Elderly patients represent the fastest growing population globally. They experience many age-related physiological changes that increase surgical risk. Preoperative evaluation and optimization is important to identify risks like cardiovascular disease and pulmonary issues. Anesthesia in the elderly requires lower doses of induction agents and opioids due to pharmacokinetic changes. Regional anesthesia may provide benefits over general anesthesia. Close postoperative monitoring is needed due to risks of complications like delirium, cognitive dysfunction, hypotension, and hypothermia.
In critical care medicine the invasive life saving techniques are often employed and when all goes well such interventions will be withdrawn to all for normal physiology to resume. Identifying this point for safe withdrawal for the resumption of normal respiratory function is of utmost importance.
In critical care medicine the invasive life saving techniques are often employed and when all goes well such interventions will be withdrawn to all for normal physiology to resume. Identifying this point for safe withdrawal for the resumption of normal respiratory function is of utmost importance.
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.
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.
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.
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.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
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Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
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CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
3. Elderly-fastest growing population globally.
India→census registrar general of india
from independence 18 million→78 million
in 2001→150 million in mid century
More than 50% of them require two or more
surgeries in lifetime.
4. Related directly to stiffening and decreased destensibility of
arterial and cardiac wall.
Age related changes include:
1.↑MAP and pulse pressure
2. ↓cardiac output,SV,EF in response to stress
3. Calcification of valves(aortic and mitral)→↑risk of CVS
death by 50%
4.↓in compliance of venous system which hinders
changes in intravascular volumes
5. Cardiac conduction system →fibrotic changes,making
them more prone for arrythmias
6. Impairement of diastolic relaxation→diastolic
dysfunction in ageing heart→diastolic heart failure
now referred to as Heart failure with preserved
ejection fraction(HFpEF).SO in patients with clinically
evident heart failure EF is preserved in over half.
7.↓arterial elasticity and peripheral sclerosis
8. ↑sympathetic nervous system activity
9. ↓b receptor stimulation
5. 1.ANATOMICAL:
Loss of muscular pharyngeal support→↓in
function of pharyngeal and laryngeal
function
Loss of ciliary function
Barrel chest deformity
Flattening of diaphgram
Chostochondral joint calcification making
chest less compliant
6. 2.PHYSIOLOGICAL:
↑incidence of upper airway obstruction→more
prone to have apnea and airway obstruction in
RR
Loss of elastic tissue-more airways collapse
during expiration leading to VP mismatch
Volume of pulmonary vascular bed ↓→↑in
pulmonary vascular resistance by 80%
Impaired response to hypoxia,hypercapnia and
mechanical stress→more sensitive to depressant
effects of opioids and BZDs
Loss of elastic recoil+↓surfactant→increase in
lung compliance
VC ↓ and RV↑
FEV1 decreases by 6-8%/decade
Hypoxic pulmonary vasoconstriction is blunted
7. At rest elderly have to workharder because
of less compliant chest wall
Ventilatory response to hypoxemia and
hypercapnia are decrease so ABG monitoring
would be more reliable sign in assesing
respiratory function
Post op age associated muscular weakness
will reduce their ability to cough forcibly
and remove secretions thus chances of post
op pulmonary complications are high
8. ↑ in threshholds for virtually all forms of perception
i.e vision,hearing,touch,sense of joint
position,peripheral pain due to in
1.reduction in electrical activity
2.attrition of afferent conduction pathway
peripheral nervous system and spinal cord
↑ in number of cholinergic receptors at end plate
and surrounding areas compensate for age related
decline in number and density of motor end plate
units.→doses of competitive blockers is not reduced
9. ↓sensitivity of baroreceptor→orthostatic
hypotension and syncope
↓no of receptors,reduced affinity of agonist
molecules e.g ↓ability of b adrenergic
agonists to enhance velocity and force of
cardiac conduction
Thermoregulation is affected→↑heat loss
and↓ heat tolerance making them
vulnerable to hypothermia and heat stroke
10. Brain size↓→cerebral blood flow and
oxygen consumption ↓
Continual loss of neuronal
substance→↓dopamine,norepinephrine,
tyrosine,serotonin →depression,loss of
memory and motor dysfunction
11. ↓renal mass-↓in glomeruli and nephrons by
40%
Renal blood flow ↓approx 10% /decade after
40 years→↓GFR
Serum creatinine level →poor indicator of
GFR
Alterations in response to abnormal
electrolyte concentration→renal capacity to
conserve sodium↓→fluid and electrolyte
status should be carefully monitored
1/5th of geriatricperianesthetic surgical
mortality due to accute renal failure
12. Characterised by
gastric acidity
↓colon motility and anal
function→constipation
Fecal impaction,fecal incontinence
HEPATIC SYSTEM:
Liver tissue ↓ by 40%→↓hepatic
function→delayed drug metabolism and
earlier saturation of metabolic pathways
13. Loss of skeletal muscle(↓in lean body mass)
↓TBW due to ↓ in intracellular water
↑ in percentage of body fat
14. Glucose intolerance,decresed thyroxin
production or clearance,decreased
production of renin,aldosterone and
testosterone,and increased plasma conc of
ADH
Leads to DM,thyroid dysfunction,↓sodium
retention,↑potassium absorption and
osteoporosis
15. plays a significant part in reducing
postoperative complications
Detailed medical history, physical
examination, laboratory investigations and
an assessment of surgical risk should be
focussed
Informed Consent
History and Nutritional status
prior medical and surgical conditions
history detailed
medication list →multiple drug therapy.
Physical Examination:regarding hydration,
nutrition, blood pressure, pulse
irregularities,preoperative mental status
16. directed towards identifying physiologic
deficits and comorbid conditions that may
increase the chances of postoperative
complications
Various comorbid conditions that should be
predicted in elderly are as follows:
1.CVS:
a. Hypertension:1.DBP >110 mm Hg
requires control
b. CHF:1.H/O chronic CHF → established
predictor of adverse
perioperative cardiac events.
17. C. Arrhythmias:▪ sinus node cells are reduced
▪risk of bradycardia and sick
sinus syndrome
▪AF is too high
D. Diastolic Dysfunction:
▪ECG findings or ejection
fraction are normal
▪cardiac output does not
increase with stress and CHF
may be precipitated with
atrial
18. 2. Diabetes Mellitus:
stress of surgery will increase hyperglycemia
discontinue the oral hypoglycemic regimes during
the preoperative preparation
start insulin regime
American Diabetic Association (ADA)
recommends:▪pre prandial blood glucose
levels between 80 – 120 mg/dl,
▪bed time concentration
between 100 – 140 mg/dl and
▪ haemoglobin A1C levels < 7%.
19. 3. Pulmonary disease:
Patients with active pulmonary disease
(bronchial asthma, COPD) should undergo
vigorous preoperative management and
optimization before subjecting them for
surgery
Smoking:A/E→▪functional anaemia from
carboxyhemoglobin,
▪ increased airway
complication due to hyper
reactive airway,
▪ bronchospasm,
▪ atelectasis
20. 1.ATYPICAL PRESENTATION OF DISEASE:
▪Not infrequently,accute illness→atypical
presentation. eg,appearance of
pneumonia→uncharacteristic features as
confusion,lethargy and general deterioration of
condition.
2.POLYPHARMACY:
▪ Occurs in 61% of acutely hospitalised older
patients
22. Preoxygenation:
▪desaturation occurs faster in older patients
▪8 deep breaths of 100% oxygen within 60
seconds with an oxygen flow of 10 L/min
Induction of Anaesthesia:
▪ Use of aspiration prophylaxis and rapid
sequence intubation (RSI)
▪Concurrent use of propofol, midazolam
opioids, increase the depth of anaesthesia
▪Hypotension is very common
▪Peak effects of drugs administered is
delayed:midazolam 5 min, fentanyl 6-8min,
23. 1.THIOPENTONE SODIUM:
↓in lean body mass→reduction in vd→high
plasma concentrations→↑sensitivity
Induction doses about 85% of younger patients
2.PROPOFOL:
-smaller central compartment and↓vd
-reduced clearance→induction dose(1.7mg/kg)
maintainence dose reduced
by 30-50%
24. 3.BENZODIAZEPINES:
Midazolam,lorazepam,diazepam have
comparable protein binding and vd
High clearance of midazolam makes it an
attractive alternative
4.OPIODS:
Twice as potent in elderly
50% reduction in doses
Shorter acting opiods i.e fentanyl,alfentanil
remifentanyl are better choices
25. 5.MUSCLE RELAXANTS:
No of Ach receptors at NMJ and their sensitivity
to NDMR not altered. Hence dosage required to
block NMJ is unaltered
Dereased hepatic and renal blood flow and
function responsible for prolonged action
6.INHALATIONAL AGENTS:
(MAC) of all inhalational agents is reduced by
about 4–5% per decade above 40 years of age
↓ MAC leads to rapid induction
Recovery prolonged due to larger vd and ↓hepatic
clearance and↓pulmonary gas exchange
26. INTRA OP HYPOTHERMIA:
Elderly→ higher risk of becoming
hypothermic because of anaesthetic induced
altered thermoregulatory mechanisms and
low BMR
Prepping preoperatively and cleaning
postoperatively with warm solutions, using
warming systems, warming IV fluids, keeping
the environmental temperature warmer,
Covering the patients with blankets before
and after the surgery
27. Difference in outcome between regional and
general anaesthesia in older patients is not clear
Yet some specific benefits of regional
anaesthesia may provide some benefits;
1.affects coagulation system by preventing post
op inhibition of fibrinolysis→↓incidence of DVT
or pulmonary embolism
2.haemodynamic effects may be associated
with ↓blood loss in lower extremity surgeries
3.does not necessitate instrumentation of
airway→lowers risk of hypoxaemia
4.opiate sparing effect
28. 1.FOR NEURAXIAL BLOCKS:
size of epidural space is reduced
permeability of dura is increased
volume of CSF decreased
narrowing if intervertebral space and
osteophyte growth→decreases
transforaminal escape of local anaesthetics
producing an increased level of block
onset of analgesia with epidural
anaesthesia is more rapid due to increased
permeability of extraneural tissues to local
anaesthetics
29. 2.FOR LOCAL ANAESTHESIA/PERIPHERAL
NERVE BLOCKS:
decrease in conduction velocity of
peripheral nervesdue todecrease in inter
schwann distance
decreased no of axons in peripheral
nerves
30. 1.OXYGENATION:
Increase in CO and ventilation to satisfy O2 demands
does not occur readily
Diffusion hypoxia may be more prolonged and
serious
2.POSTOPERATIVE ANALGESIA:
Poor pain control can lead to slow recovery and life
threatning complications
Pain →risk factor for POCD
NASAIDs and paracetamol by iv,im,oralor rectal
routes.but should be avoided in >70 years of
age,renal dysfunction,suffered hymodynamic
instability.
Peripheral blocks when feasible shouldbe used
31. 3.HAEMODYNAMICS:
a.HR→may not be a reliable indicator ofhypovolemia
in elderly
due to reduced no of adrenergic
receptors,decreased efficacy ofbaroreceptor reflexes
and administration of concomitant b-blockers
hypotension may exist without tachycardia.
b.HYPOTENSION→safer to administer volume in small
intermittent boluses watching response of CVP,BP
and urine output
c.administration of hypotonic fluids(5%dextrose etc)
may result in hyponatraemia and low serum
osmolalilty resulting in cerebral oedema
d.ARRYTHMIAS:may represent disturbances due to
pre existing cardiac
disease,hypokalemia,hypomagnesemia,hypocalcemia,
hypoxiaor hypercarbia.
may indicate MI(esp.
VPCs>5/min,bigeminy,ventricular tachycardia,heart
blocks other than first degree)
32. 4.HYPOTHERMIA:
Manifests as altered mental status
delayed recovery from
anaesthesia
sluggish DTRs
slow respiratory pattern
Leads to metabolic disturbances
↓liver and kidney perfusion
induce coagulopathy
Management:mild→warming with blankets
and warm rooms
severe:active warming methods such as use
of warm iv fluids and surface warming with continuous
core temperature monitoring
33. Post-Operative Delirium (POD) •
DSM-MS IV: A change in mental status,
characterized by: –
a prominent disturbance of attention and
reduced clarity of awareness of the
environment;
an acute onset, developing within hours to
days, and tends to fluctuate during the
course of the day.
35. Postoperative Cognitive Dysfunction (POCD)
• Deterioration of intellectual function
presenting as impaired memory or
concentration.
• Not detected until days or weeks after
anesthesia
• Duration of several weeks to permanent
• Diagnosis is only warranted if:
– corroborated with neuropsychological
testing
– evidence of greater memory loss than one
would expect due to normal aging
36. • POCD
– Common in all age groups at hospital
discharge (33- 44%)
– 3 months after surgery the POC incidence
was:
• 4-5% in those younger than 65
• 13% in adults older than 60 years
particularly on those with lower educational
achievement
• Associated with increased one-year
mortality