Geriatric Anaesthesia - considerations

1. REVIEW ARTICLE
Ref: ANESTHESIOLOGY CLINICS SEPTEMBER 2015
Dr. Anuradha T
Jubilee Mission Medical College & Research Institute,
Thrissur, Kerala , India

2.  Citizens > 65 years , 30% population by 2030.
 More complications, morbidity, mortality,
longer ICU stay, cost
 Hip surgery, emergency abdominal surgery,
TAVR

3.  Risk factors for periop compli, mortality:
 Age
 ASA
 Albumin
 Fraility

4.  Preop evaluation, optimisation
 After that a focused history and physical
evaluation for new, unappreciated conditions
 Pharmacokinetic and pharmacodynamic changes
in old age considered
 Increased sensitivity to anaesthetics
 And reduced requirements
 More time to peak effect

5.  Impatience and failure to consider leads to “
drug stacking”- a dangerous overshoot of
desired drug effect
 Give slowly, gently in titrated doses
 Propofol only 50% of weight based dose
needed
 Hypotension anticipated and treated

6.  Consider physiological changes of ageing in.....
 airway
 breathing
 circulation
 disability (neurological)
 renal, electrolyte
 hepatic
 endocrine
 hematologial
 infectious issues

7.  Timely, appropriate antibiotic
 DVT prophylaxis
 Careful positioning of the frail- risk of spinal
stenosis, decubitus ulcer, tearing of skin
 Maintain normothermia- hypothermia causes
cardiac ischemia

8.  # Hip, femur, knee are the MC sx in > 65 yrs
 Stabilise patient in ED before shifting to ward
or theatre
 Delay in time to surgery is a risk factor for
poor periop outcomes
 Important to minimise delay
 Focused history, examination and review of
prior investigations is prudent

9.  Majority studies suggest that RA is better
 Neuman et. al in a record analysis of 18000 pts for
intertrochanteric #, RA had 25% less of major
pulmonary complications and mortality than GA.
 Memtsudis and colleagues evaluated data from 3.8
lakh records of TKR patients and showed lower
incidence of major morbidity and mortality with RA
 Another study of > 56000 pts showed shorter
duration of stay with RA, no difference in mortality

10.  Other studies have shown more complications
and longer duration of stay with RA than GA
 Earlier Cochrane review showed no difference
in GA Vs RA for hip surgeries

11.  RA is usually given with sedation. Few studies
have evaluated the depth of sedation
 Seiber and colleagues did a trial of RA + light
sedation ( BIS 80) vs deep sedation ( BIS 50) in
older population
 In pts with serious comorbidities, mortality was
significantly less at 1 year in mild sedation group.
 Suggests RA + light sedation in the highest risk
group.

12.  Hip bone # very prone for DVT and PE
 Prophylaxis must be begun preop and
continued intraop and into postop
 Pressure gradient stockings should be worn
 Prevention of pressure ulcers must be begun
preop- reduces morbidity significantly and
improves outcomes

13.  After # fixation , goals of care are early
mobilisation and rehabilitation
 Rapid recovery from anesthesia and sedation
while maintaining adequate analgesia is
important
 PCA or PC epidural analgesia used

14.  30 day mortality in pts > 80 years for
emergency laparotomy is 24 – 44%.
 Morbidity and mortality increases with
emergency surgery and age.
 40% pts have SIRS or sepsis
 Delay in surgery worsens outcome especially
in sepsis
 Postop ICU admission – fewer complications
and better outcome in high risk elderly pts

15.  Rapid history, physical examination, lab tests
 Review of diagnostic tests
 Especially look for SIRS, sepsis, septic shock
 Early broad spectrum antibiotic
administration
 Duration of hypotension before antibiotic is a
critical determinant of survival in septic shock

16.  Goal directed resuscitation
 Restore euvolemia
 Vasopressor support with NA
 Optimise oxygen delivery
 Once decided, do surgery at the earliest

17.  Emergecy Laparotomy Pathway Quality
Improvement Care
 Recently implemented in UK
 Showed significant reduction in risk of death
after emergency laparotomy
 5 elements

18.  1. All emergency admissions to surgical assessment area
have a (M)EWS –Early Warning Signs completed. Outreach
to review all patients with (M)EWS of 4 or more.
 2. Broad spectrum antibiotics to be given to all patients
with suspicion of peritoneal soiling or with septic shock.
 3. Once decision is made to carry out laparotomy patient
takes next available slot on emergency list (or within 6 hours
of decision made).
 4. Start resuscitation using goal directed techniques as soon
as possible or within 6 hours of admission.
 5. Admit all patients after emergency laparotomy to ICU.

19.  GA is indicated for emergency GI surgery
 Combined GA + Epidural maybe indicated for
few
 Risks of epidural outweighs benefit
 Risk of hypotension and infection in patient
with sepsis or bleeding outweigh the benefits
of postop pain control with epidural
 Particular attention in temperature control
and avoiding hypothermia

20.  Altered hepatic and renal blood flow in
hypotension and shock
 So, prolonged unpredictable effects of
anesthetics
 Pronounced hemodynamic effects
 Ketamine, Etomidate considered in
hypovolemia, shock

21.  Maintenance anesthetic decreased
 Risk of awareness
 Adjunctive Ketamine, Midazolam,
Scopolamine needed
 BZD – risk of delirium

22.  High risk for aspiration
 Goal – safely, quickly secure airway without
worsening shock or aspiration
 RSI or modified RSI to be used

23.  Tidal volumes 5-8 ml/kg
 Lung protective strategy in these pts at risk for
ARDS
 Fever or shock increases myocardial oxygen
demand, further increases risk for
desaturation

24.  Those with distributive shock are at high risk for
hypotension with induction and PPV
 Place an arterial line before induction, for BP
monitoring
 Fluid bolus before induction
 Start vasopressor, NE , before or immediately
after induction
 Central line for giving medications and moitoring
CVP and SvO2

25.  CO monitoring, PA pressure monitoring
maybe needed in some patients
 Transesophageal ECHO maybe useful in
patients with hypotension unresponsive to
IVF, pressors and inotropes

26.  Maintenance of renal perfusion is a goal of
resuscitation
 Urine output maybe abnormal in pts taking
diuretics or other medicines
 Follow electrolyte abnormalities
 Acidosis, particularly gap acidosis is s/o shock
and need for continued resuscitation
 In hypotension, severe acidosis canbe treated
with sodium bicarbonate

27.  Coagulopathy may occur due to.....
 Hemodilution
 hemorrhage
 Sepsis
 hepatic injury due to ischemia

28.  Severe hyperglycemia should be controlled
with IV Insulin
 Rarely, hypotension unresponsive to fluid and
pressors maybe due to adrenal insufficiency
 Etomidate for induction causes fall in cortisol
level, it is of unknown clinical significance

29.  Be careful
 Risk for decubitus ulcers

30.  Elderly pts undergoing emergency GI surgery
are at high risk
 Must be admitted to ICU for ongoing
resuscitation
 Pts with hemodynamic instability, persistent
acidosis, requiring resuscitation or ventilatory
support should undergo delayed extubation
in the ICU
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31.  Emergency Laparotomy Pathway - Quality
Improvement Care Bundle
 This pathway should be started for ALL
patients presenting with acute abdominal
conditions that
may need unscheduled surgery

32.  1. Immediate assessment and resuscitation
 EWS within 30 minutes of admission
 MRCS grade surgical registrar review within 2 hours
of referral (30 minutes if EWS > 3)
 Arterial lactate measurement to identify sick
patients
 Early fluid resuscitation
 2. Early antibiotics
 Within 1 hour of admission/referral if sepsis or
suspected peritonoitis/perforation

33.  3. Rapid diagnosis and surgical plan
 Rapid CT scan - within 2 hours of request, verbal
report within 1 hour
 Communication with consultant surgeon for
within 1 hour of CT
 4. Surgery within 6 hours of admission/referral
for urgent/emergency cases
 Prioritise theatre – next available slot on CEPOD
 Consultant-led perioperative care

34.  5. Clear management plan for ‘expedited’ cases, eg.
bowel obstruction
 CT scan within 12 hours to confirm diagnosis
 Regular review with consideration of lactate estimation if
sepsis or possible ischaemic bowel
 12 hourly Consultant Surgical review, 6 hourly MRCS
registrar review if sepsis
 6. Goal Directed Fluid therapy
 Stroke volume optimisation using cardiac output
monitoring intra- and postoperatively

35.  7. Postoperative ICU for patients with
predicted mortality >5%
 ICU admission for all patients with P-POSSUM
predicted mortality>5%
 ICU admission for patients with P-POSSUM <
5% at discretion of perioperative team

36.  Physiological and Operative Severity Score for
the enumeration of Mortality and morbidity
(POSSUM) and Portsmouth-POSSUM (P-
POSSUM)
 Designed to predict morbidity and mortality
in general surgery patients
 Later used in wide range of surgeries
 More accurate in elderly, high risk patients

37.  POSSUM predicts morbidity
 P-POSSUM predicts overall mortality
 Also predicts need for ICU admission

38.  Physiological parameters Operative parameters
 Age Operative severity
 Cardiac signs Multiple procedures
 Respiratory history Total blood loss
 Systolic blood pressure Peritoneal soiling
 Pulse Presence of malignancy
 Glasgow coma score Mode of surgery
 Haemoglobin
 White cell count
 Urea
 Sodium
 Potassium
 Electrocardiogram

39.  Values calculated by simple mobile apps
 Each of the 18 factors, which are weighted to a value of 1,
2, 4 ,8 depending on measured variables
 Predicted POSSUM mortality
 ln [R/(1−R) = −7.04 + 0. 13 × physiological score
+ 0.16 x operative score
where R is the predicted mortality score.
 Predicted P-POSSUM mortality
 ln [R/(1−R)] = −9.37 + 0.19 × physiological
score + 0.15 x operative score

40. THANK YOU
THANK YOU