1. Bahir Dar University
College of Medicine and Health Science
Anesthetic management for Geriatric Patient
Leiltework A.(BSC,MSC in Anesthesia)
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2. Outline
• Introduction
• Preoperative evaluation
• Intraoperative geriatrics management
• Special challenges while managing geriatric patient
• Major postoperative considerations and complications among
geriatrics patient
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4. Introduction
• Gerontology: is the broadest term applied to studies of aging.
• Geriatrics : is a medical subspeciality that focuses upon cares
of the elderly patients.
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5. PREOPERATIVE PREPARATION
PREOPERATIVE PREPARATION
Preoperative evaluation
PREOPERATIVE PREPARATION
• 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.
• If the condition can be optimized before surgery this
should be done without delay, as long delays increase
morbidity rates.
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6. Cont…
A full history and thorough clinical assessment is required -
significant cardiac, respiratory and renal disease may not have
been previously detected.
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7. Cont…
An ECG is required for all patients.
A chest X-ray should be arranged for patients with known
malignancy or possible tuberculosis, and for anyone with
symptomatic cardiovascular or respiratory disease who has not
had a recent chest X-ray.
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8. Cont…
Assessment of exercise tolerance and functional ability is
important.
The baseline functioning of the patient should be well
documented.
If a decreased functional reserve is detected, a high- care or
intensive care facility may be appropriate post-operatively.
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9. Cont…
A full explanation of the perioperative period should be given
(details such as catheters, nasogatric tubes, CVP lines are
important so the patient is expecting these when awakening).
The patient should be consented for anaesthesia.
The American Society of Anaesthesiologists (ASA) score
should be recorded - it remains a good predictor of outcome in
the elderly.
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10. • Note the level of cognitive function and the patient’s social
circumstances: these may determine both the perioperative
prognosis and plans for the patient’s rehabilitation
postoperatively.
• In patients who have sustained a fracture, actively look for an
underlying medical cause for a fall, such as arrhythmias,
myocardial infarction, transient ischaemic attack (TIA), cerebral
vascular event (CVE), pulmonary embolus, gastrointestinal
bleed.
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13. Consider day case surgery
The advantages of this include less confusion, earlier
mobilisation and less nosocomial infections.
However, day case surgery does need meticulous planning and
preoperative assessment, including a detailed social appraisal
as to the level of home support and care available.
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14. Decision to operate
Extensive surgery may be futile in certain patients.
Sometimes the best decision is not to operate and this should be
made at consultant level, ideally in consultation with the patient
and other members of the family.
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15. Cont…
• DM and CV diseases are very common.
• Pulmonary complications are one of the leading causes of
postoperative morbidity, so, pulmonary optimization is
essential.
• History, physical examination, Lab. and diagnostic studies are
of great importance.
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16. Cont…
• Some more issues that must be always in mind in a geriatric
patient is the significant possibility of depression, malnutrition,
immobility and dehydration.
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20. PERIOPERATIVE CARE
In general the full range of anaesthetic drugs and techniques
used for young, fit adults may be used in elderly patients,
within the limitations of their physiology.
Modification of the techniques, and particularly drug doses,
may be required.
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21. Cont…
• lower doses of premeds.
• Opioid premed is valuable only if there is severe preoperative
pain.
• Anticholinergics are not required since salivary gland atrophy
is usually present.
• H2 antagonists are useful to reduce the risk of aspiration.
• Metoclopramide could be used to promote gastric emptying,
although risk of extrapyramidal effects is higher
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22. Intraoperative care and anesthetic management
• Advanced age is not a contradiction for either GA or RA.
• Some aspects of RA may benefit the pt.
– It prevents postoperative inhibition of fibrinolysis
decreases the incidence of DVT after total hip
arthroplasty.
– The hemodynamic effects of RA may reduce blood
loss in pelvic and lower extremity operations.
– More important, the patient maintains his airway and
pulmonary function.
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23. Cont…
• Advanced age and general anesthesia are associated with
hypothermia, so; Maintenance of normothermia is important
as hypothermia to myocardial ischemia & hypoxemia in
the early postop. period.
• In case of general anesthesia, it is of major importance to
titrate drug doses and it would be wise to use short acting
drugs.
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24. Induction of anaesthesia
• Arm-brain circulation time is increased, and induction agent
dose requirements are drastically reduced.
• Titrate drugs slowly against effect, and inject into a running
intravenous infusion.
• Thiopentone or propofol are both useful but should be given
slowly to avoid overdose.
• An induction dose of propofol may result in hypotension and
require a vasopressor.
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25. Cont…
• Drug dose calculated according to LBW,propofol 1-1.5mg/kg,
and 0.5-1mg/kg if opioids supplemented.
• Slow onset of anesthesia due to sluggish circulation.
• Dose titrated- delayed elimination due to retarded metabolism.
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26. Cont…
• Avoid ketamine in the presence of cardiac disease as the
tachycardia and hypertension that may result can increase
myocardial oxygen consumption and precipitate ischaemia.
• However, bear in mind that ketamine’s hallucinogenic effects
are not as marked in the elderly, and that it remains a very safe
and effective analgesic, anaesthetic and sedative.
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27. Maintenance of anaesthesia
• Maintenance of anaesthesia with inhalational agents is a
suitable technique for elderly patients, as the depth of
anaesthesia can be rapidly changed and inhalational agents are
minimally metabolised.
• Isoflurane is maybe the most suitable, as it is relatively
cardiovascularly stable, has a short onset and offset time and
only 0.2% of an administered dose is metabolised.
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29. Temperature
• Maintenance of body temperature pre-, intra- and
postoperatively is essential.
• Elderly patients have a reduced basal metabolic rate (BMR)
and are susceptible to heat loss as a result of impaired
thermoregulation.
• Shivering may increase oxygen demand significantly and so
should be avoided whenever possible.
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30. Fluid management
Careful peri-operative fluid balance is mandatory in the elderly.
Always consider measuring the CVP with large fluid shifts.
Patients are more often underfilled than overloaded, although
care should be taken to avoid fluid overload: excess fluids in an
elderly patient, especially in the presence of renal failure, can
cause pulmonary edema.
Conversely, dehydration, which can be difficult to assess in the
elderly, can precipitate renal failure.
Regular review of fluid therapy is essential after major surgery.
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31. Pressure areas
Most pressure sores develop within the first 24 hours after
surgery, and are more common in patients who have undergone
long procedures, and those who have been exposed to periods
of hypotension and poor tissue perfusion.
Pressure sores should be avoided as they prolong hospital stay,
delay rehabilitation and may cause sepsis.
Suitable measures to prevent sores should be taken in both the
operating theatre and recovery areas.
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32. General or regional anaesthesia?
• Regional anaesthesia may have some advantages over general
anaesthesia, including less thromboembolic events, confusion
and respiratory problems post-operatively.
• Limb and plexus anaesthesia are ideal for peripheral surgery.
• Hernias and cataracts are widely performed under local
anaesthesia.
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33. Cont…
• Hypotension is more commonly seen in elderly patients
undergoing spinal/epidural anaesthesia due to impaired
autonomic function and reduced compliance of the arterial
tree.
• In patients with severe cardiovascular disease who require
tight control of their blood pressure, general anaesthesia may
be better.
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37. Analgesia
Consider prescribing a regular simple analgesic such as
paracetamol, and use NSAID’s with caution; the complications
of NSAIDs, including renal impairment and peptic ulceration,
are more prevalent in older patients
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38. Cont…
Intramuscular and subcutaneous opioids may be unreliably
absorbed due to variable tissue perfusion, and an elderly
confused patient may have difficulty using a PCA.
Regional techniques or an iv opioid infusion (with appropriate
close supervision) may be the most appropriate method of pain
relief.
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39. Oxygen therapy
• It is good practice to prescribe post-operative oxygen therapy
for all elderly patients, and especially following abdominal or
thoracic surgery, in the presence of cardiovascular or
respiratory disease, in situations where there has been
significant blood loss, or when opioid analgesia has been
prescribed.
• Nasal cannulae are often better tolerated than facemasks.
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40. High dependency care
If high dependency care or intensive care facilities are
available, these may improve the long-term outcome of elderly
patients, especially those undergoing urgent or emergency
surgery.
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41. Fluid management
Meticulous fluid management continues to be extremely
important during the post-operative phase.
Fluid balance charts should be utilised and carefully
interpreted: failure to do so has been shown to be a major
contributing factor in post-operative morbidity and mortality.
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42. Other considerations
Frequent and regular review of the patient should be routine.
Early and frequent physiotherapy and mobilization facilitate
post-operative recovery and have been shown to reduce
hospital stay significantly.
Consider deep vein thrombosis (DVT) prophylaxis: elderly
patients are a high-risk group, especially those with a fractured
neck of femur or those who have been bed bound for some
days.
Regular review looking for postoperative complications.
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43. Other considerations
Common complications include infection (especially wound,
chest, urine), DVT and pulmonary embolus.
Parenteral or enteral nutrition should be continued from the
pre-operative period, or instigated early after surgery to
facilitate healing and aid recovery.
Rehabilitation using a multidisciplinary team is strongly
recommended.
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45. Postoperative delirium
• Postoperative delirium is common in the elderly in the
postoperative period.
• It can result in increased morbidity, delayed functional
recovery, and prolonged hospital stay.
• In surgical patients, factors such as age, alcohol abuse, low
baseline cognition, severe metabolic derangement, hypoxia,
hypotension, postop. Pain and type of surgery appear to
contribute to postoperative delirium.
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46. Cont…
• Anesthetics, esp. anticholinergics and benzodiazepines,
increase the risk for delirium.
• Despite the above recommendations, postoperative delirium in
the elderly is poorly understood.
• Research is needed to define the effects of hypoxemia on
cerebral function and whether oxygen therapy has any
benefits.
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47. The geriatric-anesthesiologic intervention program:
• pre- and postop. geriatric assessment,
• early surgery,
• thrombosis prophylaxis,
• oxygen therapy,
• prevention and treatment of perioperative decrease in BP, and
• vigorous types of any postoperative complication.
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49. Conclusion
• Elderly patients are uniquely vulnerable and particularly
sensitive to the stress of trauma, hospitalization, surgery and
anesthesia.
• Accordingly, minimizing perioperative risk in geriatric patients
requires:
– meticulous preoperative assessment of organ function and
reserve,
– meticulous intraoperative management of coexisting
disorders,
– Careful drug selection & dosage titration,
– Careful fluid therapy,
– RA better than GA
– Proper psychological preparation & management
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