The document discusses important considerations for anesthetic choice in elderly patients undergoing surgery. Older patients are at higher risk of complications and mortality compared to younger patients. Even minor physiologic disturbances during surgery can have serious consequences for frail elderly patients with limited reserve. The choice of anesthetic regimen and agents can help minimize risks. For example, etomidate is preferred over propofol for induction due to lower risk of hypotension in older patients. Careful preoperative evaluation and avoidance of complications is important for optimizing outcomes in elderly surgical patients.
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.
- The document discusses the physiological changes that occur with aging and their implications for anesthesia and surgery. Some key points:
1. Aging is associated with declines in organ function, functional capacity, and homeostatic mechanisms. Approximately 15-25% of surgical patients are aged 65 or older.
2. Common physiological changes with aging include declines in brain/nervous system function, cardiovascular function, respiratory function, renal/hepatic function, and altered pharmacokinetics.
3. These changes require special considerations for preoperative evaluation and perioperative management, including more judicious use of medications, fluid management, and temperature regulation. Regional anesthesia may provide some benefits over general anesthesia for elderly patients.
ANAESTHESIA CONSIDERATIONS IN GERIATRIC PATEINTSHimanshu Sharma
This document provides an overview of geriatric anaesthesia. It discusses the physiological changes that occur with aging and their implications for anaesthesia management. Key points include:
1. Organ systems like the cardiovascular, respiratory and renal systems undergo age-related changes that reduce functional reserve and increase vulnerability to haemodynamic fluctuations.
2. Anaesthetic pharmacokinetics and pharmacodynamics are also altered in elderly patients, requiring lower doses of drugs.
3. Thorough preoperative assessment of medical history, functional status and frailty is important for risk stratification and care planning. Close perioperative monitoring and attention to fluid balance, temperature regulation and delirium prevention are also crucial.
Geriatric anaesthesia- Dr harsimran Waliaharry11818a
This document discusses the physiological and pharmacological considerations for geriatric anesthesia. It notes that aging is characterized by a progressive loss of functional reserve in organ systems. Some key changes in the elderly include decreased cardiac output and vascular compliance, reduced lung function and respiratory drive, diminished liver and kidney function, loss of muscle mass and bone density, and impaired thermoregulation. These alterations require adjustments to anesthesia management such as modified drug dosing and extra precautions to avoid complications like hypotension, hypoxemia, hypothermia and delirium.
Anaesthetic Management of Elderly PatientsMd Rabiul Alam
Elderly patients undergoing anaesthesia and surgery present unique challenges due to age-related physiological changes. A comprehensive preoperative evaluation assessing organ system function and functional capacity is important to optimize medical conditions, identify high-risk patients, and guide anaesthetic management. The goal is to minimize risk of postoperative complications like delirium through a multidisciplinary approach, careful optimization, and selection of the most appropriate anaesthetic technique for each patient's needs and abilities. Consideration of futility is also important to avoid inappropriate procedures with no benefit for the elderly patient.
Geriatric anesthesia with special consideration Petrus IitulaPetrus Iitula
Geriatric anaesthesia requires special consideration due to age-related physiological changes that increase risks for elderly patients undergoing surgery. Pre-operative assessment is important to identify risk factors like cardiovascular, pulmonary, renal and neurological conditions. During surgery, risks of hypotension, hypothermia and delayed drug effects must be managed. Post-operatively, risks include delirium, pneumonia, cardiac complications, and other issues that require close monitoring. Regional anesthesia may provide some benefits over general anesthesia for elderly patients by reducing certain risks. Thorough pre-operative evaluation and optimization of patient conditions can help improve outcomes for elderly surgical patients.
Anesthetic management of elderly patients requires special considerations. The elderly population is growing rapidly. Preoperative testing may not be needed for low or intermediate risk surgery if the patient is followed by their primary care physician and has no concerning findings on history and physical. Anesthetic drugs have longer durations of action in the elderly and some require lower doses for induction to avoid hypotension. Emergence from anesthesia takes longer in the elderly and regional anesthesia may be preferable to general anesthesia when possible. Careful titration of anesthetic drugs is important due to age-related changes in pharmacokinetics and pharmacodynamics.
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.
- The document discusses the physiological changes that occur with aging and their implications for anesthesia and surgery. Some key points:
1. Aging is associated with declines in organ function, functional capacity, and homeostatic mechanisms. Approximately 15-25% of surgical patients are aged 65 or older.
2. Common physiological changes with aging include declines in brain/nervous system function, cardiovascular function, respiratory function, renal/hepatic function, and altered pharmacokinetics.
3. These changes require special considerations for preoperative evaluation and perioperative management, including more judicious use of medications, fluid management, and temperature regulation. Regional anesthesia may provide some benefits over general anesthesia for elderly patients.
ANAESTHESIA CONSIDERATIONS IN GERIATRIC PATEINTSHimanshu Sharma
This document provides an overview of geriatric anaesthesia. It discusses the physiological changes that occur with aging and their implications for anaesthesia management. Key points include:
1. Organ systems like the cardiovascular, respiratory and renal systems undergo age-related changes that reduce functional reserve and increase vulnerability to haemodynamic fluctuations.
2. Anaesthetic pharmacokinetics and pharmacodynamics are also altered in elderly patients, requiring lower doses of drugs.
3. Thorough preoperative assessment of medical history, functional status and frailty is important for risk stratification and care planning. Close perioperative monitoring and attention to fluid balance, temperature regulation and delirium prevention are also crucial.
Geriatric anaesthesia- Dr harsimran Waliaharry11818a
This document discusses the physiological and pharmacological considerations for geriatric anesthesia. It notes that aging is characterized by a progressive loss of functional reserve in organ systems. Some key changes in the elderly include decreased cardiac output and vascular compliance, reduced lung function and respiratory drive, diminished liver and kidney function, loss of muscle mass and bone density, and impaired thermoregulation. These alterations require adjustments to anesthesia management such as modified drug dosing and extra precautions to avoid complications like hypotension, hypoxemia, hypothermia and delirium.
Anaesthetic Management of Elderly PatientsMd Rabiul Alam
Elderly patients undergoing anaesthesia and surgery present unique challenges due to age-related physiological changes. A comprehensive preoperative evaluation assessing organ system function and functional capacity is important to optimize medical conditions, identify high-risk patients, and guide anaesthetic management. The goal is to minimize risk of postoperative complications like delirium through a multidisciplinary approach, careful optimization, and selection of the most appropriate anaesthetic technique for each patient's needs and abilities. Consideration of futility is also important to avoid inappropriate procedures with no benefit for the elderly patient.
Geriatric anesthesia with special consideration Petrus IitulaPetrus Iitula
Geriatric anaesthesia requires special consideration due to age-related physiological changes that increase risks for elderly patients undergoing surgery. Pre-operative assessment is important to identify risk factors like cardiovascular, pulmonary, renal and neurological conditions. During surgery, risks of hypotension, hypothermia and delayed drug effects must be managed. Post-operatively, risks include delirium, pneumonia, cardiac complications, and other issues that require close monitoring. Regional anesthesia may provide some benefits over general anesthesia for elderly patients by reducing certain risks. Thorough pre-operative evaluation and optimization of patient conditions can help improve outcomes for elderly surgical patients.
Anesthetic management of elderly patients requires special considerations. The elderly population is growing rapidly. Preoperative testing may not be needed for low or intermediate risk surgery if the patient is followed by their primary care physician and has no concerning findings on history and physical. Anesthetic drugs have longer durations of action in the elderly and some require lower doses for induction to avoid hypotension. Emergence from anesthesia takes longer in the elderly and regional anesthesia may be preferable to general anesthesia when possible. Careful titration of anesthetic drugs is important due to age-related changes in pharmacokinetics and pharmacodynamics.
A vivid description of the anaesthetic management in a case of congenital heart disease posted for non cardiac surgery.Briefing of the various CHD'S from basics.Clear description of the pathophysiology,Illustrated with flowcharts and understanding of the complex modified circulatory states.Completely discussed with Head Of the Department and Cardiac Anaesthetic.
This document discusses geriatric anesthesia and the age-related physiological changes that are important to consider. It notes that people over 65 are more likely to have surgery and aging results in declining organ function and reserve. It then summarizes the key age-related changes in major organ systems like cardiovascular, respiratory, renal, and neurological function that are important for anesthesiologists to be aware of when treating elderly patients. Finally, it provides recommendations for the preoperative, intraoperative, and postoperative care of geriatric patients undergoing anesthesia.
This document provides an overview of pacemakers and implantable cardioverter defibrillators (ICDs). It discusses the different types of pacemakers including single-chamber pacemakers (VVI), dual-chamber pacemakers (DDD), and biventricular pacemakers (CRT). It outlines the indications for pacemaker and ICD implantation and reviews potential complications of the procedures such as infection, lead issues, and pacemaker syndrome. Guidelines for device implantation and management are summarized including recommendations on timing after heart events, upgrades, and device selection. Risks associated with dual chamber devices are also mentioned.
This document discusses heart failure, including:
- Heart failure affects over 26 million people worldwide and 1% of the Indian population.
- Common symptoms include fatigue, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and Cheyne-Stokes respiration.
- Echocardiography, cardiac MRI, biopsy and BNP levels are important for diagnosis and evaluating the etiology and severity of heart failure.
- Treatment involves lifestyle modifications like diet, exercise and medication including diuretics, ACE inhibitors, ARBs, beta blockers, aldosterone antagonists and sacubitril-valsartan which have been shown to reduce symptoms and mortality in heart
This document discusses coronary artery spasm (CAS), a condition where the coronary arteries constrict unexpectedly, reducing blood flow and causing chest pain. It notes that CAS was first described by Dr. Myron Prinzmetal in 1959 and further studied by Atilio Maseri. CAS can cause a range of symptoms from silent ischemia to heart attack and sudden death. The diagnosis of CAS requires coronary angiography with provocative testing showing reduced coronary artery diameter during spasm. Treatment focuses on calcium channel blockers and nitrates, with stenting or bypass only used for obstructive coronary disease complications from CAS.
The document discusses geriatric anesthesia and the anatomical and physiological changes that occur with aging. Key points:
- Aging is associated with a progressive decline in organ system function and physiological reserves. This limited reserve is most evident during times of physiological stress like surgery.
- Common changes include decreased brain, liver and kidney function, increased sensitivity to medications, and altered cardiovascular, respiratory and endocrine systems.
- These anatomical and physiological alterations are important considerations for preoperative evaluation, intraoperative management, and postoperative care of elderly patients undergoing anesthesia and surgery. Close monitoring and adjusted dosing of medications are often needed.
1) Atrial fibrillation is the most common cardiac arrhythmia characterized by irregular electrical activity in the atria. It increases in prevalence with age and can cause complications like heart failure, stroke, and systemic embolism.
2) Management of atrial fibrillation involves rate or rhythm control as well as long-term anticoagulation to prevent thromboembolism depending on stroke risk factors. The CHA2DS2-VASc score is used to assess this risk.
3) While antiarrhythmic drugs and cardioversion can restore normal sinus rhythm, rate control is preferred for many patients. Newer anticoagulants like dabigatran and rivar
This document provides guidelines on the management of stable coronary artery disease (SCAD). SCAD is characterized by reversible episodes of ischemia that are usually induced by stress and reproducible. The main features of SCAD include plaque-related obstruction, focal or diffuse arterial spasm, microvascular dysfunction, and left ventricular dysfunction from prior acute necrosis. Diagnosis involves assessing symptoms, obtaining a medical history, and performing tests like electrocardiograms, imaging, and invasive coronary angiography. Risk stratification uses test results to determine a patient's annual mortality risk as low (<1%), intermediate (1-3%), or high (>3%) to guide management, which includes lifestyle changes, pharmacological therapy, and possible revascularization.
Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/ARVC) is a genetic heart condition characterized by structural abnormalities and fatty infiltration of the right ventricle, leading to ventricular arrhythmias and sudden cardiac death. It is a common cause of sudden cardiac death in young athletes. Clinical features include palpitations, syncope, chest pain, and dyspnea. Diagnosis relies on a combination of ECG findings, echocardiogram abnormalities of the right ventricle, and genetic testing.
Physician should have a high suspicion to diagnose patient with pulmonary Embolism, this slides will give you precise Diagnosis, Investigation and guideline directed Treatment.
- Implantable cardioverter defibrillators (ICDs) are recommended for patients with hypertrophic cardiomyopathy (HCM) who have survived sudden cardiac arrest, have spontaneous sustained ventricular tachycardia, or meet certain high-risk criteria.
- Risk stratification should be performed at initial evaluation and periodically to determine ICD need based on factors like family history of sudden cardiac death and abnormal blood pressure response.
- For left ventricular outflow tract obstruction, beta blockers and calcium channel blockers are first-line medical therapies while septal myectomy or alcohol septal ablation are invasive options that provide long-term reduction in outflow gradient.
This document discusses the management of hypertrophic cardiomyopathy (HCM). It covers the natural history of HCM, risk stratification including the role of implantable cardioverter defibrillators, pharmacological treatments, and invasive treatments such as alcohol septal ablation and surgical myectomy. Key points discussed include the use of beta blockers as first-line pharmacological therapy, guidelines for ICD implantation, the technique and outcomes of alcohol septal ablation versus surgical myectomy, and recommendations for experienced centers to perform these invasive procedures.
Aortic stenosis is the abnormal narrowing of the aortic valve opening. It can be caused by congenital heart defects, calcification of the valve, or rheumatic fever. Symptoms include chest pain, fainting, fatigue, and heart failure. Diagnosis involves echocardiogram, ECG, chest x-ray and cardiac catheterization. Treatment depends on severity and includes medications, balloon valvuloplasty, transcatheter aortic valve replacement, surgical aortic valve replacement, and lifestyle changes like quitting smoking.
Device therapy for heart failure monitoring and managementDIPAK PATADE
1) Device therapy such as ICDs and CRT play an important role in managing advanced heart failure by treating life-threatening arrhythmias and improving morbidity and survival.
2) Clinical trials such as MUSTIC, MIRACLE, and CARE-HF demonstrated that CRT improves symptoms, exercise capacity, quality of life and reduces mortality in patients with heart failure and ventricular dyssynchrony.
3) The COMPANION trial showed that CRT with or without an ICD provided greater benefits than medical therapy alone in reducing the risk of all-cause mortality and hospitalizations.
Atrial fibrillation is the most common arrhythmia, affecting over 2 million people in the US. It can cause palpitations, weakness, and reduced exercise capacity. Risk factors include structural heart disease, lung disease, hyperthyroidism, and alcohol use. Diagnosis is made through EKG and echocardiogram. Treatment involves rate or rhythm control with medications, cardioversion, or ablation, as well as long-term anticoagulation to prevent stroke for high-risk patients.
Hypertrophic cardiomyopathy (HCM) is a genetic cardiovascular disease characterized by increased and thickened heart muscle. It is the most common cause of sudden cardiac death in young people. HCM can cause symptoms such as chest pain, heart failure, and palpitations. Treatment involves managing left ventricular outflow tract obstruction through medications, septal reduction procedures, or alcohol septal ablation. Patients at high risk for sudden cardiac death may receive an implantable cardioverter defibrillator for prevention. Risk factors include a family history of sudden death, abnormal blood pressure response to exercise, and extensive thickening of the heart muscle.
This document discusses heart failure with normal ejection fraction (HFNEF). It defines HFNEF and explains that nearly half of heart failure patients have normal ejection fraction. The pathophysiology of HFNEF involves diastolic dysfunction, systolic dysfunction, impaired ventricular vascular coupling, and other factors. The document examines mechanisms of diastolic dysfunction like relaxation abnormalities, stiffness, and the role of calcium and titin. It discusses the diagnosis and evaluation of HFNEF.
Anatomy, physiology & patophysiology of the cardiovascularCarlos Galiano
This document provides an overview of the anatomy, physiology, and pathophysiology of the cardiovascular system as it relates to anesthesia. It discusses the structure and function of the heart and coronary circulation. It then covers topics such as cardiac cycle, hemodynamics, effects of the autonomic nervous system, and cardiovascular disorders including heart failure, hypertension, ischemic heart disease, and cardiac tamponade. For each topic, it provides details on pathophysiology and considerations for anesthesia management.
Geriatrics focuses on healthcare for the elderly. It aims to promote health and prevent/treat diseases and disabilities in older adults. There are differences between adult and geriatric medicine, as geriatricians focus more on functional ability, independence, and quality of life than physicians for adults. Employment of physical therapist assistants in geriatrics is expected to grow substantially due to the aging baby boomer population and medical advances enabling more trauma survivors who will need therapy. Minimum competencies for geriatric physical therapy include treatment of cognitive/behavioral disorders, medication management, and palliative care.
A vivid description of the anaesthetic management in a case of congenital heart disease posted for non cardiac surgery.Briefing of the various CHD'S from basics.Clear description of the pathophysiology,Illustrated with flowcharts and understanding of the complex modified circulatory states.Completely discussed with Head Of the Department and Cardiac Anaesthetic.
This document discusses geriatric anesthesia and the age-related physiological changes that are important to consider. It notes that people over 65 are more likely to have surgery and aging results in declining organ function and reserve. It then summarizes the key age-related changes in major organ systems like cardiovascular, respiratory, renal, and neurological function that are important for anesthesiologists to be aware of when treating elderly patients. Finally, it provides recommendations for the preoperative, intraoperative, and postoperative care of geriatric patients undergoing anesthesia.
This document provides an overview of pacemakers and implantable cardioverter defibrillators (ICDs). It discusses the different types of pacemakers including single-chamber pacemakers (VVI), dual-chamber pacemakers (DDD), and biventricular pacemakers (CRT). It outlines the indications for pacemaker and ICD implantation and reviews potential complications of the procedures such as infection, lead issues, and pacemaker syndrome. Guidelines for device implantation and management are summarized including recommendations on timing after heart events, upgrades, and device selection. Risks associated with dual chamber devices are also mentioned.
This document discusses heart failure, including:
- Heart failure affects over 26 million people worldwide and 1% of the Indian population.
- Common symptoms include fatigue, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and Cheyne-Stokes respiration.
- Echocardiography, cardiac MRI, biopsy and BNP levels are important for diagnosis and evaluating the etiology and severity of heart failure.
- Treatment involves lifestyle modifications like diet, exercise and medication including diuretics, ACE inhibitors, ARBs, beta blockers, aldosterone antagonists and sacubitril-valsartan which have been shown to reduce symptoms and mortality in heart
This document discusses coronary artery spasm (CAS), a condition where the coronary arteries constrict unexpectedly, reducing blood flow and causing chest pain. It notes that CAS was first described by Dr. Myron Prinzmetal in 1959 and further studied by Atilio Maseri. CAS can cause a range of symptoms from silent ischemia to heart attack and sudden death. The diagnosis of CAS requires coronary angiography with provocative testing showing reduced coronary artery diameter during spasm. Treatment focuses on calcium channel blockers and nitrates, with stenting or bypass only used for obstructive coronary disease complications from CAS.
The document discusses geriatric anesthesia and the anatomical and physiological changes that occur with aging. Key points:
- Aging is associated with a progressive decline in organ system function and physiological reserves. This limited reserve is most evident during times of physiological stress like surgery.
- Common changes include decreased brain, liver and kidney function, increased sensitivity to medications, and altered cardiovascular, respiratory and endocrine systems.
- These anatomical and physiological alterations are important considerations for preoperative evaluation, intraoperative management, and postoperative care of elderly patients undergoing anesthesia and surgery. Close monitoring and adjusted dosing of medications are often needed.
1) Atrial fibrillation is the most common cardiac arrhythmia characterized by irregular electrical activity in the atria. It increases in prevalence with age and can cause complications like heart failure, stroke, and systemic embolism.
2) Management of atrial fibrillation involves rate or rhythm control as well as long-term anticoagulation to prevent thromboembolism depending on stroke risk factors. The CHA2DS2-VASc score is used to assess this risk.
3) While antiarrhythmic drugs and cardioversion can restore normal sinus rhythm, rate control is preferred for many patients. Newer anticoagulants like dabigatran and rivar
This document provides guidelines on the management of stable coronary artery disease (SCAD). SCAD is characterized by reversible episodes of ischemia that are usually induced by stress and reproducible. The main features of SCAD include plaque-related obstruction, focal or diffuse arterial spasm, microvascular dysfunction, and left ventricular dysfunction from prior acute necrosis. Diagnosis involves assessing symptoms, obtaining a medical history, and performing tests like electrocardiograms, imaging, and invasive coronary angiography. Risk stratification uses test results to determine a patient's annual mortality risk as low (<1%), intermediate (1-3%), or high (>3%) to guide management, which includes lifestyle changes, pharmacological therapy, and possible revascularization.
Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/ARVC) is a genetic heart condition characterized by structural abnormalities and fatty infiltration of the right ventricle, leading to ventricular arrhythmias and sudden cardiac death. It is a common cause of sudden cardiac death in young athletes. Clinical features include palpitations, syncope, chest pain, and dyspnea. Diagnosis relies on a combination of ECG findings, echocardiogram abnormalities of the right ventricle, and genetic testing.
Physician should have a high suspicion to diagnose patient with pulmonary Embolism, this slides will give you precise Diagnosis, Investigation and guideline directed Treatment.
- Implantable cardioverter defibrillators (ICDs) are recommended for patients with hypertrophic cardiomyopathy (HCM) who have survived sudden cardiac arrest, have spontaneous sustained ventricular tachycardia, or meet certain high-risk criteria.
- Risk stratification should be performed at initial evaluation and periodically to determine ICD need based on factors like family history of sudden cardiac death and abnormal blood pressure response.
- For left ventricular outflow tract obstruction, beta blockers and calcium channel blockers are first-line medical therapies while septal myectomy or alcohol septal ablation are invasive options that provide long-term reduction in outflow gradient.
This document discusses the management of hypertrophic cardiomyopathy (HCM). It covers the natural history of HCM, risk stratification including the role of implantable cardioverter defibrillators, pharmacological treatments, and invasive treatments such as alcohol septal ablation and surgical myectomy. Key points discussed include the use of beta blockers as first-line pharmacological therapy, guidelines for ICD implantation, the technique and outcomes of alcohol septal ablation versus surgical myectomy, and recommendations for experienced centers to perform these invasive procedures.
Aortic stenosis is the abnormal narrowing of the aortic valve opening. It can be caused by congenital heart defects, calcification of the valve, or rheumatic fever. Symptoms include chest pain, fainting, fatigue, and heart failure. Diagnosis involves echocardiogram, ECG, chest x-ray and cardiac catheterization. Treatment depends on severity and includes medications, balloon valvuloplasty, transcatheter aortic valve replacement, surgical aortic valve replacement, and lifestyle changes like quitting smoking.
Device therapy for heart failure monitoring and managementDIPAK PATADE
1) Device therapy such as ICDs and CRT play an important role in managing advanced heart failure by treating life-threatening arrhythmias and improving morbidity and survival.
2) Clinical trials such as MUSTIC, MIRACLE, and CARE-HF demonstrated that CRT improves symptoms, exercise capacity, quality of life and reduces mortality in patients with heart failure and ventricular dyssynchrony.
3) The COMPANION trial showed that CRT with or without an ICD provided greater benefits than medical therapy alone in reducing the risk of all-cause mortality and hospitalizations.
Atrial fibrillation is the most common arrhythmia, affecting over 2 million people in the US. It can cause palpitations, weakness, and reduced exercise capacity. Risk factors include structural heart disease, lung disease, hyperthyroidism, and alcohol use. Diagnosis is made through EKG and echocardiogram. Treatment involves rate or rhythm control with medications, cardioversion, or ablation, as well as long-term anticoagulation to prevent stroke for high-risk patients.
Hypertrophic cardiomyopathy (HCM) is a genetic cardiovascular disease characterized by increased and thickened heart muscle. It is the most common cause of sudden cardiac death in young people. HCM can cause symptoms such as chest pain, heart failure, and palpitations. Treatment involves managing left ventricular outflow tract obstruction through medications, septal reduction procedures, or alcohol septal ablation. Patients at high risk for sudden cardiac death may receive an implantable cardioverter defibrillator for prevention. Risk factors include a family history of sudden death, abnormal blood pressure response to exercise, and extensive thickening of the heart muscle.
This document discusses heart failure with normal ejection fraction (HFNEF). It defines HFNEF and explains that nearly half of heart failure patients have normal ejection fraction. The pathophysiology of HFNEF involves diastolic dysfunction, systolic dysfunction, impaired ventricular vascular coupling, and other factors. The document examines mechanisms of diastolic dysfunction like relaxation abnormalities, stiffness, and the role of calcium and titin. It discusses the diagnosis and evaluation of HFNEF.
Anatomy, physiology & patophysiology of the cardiovascularCarlos Galiano
This document provides an overview of the anatomy, physiology, and pathophysiology of the cardiovascular system as it relates to anesthesia. It discusses the structure and function of the heart and coronary circulation. It then covers topics such as cardiac cycle, hemodynamics, effects of the autonomic nervous system, and cardiovascular disorders including heart failure, hypertension, ischemic heart disease, and cardiac tamponade. For each topic, it provides details on pathophysiology and considerations for anesthesia management.
Geriatrics focuses on healthcare for the elderly. It aims to promote health and prevent/treat diseases and disabilities in older adults. There are differences between adult and geriatric medicine, as geriatricians focus more on functional ability, independence, and quality of life than physicians for adults. Employment of physical therapist assistants in geriatrics is expected to grow substantially due to the aging baby boomer population and medical advances enabling more trauma survivors who will need therapy. Minimum competencies for geriatric physical therapy include treatment of cognitive/behavioral disorders, medication management, and palliative care.
Geriatrics is the branch of medicine focused on healthcare for the elderly. It aims to promote health and prevent/treat diseases and disabilities in older adults. Gerontology studies the process of aging. As people age, their skin, eyes, ears, kidneys, bones, nervous system, heart, lungs, and gastrointestinal system all undergo changes that can impact health. Common diseases in older adults include Alzheimer's, arthritis, cancer, cardiovascular disease, incontinence, and stroke. Geriatric physiotherapy addresses three main issues - deconditioning, cardiovascular diseases, and musculoskeletal problems. It focuses on reconditioning, exercise therapies, and addressing conditions like osteoporosis and osteoarthritis.
Geriatric anesthesia physiological changes and preoperative preparationTushar Chokshi
This document provides an outline for a lecture on anesthesia implications for elderly patients. It discusses the normal age-related physiological changes in several body systems and how they impact anesthesia considerations. Some key points include:
- The cardiovascular system shows decreased cardiac output, increased blood pressure, and reduced beta receptor response with age. This increases risks of hypotension, arrhythmias, and heart failure during anesthesia.
- Respiratory function declines with stiffer lungs and weaker muscles. Elderly are more prone to aspiration, infection, and oxygen desaturation.
- Other organ systems like kidneys, liver and skin also experience changes that slow drug metabolism and clearance. This increases risks of toxicity.
- Thorough
The document discusses the importance of preoperative assessment and preparation of patients prior to surgery. Key aspects of assessment include taking a thorough medical history, conducting a physical examination, evaluating nutritional status, ordering relevant investigations, and determining surgical risk. Important elements of preparation are obtaining informed consent, preventing cardiovascular and respiratory complications, reducing risk of aspiration, preparing the bowels if needed, and ensuring adequate sleep, skin preparation, catheterization and pre-medication when applicable. The goals are to identify risk factors, optimize the patient's health status, and reduce postoperative complications.
This document discusses preoperative and postoperative care. The goals of preoperative care are to optimize the patient's condition before surgery to achieve the best surgical outcome and minimize complications. This involves assessing risk factors, performing examinations and tests to evaluate fitness for surgery, and developing a management plan. Postoperative care focuses on recovery and addressing any medical issues that arise.
Dr Rowan Molnar #DrRowanMolnar - Popular profiles on GoogleDr. Rowan Molnar
Dr Rowan Molnar is dedicated to medical education at all levels, particularly in establishment, deployment and implementation of simulation based teaching. Dr Rowan Molnar is a recognised leader with a demonstrated ability to constantly strive for excellence in the ever changing world of medicine.
#DrRowanMolnar, #RowanMolnar, #DrRowan, #Molnar, #DrRowanMolnarAustralia, #RowanMolnarAustralia, #DrRowanMolnarMelbourneAustralia
The document discusses the assessment and management of critically ill surgical patients. Key points include:
- Early identification of at-risk patients is important to improve outcomes. Tachypnea and metabolic acidosis are important predictors of risk.
- Patients undergoing surgery experience physiological stress responses that can impair volume status, cardiac output, temperature regulation and coagulation.
- In the postoperative period, goals include optimizing perfusion and organ function, encouraging early feeding and mobilization to prevent complications, and considering complications related to anesthesia interactions and the patient's underlying health issues.
- For a deteriorating postoperative patient, interventions and differential diagnoses should be considered along with the potential need for reoperation or repeat surgical consultation. Effective
This document summarizes recent literature on anesthesia for patients with congenital heart disease presenting for noncardiac surgery. It finds that the highest risk patients are infants with a single functioning ventricle, those with suprasystemic pulmonary hypertension, left ventricular outflow tract obstruction, or dilated cardiomyopathy. Understanding the anatomy, physiology, and risks associated with different congenital heart defects and stages of palliation is important for optimizing outcomes. Multidisciplinary planning and careful anesthetic management are also critical to reduce risks in this patient population undergoing noncardiac procedures.
This document discusses perioperative care considerations for geriatric patients undergoing surgery. It outlines several key areas that should be addressed preoperatively, including assessing a patient's capacity to consent, discussing treatment goals and prognosis, evaluating pulmonary and cardiovascular risk, managing diabetes, and screening for delirium risk factors. Intraoperatively, proper administration of antibiotics and appropriate use of anticoagulation are emphasized. Perioperative beta blockade may benefit select high-risk patients. Thorough preoperative evaluation and optimization of patient risks can help reduce surgical morbidity and mortality in older adults.
This document discusses total hip and knee replacement surgeries and associated comorbidities. It notes that osteoarthritis is a common cause of joint pain and disability in older individuals, and that joint replacement may be considered when conservative treatments fail. It then summarizes several major cardiovascular, neurological, thromboembolic, and pulmonary comorbidities that are important to assess preoperatively due to increased risks they pose. These include conditions like coronary artery disease, pulmonary hypertension, stroke risk, and chronic lung disease. A thorough evaluation and optimization of high-risk patients' comorbidities is recommended prior to surgery.
This document provides guidance on patient assessment prior to surgery. It outlines the importance of correcting medical issues like anemia and diabetes, as well as gaining an understanding of a patient's history and comorbidities to estimate surgical risks. The assessment involves taking a thorough history, conducting an examination, and ordering relevant investigations. High-risk patients are identified and their management is optimized to reduce postoperative morbidity and mortality. The document provides detailed guidance on assessing various organ systems and comorbidities, and developing perioperative management plans tailored to individual patient needs and risks.
2019 ESC guidelines for pulmonary embolism Dina Mostafa
The document summarizes the key points of the 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism (PE). Some of the main updates in the new guidelines include: using age-adjusted D-dimer cut-offs rather than fixed values; revising the risk stratification algorithm to emphasize multidisciplinary care and early risk assessment; strengthening recommendations for rescue thrombolysis and interventional treatments for unstable patients; and recommending direct oral anticoagulants over warfarin as first-line treatments. The guidelines also provide a dedicated diagnostic algorithm for PE in pregnancy and recommend follow-up care after PE to monitor for long-term sequelae.
Anesthetic Management of Abdominal Surgery.pptxTadesseFenta1
This document outlines an anesthesia course for abdominal and genitourinary surgery. The course aims to enable anesthetists to safely manage anesthesia for patients undergoing abdominal, gastrointestinal, hepatobiliary, anal, and genitourinary surgeries. It covers preoperative evaluation, risks associated with abdominal surgery, anesthetic techniques for different procedures, postoperative complications, and management of patients with hepatic or cardiovascular disease. The course assessments include assignments, quizzes, and a final written exam.
This document discusses anesthetic concerns for trauma victims requiring operative intervention who are too sick to anesthetize. It covers cardiac trauma such as blunt myocardial injury, traumatic aortic injury, and cardiac tamponade. It also discusses pulmonary trauma such as pulmonary contusions, flail chest, fat embolism syndrome, and acute lung injury. The case study presented is of an obese man in shock following a motor vehicle crash requiring emergency surgery. The priorities are stabilizing the patient's hemodynamics and oxygenation through fluid resuscitation and ventilation before inducing anesthesia to improve outcomes.
Principles of preoperative and operative surgeryMEEQAT HOSPITAL
This document discusses principles of preoperative and operative surgery. It covers four main principles: preoperative preparation of the patient, a systems approach to preoperative evaluation, additional preoperative considerations, and a preoperative checklist. For preoperative evaluation and preparation, the document emphasizes assessing patient risk factors, especially cardiovascular risk, and optimizing high-risk patients prior to surgery through testing, medication, and consultation with specialists. The goal is to identify any medical issues that could impact the surgical outcome and take steps to improve the patient's status and reduce perioperative risk.
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Non cardiac surgery in cardiac patients moTamer Taha
This document discusses guidelines for evaluating and managing cardiac risk in patients undergoing non-cardiac surgery. It outlines factors that increase surgical risk like prolonged stress and changes in thrombotic factors. Complication rates are reported to be 7-11% with 0.8-1.5% mortality depending on precautions. Up to 42% of complications are cardiac related. It provides recommendations on pre-operative testing and risk stratification using indices. Risk reduction strategies discussed include use of beta-blockers, statins, and revascularization. Perioperative management of antiplatelets and anticoagulants is also covered.
1. Management of older patients on dialysis requires a focus on overall aging aspects and quality of life rather than just dialysis.
2. Almost all frail elderly patients receive in-center hemodialysis due to physical and cognitive impairments, though assisted peritoneal dialysis enables home dialysis.
3. Understanding individual patient goals and life expectancy is important for elderly patients, as some may choose no dialysis or conservative care over treatment burdens when remaining life is short.
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This document provides guidance on the perioperative management of patients with various neurological diseases. It outlines considerations for patients with cerebrovascular stroke, epilepsy, neuromuscular disorders, muscle diseases, peripheral neuropathies, Parkinson's disease, multiple sclerosis, and Alzheimer's disease. Key recommendations include continuing antiplatelet therapies for stroke patients during many procedures, maintaining epilepsy patients' regular anticonvulsant medications, assessing respiratory function for neuromuscular disease patients, and timing Parkinson's disease medications around surgery to avoid complications. Careful planning is needed to minimize risks for each condition.
This document discusses the diagnosis and management of pneumonia in the emergency department. It outlines the diagnostic testing approaches for pneumonia, including chest radiography, laboratory studies, and pulse oximetry. Chest radiography is generally the most important test for establishing a pneumonia diagnosis. Vital signs, physical exam findings, and pulse oximetry can help identify patients who would benefit from further evaluation with chest radiography. Laboratory studies are of limited use for diagnosis but can provide clues about immunosuppression or severity. The priorities in the emergency department are providing respiratory support, assessing severity, initiating empiric antibiotics, and determining need for hospitalization.
The document discusses patient-centered outcomes for perioperative research. It proposes "disability-free survival" as a new outcome measure that is meaningful to patients. Disability-free survival combines survival rates with a validated patient-reported assessment of disability. The authors validate a short version of the World Health Organization Disability Assessment Schedule (WHODAS) for use in surgical patients. Widespread use of disability-free survival could improve shared decision making, quality metrics, and benchmarking by focusing on outcomes that matter to patients rather than surrogate outcomes or doctor perceptions of success.
This document outlines preoperative, intraoperative, and postoperative care. Preoperative care includes assessing risk factors, obtaining consent, and optimizing patient health. Intraoperative care focuses on monitoring vital signs and maintaining homeostasis. Postoperative care goals are a quick and safe recovery, including monitoring in recovery and treating any complications across body systems.
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Actinium is the first member of the actinide series of elements according to its electronic configuration. Actinium closely resembles lanthanum chemically. The three most important isotopes of actinium are 227Ac, 228Ac, and 225Ac. 227Ac is a naturally occurring isotope in the uranium-actinium decay series with a half-life of 21.772 years. 228Ac is in the thorium decay series with a half-life of 6.15 hours. 225Ac is produced from 233U with applications in medicine.
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1) Ranchers in Idaho observed lambs born with cyclopia (one eye) due to ewes grazing on corn lily plants. Cyclopamine was identified as the compound responsible and was later found to inhibit the Hedgehog signaling pathway.
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This document reviews solid-state NMR techniques that have been used to determine the molecular structures of amyloid fibrils. It discusses five categories of NMR techniques: 1) homonuclear dipolar recoupling and polarization transfer via J-coupling, 2) heteronuclear dipolar recoupling, 3) correlation spectroscopy, 4) recoupling of chemical shift anisotropy, and 5) tensor correlation methods. Specific techniques described include rotational resonance, dipolar dephasing, constant-time dipolar dephasing, REDOR, and fpRFDR-CT. These techniques have provided insights into the hydrogen-bond registry, spatial organization, and backbone torsion angles of amyloid fibrils.
This document discusses principles of ionization and ion dissociation in mass spectrometry. It covers topics like ionization energy, processes that occur during electron ionization like formation of molecular ions and fragment ions, and ionization by energetic electrons. It also discusses concepts like vertical transitions, where electronic transitions occur much faster than nuclear motions. The document provides background information on fundamental gas phase ion chemistry concepts in mass spectrometry.
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Principles and applications of esr spectroscopySpringer
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This document discusses crystal structures of inorganic oxoacid salts from the perspective of periodic graph theory and cation arrays. It analyzes 569 crystal structures of simple salts with the formulas My(LO3)z and My(XO4)z, where M are metal cations, L are nonmetal triangular anions, and X are nonmetal tetrahedral anions. The document finds that in about three-fourths of the structures, the cation arrays are topologically equivalent to binary compounds like NaCl, NiAs, and FeB. It proposes representing these oxoacid salts as a quasi-binary model My[L/X]z, where the cation arrays determine the crystal structure topology while the oxygens play a
Field flow fractionation in biopolymer analysisSpringer
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1) The document discusses phonons, which are quantized lattice vibrations in crystals that carry thermal energy. It describes modeling crystal vibrations using a harmonic lattice approach.
2) Normal modes of the lattice vibrations can be described as a set of independent harmonic oscillators. Quantum mechanically, these normal modes are quantized as phonons with discrete energy levels.
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This chapter discusses 3D electroelastic problems and applied electroelastic problems. For 3D problems, it presents the potential function method for solving problems involving a penny-shaped crack and elliptic inclusions. It derives the governing equations and introduces potential functions to obtain the general static and dynamic solutions. For applied problems, it discusses simple electroelastic problems, laminated piezoelectric plates using classical and higher-order theories, and piezoelectric composite shells. It also presents a unified first-order approximate theory for electro-magneto-elastic thin plates.
Tensor algebra and tensor analysis for engineersSpringer
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1. Vector- and tensor-valued functions can be differentiated using limits, with the derivatives being the vector or tensor equivalent of the rate of change.
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This document provides a summary of carbon nanofibers:
1) Carbon nanofibers are sp2-based linear filaments with diameters of around 100 nm that differ from continuous carbon fibers which have diameters of several micrometers.
2) Carbon nanofibers can be produced via catalytic chemical vapor deposition or via electrospinning and thermal treatment of organic polymers.
3) Carbon nanofibers exhibit properties like high specific area, flexibility, and strength due to their nanoscale diameters, making them suitable for applications like energy storage electrodes, composite fillers, and bone scaffolds.
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This document discusses nanomaterials for biosensors and implantable biodevices. It describes how nanostructured thin films have enabled the development of more sensitive electrochemical biosensors by improving the detection of specific molecules. Two common techniques for creating nanostructured thin films are described - Langmuir-Blodgett films and layer-by-layer films. These techniques allow for the precise control of film thickness at the nanoscale and have been used to immobilize biomolecules like enzymes to create biosensors. Recent research is also exploring how these nanostructured films and biomolecules can be used to create implantable biosensors for real-time monitoring inside the body.
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This chapter introduces and classifies various types of damage that can occur in structures. Damage can be caused by forces, deformations, aggressive environments, or temperatures. It can occur suddenly or over time. The chapter discusses different damage mechanisms including corrosion, excessive deformation, plastic instability, wear, and fracture. It also introduces concepts that will be covered in more detail later such as damage mechanics, fracture mechanics, and the influence of microstructure on damage and fracture. The chapter aims to provide an overview of damage types before exploring specific mechanisms and analyses in later chapters.
This document summarizes research on identifying spin-wave eigen-modes in a circular spin-valve nano-pillar using Magnetic Resonance Force Microscopy (MRFM). Key findings include:
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2. 32 S.R. Barnett
anesthesiologists can contribute to a more viable health system. Preoperatively
anesthesiologists can contribute by advising on preoperative testing guidelines and
reducing the request for needless and repetitive preoperative laboratory tests.
Choosing the Anesthetic Regimen
The choice of anesthetic regimen is primarily dictated by the needs of the surgeon
or the proceduralist. Several factors are important to consider, including the patient’s
medical and psychological condition, the type and duration of the procedure or
surgery, and the requirements of the surgery itself. However even within one cate-
gory of anesthesia—for example, a general anesthetic—there are multiple decisions
made by the anesthesiologist that may influence a patient’s response to the surgery.
For example an elderly patient presenting with a perforated bowel for an explor-
atory laparotomy will require a general anesthesia with endotracheal intubation. In
this example there are no viable alternatives for the anesthetic type. However there
will be decisions to be made that require an understanding and appreciation of basic
age-related physiologic changes. The choice of induction agent is important; etomi-
date is preferred over propofol, thus avoiding the exaggerated hypotension observed
following a propofol bolus in an older patient. Blood pressure lability may be an
issue, and the decision to proceed with invasive monitoring with an arterial line may
be needed. Pain control in the setting of a large abdominal incision may be challeng-
ing, yet appropriate pain control in this instance may reduce the risk of a pulmonary
complication.
General Considerations for the Elderly Patient
Mortality and risk of an adverse event associated with surgery increase with
advanced age. This is due to multiple factors including age-related reductions in
physiologic reserve, the increase in comorbid conditions, and the magnitude and
type of the surgery itself. Complex emergency cases in the elderly carry the highest
mortality, with a suggested threefold increase in mortality. The risk of cardiac
complications in geriatric patients following emergency surgery increases 3–5
times, and the chance of postoperative intubation and ventilation is five times that of
a young patient undergoing a major emergency surgery. The magnitude and size of
surgery is very relevant: thoracotomy mortality in patients over 70 years has been
reported as high as 17%, and emergency abdominal surgery in patients over the age
80 years carries a mortality rate of 10–25%.
As stated, the occurrence of any complications appears to be a major factor
influencing outcomes in the elderly surgical patient. Several studies have shown a
significant increase in 30-day mortality in patients who experienced complications
following noncardiac surgery. In addition, patients experiencing a cardiac or
3. 333 The Anesthetic Regimen for the Elderly Patient
noncardiac complication had a threefold increase in length of stay. Thus, avoiding
complications—even minor ones—and conducting a careful review of the patients’
physical and medical status prior to anesthesia must be a primary focus for all
anesthesiologists taking care of older patients.
The increased morbidity experienced by older patients largely reflects the burden
of disease encountered in this age group. Data from a study examining preoperative
health status in elderly patients found that over 84% of 544 patients had at least one
comorbid condition, 30% of patients had three or more preoperative health condi-
tions, and 27% had two and 28% had one preexisting disease. Common conditions
include hypertension, diabetes mellitus, cardiac dysrhythmias, pulmonary disease,
neurologic disease, arthritis, and ischemic heart disease, including congestive failure.
Despite a long list of diseases, functional status and clinical evidence of congestive
heart failure are two of the most important predictors of an adverse postoperative
event. Functional status is particularly important, yet in the oldest patients—over
80 years—74% have a disability and 35% of the group requires assistance with
daily activities.
Atypical and Delayed Presentations
The presentation of common diseases in the older patient can be different, frequently
the elderly present with more subtle symptoms; this can result in a missed or delayed
diagnosis. This can lead to devastating consequences. A study comparing autopsy
results to the immediate premortem diagnosis in elderly patients found a discrep-
ancy in over one-third of autopsy cases. Significant missed diagnoses included
unrecognized ruptured aortic aneurysm, the existence of a pulmonary embolus, and
tracheal obstruction. In another group, myocardial infarction in older male patients
was unrecognized in patients that presented with nonspecific symptoms including
nausea, cough, fatigue, and syncope. Similarly, elderly patients sustaining a pulmo-
nary embolus tend to present with vague symptoms. These atypical presentations
may lead to an underestimation of a preoperative condition and potentially resulting
in an intraoperative catastrophic event. The preoperative evaluation of the elderly
patient should take into account the potential for an unusual presentation of a
significant cardiac or pulmonary event.
The initial presentation of a surgical condition may also be different in the older
patient. In over 50% of elderly patients undergoing surgery for appendicitis; the
appendix had already ruptured. The delayed care in these cases means the older
patient may require a more complex and extensive surgery and be hemodynamically
compromised. This is in sharp contrast to the classic presentation of the 20-year-old
college student with localizing abdominal pain who presents and is in the operating
room undergoing a laparoscopic appendectomy just a few hours from the original
symptoms. Similar late presentations have been described in patients with colon
cancer undergoing colorectal surgery. The oldest patients tended to present later,
have more comorbidities, and emergency surgery is more common. Not surprisingly,
4. 34 S.R. Barnett
ultimate survival for these patients is lower. The constellation of presenting later
with more advanced disease and complicated medical histories probably accounts
in part for the increased mortality and morbidity in the elderly patient.
Anesthetic Choices
Aspiration
The geriatric patient is at increased risk of aspirating due to physiologic changes
and common disease conditions. A reduction in pharyngeal sensitivity has been
demonstrated and common comorbidities such as a previous cerebrovascular acci-
dent, swallowing disorders, and diseases such as Parkinson’s disease lead to the
increased possibility of aspiration. The development of aspiration pneumonia can
be devastating in the in older patient with reduced functional reserve. Thus, regard-
less of the anesthetic regimen, protection of the airway is paramount, and sedation
should be administered cautiously in elderly patients with an unprotected airway.
General Anesthesia
A general endotracheal anesthesia with paralysis allows maximal exposure for
abdominal surgery and is necessary for abdominal and laparoscopic surgeries. When
paralysis is not required, provided the patient is fasting and not significantly obese
with a low risk of aspiration and the surgery site and positioning is appropriate, the
laryngeal mask airway (LMA) has largely replaced the traditional mask anesthetic.
For certain very brief surgeries, a mask anesthetic is still desirable. Advantages of
intubation compared to the LMA include the ability to protect the airway from aspi-
ration and possible reduction in the risk of development of intraoperative atelectasis
through the use of positive pressure volume ventilation with or without additional
positive end-expiratory pressure. Mucociliary dysfunction occurs after using an
LMA or an endotracheal tube, but is worse following intubation.
The prevalence of dementia increases with age, and depending on the ability to
cooperate, these patients may require a general anesthesia or deeper sedation than
would normally be indicated by the procedure itself. Examples include a brain MRI
during which a patient must lie still or a simple breast biopsy. The patient’s safety
must come first, and sometimes a general anesthetic may provide the least trauma-
tizing experience for the patient, even for a simple procedure.
Regional Anesthesia
Regional anesthesia includes both neuraxial techniques such as spinal and epidural
anesthesia and peripheral nerve blocks. Regional anesthesia may be administered as
5. 353 The Anesthetic Regimen for the Elderly Patient
the primary anesthetic or as an adjuvant for pain relief during or after the surgery.
When utilized to treat postoperative pain as well, epidural analgesia and peripheral
nerve blocks improve pain relief and functional outcomes and have been shown to
reduce hospital stay in selected patient groups. Advantages of a pure regional
anesthesia include a reduction in the requirement for sedatives, preservation of
spontaneous ventilation, the absence of airway instrumentation, and potential
decrease in the incidence of postoperative thrombosis and blood loss following
orthopedic surgery.
Monitored Anesthesia Care
Monitored anesthesia care (MAC) is the most common type of anesthesia adminis-
tered. This can range from the administration of minimal anxiolysis to deep sedation.
In older patients continuous supplemental oxygen is recommended in all cases.
Physiologic changes with aging result in a lower arterial oxygen tension on room
air, even before the administration of sedation. Patients undergoing a MAC frequently
need to be at least partially cooperative and able to lie still without significant pain.
For the older patient with agitation, dementia, uncontrollable tremors, chronic
cough, or chronic pain, this can be difficult, and a lower threshold for recommend-
ing a general anesthesia may be needed.
Medications
Elderly patients are on average taking three medications, and patients should receive
clear instructions on which medications should be held or continued on the day of
surgery. As a general rule most medications should be continued until the morning
of surgery, especially cardiac and antihypertensive medications. Angiotensin-
converting-enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs)
have been associated with profound and prolonged hypotension following the induc-
tion of anesthesia, and provided they are not being administered for congestive heart
failure, these should be held prior to surgery. Similarly, diuretics can be continued
in the presence of significant fluid overload; however, for the most part, thiazide
diuretics can be held for patient convenience.
Special Consideration
Cardiac Adverse Events and Risk Reduction
In general, the risk of a cardiac event following a noncardiac surgery is 1–2%, and
advanced age (over 65 years) is associated with an almost 2½-fold increase in risk
of a significant event. In a prospective observational study of over 8,000 patients
6. 36 S.R. Barnett
undergoing general, urological, and vascular surgery, Kheterpal et al. identified nine
risk predictors for a cardiac adverse event. These predictors were age >65 years,
BMI >30, emergent surgery, prior cardiac intervention or surgery, active congestive
heart failure, cerebrovascular disease, hypertension, operative duration >3.8 h, and
administration of packed red blood cells intraoperatively. They also found that
high-risk patients experiencing hypotension or tachycardia were more likely to
experience a cardiac adverse event.
Beta Blockers
Early data on perioperative beta-blocker use resulted in widespread perioperative
administration of beta blockers to low- and moderate-risk as well as high-risk
patients. Data from more recent randomized control trials including over 8,000
patients found a reduction in myocardial infarction, coronary revascularization, and
atrial fibrillation within 30 days of surgery in the metoprolol vs. placebo group.
However, they also found a significant increase in death, stroke, hypotension, and
bradycardia. These data and others have resulted in a reevaluation of the beta-block-
ade recommendations. The most recent guidelines recommend (class 1 evidence)
that beta blockers should be continued in patients who are currently receiving beta
blockers during the perioperative period. There is class 2a evidence to suggest that
beta blockers should be administered to patients with inducible ischemia on testing
prior to high-risk vascular surgery. There is also some evidence to recommend beta
blockers for high-risk patients, defined as more than one clinical risk factor, under-
going vascular or intermediate surgery, with careful titration of heart rate and blood
pressure. In contrast to the earlier guidelines, beta blockers are not recommended in
patients undergoing low-risk surgery. These recommendations are not specific to
the elderly but clearly will impact a large percentage of vascular patients.
Statins
Statins have been shown to reduce lipid levels, decrease vascular inflammation, and
stabilize atherosclerotic plaques. Several trials have demonstrated significant
benefits in patients with coronary artery disease demonstrating a reduction in myo-
cardial infarction, stroke, and death. Recommendations for perioperative statin use
are based on observational data, and there are limited randomized trials. Current
guidelines recommend that patients undergoing vascular surgery be started on
statins in advance of surgery, preferably 30 days. Abrupt discontinuation of statins
has been associated with increased risk of myocardial infarction and death, and
continuing statin therapy in the perioperative period is recommended. Statins are
not available intravenously. However, there are extended-release formulations
(e.g., fluvastatin) available that may be used to bridge the NPO status over surgery.
7. 373 The Anesthetic Regimen for the Elderly Patient
The Intraoperative Course
Monitoring
Basic monitoring standards for all patients, including the elderly, undergoing anes-
thesia have been established by the American Society of Anesthesiology (ASA).
The first standard requires the continuous presence of qualified anesthesia personnel
in the operating room. The second standard requires a continuous assessment of the
patient’s oxygenation, ventilation, circulation, and temperature. Although these
standards are not different for older patients, aging patients may have associated
comorbid conditions that influence monitoring choices.
A fall in oxygenation may actually be a late indicator of hypoventilation, and
ventilation should be monitored using end-tidal carbon dioxide to provide early
identification of hypoventilation and possible hypercapnia. The decision to use
additional invasive monitoring depends on the patient and the procedure. In the
older patient, labile blood pressure is commonly encountered, and a low threshold
for continuous arterial blood pressure monitoring should be maintained. An arterial
line can assist in both the precise titration of medications as well as access for blood
sampling during the case.
Aging cardiac changes render the older patient more susceptible to congestive
heart failure in the event of excessive fluid administration or significant shifts in vol-
ume. Central monitoring of the central venous pressure or pulmonary artery catheter
may be useful to manage the fluid administration during a case. Interpretation of the
central pressure requires a careful consideration of the aging patient’s underlying
physiologic condition. For instance, an older hypertensive patient with a “normal”
CVP may actually be modestly hypovolemic. In general, elderly patients benefit from
higher preloads and are very dependent on the atrial contraction during diastole.
The Surgery
Laparoscopic surgery carries significant advantages in the elderly patient including
a more rapid recovery, less pain following surgery, and reduced fluid requirements.
Laparoscopic cholecystectomy has been associated with improved postoperative
pulmonary function vs. open cholecystectomy, and that may be advantageous for
the frail elder with reduced pulmonary reserve. General anesthesia with controlled
ventilation is preferred to allow adequate abdominal insufflation. During the surgery,
absorption of CO2
can result in hypercapnia and acidosis. The rise in intra-abdominal
pressure accompanying the insufflation can lead to reduced venous return and
increased peripheral resistance and intrathoracic pressure leading to a diminished
cardiac output and hypotension. In the frail elderly patient with reduced cardiac func-
tion, these cardiovascular challenges can be significant, requiring increased moni-
toring and adjustment of the anesthetic medications to optimize cardiac function.
8. 38 S.R. Barnett
Medications
Neuromuscular Blocking Agents and Risk Reduction
Muscle relaxation during surgery is critical for exposure and to prevent patient
movement and is generally achieved through the administration of nondepolarizing
drugs such as vecuronium and cisatracurium. These drugs are competitive antago-
nists of acetylcholine at the nicotinic receptor and act at the postjunctional mem-
brane of the neuromuscular junction. The most important anesthetic concern for the
elderly patients is the complete reversal of these agents at the end of the surgery.
Results from a randomized controlled trial found that 26% of patients receiving
pancuronium vs. 5% (p<0.001) receiving atracurium or vecuronium had residual
block. In patients with residual blockade, patients that received pancuronium also
had a higher rate of pulmonary complications 17% vs. 5% (p<0.02). Although this
trial was not designed to address age risk factors per se, their conclusions are highly
relevant to the elderly patient for several reasons. Advanced age is associated with
a gradual decrease in chest wall compliance and decreased respiratory muscle
strength, so any diminution in strength may lead to hypoventilation and postopera-
tive pulmonary complications. In addition, older patients have blunted responses to
hypoxia and hypercapnia; thus, respiratory drive is also impacted. In general, it is
reasonable to conclude that the evidence supports that long-acting neuromuscular
blockers such as pancuronium should be avoided in elderly patients.
Ambulatory Surgery
Older age is not a contraindication to ambulatory surgery. Indeed, some studies have
suggested elderly patients may be more able to be fast tracked through the recovery
area and discharged, possibly due to a reduction in medications and a lighter level
of sedation administered compared to young healthy patients. In general, there is
limited data on outcomes in older patients following surgery; however, there is the
suggestion that intraoperative arrhythmias and hypertension are more common in
older patients vs. younger and that the incidence of postoperative nausea may be
diminished with age. Postoperative urinary retention can lead to significant morbidity,
for instance, in older males following hernia repair. In general, urinary retention has
been associated with the administration of opioids, regional anesthesia (spinal or
epidural anesthetics), male sex, older age, and anticholinergic medications.
Positioning
The elderly patient may have particular characteristics that predispose them to acci-
dental injury from seemingly benign positions. Predisposing features include bony
prominences that are accentuated by the age-related loss of subcutaneous and
9. 393 The Anesthetic Regimen for the Elderly Patient
intramuscular fat. Atrophy of elasticized tissues such as the skin makes the skin more
likely to tear, and older patients tend to heal slower as well, so skin abrasions may be
more significant. Demineralized long bones and osteoporosis result in fragile bones
that are susceptible to fracture in the event of a relatively minor accident and/or fall.
Vertebrobasilar insufficiency may predispose the vasculopathic patient to unex-
pected cerebral ischemia during positioning that involves neck extension.
Cardiopulmonary compromise secondary to positioning, for example, in the prone
position, may be less well tolerated in the elderly patient. Malnutrition is more com-
mon especially in the very old as evidenced by a high number of older patients
presenting with reduced albumin levels. This contributes to poor wound healing,
and in general a preoperative low albumin is associated with increased mortality.
Temperature Control
In general, exposure of a nonanesthetized patient to a cold environment such as the
operating room will result in activation of receptors peripherally and centrally that
lead to vasoconstriction and an increase in heat production and basal metabolic rate.
Usually, the core temperature is maintained a few degrees higher than the peripheral
tissues through tonic vasoconstriction. Unfortunately, normal aging results in the
deterioration in thermoregulation both peripherally and centrally leading to an
increased risk of hypothermia. The age-related physiologic changes blunt vasocon-
striction and heat production; shivering is less effective and induced at lower tem-
peratures compared to younger subjects. Furthermore, older patients have less lean
body mass and lower basal metabolic rates at the outset, and they lose heat more
quickly compared to younger patients.
The issues with temperature regulation are further exacerbated in the anesthe-
tized elderly patient, and the ability to withstand cold temperatures is inhibited in
the presence of all anesthetic agents. Disordered temperature regulation has been
observed following both general and regional anesthetics. The risks of hypothermia
to an older patient are substantial and include myocardial ischemia, surgical infec-
tion, coagulopathy, bleeding, delayed drug metabolism, and arousal.
Since older patients may not respond appropriately to a drop in core temperature,
the anesthetic plan should include the ability to actively warm older patients in and
outside of the operating room. Intraoperative heat loss may be minimized by pre-
warming surfaces and maintaining room temperatures high until the patient is fully
draped. Warmed forced-air blankets have been associated with improved mainte-
nance of temperature.
Quality Measures
Despite the growing popularity of quality measurements in healthcare, there are few
recognized quality measures directed at the elderly surgical population. Standard
10. 40 S.R. Barnett
quality assessment performance measures for surgery (myocardial infarction, surgical
site infection, and deep venous thrombosis) are not specific to the elderly. Although
older patients do have a higher incidence of cardiac complications, the same has not
been shown for deep venous thrombosis and surgical site infection. It seems clear
that the development of more relevant quality improvement methods and markers
for elderly surgical patients are needed especially for postoperative pulmonary and
urological complications. In contrast to quality measures, process measures assess
multiple aspects of care such as interpersonal communication and diagnostic and
treatment strategies. These more global markers may provide more valuable meth-
ods of assessing the quality of care in complex elderly patients. So far, 96 periopera-
tive quality candidate indicators of care in eight domains for elderly surgical patients
have been identified. The eight domains identified are comorbidity assessment,
medication usage, patient’s provider discussion, postoperative management, dis-
charge planning, and ambulatory surgery. Within each domain, a number of quality
indicators were identified. In many instances, these are quite specific to the elderly,
for example, an assessment of an elderly patient’s decision-making capacity and
specific discussions about expected functional outcome. This approach provides an
opportunitytoinvestigateinmoreelder-specificissues.However,therearesignificant
difficulties in implementing follow-up on such a vast number of both objective and
subjective indicators. Despite these challenges, measuring quality of care is espe-
cially important given the excess morbidity and mortality in this growing
population.
Guidelines for Treating Geriatric Patients
As stated, elderly patients can be challenging to take care of, as there is tremendous
heterogeneity within this age group. However, a few common themes arise when
taking care of older patients which can help guide the care of the elderly patient.
Clinical presentation of disease is frequently atypical, leading to delays and•
errors in diagnosis. This may result in a later presentation to the operating room
and more advanced disease condition and instability.
Individuals over age 65 years have on average three or four medical diseases,•
often limiting function and increasing morbidity.
Polypharmacy is a major issue in this population, and many older patients are on•
multiple medications that may impact the administration of anesthesia.
Diminished organ reserve can be unpredictable, and even significant limitations•
may only become apparent during stressful events.
The impact of extrinsic factors—smoking, environment, and socioeconomic—on•
physiologic age is difficult to quantify.
Significant interindividual variability and heterogeneity exists in the aged popu-•
lation making responses difficult to predict based on age alone.
A disproportionate increase in perioperative risk may occur without adequate•
preoperative optimization, and adverse events are more frequent when cases are
done on an emergent basis.
11. 413 The Anesthetic Regimen for the Elderly Patient
Meticulous attention to detail can help avoid minor complications—which in•
elderly patients can rapidly escalate into major adverse events.
Summary
In summary, “choosing the best anesthetic” for the geriatric patient requires meticu-
lous attention to detail, knowledge of the physiologic changes that can be expected
to occur during aging, and an understanding of common comorbidities found in the
elderly population. The risk of anesthesia and surgery is increased in frail older
patients, and anesthetics should be designed to avoid side effects and eliminate the
occurrence of even small complications.
Key Points
Elderly represent a heterogeneous group of patients.•
Functional capacity is one of the most important makers of outcome in the elderly•
patients.
Atypical disease presentation can predispose to missed diagnoses and a more•
advanced stage of disease at the time of surgery.
Aspiration risk is increased in older patients.•
Even minor complications can lead to increase in morbidity and mortality.•
Positioning in the older patient can be more complex.•
Risk reduction strategies, for example, through beta-blocker administration and•
avoidance of long-acting muscle relaxants, can improve outcomes select
patients.
Elderly patients are predisposed to developing hypothermia, and management•
should include active warming whenever possible.
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