1、Anesthetic Management of the Elderly Patient Raymond C.Roy,PhD,MD Professor&Chair of Anesthesiology Wake Forest University Health Sciences Winston-Salem,NC,USA 27157-1009 http:/www.wfubmc.edu/anesthesia Education:Annual Meeting American Society of Anesthesiologists Hayflicks View of Aging“Because mo
2、dern humans,unlike feral animals,have learned how to escape death long after reproductive success,we have revealed a process that,teleologically,was never intended for us to experience.”#Older Americans 2000 2030 65 yrs 12.4%19.6%35 mil 71 mil 80 yrs 9.3 mil 19.5 mil The Oldest.?MAN 120 yrs?WOMAN 12
3、2 Guinness Book of Records?GENERAL ANESTHETIC 113 Br J Anaesth 2000;84:260 Life Expectancy at birth USA-1997 WOMEN Caucasian 79.9 yrs African-American 74.7 MEN Caucasian 74.3 African-American 67.2 Life Expectancy,Life Span,&Maximum Length of Life?Maximum Length of Life 120 yrs?Life Span 85-100 Natur
4、al death(no trauma or disease)?Life Expectancy(USA)67-80 Premature death(trauma,disease)Oldest Surgical Patient?Oliver.Br J Anaesth 2000;84:260?Woman,113 yrs,femoral fracture?General anesthesia?CVP,no arterial-line?Extubation in ICU after 5h?Hospital discharge POD 23#Anesthetics per 100 Population?C
5、lergue.Anesthesiology 1999;91:1509(France)Ages(yrs)Men Women 35 44 8.9 13.2 55-64 17.7 14.6 75-84 30.2 23.6 Vascular Surgery Mortality vs Age Fleisher.Anesth Analg 1999;89:849 0%5%10%15%20%25%85 yrsaorticinfrainquinalPerioperative Complication Rates in Medicare Patients?Intermediate Risk Surgery-42%
6、Silber,Anesthesiology 2000;93:152 217,440 general&orthopedic surgery?Low Risk Surgery-3%Schein,N Engl J Med 2000;342:168 18,901 cataract surgery Age&Perioperative Outcome?With advancing age More surgery Morbidity increases Mortality increases?Cause-disease vs age?Disease age when 85 yrs Increase ASA
7、 PS when 85 yrs Preoperative Considerations?Preoperative Assessment No routine preoperative testing Statin myopathic syndromes Diastolic dysfunction?Diabetes Mellitus Tighter glucose control with insulin Stop oral hypoglycemic agents Why Obtain Preoperative Tests?Screening NO with one exception Urin
8、alysis if hip surgery or acutely ill Cook&Rooke,Anesth Analg 2003;96:1823?Treatment effectiveness-YES?Baseline MAYBE,but overused?Risk Assessment-YES Value of Preoperative Testing Before Low Risk Surgery Schein.N Engl J Med 2000;342:168 Rate/100 Untested Tested Medical Event:Intraop 1.87 1.94 Postop
9、 .92 .94 Unplanned Hospitalization .34 .29 Death .02 .01 Total 3.13 3.13 Value of Preoperative Testing Before Low Risk Surgery Schein.N Engl J Med 2000;342:168“Tests should be ordered only when the history or a finding on a physical examination would have indicated the need for the test even if surg
10、ery had not been planned.”Intermediate Risk Noncardiac Surgery(Mortality 1%,69 yrs-Dzankic.Anesth Analg 2001;93:301 Creatinine 1.5 mg/dL 12%Hemoglobin 200 mg/dL 7%K+5.0 mEq/L 4%Platelets 7 METs-excellent 4-7 METs-moderate 4 METs eat,dress,use toilet walk indoors around house walk 1-2 blocks on level
11、 ground light house work Estimated Energy Requirements for Activities of Daily Living-2 4 METs-10 METs climb flight of stairs,walk up a hill walk briskly on level ground run a short distance do heavy house work golf,bowling,dancing,doubles tennis Most Difficult ROUTINE Preoperative Tests to Justify?
12、Chest X-ray?PT and aPTT(if no heparin or warfarin)?Liver Function Tests 4 Statin Myopathic Syndromes Thompson.JAMA 2003;289:1681?STATIN MYOPATHY Any muscle complaint with onset coincident with start of statin therapy?MYALGIA with normal CK?MYOSITIS with elevated CK?RHABDOMYOLYSIS%of Older Patients w
13、ith Diastolic Dysfunction 010203040506045-5455-6465-7475 orgreaterMildModerateSevereDiabetes Mellitus 8.7%of Elderly?Ischemic heart disease?Problems with all oral hypoglycemic agents?More infections pulmonary,wound?Decreased pulmonary function?Decreased response to hypoxia?Prolonged response to vecu
14、ronium Problems with Oral Hypoglycemic Agents Gu.Anesthesiology 2003;98:1359?Sulfonylureas myocardial ischemia Interfere with K-ATP channels Prevent ischemic preconditioning Eliminate ECG benefit of warm-up Eliminate functional benefit of warm-up Worsen dipyridamole-induced ischemia?Metformin lactic
15、 acidosis Diabetes Mellitus Tight Control of Glucose Gu.Anesthesiology 2003;98:1359?Insulin infusions to maintain glucose:80-150 mg/dl intraoperatively 80-110 mg/dl postoperatively?Reduce ICU mortality by 40%?Improve outcome from acute MI?Decrease infections Beta-adrenergic Blocking Agents Periopera
16、tive Administration?Reduces myocardial ischemia?Reduces myocardial infarction?Secondary Observations Zaugg.Anesthesiology 1999;91:1674 Decrease anesthetic administration Enable faster emergence Decrease post-op analgesic requirement Perioperative Myocardial Ischemia Wallace.Anesthesiology 1998;88:7
17、MYOCARDIAL ISCHEMIA ATENOLOL(N=99)PLACEBO(N=101)POD 0-2 17 34*p=0.008 POD 0-7 24 39*p=0.029 Perioperative Beta-Blockade-Therapeutic Target Auerbach.JAMA 2002;287:1435?HEART RATE 55 65 bpm?SYSTOLIC 100 mm Hg?Before,during,and after surgery Actual Practice versus Evidenced-based Beta-blockade “Wrong”A
18、nswers from ABA Oral Examinees?DID NOT ADD IN PREOP CLINIC?USED HR 80 AS TARGET INTRAOP?DID NOT ORDER POSTOP(7 days)?ASSUMED ESMOLOL-BOLUS=LONG-ACTING PRE-,INTRA-,POSTOP (REACTIVE vs PROPHYLACTIC)General Anesthesia?Anesthetic depth?Neuromuscular blocking agents?Diastolic pressure?Transfusion trigger
19、?Regional vs general anesthesia MAC&Age Nickalls.Br J Anaesth 2003;91:170 0123456789IsofluraneSevofluraneDesflurane1 yr40 yr80 yrNitrous Oxide MAC&Age Nickalls.Br J Anaesth 2003;91:170 020406080100120140Nitrous Oxide1 yr40 yr80 yrEnd-tidal Isoflurane to Provide MAC with N2O in 80 Year Olds Nickalls.
20、Br J Anaesth 2003;91:170 00.20.40.60.81Isoflurane0%N2O50%N2O67%N2OMost of Us Overdose Elderly?Gas monitors Assume patient is 40 yrs old Do not know what other drugs given Do not know opioids&epidurals lower MAC Underestimate brain concentration on emergence?BIS Index 55-60 with beta-blockers better
21、than BIS Index 35-45 End-tidal Concentrations Under-estimate Brain Concentrations During Emergence from Isoflurane Lockhart.Anesthesiology 1991;74:575 00.10.20.30.40.50.60.70-613-1825-30 minEnd-tidal concratioCerebral conc ratioPROPOFOL INDUCTIONS IN 25 81 YR-OLDS Schnider.Anesthesiology 1999;90:150
22、2?Propofol:2 mg/kg 65 yrs?Injection time 13-24 s?Loss of consciousness Young=old=40 s?Return of consciousness 30 yrs 5 min,75 yrs 10 min PROPOFOL INDUCTIONS 20 84 YRS Kazama.Anesthesiology 1999;90:1517 HALF-TIME FOR NADIR IN BP 20 29 yrs 5.7 min 70 85 yrs 10.2 min PROPOFOL INDUCTIONS 65 YRS Habib.Br
23、 J Anaesth 2002;88:430 Glycopyrrolate,propofol 1 mg/kg,and either alfentanil 10 g/kg or remifentanil 0.5 g/kg+0.1 g/kg/min SBP:100 mmHg 50%,65 yrs old IF BOLUS(30 s)No concurrent drugs 1.0-1.5 mg/kg Concurrent drugs 0.5-1.0 mg/kg HYPOTENSION Continues for 10 min after injection Fentanyl peak 6-8 min
24、,midazolam peak 5 min PREFER SLOWER INJECTION(1 min)Less hypotension if slow with 29.2 Flegal.JAMA 2002;288:1723 051015202530354060-6970-7980+yrs19902000Obesity in Older Women%with BMI 29.2 Flegal.JAMA 2002;288:1723 05101520253035404560-6970-7980+yrs19902000Times to Reappearance of T1,T2,T3,&T4 afte
25、r Vecuronium 0.1 mg/kg in Patients with Diabetes Mellitus Saito.Br J Anaesth 2003;90:480 010203040506070T1T2T3T4No DMDMEffect of Hypothermia on Time-to-25%-Recovery from Vecuronium 0.1 mg/kg Caldwell.Anesthesiology 2000;92:84 0102030405060703435363738 CTime(min)Rocuronium Vecuronium Pancuronium(My P
26、ractice)Fastest onset Shortest duration Least inter-patient variability Easiest to reverse Shortest PACU length of stay Fewest post-op pulmonary complications Cisatracurium rocuronium if renal insufficiency Transfusion Trigger for Elderly Hgb 10 g/dl or Hct 0.30?Ischemic Heart Disease Especially if
27、reversible ischemia,unstable angina,recent infarction or dysfunction?Pulmonary Disease Intra-thoracic or intra-abdominal surgery?Leukocyte-reduced?Walsh,McClelland,Br J Anaesth 2003;719 Minimum Diastolic Pressure Pauca Abstract ASA 2003?When treating systolic pressure(SP),pay attention to diastolic
28、pressure(DP)?To maintain coronary perfusion,keep DP at least 2/3rd SP DP greater than Pulse Pressure DP at least 60 mmHg Regional vs General Anesthesia Mortality&Morbidity REGIONAL=GENERAL?BP,HR tightly controlled in studies?More interventions to control BP,HR in general anesthesia group REGIONAL GE
29、NERAL?“Real world”,BP,HR not tightly controlled?Included combined regional-general in regional group?Rogers et al.Br Med J 2000;321:1493 Postoperative Considerations?Postoperative Analgesia?Postoperative Delirium Postoperative Titration of Intravenous Morphine in Elderly Patients Abrun.Anesthesiolog
30、y 2002;96:17?Bolus q 5 min to VAS=30(max 100)2 mg if 60 kg?Total mg/kg dose:young=old Young(70,mean 76)?Morbidity young=old adverse opioid effects,sedation,stopped titrations Age is not an Impediment to Effective Use of PCA Gagliese.Anesthesiology 2000;93:601?Initial Dose for Pain Relief:young=old?T
31、otal Dose:old Pre-op Testing CXR,PT,PTT 2.Beta-blockers pre-.intra-,post-op 3.Timely antibiotic administration 4.Lower doses of inhaled&iv agents 5.Rocuronium or cisatracurium Ten Ways to Improve Anesthesia in Older Patients 6.Higher FIO2 intra-,post-op 7.Transfusion trigger Hct.30 8.Diastolic pressure 60 mmHg 9.Blood glucose-periop 80-150 mg/dl 10.Reduce post-op opioid requirements
