Transcript Slide 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
Hayflick’s View of Aging
“Because modern 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
> 65 yrs
> 80 yrs
2000
2030
12.4%
19.6%
35 mil
71 mil
9.3 mil 19.5 mil
The Oldest…..
• MAN
120 yrs
• WOMAN
122
– Guinness Book of Records
• GENERAL ANESTHETIC
– Br J Anaesth 2000; 84:260
113
Life Expectancy at birth
USA - 1997
WOMEN Caucasian
MEN
79.9 yrs
African-American
74.7
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
– Natural 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?
Clergue. 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
25%
20%
15%
aortic
infrainquinal
10%
5%
0%
<65
66-70
71-75
76-80
81-85 >85 yrs
Perioperative Complication
Rates in Medicare Patients
• Intermediate Risk Surgery - 42%
– 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
– Age may = disease when > 85 yrs
– Increase ASA 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
– Urinalysis 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
Medical Event:
Untested Tested
Intraop
1.87
1.94
Postop
.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 surgery had
not been planned.”
Intermediate Risk Noncardiac
Surgery (Mortality > 1%, < 5%)
CAROTID
HEAD & NECK
INTRAPERITONEAL
INTRATHORACIC
ORTHOPEDIC
PROSTATE
Preoperative Tests - Prevalence of
Abnormal Results
544 consecutive intermediate risk non-cardiac surgical
patients > 69 yrs - Dzankic. Anesth Analg 2001; 93:301
Creatinine > 1.5 mg/dL
12%
Hemoglobin < 10 mg/dL
10%
Glucose > 200 mg/dL
7%
K+ < 3.5 mEq/L
5%
K+ > 5.0 mEq/L
4%
Platelets < 115,000/ml
2%
Outcomes of Patients with No
Laboratory Assessment for
Intermediate Risk Surgery
N = 1,044
Narr. Mayo Clin Proc 1997; 72:505
“Patients … assessed by history and
physical examination … safely
undergo … operation with tests drawn
only as indicated intraoperatively and
postoperatively.”
Is ROUTINE Preoperative
Testing Indicated?
NO (my opinion), IF
– FOLLOWED BY PRIMARY CARE MD
– RELIABLE SYSTEM TO OBTAIN H & P
– NO “RED FLAGS” IN H & P
– MODERATE FUNCTIONAL STATUS +
INTERMEDIATE RISK SURGERY
OR
POOR BUT STABLE FUNCTIONAL STATUS +
LOW RISK SURGERY
No Non-invasive or Invasive
Cardiac Testing for Intermediate
Risk Surgery
MODERATE FUNCTIONAL CAPACITY +
INTERMEDIATE CLINICAL PREDICTORS
OR
POOR FUNCTIONAL CAPACITY + MINOR
CLINICAL PREDICTORS
J Am Coll Cardiol 1996; 27:910
INTERMEDIATE
CLINICAL PREDICTORS
MILD STABLE ANGINA
PRIOR MI
COMPENSATED CHF
PRIOR CHF
DIABETES MELLITUS
FUNCTIONAL CAPACITY
MET= metabolic equivalent O2
consumption of 70 kg, 40 yr old
man in resting state
> 7 METs - excellent
4-7 METs - moderate
< 4 METs - poor
– J Am Coll Cardiol 1996; 27:910-48
Estimated Energy Requirements
for Activities of Daily Living - 1
1 MET -------------------------> 4 METs
– eat, dress, use toilet
– walk indoors around house
– walk 1-2 blocks on level 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
• 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 with
Diastolic Dysfunction
60
50
40
Mild
Moderate
Severe
30
20
10
0
45-54
55-64
65-74
75 or
greater
Diabetes 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 vecuronium
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 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 – Perioperative
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
MYOCARDIAL
ISCHEMIA
ATENOLOL
PLACEBO
(N = 99)
(N = 101)
POD 0 - 2
17
34*
24
* p = 0.008
39**
POD 0 - 7
**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 Evidencedbased Beta-blockade – “Wrong”
Answers 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 = LONGACTING PRE-, INTRA-, POSTOP
(REACTIVE vs PROPHYLACTIC)
General Anesthesia
• Anesthetic depth
• Neuromuscular blocking agents
• Diastolic pressure
• Transfusion trigger
• Regional vs general anesthesia
MAC & Age
Nickalls. Br J Anaesth 2003; 91:170
9
8
7
6
5
4
3
2
1
0
1 yr
40 yr
80 yr
Isoflurane
Sevoflurane
Desflurane
Nitrous Oxide MAC & Age
Nickalls. Br J Anaesth 2003; 91:170
140
120
100
1 yr
40 yr
80 yr
80
60
40
20
0
Nitrous Oxide
End-tidal Isoflurane to Provide
MAC with N2O in 80 Year Olds
Nickalls. Br J Anaesth 2003; 91:170
1
0.8
0.6
0% N2O
50% N2O
67% N2O
0.4
0.2
0
Isoflurane
Most 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 than
BIS Index 35-45
End-tidal Concentrations Underestimate Brain Concentrations
During Emergence from Isoflurane
Lockhart. Anesthesiology 1991; 74:575
0.7
0.6
0.5
End-tidal conc
ratio
Cerebral conc ratio
0.4
0.3
0.2
0.1
0
0-6
13-18
25-30 min
PROPOFOL INDUCTIONS IN 25 –
81 YR-OLDS
Schnider. Anesthesiology 1999; 90:1502
• Propofol: 2 mg/kg < 65 yrs; 1 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 J Anaesth 2002; 88:430
Glycopyrrolate, propofol 1 mg/kg, and
either alfentanil 10 μg/kg or remifentanil
0.5 μg/kg + 0.1 μg/kg/min
SBP: < 100 mmHg 50%,
< 80 mmHg 8%
RECOMMENDED PROPOFOL DOSE
FOR INDUCTION IF > 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, midazolam peak 5 min
PREFER SLOWER INJECTION (1 min)
Less hypotension if slow with < 1.0 mg/kg
Elderly Take Longer to Emerge
Than Younger Patients
• Lower MACawake and higher pain threshold
• Hypothermia more likely
• Emergence hypertension treated as light anesthesia
• Reluctance to turn off vaporizer
• Longer durations of action for drugs in elderly
• Relative drug overdoses
• Synergistic drug interactions
Neuromuscular Blocking Agents
in the Elderly - 1
• Same initial dose as in younger
• Longer onset times with:
– Advanced age
– Vecuronium vs rocuronium
• Tullock. Anesth Analg 1990; 70:86
– Esmolol
• Szmuk. Anesth Analg 2000; 90:1217]
Onset Time (sec) Increases with
Advancing Age
Koscielniak-Nelson. Anesthesiology 1993; 79:229
300
250
200
succinylcholine 1
mg/kg
vecuronium 0.1
mg/kg
150
100
50
0
3-10 yrs
20-40
60-80
Neuromuscular Blocking Agents
in the Elderly - 2
• Longer duration (except cisatracurium)
– Advanced age
– Intraoperative hypothermia (34.7o C)
– Diabetes mellitus (8.7% of elderly)
– Obesity – dosing mg/kg
Obesity in Older Men
% with BMI > 29.2
Flegal. JAMA 2002; 288:1723
40
35
30
25
1990
2000
20
15
10
5
0
60-69
70-79
80+ yrs
Obesity in Older Women
% with BMI > 29.2
Flegal. JAMA 2002; 288:1723
45
40
35
30
25
20
15
10
5
0
1990
2000
60-69
70-79
80+ yrs
Times to Reappearance of T1, T2, T3,
& T4 after Vecuronium 0.1 mg/kg in
Patients with Diabetes Mellitus
Saito. Br J Anaesth 2003; 90:480
70
60
50
40
No DM
DM
30
20
10
0
T1
T2
T3
T4
Effect of Hypothermia on Time-to25%-Recovery from Vecuronium 0.1
mg/kg
Caldwell. Anesthesiology 2000; 92: 84
70
60
50
40
30
20
Time (min)
10
0
34
35
36
37
38 C
Rocuronium > Vecuronium >
Pancuronium (My Practice)
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 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 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 < GENERAL
• “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. Anesthesiology 2002; 96:17
• Bolus q 5 min to VAS = 30 (max 100)
– 2 mg if <60 kg; 3 mg if > 60 kg
• Total mg/kg dose: young = old
– Young (< 70, mean 45) vs Old (> 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
• Total Dose:
– old < young
Postoperative Delirium in 5-50%
That Appears on POD’s 1-3
Cook. Anesth Analg 2003; 96:1823
• Cellular proteins altered by potent inhaled agents
• Central cholinergic insufficiency, Microemboli
• Preexisting subclinical dementia, Hypoxia
• Fever, Infection (UTI, sinusitis, pneumonia)
• Electrolyte abnormalities, Anemia, Pain
• Sleep deprivation, Unfamiliar environment
Ten Ways to Improve
Anesthesia in Older Patients
1. H & P > 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