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What’s New In Geriatric Anesthesia

What’s New In Geriatric Anesthesia. Refresher course 2006 마취통증의학과 김현석. Four clinical scenarios A 72-yr-old man presents on the day of surgery for an inguinal hernia repair with a blood pressure of 200/90 mmHg . He regularly takes lisinopril, atenolol, aspirin, and atorvastatin.

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What’s New In Geriatric Anesthesia

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  1. What’s New In Geriatric Anesthesia Refresher course 2006 마취통증의학과 김현석

  2. Four clinical scenarios • A 72-yr-old man presents on the day of surgery for an inguinal hernia repair with a blood pressure of 200/90 mmHg. He regularly takes lisinopril, atenolol, aspirin, and atorvastatin. • A 75-yr-old woman presents for a total hip replacement. Two months earlier she was admitted to the hospital for treatment of congestive heart failure. She was diagnosed with diastolic heart failure based on an echocardiogram that revealed no mitral stenosis, a thickened left ventricle, normal left ventricular volume, left atrial enlargement, and an ejection fraction of 65%. She was discharged on spironolactone, verapamil, and enalapril. • A 70-yr-old woman with type 2 diabetes mellitus presents for a colon resection. She regularly takes metformin (Glucophage) and rosiglitazone (Avandia). Her blood glucose in the preoperative holding area was 185 mg/dL. • A 68-yr-old man undergoing surgery for a retinal detachment demonstrates ST depression on his electrocardiogram during emergence from general anesthesia.

  3. HIGH BLOOD PRESSURE (BP) • 7th Report of the Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure (JNC 7) • high normal (systolic 130-139 mmHg or diastolic 85-89 mmHg) • stage 1 (systolic 140-159 mmHg or diastolic 90-99 mmHg) • stage 2 (systolic 160-179 mmHg or diastolic 100-109 mmHg) • stage 3 (systolic 180 mmHg or diastolic 110 mmHg) • Uncontrolled hypertension • small increase of SP -> LVH • LV mass -> cardiovascular risk • Risk factor : systolic pressure (SP) > diastol pressure (DP) • angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) : lower BP, LV remodel • 60세 미만에서 HTN의 incidence는 27%, 60-79세 에서는 63%, 80세 이상에서는 74% 이다.

  4. Btw 20-50 yrs :DP increases, 50s :DP level off or decrease, SP 80세 까지 계속해서 상승한다. • Advancing Age : major artery stiffen - arterial pressure wave는 더 빨리 reflection 된다. Middle-age : large artery가 diastole동안 충분한 elasticity를 유지하여 LVH가 진행할 때 까지 DP과 coronary perfusion 이 상승된다. • Systolic hypertension, LVH : increase oxygen demand • DP decrease : reduction of coronary perfusion, oxygen supply in older pt., absence coronary heart disease : myocardial ischemia • Howell et al., American College of Cardiology (ACC) and the American Heart Association (AHA) : stage 2 systolic hypertension : surgery 진행, stage 3 systolic hypertension : no clear consensus

  5. Preoperative high BP measurement, • White coat hypertension component? • 환자의 normal antihypertension medication이 중단되어서 BP가 오른 것은 아닌지? • Antihypertension medication을 했을 때의 BP가 얼마인지? • ACC, AHA Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery 는 clinical cardiovascular risk factors, exercise capacity, surgical risk등을 통합한다. • Preooperative evaluation에서 Elective surgery rescheduling이 요구되는 것은 BP control, 추가적인 diagnostic study가 필요한 경우로, • new symptoms of reduced functional capacity • recent decrease in the dyspnea threshold • change in previously stable anginal symptoms, or transient ischemic attacks • new physical findings of a carotid, bruit, jugular venous distention, an S3 or S4 gallop, tachycardia, tachypnea, or rales • new diagnostic or laboratory abnormality such as a change in the electrocardiogram, serum B-type natriuretic peptide (BNP) levels above baseline, or a recent increase in serum creatinine concentration

  6. Absent New finding, most anesthesiologist : heart rate 70 bpm, systolic BP 140mmHg이하, diastolic BP 70mmHg이상으로 유지 A-line monitoring • beta-blocker, clonidine : continue, ACE inhibitor, ARBs, calcium channel blocker, diuretics : discontinue • Surgical incision, emergence, postoperative에는 aggressive하게 treat해야하는데, 주로 beta-blocker가 first line drug으로 쓰인다. • Perioperatively aggressive한 beta-blocker의 사용은 cardiovascular risk factor를 가진 환자에서 heart rate 60정도, 정상범위의 BP를 유지할 수 있다는 자료가 있다. • Cardiovascular risk가 없는 환자에서는 덜 확실하고, compensated heart failure를 가진 환자에서는 수술 당일에 ACE inhibitor, ARBs는 유지한다.

  7. DIASTOLIC DYSFUNCTION (DD) • 2001 ACC, AHA congestive heart failure 4단계로 분류 • Stage A : a pre-disease state. do not have structural or functional cardiac abnormalities. • Stage B : CHF의 발병과 관련된 structural abnormalities. but have not yet displayed symptoms or signs. • Stage C : dyspnea or fatigue with exertion, but are symptom free during activities of daily living or have a history of CHF • Stage D : CHF with symptoms at rest • Diastolic heart failure는 normal left ventricular ejection fraction, heart failure 의 sign, symptom이 특징, heart failure 없는 diastolic dysfunction의 원인으로는 poor left venticular relaxation, decreased LV compliance등이 있다. • 75세 이상 mild, moderate, severe DD : 50%, 15%, 5%, BNP concentration mild elevation으로 의심, no mitral stenosis, elevated left atrial pressures, and increased diastolic filling pressure의 echocardiographic finding으로 confirm된다.

  8. LV filling 3phases • rapid filling associated with LV relaxation • slow passive filling that relies on LV compliance, interventricular interaction, pericardial restraint, and diastolic time • atrial systole • 건강한 20대 : end-diastolic volume의 95%-rapid filling때 middle age : 50-60%가 rapid filling, 10-20% slow passive filling, 20-30% atrial kick • DD patient에서는 rapid filling에 제한이 있어서, atrial contraction의 force가 증가되어 compensation하기 때문에 LV filling은 slow passive filling과 atrial systole의 2 phase로만 이루어진다. • S3, S4와 같은 abnormal diastolic heart sound가 DD에서는 specific하지만, sensitive하지는 않다. DD의 결과로 생길 수 있는 LAE는 coronary heart disease의 독립적인 predictor이고, DD patient에서는 intravenous fluid가 너무 빠르게, 많이 주입되면 pulmonary edema가 생기기 쉽다.

  9. TYPE 2 DIABETES MELLITUS (Type 2 DM) • 1997, American Diabetes Association(ADA) • eliminated the terms insulin-dependent DM and non-insulin dependent DM • classified DM as either type 1 (destruction of insulin-producing beta cells resulting in an absolute lack of insulin) or type 2 (insulin present but impaired secretion or insulin resistance) • lowered the diagnostic criteria for fasting serum glucose from 140 mg/dL to 126 mg/dL. • abnormal fasting glucose concentrations, impaired glucose tolerance, and hyperglycemia등을 보이기 이전에 type 2 DM 환자는 insulin resistance로 시작하여 hyperinsulinemia, abnormal pancreatic cell function, and excess accumulation of intracellular triglyceride in both muscle and liver abnormal metabolic change가 진행된다. • Beta cell function의 저하와 type 2 DM의 발현사이의 평균 기간은 약 10년 정도이고, hyperglycemia는 beta cell function 이 정상의 30%이하로 감소했을 때 나타난다.

  10. Thiazolidine은 beta cell을 보호하고, insulin sensitivity와 glucose transport 를 개선시킨다. • 75세이상 인구의 20%는 DM이 발생한다. • Type 2 DM Sx.: mild to moderate hyperglycemia, macrovascular disease에 의한 coronary heart disease, stroke, peripheral vascular insufficiency와 같은 end-organ damage, retinopathy, nephropathy, neuropathy와 같은 microvascular disease. • Type 2 DM patient에서 first myocardial infarction의 비율이 이미 one heart attack이 있었던 non-diabetic patient에서의 second myocardial infarction의 비율보다 높기 때문에 Adult Treatment Panel III of the National Cholesterol Education Program (ATP III)에서는 type 2 DM을 coronary heart disease와 같이 선정하고 있다. • ADA에서는 hypoglycemic therapy가 preprandial blood glucose concentration 80-120 mg/dl, bedtime concentration 100-140mg/dl, Hemoglobin A1c concentration 7%미만으로 유지할 것을 recommend하고 있다.

  11. Intraoperatively 80-150mg/dl, postoperativerly 80-120mg/dl의 insulin infusion tight control : acute myocardial infarction, cardiac surgery후의 outcome을 향상시키고, 다른 surgical procedure후의 infection rate를 줄인다. • Central nervous system손상전의 normal blood glucose는 손상후에 treated된 high blood glucose보다 outcome이 좋다. • Surgery stress response - blood glucose 상승, but fasting시의 hypoglycemia를 피하고, potential ischemic insult 동안의 myocardial damage(sulfonylurea), lactic acidosis(metformin)를 피하기 위해 수술 당일의 oral hypoglycemic agent는 중단해야 한다. • Hyperglycimia : 1-3units/hr continuous infusion, sliding scale intravernous bolus. 술전에 thiazolidinedione의 경구투여는 insulin의 sensitivity를 증가시키고, cardiovascular event를 줄인다고 하기도 한다.

  12. CORONARY HEART DISEASE (CHD) • Typical 4 phase • non-obstructive • Obstructive • Ischemic • Acute coronary syndromes • Lumen의 바깥 쪽에서 생기는 atherosclerotic lesion으로 시작, plaque는 안쪽으로 coronary artery의 lumen을 막기도 하고, normal luminal diameter, normal coronary blood flow를 가지는 vessel의 바깥 쪽으로도 생긴다. • Positive remodeling의 임상적 결과는 significant할 수도 있지만, stress testing or angiography에 의해 undetect될 수도 있다. • Subclinical phase에서 C-reactive proterin와 같은 inflammatory marker는 plaque burden이 증가함에 따라 상승한다.

  13. Plaque의 distal 쪽의 myocardium으로 blood supply 가 유지되고 lesion이 stenosis 되지 않아서 myocardial infarction이 없더라도 angiographic obstruction을 보일 수 있다. • Ischemic CHD는 strenous activity(chronic stable angina), stress testing(inducible ischemia), high metabolic state동안에 supply 이상의 oxygen demand가 있을 때 발생한다. • Plaque rupture, rapid thrombus formation은 disease process동안 아무 때에나 일어날 수 있다. • acute coronary syndrome(ACS) : Unstable angina, non-ST-elevation myocardial infarction(NSTEMI), ST-elevation myocardial infarction(STEMI) • rupture of mild-to-moderate-sized plaque, rapid platelet thrombus formation, ST-segment elevation, and development of Q-waves • End of PR segment와 관련된 ST elevation을 측정하는 것이 중요한다.

  14. Elderly patients, women, diabetic patients에서는 silent ischemia부터 breathlessness, weakness, collapse, diaphoresis, palpitation까지 다양한 atypical presentation을 보이는 경우가 흔하다. • Chest pain은 65세 이하의 환자의 80%가 보이는 main complaint이지만 65세 이상에서는 50%에서만 나타나다. • Acute myocardial infarction 의 initial ECG는 8% 에서 normal이거나 35%에서 nonspecific 할 수 있다. • Angiography에서 visible disease나 obstructive lesion이 없는 경우가 unstable angina 환자에서 남자에서 8-14%, 여자에서 26-30%, NSTEMI에서는 남자에서 4%, 여자에서 9%, STEMI에서는 남자에서 7%, 여자에서 10% 정도로 나타난다. • Perioperative myocardial infarctions(PMI)는 peak cardiac troponin I (cTnI) concentration에서 bimodal distribution을 보인다. • 한 연구에 따르면 infrarenal artery aortic surgery를 시행받는 1136명의 환자 중 163명이 postoperative period에 abnormal cTnI concentration을 보였다. Early group(40%)는 수술 후 37+/-22hrs에 myocardial infarction가 진단되었고, delayed group은 74+/-39hrs에 진단되었다.

  15. Unstable plaque : surgery, inflammation, postoperative pain stress response -> prothrombotic activity가 증가되고 fibrionolytic activity가 감소하여 생기는 thrombus formation과 adrenergic stimulation으로 인해 trigger되는 plaque rupture로 인한 PMIs를 일으킬 수 있다. • 대부분의 PMI는 non-perioperative MI보다 silent, non-Q-wave, ST depression, lower troponin concentration을 보이기 쉽다. • Elderly CHD patient • obstructive CHD reducing myocardial oxygen delivery • systolic hypertension -> LVH -> increasing myocardial oxygen demand • COPD and carbon monoxide inhalation with cigarette smoke -> inadequate arterial oxygen content • activity and disease that variably increase oxygen demand • Beta-blocker, ACE inhibitor, ARBs administration • Low-dose aspirin는 thrombus formation을 줄이지만, aspirin withdrawl - myocardial infarction, cerebrovascular accident, lower limb ischemia과 관련

  16. Statin : plaque size 증가 제한 inflammatory response attenuation Major noncardiac surgery 전에 high intensity statin therapy가 PMI발생율을 줄일 수 있는지의 연구는 진행중이다.

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