ASA 2006: WHATS NEW IN GERIATRIC ANESTHESIA

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ASA 2006 WHATS NEW IN GERIATRIC ANESTHESIA?

• Raymond C. Roy, PhD, MD
• Professor Chair of Anesthesiology
• Wake Forest University School of Medicine
• Winston-Salem, NC, USA 27157-1009
• rroy_at_wfubmc.edu

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Present a reasonable way, not the one right
way, to handle clinical situations

• Applying conclusions from chronic disease
  management studies to acute perioperative
  management
• Too few studies addressing how well they
  translate
• Applying conclusions from studies on higher risk
  patients to
• lower risk patients, or
• higher risk patients for low risk surgery
• Greater overall population benefit versus
• Increase of adverse events in low risk
  population

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Encourage medical anesthesia

• Minimal interference with medical management
• Discontinue as few drugs as possible
  perioperatively
• Light anesthesia
• Lower doses of inhaled agents
• Aggressive pain control, preemptive analgesia
• Regional or combined regional/general when
  possible
• Bridge (OR?PACU?post-PACU) rather than silo
• Pain, cardiovascular, and metabolic control
• Aggressive use of medical drugs
• Cardiovascular control
• Medical drugs anesthetic drugs, volume
  administration
• Metabolic control
• Insulin infusions, glitazones, K, Mg

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4 PROBLEMS COMMON IN THE ELDERLY

• HYPERTENSION
• DIASTOLIC DYSFUNCTION
• TYPE 2 DIABETES MELLITUS
• CORONARY HEART DISEASE

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Changes in BP with Normal Aging Franklin SS, et
al Circulation 1997 96308-15
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Hypertension 3 Stages7th Report of Joint
National Committee on Prevention, Detection, and
Treatment of High Blood Pressure (JNC-7)Mean of
2 measured readings 2 clinic visits seated
quietly for 5 min auscultatory method BP cuff
bladder encircles 80 armChobanian. JAMA
20032892560
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Prevalence () of Stage 2 Hypertension in
MenLloyd-Jones JAMA 2005 294466

• SP increases with increasing age
• LV mass increases with increasing SP
• DP increases with increasing age
• DP decreases with increasing age 55
• Key to explanation is reflected aortic wave

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HYPERTENSION

• 72-yr-old 85 kg man, inguinal hernia repair
• Meds lisinopril, atenolol, aspirin, statin
• BP 200/90 immediately preoperatively
• Postpone to control BP? What if BP 220/105?

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Postpone to control BP? What if BP 220/105?

• Pro (risk averse)
• Philosophy Not in best medical condition
• Perioperative hemodynamic instability
• Create need-to-rescue events if proceed
• Con (risk tolerant)
• Basing decision on inaccurate single BP
  measurement
• Outcome data do not support delay
• Perceived risks overestimated easily managed
• Control requires 1-2 months impractical

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HYPERTENSION

• 72-yr-old 85 kg man, inguinal hernia repair
• Meds lisinopril, atenolol, aspirin, statin
• BP 200/90 immediately preoperatively
• Is this high BP measurement iatrogenic?
• Is high BP a green, yellow, or red light?
• Treat this BP before induction?
• What BP is too low in hypertensive patients?
• Which antihypertensive agents should be
  discontinued prior to surgery?

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Is High BP Measurement Iatrogenic?

• Deliberate loose control by PCP
• Tight control in elderly leads to side effects,
  complications, decreased compliance
• White coat hypertension
• Withholding of anti-hypertensive medication by
  anesthesiologists
• Inaccurate BP measurement

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Inaccurate BP Measurement

• Automated devices (Jones, et al JAMA 2003
  2891027-30)
• AAMI validation, not required by FDA, questioned
• Association for Advancement of Medical
  Instrumentation
• Mean rather than measurements exceeding limits
• Systolic and diastolic derived from mean
• Error greatest in elderly Diastolic
  overestimated
• BP cuff bladder
• Problem increasing with obese elderly

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STAGE 2 HYPERTENSION RED, YELLOW, OR GREEN
LIGHT?

• RED stop
• Cancel surgery
• Medical treatment
• End-organ disease
• BP itself
• YELLOW proceed with caution
• Co-morbidity control
• Perioperative BP control
• GREEN go
• Perioperative BP control

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Stage 2 Hypertension Green LightGreen light.
Go

• Hypertension is never a green light in patients
  65 yrs of age

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Stage 2 Hypertension Yellow LightProceed with
caution

• Hypertension per se minor risk factor
• American College of Cardiology
• American Heart Association
• JNC-7 eliminated Stage 3 classification in 2003
• JNC-6 Stage 3 Systolic 180 or diastolic 110
  mm Hg
• Meta-analysis
• Howell, Sear, Foëx Br J Anaesth 200492570

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Howell, Sear, Foëx RecommendationsBr J Anaesth
200492570-83

• anaesthesia and surgery should not be cancelled
  on the grounds of elevated preoperative arterial
  pressure
• attention should be paid to the presence of
  target organ damage, such as coronary artery
  disease

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Howell, Sear, Foëx RecommendationsBr J Anaesth
200492570-83

• intraoperative arterial pressure should be
  maintained within 20 of best estimate of
  preoperative arterial pressure, especially in
  patients with markedly elevated preoperative
  pressures
• Best estimate of preoperative arterial
  pressure
• Auscultatory (Hg manometer)
• Office, clinic and hospital records
• Does not apply to aortic dissection
• Systolic

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Stage 2 Hypertension Yellow LightProceed with
caution

• Preoperative hypertension remain wary? Yes
  cancel surgery? No
• Spahn DR, Priebe H-J
• Br J Anaesth 2004 92461-4 Editorial

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Stage 2 Hypertension Yellow LightProceed with
caution

• Manage comorbidities to avoid
• Myocardial ischemia
• Congestive heart failure
• Expect hemodynamic instability
• Hypotension on induction
• Hypertension on emergence, in PACU,
  postoperatively

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Stage 2 Hypertension Red LightRed light.
Stop

• high BP measurement
• recent change in coronary heart disease signs
  symptoms
• decompensated congestive heart failure
• Really high BP

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Really High Blood PressureElliott WJ
Progress in Cardiovascular Disease 2006 48316-25

• Hypertensive emergency stop
• Signs symptoms acute target-organ damage
• Hypertensive urgency controversy
• Signs or history chronic target-organ damage
• Hypertensive situation proceed
• Untreated or poorly treated Stage 2 hypertension

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Hypertensive Urgency Elliott WJ Progress in
Cardiovascular Disease 2006 48316-25

• Treating physician feels that it would be unsafe
  to leave such a patient without lowering the BP.
  There is very limited evidence in the medical
  literature that this feeling is, in fact, true,
  and even less evidence to support BP lowering in
  this setting.

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Really High Blood Pressure

• My feeling really high auscultatory BP
  measurement
• Normal mental status, no acute ECG changes, no
  increased dyspnea, JVD, S3, S4, or rales.
• Systolic 180 or diastolic 110 mm Hg
  tachycardia
• Old JNC-6 Stage 3 tachycardia
• Isolated systolic 220 mm Hg
• 20 above old JNC-6 Stage 3
• Systolic 200 mm Hg and diastolic 120 mm Hg
• Combined really high systolic and diastolic
• 10 above old JNC-6 Stage 3

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Treat BP before induction?

• Controversies with biased answers
• Anesthetic agents versus medical drugs?
• I prefer medical drugs
• End-point if use medical drugs?
• I use HR
• Shorter- versus longer-acting agents?
• e.g., labetalol versus esmolol
• I use longer-acting for most elective cases
• I use shorter-acting for longer, complex cases

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What BP is too Low?

• Diastolic pressure end-organ issues
• Heart primary concern
• Only organ whose perfusion occurs primarily
  during diastole
• If take care of the heart, the other organs will
  take care of themselves
• Ed Lowenstein, MD
• Kidneys second order concern
• Acute renal decompensation
• Brain distant third order concern
• Embolic strokes hemorrhagic hypotensive
  strokes

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Diastolic Pressure Coronary Heart
DiseaseMesserli FH, et al Ann Intern Med
2006144884 - 893

• 22,776 patients
• Chronic treatment
• J-shaped relationship for all-cause death DP
• Nadir DP 84 mm Hg
• MI/stroke ratio constant at DP above nadir
• MI/stroke ratio increases with decreasing DP
  below nadir, i.e, more MIs

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Appropriate Blood Pressure for Patients with
Contrast Nephropathy
Palmer N Engl J Med 2002 348491
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Suggested Pressure Minimums

• Goal Rule of 70s
• 70 yrs
• DP 70 mm Hg
• PP
• HR 70 bpm
• If A-line phenylephrine infusion, consider
  co-infusion NTG to create the best arterial wave
  form (equivalent to timing IABP)
• Pauca AL, et al Heart 2005 911428-32

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Which antihypertensive agents should be
discontinued prior to surgery?

• ACE-I and ARBs
• Beta blockers
• Calcium channel blockers
• Diuretics

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Which antihypertensive agents should be
discontinued prior to surgery?

• ASA Panel Highs and Lows of Blood Pressure
  When Does It Really Matter?
• 10/15 Drs. Barnett, Communale, Groban, Prielipp
• Key comorbidities
• Congestive heart failure
• More likely to continue ABCD
• Coronary heart disease
• More likely to continue only BC

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Comfere T, et al Angiotensin system inhibitors
in a general surgical population.Anesth Analg
2005 100636-44

• N267
• 2 groups ACE-I/ARB
• 10 hrs
• Significant ? incidence of hypotension on
  induction
• BUT

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Comfere T, et al Angiotensin system inhibitors
in a general surgical population.Anesth Analg
2005 100636-44

• This hypotension responded to conventional
  therapy i.e., no refractory hypotension and
  thus seemed to be of little clinical consequence
  withholding should be considered for patients
  who may be especially prone to hypotension-induced
  complications (e.g., severe aortic stenosis).
• No ? in cardiac events
• Induction doses essentially same in both groups
• Midazolam 2 mg, Propofol 150 mg, Fentanyl 150 µg
• Arguably high doses for this age group

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HYPERTENSION

• 72-yr-old 85 kg man, inguinal hernia repair
• Meds lisinopril, atenolol, aspirin, statin
• BP 200/90 immediately preoperatively
• Is this high BP measurement iatrogenic?
• Auscultatory BP 183/86, HR 62, ACE-I held,
  anxious
• Is high BP a green, yellow, or red light? -
  yellow
• Treat this BP before induction?
• Midazolam 0.5 mg 164/82 Labetalol 10 mg 135/75
• Induction fentanyl 50 µg, propofol 50 mg,
  lidocaine 75 mg
• What BP is too low in hypertensive patients?
• Single dose of ephedrine 5 mg for diastolic 65 mm
  Hg

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MAJOR TOPICS - PATIENTS PRESENTING WITH

• HYPERTENSION
• DIASTOLIC DYSFUNCTION
• TYPE 2 DIABETES MELLITUS
• CORONARY HEART DISEASE

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DIASTOLIC DYSFUNCTION

• 75-yr-old 80 kg woman for THR History of CHF
• Echo EF 65, normal valvular function, LA
  enlargment, thickened LV, normal LV volume
• Meds spironolactone, verapamil, enalapril
• Diastolic dysfunction?
• Perioperative concerns?

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DIASTOLIC DYSFUNCTION vs AGERedfield et al
JAMA 2003 289194

• Impaired LV filling at normal LA pressure
• Concentric LV hypertrophy
• LV ejection fraction 50
• LA enlargement

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LEFT VENTRICULAR FILLING

• Rapid filling phase (suction from LV
  relaxation)
• Young adult 90 Elderly
• Slow passive filling phase
• Up to 50 in elderly
• Maintain preload, diastolic filling time
• Backs up if overload, reduce duration of
  diastole (tachycardia), increase LVEDP
  (myocardial ischemia, hypertension)
• Atrial systole
• Up to 50 in elderly
• Preserve sinus rhythm

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Diagnosis of Diastolic Dysfunction

• Abnormal diastolic heart sounds (S3, S4 gallops)
• Specificity 80 sensitivity
• Left ventricular hypertrophy
• Normal ejection fraction ( 50)
• Elevated B-type natriuretic peptide (BNP)
• Enlarged left atrium
• Increased diastolic filling pressure
• Echocardiographic measures

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B-type Natriuretic Peptide Plasma LevelsMaisel.
N Engl J Med 2002 347163

• A-type natriuretic peptide - secreted by atria
  when chamber dilates
• B-type natriuretic peptide (BNP) - secreted by
  ventricles when increased end-diastolic pressure
  and volume expansion

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Left Ventricular Heart Failure

• Systolic heart failure
• Diastolic heart failure 40
• a.k.a. heart failure with preserved systolic
  function
• flash pulmonary edema
• Rapid fluid administration
• Routine fluid administration during
  decompensation
• Tachycardia
• Myocardial ischemia
• Hypertension
• Loss of atrial kick

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DIASTOLIC DYSFUNCTION

• 75-yr-old 80 kg woman for THR History of CHF
• Echo EF 65, normal valvular function, LA
  enlargment, thickened LV, nl LV vol
• Meds spironolactone, verapamil, enalapril
• Diastolic dysfunction? Yes
• Perioperative concerns?
• Received enalapril, ?BP on induction
• Tight fluid management
• Avoid tachycardia, hypertension, myocardial
  ischemia
• Preserve sinus rhythm

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MAJOR TOPICS - PATIENTS PRESENTING WITH

• HYPERTENSION
• DIASTOLIC DYSFUNCTION
• TYPE 2 DIABETES MELLITUS
• CORONARY HEART DISEASE

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Diabetes Mellitus New Terminology

• American Diabetes Association (1997)
• Eliminated terms
• Insulin-dependent DM
• Non-insulin-dependent DM
• Re-classified Diabetes Mellitus
• Type I absolute lack of insulin
• Type 2 insulin present
• Impaired secretion
• Insulin resistance

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Type 2 DM 10 Year Progression

• Insulin resistance in muscle cells
• Hyperinsulinemia
• Decline in pancreatic function
• Hyperglycemia (ß-cell function
• Type 2 DM
• 20 of 75 year olds
• Coronary heart disease equivalent
• Rate of 1st MI in patient with type 2 DM rate
  of 2nd MI in patient with CAD without DM

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Oral Hypoglycemic Agent IssuesGu
Anesthesiology 2003 981359

• Sulfonylureas discontinue
• Predispose to myocardial ischemia
• Metformin discontinue
• Lactic acidosis
• Thiazolidinediones (glitazones) continue?
• Actos, Avandia
• Sensitize response to insulin, better
  intraoperative control
• Kersten et al Anesthesiology 2005 103677-8

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Kersten, Warltier, Pagel Aggressive control of
intra-operative glucose concentration.Anesthesiol
ogy 2005 103677-8 (Editorial)

• Stated strong evidence exists to indicate
  hyperglycemia alone, with or without diabetes,
  contributes to morbidity and mortality in
  patients at risk for myocardial ischemia and
  reperfusion injury
• Speculated thiazolidinedione insulin
  sensitizing agents may improve patient outcome by
  enhancing degree to which tight control of blood
  glucose concentrations may be achieved with
  exogenous insulin. Actos, Avandia

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Type 2 Diabetes MellitusTight Control of
GlucoseGu. Anesthesiology 2003 981359

• Perioperative insulin infusions
• Glucose 80-150 mg/dl intraop
• Glucose 80-110 mg/dl postop
• Reduces ICU mortality by 40
• Improves outcome from acute MI
• Decreases infections

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Ouattara et al Poor intraoperative blood
glucose control is associated with a worsened
hospital outcome after cardiac surgery in
diabetic patients. Anesthesiology 2005
103687-94.

• Attempted tight glycemic control in all patients
• 18 insulin resistance ? poor control
• Morbidity
• Poor control 37 (odds ratio 7.2)
• Tight control 10
• Could not predict poor control preop
• Identifies vs. responsible for higher risk?

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INTRAOPERATIVE BLOOD GLUCOSE CONCENTRATIONS IN
DIABETIC CARDIAC SURGERY PATIENTS WITH SAME
INSULIN REGIMEN
Ouattara et al Anesthesiology 2005 103687-94
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IN-HOSPITAL MORBIDITY VERSUS INTRAOPERATIVE
GLUCOSE CONTROL
Ouattara et al Anesthesiology 2005 103687-94
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TYPE 2 DIABETES MELLITUS

• 70-yr-old woman for colon resection. Type 2 DM.
  Preop blood glucose 185 mg/dL. Medications
  metformin (Glucophage), rosiglitazone (Avandia).
• Discontinue oral hypoglycemic agents?
• Stop metformin, continue glitazone
• Treat blood glucose?
• Insulin infusion (1-3 units/hr) - encouraged
• Sliding scale - discouraged

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MAJOR TOPICS - PATIENTS PRESENTING WITH

• HYPERTENSION
• DIASTOLIC DYSFUNCTION
• TYPE 2 DIABETES MELLITUS
• CORONARY HEART DISEASE

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CORONARY HEART DISEASE

• 68-yr-old man for repair of retinal detachment.
  ECG ST depression in II and V5 during emergence
• Should he have received ß-blockers in
  perioperative period?
• What is significance of the ST depression?
• Is this patient suffering a perioperative
  myocardial infarction?

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CLINICAL RISK FACTORS

• Age 70 yrs
• Angina
• Past MI
• CHF

• Past CVA
• DM
• CRI
• COPD

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MI AFTER AAA SURGERYKertai et al.
Anesthesiology 2004 1004-7
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Conclusions for High Risk Patients

• Clear benefit to ß-blockers
• pre-/intra-/post-op
• targets Rule of 70s
• esmolol boluses intra-op insufficient
• Statins pre-/post-op?

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REVISED CARDIAC RISK INDEX

• RCRI - one point each for
• High risk surgery
• Intrathoracic, intraperitoneal, suprainguinal
  vascular
• Ischemic heart disease
• Cerebrovascular disease
• Renal insufficiency
• Diabetes mellitus
• Lindenauer et al N Engl J Med 2005 353349-61

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Adjusted Odds Ratio for Death Associated with
Perioperative ß-Blockade in Patients Undergoing
Major Noncardiac Surgery
RCRI Revised Cardiac Risk Index
Lindenauer et al N Engl J Med 2005 353349-61
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Conclusions for Low Risk Patients

• ß-blocker controversy
• No benefit Juul AHA Abstract 2004
• 921 diabetic patients, non-cardiac surgery,
  metoprolol
• Harm Lindenauer et al N Engl J Med 2005
  353349-61 ( 600,000 patients)
• 2 ongoing randomized trials (results in 4 yrs)
• POISE Perioperative Ischemic Evaluation
  10,000 patients
• DECREASE IV 6000 patients
• Recommend still yes to ß-blockers
• Poldermans, Boersma N Engl J Med 2005 353412-4
  (Editorial)

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ESC/ACC Criteria for Acute, Evolving, or Recent
Myocardial Infarction

• Either one of
• Typical rise and fall of biochemical markers of
  myocardial necrosis (e.g., troponin, CK-MB) with
  at least one of following
• Ischemic symptoms
• Development of Q-waves on the ECG
• ST changes indicative of ischemia (ST ? or ?)
• Coronary artery intervention
• Pathologic findings of acute MI

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Does ST Depression Mean Myocardial
Infarction?Priebe H-J Br J Anaesth 2004
939-20

• Although ST-segment depression usually reflects
  subendocardial ischaemia and is often regarded as
  reversible injury, it is not inconsistent with a
  myocardial infarction. Especially elderly
  patients may present with myocardial infarction
  without ST-segment elevation.

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Pre- and Postoperative Troponin
Determinations?Howell SJ, Sear JW Br J Anaesth
2004 933-8

• It now seems reasonable to ask if patients with
  one or more risk factors for cardiovascular
  disease, who undergo surgery, should have pre-
  and postoperative measurements of cardiac
  troponin and should receive cardiovascular
  secondary prevention if any postoperative
  elevation is detected.

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EFFECT OF ß-BLOCKERS ON TROPONIN RELEASE DURING
MAJOR NONCARDIAC SURGERY IN PATIENTS WITH
ISCHEMIC HEART DISEASE

• Elevated troponin I
• Atenolol - 22 (9/40)
• No atenolol 42 (8/19)
• troponin I detected during surgery
• Zaugg Anesthesiology 1999 911674

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DEATH BY 42 DAYS () VS TROPONIN I RELEASE IN
PATIENTS WITHOUT ST ELEVATIONS
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CORONARY HEART DISEASE

• 68-yr-old man for repair of retinal detachment.
  ECG ST depression in II and V5 during emergence
• Should he have received ß-blockers in
  perioperative period? - yes
• What is significance of the ST depression?
• Myocardial ischemia or myocardial infarction
• Is this patient suffering a perioperative
  myocardial infarction?
• Maybe! Draw troponin levels if ST depression
  persists beyond several minutes. Observe for
  evolution of signs and symptoms of myocardial
  infarction

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HYPERTENSION

• USUALLY PROCEED
• REDISCOVER AUSCULTATORY BP
• MANAGE TO PREVENT
• MYOCARDIAL ISCHEMIA
• CONGESTIVE HEART FAILURE
• MAINTAIN DIASTOLIC PRESSURES
• RULE OF 70S
• 70 yrs, DP 70, PP

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DIASTOLIC DYSFUNCTION

• VOLUME TIGHT CONTROL
• INOTROPES versus VOLUME FOR ?BP
• MAXIMIZE FILLING DURING DIASTOLE
• PROPER PRELOAD
• gentle push because no suction
• ADEQUATE FILLING TIME
• HR 70 avoid tachycardia
• AVOID INCREASES IN LVEDP
• Control afterload (systolic hypertension)
• Avoid myocardial ischemia
• MAINTAIN ATRIAL KICK

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TYPE 2 DIABETES MELLITUS

• INSULIN INFUSIONS
• GLUCOSE 80-150 mg/dl
• CONTINUE GLITAZONES

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CORONARY HEART DISEASE

• ß-BLOCKERS
• HR 70 bpm
• ST DEPRESSION MAY MEAN MYOCARDIAL INFARCTION
• Serial troponins
• Treat if elevated