 10 mg/dL 10% Glucose > 200 mg/dL 7% K+ < 3.5 mEq/L 5% K+ > 5.0 mEq/L 4% Platelets < 115,000/ml 2%
  18. 18. Outcomes of Patients with NoLaboratory Assessment forIntermediate Risk Surgery N = 1,044 Narr. Mayo Clin Proc 1997; 72:505“Patients … assessed by history and physical examination … safely undergo … operation with tests drawn only as indicated intraoperatively and postoperatively.”
  19. 19. Is ROUTINE PreoperativeTesting 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
  20. 20. No Non-invasive or InvasiveCardiac Testing for IntermediateRisk Surgery MODERATE FUNCTIONAL CAPACITY + INTERMEDIATE CLINICAL PREDICTORS OR POOR FUNCTIONAL CAPACITY + MINOR CLINICAL PREDICTORS J Am Coll Cardiol 1996; 27:910
  21. 21. INTERMEDIATECLINICAL PREDICTORS MILD STABLE ANGINA PRIOR MI COMPENSATED CHF PRIOR CHF DIABETES MELLITUS
  22. 22. FUNCTIONAL CAPACITY MET= metabolic equivalent O2 consumption of 70 kg, 40 yr old man in resting state > 7 METs - excellent 4-7 METs - moderate < 4 METs - poor – J Am Coll Cardiol 1996; 27:910-48
  23. 23. Estimated Energy Requirementsfor Activities of Daily Living - 1 1 MET -------------------------> 4 METs – eat, dress, use toilet – walk indoors around house – walk 1-2 blocks on level ground – light house work
  24. 24. Estimated Energy Requirementsfor Activities of Daily Living - 2 4 METs -------------------> 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
  25. 25. Most Difficult ROUTINEPreoperative Tests to Justify• Chest X-ray• PT and aPTT (if no heparin or warfarin)• Liver Function Tests
  26. 26. 4 Statin Myopathic SyndromesThompson. JAMA 2003; 289:1681 • STATIN MYOPATHY – Any muscle complaint with onset coincident with start of statin therapy • MYALGIA with normal CK • MYOSITIS with elevated CK • RHABDOMYOLYSIS
  27. 27. % of Older Patients withDiastolic Dysfunction 60 50 40 30 Mild Moderat e 20 Severe 10 0 45-54 55-64 65-74 75 or great er
  28. 28. Diabetes Mellitus – 8.7% ofElderly• Ischemic heart disease• Problems with all oral hypoglycemic agents• More infections – pulmonary, wound• Decreased pulmonary function• Decreased response to hypoxia• Prolonged response to vecuronium
  29. 29. Problems with Oral Hypoglycemic Agents Gu. Anesthesiology 2003; 98:1359• 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
  30. 30. Diabetes Mellitus – TightControl of GlucoseGu. Anesthesiology 2003; 98:1359• 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
  31. 31. Beta-adrenergic BlockingAgents – PerioperativeAdministration• Reduces myocardial ischemia• Reduces myocardial infarction• Secondary Observations – Zaugg. Anesthesiology 1999; 91:1674 – Decrease anesthetic administration – Enable faster emergence – Decrease post-op analgesic requirement
  32. 32. Perioperative MyocardialIschemiaWallace. Anesthesiology 1998; 88:7MYOCARDIAL ATENOLOL PLACEBOISCHEMIA (N = 99) (N = 101)POD 0 - 2 17 34* * p = 0.008POD 0 - 7 24 39** **p = 0.029
  33. 33. Perioperative Beta-Blockade -Therapeutic TargetAuerbach. JAMA 2002; 287:1435• HEART RATE 55 – 65 bpm• SYSTOLIC >100 mm Hg• Before, during, and after surgery
  34. 34. 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)
  35. 35. General Anesthesia• Anesthetic depth• Neuromuscular blocking agents• Diastolic pressure• Transfusion trigger• Regional vs general anesthesia
  36. 36. MAC & AgeNickalls. Br J Anaesth 2003; 91:170 9 8 7 6 5 1 yr 4 40 yr 3 80 yr 2 1 0 I soflurane Sevoflurane Desflurane
  37. 37. Nitrous Oxide MAC & AgeNickalls. Br J Anaesth 2003; 91:170 140 120 100 80 1 yr 40 yr 60 80 yr 40 20 0 Nit rous Ox ide
  38. 38. End-tidal Isoflurane to ProvideMAC with N2O in 80 Year OldsNickalls. Br J Anaesth 2003; 91:170 1 0.8 0.6 0% N2O 50% N2O 0.4 67% N2O 0.2 0 I sof lurane
  39. 39. 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
  40. 40. End-tidal Concentrations Under-estimate Brain ConcentrationsDuring Emergence from IsofluraneLockhart. Anesthesiology 1991; 74:575 0.7 0.6 0.5 0.4 End-t idal conc rat io 0.3 Cerebral conc rat io 0.2 0.1 0 0-6 13-18 25-30 m in
  41. 41. PROPOFOL INDUCTIONS IN 25 –81 YR-OLDSSchnider. Anesthesiology 1999; 90:1502• Propofol: 2 mg/kg < 65 yrs; 1 mg/kg > 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
  42. 42. PROPOFOL INDUCTIONS 20– 84 YRSKazama. Anesthesiology 1999; 90:1517 HALF-TIME FOR NADIR IN BP 20 – 29 yrs 5.7 min 70 – 85 yrs 10.2 min
  43. 43. PROPOFOL INDUCTIONS >65 YRSHabib. Br J Anaesth 2002; 88:430 Glycopyrrolate, propofol 1 mg/kg, and either alfentanil 10 μg/kg or remifentanil 0.5 μg/kg + 0.1 μg/kg/min SBP: < 100 mmHg 50%, < 80 mmHg 8%
  44. 44. RECOMMENDED PROPOFOL DOSE FOR INDUCTION IF > 65 yrs oldIF BOLUS (< 30 s) No concurrent drugs 1.0-1.5 mg/kg Concurrent drugs 0.5-1.0 mg/kgHYPOTENSION Continues for 10 min after injection Fentanyl peak 6-8 min, midazolam peak 5 minPREFER SLOWER INJECTION (1 min) Less hypotension if slow with < 1.0 mg/kg
  45. 45. Elderly Take Longer to EmergeThan 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
  46. 46. Neuromuscular Blocking Agentsin the Elderly - 1• Same initial dose as in younger• Longer onset times with: – Advanced age – Vecuronium vs rocuronium • Tullock. Anesth Analg 1990; 70:86 – Esmolol • Szmuk. Anesth Analg 2000; 90:1217]
  47. 47. Onset Time (sec) Increases withAdvancing AgeKoscielniak-Nelson. Anesthesiology 1993; 79:229 300 250 200 succinylcholine 1 150 m g/ kg vecuronium 0.1 100 m g/ kg 50 0 3-10 yrs 20-40 60-80
  48. 48. Neuromuscular Blocking Agentsin the Elderly - 2 • Longer duration (except cisatracurium) – Advanced age – Intraoperative hypothermia (34.7o C) – Diabetes mellitus (8.7% of elderly) – Obesity – dosing mg/kg
  49. 49. Obesity in Older Men% with BMI > 29.2Flegal. JAMA 2002; 288:1723 40 35 30 25 20 1990 15 2000 10 5 0 60-69 70-79 80+ yrs
  50. 50. Obesity in Older Women% with BMI > 29.2Flegal. JAMA 2002; 288:1723 45 40 35 30 25 1990 20 2000 15 10 5 0 60-69 70-79 80+ yrs
  51. 51. Times to Reappearance of T1, T2, T3,& T4 after Vecuronium 0.1 mg/kg inPatients with Diabetes MellitusSaito. Br J Anaesth 2003; 90:480 70 60 50 40 No DM 30 DM 20 10 0 T1 T2 T3 T4
  52. 52. Effect of Hypothermia on Time-to-25%-Recovery from Vecuronium 0.1mg/kgCaldwell. Anesthesiology 2000; 92: 84 70 60 50 40 30 Time (min) 20 10 0 34 35 36 37 38 C
  53. 53. Rocuronium > Vecuronium >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 > rocuronium if renal insufficiency]
  54. 54. Transfusion Trigger for ElderlyHgb 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
  55. 55. Minimum Diastolic PressurePauca 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
  56. 56. Regional vs GeneralAnesthesia – Mortality &MorbidityREGIONAL = GENERAL • BP, HR tightly controlled in studies • More interventions to control BP, HR in general anesthesia groupREGIONAL < GENERAL • “Real world” , BP, HR not tightly controlled • Included combined regional-general in regional group • Rogers et al. Br Med J 2000;321:1493
  57. 57. Postoperative Considerations• Postoperative Analgesia• Postoperative Delirium
  58. 58. Postoperative Titration ofIntravenous Morphine in ElderlyPatientsAbrun. Anesthesiology 2002; 96:17 • Bolus q 5 min to VAS = 30 (max 100) – 2 mg if <60 kg; 3 mg if > 60 kg • Total mg/kg dose: young = old – Young (< 70, mean 45) vs Old (> 70, mean 76) • Morbidity – young = old – adverse opioid effects, sedation, stopped titrations
  59. 59. Age is not an Impediment toEffective Use of PCAGagliese. Anesthesiology 2000; 93:601 • Initial Dose for Pain Relief: – young = old • Total Dose: – old < young
  60. 60. Postoperative Delirium in 5-50%That Appears on POD’s 1-3Cook. Anesth Analg 2003; 96:1823• 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
  61. 61. Ten Ways to ImproveAnesthesia in Older Patients 1. H & P > Pre-op Testing > 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
  62. 62. Ten Ways to ImproveAnesthesia 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/dl10. Reduce post-op opioid requirements

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