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Similar to Geriatric anesthesia physiological changes and preoperative preparation
Geriatric anesthesia physiological changes and preoperative preparation
- 1. Dr. Tushar Chokshi M.D.(Anesthesia)
- 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 GeriatricPatients 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 tmc 3
- 4. tmc 4 30 4050 60 70 80
- 5. Realities for thegeriatric 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 ! tmc 5
- 6. tmc 6 Guinness Bookof 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 ThreeGroups 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 tmc 7
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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 tmc 9
- 10. Changes and itsEffects 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 arterialwall Narrow lumen Sclerosis of atrial and mitral valves SA node Dysfunction Increased Stiffness and Endothelial Dysfunction arrhythmia Diastolic Dysfunction
- 12. Anaesthesia Implication • Hypotensionand 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
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- 16. tmc 16 Reduced gasExchange Increase Wall Rupture Alveolar Size increase Alveolar changes in Older Lungs
- 17. Changes and itseffects 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 tmc 17
- 18. Anesthetic Implications • Adviceto 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 tmc 18
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- 20. Genitourinary System Changes Kidneys --Gradualdecrease 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 • Agerelated 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 tmc 21
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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 in 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 • CorrectFluid, 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
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- 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 • Hyperglycemiaincrease 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 MusculoskeletalSystem 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 • Considerdifficult 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
- 30. tmc 30 Nervous SystemChanges
- 31. Nervous system Changes Asthe 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 • Weightof 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 • Difficultyin 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 tmc 33
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- 35. Temperature Regulation Changes Elderlyare 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 tmc 35
- 36. Anesthesia Implication • Hypothermiashould be avoided • Shivering will increase oxygen demands • To prevent heat loss - Use warm solutions - Use warm Blankets - Keep OT temperature warm tmc 36
- 37. tmc 37 Immune SystemChanges
- 38. tmc 38 * Slowto 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.
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- 40. Psychological Changes • Lossof 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 tmc 40
- 41. Anesthetic Implications * Geriatricpatients 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. tmc 41
- 42. So considering allthese changes What Old people says tmc 42
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- 45. Pre-operative evaluation 1) CompleteHistory 2) Physical Examination 3) Laboratory Investigations 4) Tailor made Anaesthesia plan according to surgery tmc 45
- 46. tmc 46 BEST PRACTICESFOR 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 communicatewith 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 . tmc 47
- 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 tmc 48
- 49. So again torepeat, 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 tmc 49
- 50. Different Risk factorScales 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 tmc 50
- 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 tmc 51
- 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 tmc 52
- 53. Investigations Routine Complete Haemogram FBS/HbA1C ECG X-Ray Chest Renalfunctions 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 tmc 53
- 54. So, after assessmentof 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. tmc 54
- 55. Use of Smartphonein assessment of geriatric patients Android apps tmc 55
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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) tmc 63
- 64. And • The decreasein 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 tmc 64
- 65. So for, Dose andDuration 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 tmc 65
- 66. Doses of AnestheticAgents • 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 tmc 66
- 67. Regional & PeripheralNerve 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 tmc 67
- 68. To Sum-Up Pharmacologyof 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. tmc 68
- 69. Drug Strategy forthe Elderly: GO LOW ! GO SLOW ! ALWAYS FOLLOW ! tmc 69
- 70. Some words forFluid 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 tmc 70
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- 72. Decreased Physiologic Reserve Provider Lack of Knowledge Increased Preexisting Diseases High incidenceof morbidity & mortality in old age Because of tmc 72
- 73. Elderly patients arevulnerable 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 tmc 73
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