This document provides an outline for a lecture on anesthesia implications for elderly patients. It begins by defining geriatric age groups as elderly (65-74), aged (75-84), and very old (85+). It then discusses the physiological changes that commonly occur with aging, including reductions in organ mass/function and changes to the cardiovascular, respiratory, genitourinary, gastrointestinal, endocrine, skin/musculoskeletal, and nervous systems. Finally, it notes some key anesthesia implications of these age-related changes, such as a higher risk of hypotension, arrhythmias, infection, and adverse drug reactions in elderly patients.
new technique for pain management ,described by dr forero ,it can replace epidural anesthesia,paravertebral anesthesia and other regional blocks.it can be used for both acute and chronic painful conditions
Anesthetic consideration in smokers,alcoholics and addictsAftab Hussain
Anaesthetic consideration in smokers alcoholic and drug addicts. As an anaesthesiologist we must be aware with the problems associated with their management and interaction with anaesthetics.
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
Preanesthetic checkups in Geriatric PopulationReema Chaudhary
There are many important physiological age related changes in geriatric population,so before going to any surgery we plan to do PAC ,this presentation defines all the important anesthetic consideration worth keeping in mind.
new technique for pain management ,described by dr forero ,it can replace epidural anesthesia,paravertebral anesthesia and other regional blocks.it can be used for both acute and chronic painful conditions
Anesthetic consideration in smokers,alcoholics and addictsAftab Hussain
Anaesthetic consideration in smokers alcoholic and drug addicts. As an anaesthesiologist we must be aware with the problems associated with their management and interaction with anaesthetics.
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
Preanesthetic checkups in Geriatric PopulationReema Chaudhary
There are many important physiological age related changes in geriatric population,so before going to any surgery we plan to do PAC ,this presentation defines all the important anesthetic consideration worth keeping in mind.
Geriatric anesthesia with special consideration Petrus IitulaPetrus Iitula
With age, comes changes in normal physiological functions of the body and different diseases are picked up in certain population groups as we age. all this factors predisposes the geriatric population to certain complications once under anesthesia. Hence anesthetic preparation for the geriatric patients is needed to avoid mortality and morbidity in this population.
Anaesthetic Management of Elderly PatientsMd Rabiul Alam
The Scopes of the presentations are: Anaesthetic definition of elderly & workload, Brief on age-related changes, Importance of good anaesthetic evaluation, Practice of functional reserve/capacity assessment, Morbidity and Mortality, Decision of Surgery & Planning of Anaesthesia & Perioperative management in nutshell.
Basics of Shock and its management. Compentency and SLO based learning for undergraduate medical training (MBBS)
Check out the lecture by clicking on the link below
https://www.youtube.com/watch?v=J5m4kh4FO7k
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
2. Lecture outline
Introduction
Normal physiological changes associated
with ageing and its Anaesthesia
Implication
Pre-operative Assessment
Pharmacokinetics and Pharmacodynamics
in the elderly
Take Home Message
tmc 2
3. Who are Geriatric Patients
Most of the world countries have
accepted the chronological age of 65
and more as a definition of geriatric
patients ( Three Groups)
Elderly ------ Age 65 to 74
Aged -------- Age 75 to 84
Very Old ---- Age 85 and more
Old age is not a disease
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5. Realities for the geriatric patients in Health
* In India around 200 millions (15 %) people are > 65 years
* They account for almost half of hospital care days
* 25-35% surgical cases and procedures done on this age group
* Life expectancy in India now 70-72 yrs
* Medical diseases are most common in this group
* Demographical data indicate the elderly people are most
rapidly growing in population
• Use of health care services by elderly disproportionately
higher than younger patients
• The mortality rates for patients aged 80-84 is 3 %, 85-90 is 6 %
and above 90 year is 10 % in major surgeries
But all geriatric patients are not created equal !
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6. tmc 6
Guinness Book of World Records
( Anesthesia given to Oldest Patient)
Laurie Randall
Age -102 years
Surgery – Revision of Hip Replacement
Anesthesia – Epidural
Duration – 2 Hours
Pinderfields Hospital in Wakefield, West Yorks, UK
2 February 2012
7. Age-Related Physiological Changes
Three Groups of Physiological
Changes
1) Changes in autonomic
functions and cellular
homeostasis e.g.
temperature, blood volumes
and Endocrine changes
2) Reduction in organic mass
e.g. brain, liver, kidneys,
bones and muscles
3) Reduction in organic
functional reserve e.g. lungs
and heart
Systems Affected
• Cardiovascular system
• Respiratory System
• Genitourinary System
• Gastrointestinal System
• Endocrine System
• Skin and Musculoskeletal
System
• Nervous System
• Body temperature regulation
• Immune System
• Psychological Changes
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9. Cardio-Vascular Changes
• Heart – Cardiac output Decrease 1 % per year after 30 years
of age (at 80 year age CO is half that of a 20 year old person)
• Blood Pressure – BP increase 1 mm of hg every year after 50
years as a normal consequence of aging. Systolic will increase
and Diastolic remains unchanged or increase. ( WHO data
says around 50 % are Hypertensive in geriatric age group )
• Arteriosclerosis and Coronary Artery Disease
Thickening of arterial walls and Loss of elasticity
Loss of SA node cells causing slowed conduction
Myocytes death without replacement leading to increase risk
of myocardial infarction
• Decreased response to beta-receptor stimulation
• ECG Slightly increased PR, QRS and Q-T intervals
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10. Changes and its Effects
Changes
• Arterial wall thickening, stiffening
& decrease compliance
• Left ventricular and atrial
Hypertrophy
• Sclerosis of atrial and mitral
valves
• Decrease Beta adrenergic
response
• Decrease baroreceptor sensitivity
• Decrease SA node automaticity
• Diastolic Dysfunction
Effects
• Decrease exercise tolerance
leading to easy fatigability
• Coronary artery Disease
• Congestive Heart failure
• Risk of arrhythmias
• Diminished peripheral pulse
and cold extremities
• Increased blood pressure
• Postural Hypotension
tmc 10
11. tmc 11
Thickened arterial wall
Narrow lumen
Sclerosis of atrial and
mitral valves
SA node
Dysfunction
Increased Stiffness and Endothelial Dysfunction
arrhythmia
Diastolic
Dysfunction
12. Anaesthesia Implication
• Hypotension and Bradycardia should be kept in
mind during induction
• For emergency Anesthesia BP up to 180/110
mm of hg should be allowed
• Heart Rate up to 50 at rest is allowed for induction
• Minor ECG changes are not threatening for
anesthesia induction
• Ejection Fraction up to 45 % is normal for geriatric
age group without any symptoms
• Use of Beta blockers and Anti platelets in pre
operative period gives more cardio stability in
old heart
Remember old heart can not compensate decrease CO or increase heart rates
tmc 12
16. tmc 16
Reduced gas Exchange
Increase Wall Rupture
Alveolar Size increase
Alveolar changes in Older Lungs
17. Changes and its effects
Changes
• Decrease respiratory muscle
strength and elasticity
• Stiffer chest wall, AP diameter
increase
• In alveolar oxygen, no change
• In arterial oxygen, progressive
decrease
• Ventilation perfusion
mismatch
• Every year, 25 ml of decreased
VC and 25 ml increased RV
after 20 years of age
Effects
• Functional capacity declines
• Decrease cough reflex and
airway ciliary action
• Frequent airway collapse
• Reduced Compliance
• Snoring and Sleep apnea
common
• Higher chances of aspiration
• Increased risk of infection and
bronchospasm with airway
obstruction
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18. Anesthetic Implications
• Advice to stop smoking at least 2 weeks
before planned surgery and anesthesia
• Proper Antibiotic & Anti-aspiration prophylaxis
• Educate older people for deep breathing and
coughing reflex preoperatively
• Oxygen-Oxygen-Oxygen therapy in Pre-Intra-
Post anesthesia period
• Avoid or reduce doses of Opoids
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20. Genitourinary System Changes
Kidneys
--Gradual decrease in volume and weight of kidneys with aging
--Renal blood flow decrease, GFR decrease
--Decrease in total glomeruli leading to age related decrease in
creatinine clearance (no change in serum creatinine with advance age )
--Age related increase in blood urea nitrogen
Bladder
--Urinary incontinence found in almost 20 % population more than 65
years
--Capacity of bladder decrease & late sensation leading to overflow
incontinence
Prostate
--Enlargement of prostate in 90% male more then 65 years age, but only
10 % have symptomatic hyperplasia require surgery
tmc 20
21. Anesthesia Implication
• Age related Renal changes interferes with the excretion
of anesthesia drugs
• Because of bladder and prostatic changes urinary
catheterization is prime importance in major
anesthesia and surgery
• Renal insufficiency, dehydration and renal failure
common in elderly, so prompt actions to be taken
• Geriatric patients allowed clear fluid at least two
hours before anesthesia
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23. Gastrointestinal System Changes
Esophagus --Decrease in strength of muscles of mastication, taste and thirst
--Presbyesophagus ( disturbances of esophageal activity )
--Decrease peristaltic movement & delayed transit time
leading to dysphagia
--Relaxed lower sphincter leading to chances of aspiration
Stomach
--Atrophic gastritis , which increase with age
--Increase heart burn because of chronic
enterogastric bile reflux
Colon
--Decrease in colonic motility leading to constipation and
increase storage capacity
--Laxative abuse is very common
Liver and Billiary Tract
-- Decrease in liver weight and blood flow by 20 %, but no change in
Liver Function Tests
--Catalytic enzymes activity decrease
--Synthesis of protein binding and coagulation factors decreases
-- Drug metabolism is slow in old age group
-- Billiary tract disease are common
tmc 23
24. Anesthetic Implications
• Correct Fluid, Electrolytes and Nutritional
imbalance accordingly because of GUT changes
• Increased risk of gastric aspiration(PPI cover) and
NSAID induce ulcers (avoid)
• Keep in mind about constipation & complain of
constant abdominal disturbance Post-Op
• Decrease metabolism of anesthesia drugs and
risk of adverse drug reactions because of liver
changes
tmc 24
26. Endocrine System Changes
Pancreas (Glucose Homeostasis)
--Progressive deterioration in the number and function of
beta cells, but no decline in Insulin level
-- The average fasting glucose level rises 6 to 14 mg/dL
for each 10 years after age 50.
--Decrease glucose tolerance
Thyroid --Tendency for hypothyroidism
-- No change in Thyroid Function Tests
Parathyroid Gland
--No atrophy of Gland, but some fat deposition
--After 40 years PTH level in women increase leading to
bone loss problems (calcium and vitamin D reduction)
Adrenal glands
--No atrophy, but increase fibrous tissue
--Secretions of adrenal medulla increase(psychosomatic dz)
tmc 26
27. Anesthesia Implication
• Hyperglycemia increase the mortality and
morbidity in old age , because of late diagnose of
DM
Hyperglycemia and Hypoglycemia both not
tolerated
• Accepted level of FBS is between 80 – 120 mg/dl
or HbA1C less than 7 (always ask for HbA1C)
• Discontinue metformine and sulfonyl ureas night
before and day of surgery( due to increase
chance of MI in hypovolemic and reserved
cardiac functions in old age)
tmc 27
28. Skin and Musculoskeletal System Changes
Skin --Epidermis : Atrophy around face, neck, chest and extensor surface
of limbs
--Because of epidermis loss, prone for decubitus ulcers
--Dermis : Skin loses its elasticity resulting wrinkling and sagging of
sagging of skin
--Decreased sensitivity to pain and pressure
Skeletal
--Degenerative Joint Diseases causing disability
--Pain response is severe
--30 % Muscle mass reduced leading to decrease peripheral
metabolism of drugs, Low BMR due to weight loss
--Adipose tissue increase gradually
--Edentulism ( Gradual teeth loss)
--Osteoarthritis and Osteoporosis
--Inability to chew and poor oral health
tmc 28
29. Anesthetsia Implication
• Consider difficult IPPR and Intubation
• Body temperature to be cared during anesthesia
period. Avoid excessive cold temperature in OT
and preferably cover geriatric patient fully.
• Avoid pressure ulcers and padding of pressure
points
• Handle all geriatric patients carefully to avoid
fractures and excessive manipulation during
different surgical position (Handle With Care)
• Pre operative transfer of geriatric patient from
ward to OT is always in presence of medical
attendant (in wheel chair or in supine position)
tmc 29
31. Nervous system Changes
As the nervous system is the target for virtually
every anesthetic drug, so age related changes in
nervous system have essential implications for
anesthetic management
tmc 31
32. Neurologic Changes
• Weight of brain decrease
• Loss of brain cells
• Blood flow to brain
decrease
• State of confusion
• Interference with
Thinking
Reading
Interpreting
Remembering
• Sense of smell, Vision and
hearing diminish
• Impairment of Cognitive
functions increase with age
advancement
• Problems in physiological
regulation of Hypotension
and temperature
tmc 32
33. Anesthesia implication
• Difficulty in Communication, Cooperation &
Coordination
• Cognitive functions to be noted pre operatively
• Old patients take more time to recover from GA
especially if they were disoriented preoperatively
• Old Patient experience varying degrees of delirium
• Sensitive to centrally acting anticholinergic agents
• The % of delirium is less with regional anesthesia,
provided there is no additional sedation
• Dose requirements for local, general & inhalation
anesthetics are reduced
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35. Temperature Regulation Changes
Elderly are prone to hypothermia because of
• Lower body metabolism
• Vasodilatation of skin blood flow
• Decrease thermo genesis capability
leading to
– Shivering
– Increase metabolic demand
– Slow drug metabolism
– Increase risk of myocardial ischemia
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36. Anesthesia Implication
• Hypothermia should be avoided
• Shivering will increase oxygen demands
• To prevent heat loss
- Use warm solutions
- Use warm Blankets
- Keep OT temperature warm
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38. tmc 38
* Slow to respond.
* Increases risk of getting sick.
* An autoimmune disorder may develop.
* Healing is also slowed in older persons.
* The immune system's ability to detect
and correct cell defects also declines.
* increase in the risk of cancer.
40. Psychological Changes
• Loss of physical strength
and abilities
• Loss of mental abilities
(confusion, dementia)
• Loss of relationships
when companions or
friends die
• Loss of self-esteem
• Loss of body image
• Loss of independence
• Loss of control over life
plans and lifestyle
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41. Anesthetic Implications
* Geriatric patients with
psychological changes are
difficult to handle for history
taking & physical examination.
* Anesthesiologist should calm,
cooperative and always take
help of family member in pre
assessment.
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45. Pre-operative evaluation
1) Complete History
2) Physical Examination
3) Laboratory Investigations
4) Tailor made Anaesthesia plan according to
surgery
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46. tmc 46
BEST PRACTICES FOR COMMUNICATION WITH OLDER ADULTS
1) Anaesthesiologist should make the assessment face-to-face, allowing the
patient to see lip movements when speaking; this is particularly
important if the patient has a hearing problem.
2) Voice tone should be clear, slow and slightly louder than usual.
3) The anaesthesiologist should understand by asking leading questions from the
patient or caregiver or companion.
4) One question should be asked at a time, allowing sufficient time for patient
responses. Even healthy older adults may take a little longer to process a
question and frame a response.
5) Communication should be modified to match the individual’s learning style and
incorporate language the patient uses, avoiding complex medical
terminology, acronyms, and abbreviations.
6) If the patient has cognitive impairment, assessment questions should be
verified with the assistance of the family members or primary caregiver.
47. How to communicate with deaf old patients
50 % geriatric patients are having hearing
problem. It is sometimes difficult to
communicate with them.
So, our medical stethoscope will help us
by reversing the ends.
Patients will communicate very nicely.
Simple but very useful way .
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48. Complete medical history
History
• CVS and RS complaints
present and past
• Routine activities
• Mental & Physical status
• Dependency
• Associated Diseases
• Drug history/Polypharmacy
• BMI / Nutrition
• Past history Op/Ane. experience
• Any alternative medicine
• Allergy
• Social and Family history
• Any habits
Tobacco/smoking/drinks
• Sleep patterns
Always see for
depression
malnutrition
immobility
dehydration
Denture
Pace maker
Any joint replacement
Any anti depressant Rx
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49. So again to repeat, in Assessment
• See whether geriatric patient is able to
perform mental, social and physical activities
• All patients must be examined in presence of
family or friends or guardian
• Always see for polypharmacy because these
group are suffering from 2 or 3 systemic dis.
• Note the cognitive functions status,
to compare pre and post op changes
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50. Different Risk factor Scales are available
for
Pre-Assessment
APCHE (Acute Physiological and Chronic
Health Evaluation) for critically ill patients
POSSUM (Physiological and Operative
Severity Score for enumeration of
Mortality and Morbidity) for surgical pts.
Goldman scales of Cardiac risk for non-
cardiac surgery
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51. General Physical Examination
• Physical examination of old patient always to
be done in warm area
• General appearance
• Head to Toe Examination for pressure points,
Joints, hearing and vision impairment
• Height / Weight
• Neck mobility, any spine deformity, teeth loss
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52. Physical Examination
EXAMINE FOR
• Vital signs
• CVS and RS system
• Oxygen Saturation
• Pain Threshold
• Breathing pattern
• Breath Holding Time
• Clock Drawing Test
• Trail Making test
SEE FOR
• Difficult Intubation
• Difficult regional anae.
• Difficult nerve blocks
• Difficult IV line
• Weight for BMI
• Drugs regularity
• Relatives’ attitude and
responsibility
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53. Investigations
Routine
Complete Haemogram
FBS/HbA1C
ECG
X-Ray Chest
Renal functions
LFTs with proteins
(all above investigations are
must for routine
anesthesia
administration)
Special
According to Positive
medical history & disease
Echocardiography for CVS
Spirometry for RS
Sonography for GIT & KUB
Other Tests according to
Systems affected
e.g. CVS/RS/GIT/URINARY
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54. So, after assessment of geriatric patient
• It is very important to determine the patient’s
status and physiologic reserve in the pre-
anesthetic evaluation.
• The risk from anesthesia is more related with
the presence of co-existing disease than with
the age of the patient.
• The condition should be optimized before
surgery with good nutrition, pharmacological
support, System wise and done without
delay, as long delays increase morbidity rates.
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55. Use of Smartphone in
assessment of geriatric patients
Android apps
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63. In Geriatric Patients
• The circulating level of albumin decreases.
(binding protein for acidic drugs)
• While the level of α-1 acid glycoprotein
increases. (binding protein for basic drugs)
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64. And
• The decrease in total body water
leads to a reduction in the central
compartment and increased serum
concentrations after a bolus administration of
a drug.
• Increase in body fat
results in a greater volume of distribution of
drugs and prolonging action.
• Aging effect on hepatic and renal functions
drug metabolism will be altered
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65. So for,
Dose and Duration of Drugs
One has to remember that
Altered body composition in old age leads
-- decrease blood volume
-- decrease muscle mass
-- decrease plasma proteins
-- decrease circulatory time
-- decrease metabolism & clearance
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66. Doses of Anesthetic Agents
• Sedations – Decrease
• Induction Agents – Decrease (almost 50 % )
• Opioids – Decrease ( Remifentanyl is most potent)
• Muscle Relaxants – No change
• Inhalation Agents – Reduce MAC ( Ideal is 1.5 MAC )
• Local Anesthetics – Decrease
Note :
Ideal inhalation agent for old age is Desflurane
Ideal muscle relaxants for old age is Atracurium
Induction Agents are used according to pre-
assessment and risk of surgery
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67. Regional & Peripheral Nerve Blocks
• The duration of analgesia may be prolonged
with age advancing on the baricity, dose and
strength of the local anesthetic solution
• When GA carries great risk for the patient,
Regional Anesthesia or Nerve Blocks provide
an excellent solution
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68. To Sum-Up Pharmacology of Anaesthesia drugs
• The elderly are more sensitive to anesthetic
agents and generally require smaller doses for
the same clinical effect, and drug action is
usually prolonged.
• One arm brain circulation is about 20 seconds
and drugs to reach their maximum effect
requires 3 to 4 circulation. And in old age this
time is up to 90 seconds. So drug dose
requirement is less.
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69. Drug Strategy for the Elderly:
GO LOW !
GO SLOW !
ALWAYS FOLLOW !
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70. Some words for Fluid administration
--Elderly patient compensates poorly for
hypovolemia & over transfusion.
--After one liter of infusion, better replace blood
loss with blood transfusion
--Liberal oral intake of fluids allowed 2 to 3 hours
preoperatively
--Always keep in mind about elderly
compromised heart, poor organ perfusion and
reduction in GFR for IV fluid administration
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73. Elderly patients are vulnerable and particularly
sensitive to the stress of Trauma, Hospitalization,
Surgery and Anesthesia.
Anesthesiologists must Remember and Do
* Understanding old age physiology and pre operative
management of coexisting disorders
* Meticulous preoperative assessment of organ function
and reserve
* Careful drug selection & dosage titration,
* Careful fluid therapy
* Selection between RA & GA
* Proper psychological preparation & Management
* Good post operative pain control
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