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GERIATRIC ANAESTHESIA
PRESENTED BY
DR. M.ANEEQUE ALAM KHAN
DEPARTMENT OF ANAESTHESIA, SICU AND PAIN
MANAGEMENT
CIVIL HOSPI...
 Usually we refer to patients aged ≥65 yr
 Chronological age The number of years a person has lived
 Biological age ref...
Aging is a progressive physiologic process
characterized by
 Decreased end-organ reserve
 Decreased functional capacity
...
Physiological changes
Nervous system
 Memory decline occurs in > 40% of individuals.
 There is a decrease in the volume ...
 Neuraxial changes :
a) Reduction of the area of the epidural space
b) Increased permeability of the dura
c) Decreased vo...
Cardiovascular changes
 Decreased arterial elasticity:
• Increased afterload
• Left ventricular hypertrophy
• Increased s...
 Fibrosis of the conducting system and loss of sinoatrial
node cells .
 Sclerosis calcification of valves.
 High incide...
Respiratory System
 Decreased lung tissue elasticity (due to reorganization of collagen
and elastin):
 Early collapse of...
• Increased V/Q mismatch.
• Increased chest wall rigidity leading to increased work of
breathing.
• Blunted response to hy...
Renal
 Decreased renal mass:
 Mostly renal cortex secondary to decreased functioning
glomeruli.
 Progressive decline in...
 Decreased tubular function:
 Altered sodium balance, urine concentrating ability
and drug excretion
 Increased risk fo...
• Liver
volume decreases approximately 20% to
40% with aging.
Hepatic blood flow decreases about 10%
per decade.
There ...
Other problems
 Polypharmacy
 The number of medications used is directly
proportional to the likelihood of having an adv...
 Dehydration
 Dehydration and is often associated with
hypernatremia and accompanied by infection,
e.g. pneumonia and UT...
Hypothermia
contributors
 frail constitution,
 reduced metabolic rate,
 reduced subcutaneous fat layer,
 major and lo...
Pharmacological changes
 Increased body fat and decreased total body water:
Higher plasma concentration of water-soluble...
Preoperative Evaluation
 Perform a thorough history and physical examination
 Assess optimization of preexisting conditi...
INTRAOPERATIVE
 Monitoring based on procedure type and underlying organ
involvement
 Careful titration of anesthetic age...
 Inhaled Anesthetics
 The (MAC) decreases approximately 6% per decade for most
inhaled anesthetics.
 Intravenous Anesth...
 Opiates
 Morphine clearance is decreased in elderly
patients.
 Sufentanil, alfentanil, remifentanil and fentanyl are
a...
Regional versus General Anesthesia
 Specific effects of regional anesthesia may provide some
benefit.
decrease the incide...
Postoperative Considerations
 Optimal pain management to improve respiratory effort,
prevent delirium, and promote early ...
 Chronological age is a poor predictorof physiologicage
THANK YOU
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Geriatric anesthesia

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anesthesia concerns in geriatrics,physiological changes,dose adjustment
Chronological age,Biological age
Regional versus General Anesthesia

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Geriatric anesthesia

  1. 1. GERIATRIC ANAESTHESIA PRESENTED BY DR. M.ANEEQUE ALAM KHAN DEPARTMENT OF ANAESTHESIA, SICU AND PAIN MANAGEMENT CIVIL HOSPITAL KARACHI / DOW UNIVERSITY OF HEALTH SCIENCES aneeque86@gmail.com
  2. 2.  Usually we refer to patients aged ≥65 yr  Chronological age The number of years a person has lived  Biological age refers to how old that human seems  Aging results in a progressive decline in the functional reserve of all organs; the rate at which function diminishes is highly variable between individuals
  3. 3. Aging is a progressive physiologic process characterized by  Decreased end-organ reserve  Decreased functional capacity  Increasing imbalance of homeostatic mechanisms  Increasing incidence of pathologicprocesses.
  4. 4. Physiological changes Nervous system  Memory decline occurs in > 40% of individuals.  There is a decrease in the volume of gray and white matter.  Decreases in brain reserve are manifested by :  increased sensitivity to anesthetic medications increased risk for perioperative delirium and postoperative cognitive dysfunction.
  5. 5.  Neuraxial changes : a) Reduction of the area of the epidural space b) Increased permeability of the dura c) Decreased volume of CSF d) Decreased conduction velocity in peripheralnerves. • These changes tend to make elderly individuals more sensitive to neuraxial and PNBs.  Dementia andparkinsonism • Cognitive deficits are associated with poorer rehabilitation outcomes and higher surgicalmortality. • Parkinson's patients are at increased riskfor: Postoperative pharyngeal dysfunction Risk of aspiration Autonomic instability
  6. 6. Cardiovascular changes  Decreased arterial elasticity: • Increased afterload • Left ventricular hypertrophy • Increased systolic blood pressure, mean arterial pressure, and pulse pressure  Autonomic imbalance: • Increased vagal tone • Decreased sensitivity of adrenergic receptors • Decreased baroreceptor reflex
  7. 7.  Fibrosis of the conducting system and loss of sinoatrial node cells .  Sclerosis calcification of valves.  High incidence of diastolic dysfunction .
  8. 8. Respiratory System  Decreased lung tissue elasticity (due to reorganization of collagen and elastin):  Early collapse of small airways and over distension of alveoli (V/Q mismatch).  Increased residual volume (total lung capacity unchanged). Increased closing capacity .  Decreased arterial oxygen tension.  Loss of alveolar surface area (increased anatomic and physiologic dead space).
  9. 9. • Increased V/Q mismatch. • Increased chest wall rigidity leading to increased work of breathing. • Blunted response to hypercapnia, hypoxia, and mechanical stress. • Decreased protective reflexes (coughing and swallowing) increasing the risk for aspiration. • Increased pulmonary vascular resistance and pulmonary arterial pressure. • Blunted hypoxic pulmonary vasoconstrictive response.
  10. 10. Renal  Decreased renal mass:  Mostly renal cortex secondary to decreased functioning glomeruli.  Progressive decline in creatinine clearance.  Increased risk of perioperative acute renal failure.  Decreased renal blood flow:  Decreases 10% every decade of aging.  Serum creatinine unchanged due to loss of muscle mass.
  11. 11.  Decreased tubular function:  Altered sodium balance, urine concentrating ability and drug excretion  Increased risk for dehydration and electrolyte abnormalities.  Decreased renin-aldosterone system resulting in impaired potassium excretion.  S. Cr. is a poor predictor of renal function in elderly patients.
  12. 12. • Liver volume decreases approximately 20% to 40% with aging. Hepatic blood flow decreases about 10% per decade. There is a variable decrease in the liver's intrinsic capacity to metabolize drugs.
  13. 13. Other problems  Polypharmacy  The number of medications used is directly proportional to the likelihood of having an adverse drug reaction  Malnutrition Surgical patients who are malnourished have increased morbidity and mortality and increased length of stay.
  14. 14.  Dehydration  Dehydration and is often associated with hypernatremia and accompanied by infection, e.g. pneumonia and UTI.  Immobility  Bed rest leads to ventricular atrophy, hypovolumia, and orthostatic intolerance. Prolonged bed rest causes decreases in muscle mass, which may influence pulmonary function.
  15. 15. Hypothermia contributors  frail constitution,  reduced metabolic rate,  reduced subcutaneous fat layer,  major and long operations, and  impaired thermoregulation  unintentional hypothermia has been associated with myocardial ischemia, angina, and hypoxemia during the early postoperativeperiod.
  16. 16. Pharmacological changes  Increased body fat and decreased total body water: Higher plasma concentration of water-soluble drugs. Lower plasma concentration of fat-soluble drugs.  Reduced clearance secondary to decreased hepatic and renal function.  Altered protein binding:  Reduced albumin affects binding of acidic drugs (opioids. barbiturates, benzodiazepines).  Increased a,-acid glycoprotein after binding of basic drugs local anesthetics).  Pharmacodynamics changes:  Drug effects may be intensified due to decreased number of available receptors . Reduced anesthetic requirement (or Mac).
  17. 17. Preoperative Evaluation  Perform a thorough history and physical examination  Assess optimization of preexisting conditions such as CAD, hypertension, or diabetes .  Review medication history as polypharmacy is common among the elderly, increasing the risk of medication interaction .
  18. 18. INTRAOPERATIVE  Monitoring based on procedure type and underlying organ involvement  Careful titration of anesthetic agents with cardiac and respiratory depressant effects.  Careful attention toward fluid management to avoid fluid overload  Avoid hypothermia.
  19. 19.  Inhaled Anesthetics  The (MAC) decreases approximately 6% per decade for most inhaled anesthetics.  Intravenous Anesthetics  Propofol, ketamine, thiopental, etomidate reduce dose requirement  The dose requirement of midazolam to produce sedation is decreased approximately 75% due to increased brain sensitivity and decreased drug clearance.
  20. 20.  Opiates  Morphine clearance is decreased in elderly patients.  Sufentanil, alfentanil, remifentanil and fentanyl are approximately twice as potent in elderly patients.  Muscle Relaxants  Generally, age does not significantly affect the pharmacodynamics of muscle relaxants.  Duration ofaction may be prolonged, however, if the drug depends on liver or renal metabolism.
  21. 21. Regional versus General Anesthesia  Specific effects of regional anesthesia may provide some benefit. decrease the incidence of DVT decreased blood loss regional anesthesia does not require instrumentation of the airway and may allow patients to maintain their own airway and level of pulmonary function.
  22. 22. Postoperative Considerations  Optimal pain management to improve respiratory effort, prevent delirium, and promote early ambulation.  Infection  Thromboembolism  MI and cardiac arrest more common in elderly  Stroke  Postoperative confusion, delirium, or cognitive dysfunction common in elderly.
  23. 23.  Chronological age is a poor predictorof physiologicage
  24. 24. THANK YOU

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