This document summarizes key considerations for anesthesia management in elderly patients undergoing emergency surgery. It recommends preoperative optimization, careful titration of anesthetic drugs due to increased sensitivity in elderly, and goal-directed resuscitation for patients presenting with abdominal emergencies. Regional anesthesia is preferred over general anesthesia for hip surgeries when possible. Close postoperative monitoring in the ICU is important for high-risk elderly patients after emergency laparotomy to improve outcomes.

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
---------XX-------

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