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Anesthetic Management of the Elderly Patient

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." .

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Anesthetic Management of the Elderly Patient

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    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

    2. 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.”

    3. # Older Americans 2000 2030 > 65 yrs 12.4% 19.6% 35 mil 71 mil > 80 yrs 9.3 mil 19.5 mil

    5. The Oldest….. MAN 120 yrs WOMAN 122 Guinness Book of Records GENERAL ANESTHETIC 113 Br J Anaesth 2000; 84:260

    6. Life Expectancy at birth USA - 1997 WOMEN Caucasian 79.9 yrs African-American 74.7 MEN Caucasian 74.3 African-American 67.2

    7. 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)

    8. 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

    9. # Anesthetics per 100 Population? Clergue. Anesthesiology 1999; 91:1509 (France)

    10. Vascular Surgery – Mortality vs Age Fleisher. Anesth Analg 1999; 89:849

    11. 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

    12. 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

    13. Preoperative Considerations Preoperative Assessment No routine preoperative testing Statin myopathic syndromes Diastolic dysfunction Diabetes Mellitus Tighter glucose control with insulin Stop oral hypoglycemic agents

    14. 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

    15. Value of Preoperative Testing Before Low Risk Surgery Schein. N Engl J Med 2000; 342:168

    16. 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.”

    17. Intermediate Risk Noncardiac Surgery (Mortality > 1%, < 5%) CAROTID HEAD & NECK INTRAPERITONEAL INTRATHORACIC ORTHOPEDIC PROSTATE

    18. 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%

    19. 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.”

    20. 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

    21. 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

    22. INTERMEDIATE CLINICAL PREDICTORS MILD STABLE ANGINA PRIOR MI COMPENSATED CHF PRIOR CHF DIABETES MELLITUS

    23. 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

    24. 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

    25. 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

    26. Most Difficult ROUTINE Preoperative Tests to Justify Chest X-ray PT and aPTT (if no heparin or warfarin) Liver Function Tests

    27. 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

    28. % of Older Patients with Diastolic Dysfunction

    29. 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

    30. 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

    31. 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

    32. 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

    33. Perioperative Myocardial Ischemia Wallace. Anesthesiology 1998; 88:7

    34. Perioperative Beta-Blockade - Therapeutic Target Auerbach. JAMA 2002; 287:1435 HEART RATE 55 – 65 bpm SYSTOLIC >100 mm Hg Before, during, and after surgery

    35. Actual Practice versus Evidenced-based 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 = LONG-ACTING PRE-, INTRA-, POSTOP (REACTIVE vs PROPHYLACTIC)

    36. General Anesthesia Anesthetic depth Neuromuscular blocking agents Diastolic pressure Transfusion trigger Regional vs general anesthesia

    37. MAC & Age Nickalls. Br J Anaesth 2003; 91:170

    38. Nitrous Oxide MAC & Age Nickalls. Br J Anaesth 2003; 91:170

    39. End-tidal Isoflurane to Provide MAC with N2O in 80 Year Olds Nickalls. Br J Anaesth 2003; 91:170

    40. 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

    41. End-tidal Concentrations Under-estimate Brain Concentrations During Emergence from Isoflurane Lockhart. Anesthesiology 1991; 74:575

    42. 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

    43. 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

    44. PROPOFOL INDUCTIONS > 65 YRS Habib. Br J Anaesth 2002; 88:430 Glycopyrrolate, propofol 1 mg/kg, and either alfentanil 10 ľg/kg or remifentanil 0.5 ľg/kg + 0.1 ľg/kg/min SBP: < 100 mmHg 50%, < 80 mmHg 8%

    45. 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

    46. 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

    47. 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]

    48. Onset Time (sec) Increases with Advancing Age Koscielniak-Nelson. Anesthesiology 1993; 79:229

    49. 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

    50. Obesity in Older Men % with BMI > 29.2 Flegal. JAMA 2002; 288:1723

    51. Obesity in Older Women % with BMI > 29.2 Flegal. JAMA 2002; 288:1723

    52. 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

    53. Effect of Hypothermia on Time-to-25%-Recovery from Vecuronium 0.1 mg/kg Caldwell. Anesthesiology 2000; 92: 84

    54. 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]

    55. 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

    56. 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

    57. 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

    58. Postoperative Considerations Postoperative Analgesia Postoperative Delirium

    59. 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

    60. 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

    61. 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

    62. Ten Ways to Improve Anesthesia in Older Patients H & P > Pre-op Testing > CXR, PT, PTT Beta-blockers pre-. intra-, post-op Timely antibiotic administration Lower doses of inhaled & iv agents Rocuronium or cisatracurium

    63. 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

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