Anesthetic Management of Elderly Patients

1
Anesthetic Management of Elderly Patients

• Raymond C. Roy, PhD, MD
• Professor Chair of Anesthesiology
• Wake Forest University School of Medicine (Bowman
  Gray Campus)
• Winston-Salem, NC, USA

2
Ten Things That Are Good for Elderly Patients

• Higher FIO2
• Beta-blockers
• Timely antibiotic administration
• Regional anesthesia
• Minimal to no sedatives during spinal or epidural

3
Ten Things That Are Good for Elderly Patients

• Avoiding hypothermia
• Shorter-acting neuromuscular blocking agents
• Lower doses of iv inhaled agents
• Diastolic pressure
• Time to respond

4
What Is the Difference Between Life Span Life
Expectancy?

• Longest life
• ? - 122 yrs 164 d, ? - 120 yrs 237 d
• Life span die of old age
• 85 100 yrs
• Natural death no disease, trauma
• Life expectancy at birth USA 1997
• White ?- 79.9 ? - 74.3
• Black ?- 74.7 ? - 67.2

5
How Should One View 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.
• Leonard Hayflick

6
What Is Oldest Age of Patient Having Major
Surgery?

• Oliver. Br J Anaesth 2000 84 260
• age in OR - ? 113 yrs
• general anesthesia
• repair of femoral shaft fracture
• discharged POD 23
• age at death 114 yrs

7
What Is the Annual Rate of Anesthetic
AdministrationsPer 100 Population?Clergue.
Anesthesiology 1999 911509 (France)
8
What Is the Effect of Age on Surgical Outcome?

• With advancing age
• Mortality increases
• Morbidity increases
• Disease vs. age ?
• Disease gt age when lt 85 yrs
• Age approaches disease when gt 85 yrs (ages of
  natural death)

9
What is the Cardiac Risk Stratification for
Noncardiac Surgery? J Am Coll Cardiol 1996 27
910

• High (death, MI) gt5
• Major vascular, peripheral vascular, emergent
  intermediate, prolonged with large fluid shifts
  or blood loss

10
What is the Cardiac Risk Stratification for
Noncardiac Surgery? J Am Coll Cardiol 1996 27
910

• Intermediate 15
• Carotid, head neck, intraperitoneal,
  intrathoracic, orthopedic, prostate
• Low lt 1
• Endoscopy, eye, breast, superficial

11
What Is the Mortality After Vascular Surgery?
Fleisher. Anesth Analg 1999 89 849
12
What Are the Perioperative Complication Rates in
Medicare Patients?

• Intermediate risk 42
• Silber Anesthesiology 2000 93 152
• 217,440 general surgery orthopedic patients
• Low risk 3
• Schein N Engl J Med 2000 342 168
• 18,901 cataract surgery patients

13
What Is the Prevalence of Abnormal Preoperative
Tests in 544 Consecutive Noncardiac Surgical
Patients gt 69 yrs? Dzankic. Anesth Analg
2001 93 301

• Creatinine gt 1.5 mg/dL 12
• Hemoglobin lt 10 mg/dL 10
• Glucose gt 200 mg/dL 7
• K lt 3.5 mEq/L
  5
• K gt 5.0 mEq/L
  4
• Platelets lt 115,000/ml 2

14
Is Routine Laboratory Testing in the Elderly
Indicated?

• Roizen. N Engl J Med 2000 342 204
• Without changes to the system to increase
  preoperative clinical assessment by physicians,
  we may see poorer outcomes and higher long term
  costs if eliminate routine laboratory testing in
  elderly.

15
Is Routine Laboratory Testing in the Elderly
Indicated?

• Fleisher. Anesth Analg 2001 93 249
• There is insufficient evidence to either
  advocate routinely performing any given test or
  to clearly define preoperative tests that are
  without value.

16
Is Routine Laboratory Testing in the Elderly
Indicated?

• No, if all below satisfied
• followed by primary MD
• good H P with no red flags
• moderate functional status low to intermediate
  risk surgery
• or
• poor but stable functional status low risk
  surgery

17
Why Is Preoxygenation More Important in Older
Than Younger Patients?

• Faster desaturation
• Slower onset of neuromuscular blocking agents
• Higher incidence of CAD

18
What Is the Time (sec) to SpO2 90? Benumof.
Anesthesiology 1999 91 603
19
What Is the Best Way to Preoxygenate Elderly
Patients? Benumof. Anesthesiology 1999 91
603 Baraka. Anesthesiology 1999 91 612

• 8 deep breaths in 60 s
• 10 l/min O2 flow rate
• 8DB/60 s gt 3-5 min gt 4DB/30 s

20
Is Advanced Age a Predictor of Difficult Mask
Ventilation? Langeron. Anesthesiology 2000
92 1229

• Incidence 5 (75/1502)
• Predictors any 2 of 5
• Age gt 55 yrs, body mass index gt 26 kg/m2, beard,
  edentulous, snorer
• Difficult mask ventilation -gt difficult
  intubation (8 vs 30)

21
What Are the Effects of Age and Temperature on
MAC and MACawake? Eger. Anesth Analg
2001 93 947

• MAC MACawake decrease 6.7 for each decade
  after 40 yrs
• MAC MACawake decrease 5 for each 1oC decrease
• MACawake ? MAC (des, iso, sevo)

22
Does Epidural Anesthesia Reduce MAC? Yes, by
50! Hodgson. Anesthesiology 1999 91 1687
23
Does Epidural Anesthesia Reduce MAC-BIS50? Yes,
34! Hodgson. Anesthesiology 2001 94 799
24
Does Spinal or Epidural Anesthesia Affect
Sedative Requirements? YES!!!

• Sedation, sleep, and lower BIS scores in patients
  during spinal anesthesia without iv sedation
• Pollock. Anesthesiology 2000 93 728
• Gentili. Br J Anaesth 1998 93 970

25
Does Spinal or Epidural Anesthesia Affect
Sedative Requirements? YES!!!

• Significantly decreased iv doses of midazolam,
  thiopental, and propofol required to produce LOC
  during spinal and epidural anesthesia
• Tverskoy. J Clin Anesth 1994 6 487
• Ben-David. Anesth Analg 1995 81 525
• Tverskoy. Reg Anesth 1996 21 209

26
Is Routine Sedation of Elderly Patients Required
during Solid Spinal or Epidural Anesthesia?

• Decreased requirement
• Age, spinal or epidural
• Synergistic drug interactions
• Easy to overdose
• Endpoint if will sleep anyway?

27
Who Is at Risk of Intraoperative Hypothermia?

• Diabetic Neuropathy
• Kitamura. Anesthesiology 2000 92 1131
• High spinal
• Core T (oC) 34.37 0.15 (thoracic dermatome)
• Frank. Anesthesiology 2000 92 1330
• Advanced age
• Core T (oC) 36.72 0.03 (age in yrs)
• Frank. Anesthesiology 2000 92 1330

28
What Is Effect of Hypothermia on Time to 25
Recovery after Vecuronium 0.1 mg/kg?
Caldwell. Anesthesiology 2000 92 84
29
Do Elderly Take Longer to Emerge than Younger
Patients?

• Yes, because
• lower MACawake
• higher pain threshold
• hypothermia more likely
• emergence hypertension
• longer durations of action
• relative drug overdoses

30
Alveolar Concentrations Underestimate Brain
Concentrations on Emergence Lockhart.
Anesthesiology 1991 74 575
31
Should Elderly Patients Receive Supplemental O2
after Abdominal Surgery?Rosenberg-Adamsen.
Anesthesiology 1999 90380

• YES - decreases HR
• Average from 85 to 81 bpm
• Decreased 8 bpm if initial rate gt 109
• Especially if HR gt 90 bpm
• Even if SpO2 gt 92

32
How Frequently Do New T-Wave Changes Appear in
PACU?

• Breslow. Anesthesiology 1986 64 398
• 18 of 394 consecutive patients
• Young old, regional general
• 46 flattening 25 - inversion
• No S/S of myocardial ischemia
• Ashton. J Am Geriatr Soc 1991 39 575
• 21 of 206 TURP patients
• No S/S of myocardial ischemia
• No elevations of CK-MB

33
What Is the Significance of New T-Wave Changes in
PACU?

• 20 patients no cardiac implications
• But also occurs in patients with CAD
• Elderly nontextbook S/S of ischemia
• No workup if no other soft signs
• Workup if any sign of hemodynamic dysfunction

34
Ten Things That Are Good for Elderly Patients

• Higher FIO2
• Beta-blockers
• Timely antibiotic administration
• Regional anesthesia
• Minimal to no sedatives during spinal or epidural

35
Ten Things That Are Good for Elderly Patients

• Avoiding hypothermia
• Shorter-acting neuromuscular blocking agents
• Lower doses of iv inhaled agents
• Diastolic pressure
• Time to respond

36
TOUGH ISSUES IN GERIATRIC ANESTHESIATRACKING
THE PROBLEMS

• PERIOPERATIVE DELIRIUM
• Jeffrey H. Silverstein, MD
• PREOPERATIVE ASSESSMENT
• Raymond C. Roy, PhD, MD
• PALLIATIVE CARE
• Carol W. Agin, MD
• ETHICAL DILEMMAS
• Paul J. Hoehner, MD, MATS

37
EFFECTIVE EFFICIENT PREOPERATIVE ASSESSMENTIN
THE ELDERLY

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

38
OBJECTIVES

• PRESENT EVIDENCE the elderly
• need careful preoperative assessment
• BUT many do NOT need
• routine lab testing or chest x-ray
• noninvasive cardiac testing, ECG
• SUGGEST CRITERIA for
• preoperative laboratory tests
• noninvasive cardiac testing

39
PERIOPERATIVE COMPLICATION RATES in MEDICARE
PATIENTS

• INTERMEDIATE RISK - 42
• Silber Anesthesiology 2000 93152-63
• 217,440 general surg/orthopedic patients
• LOW RISK - 3
• Schein N Engl J Med 2000 342168-75
• 18,901 cataract surgery patients

40
Schein et al. The value of preoperative testing
before cataract surgery. N Engl J Med 2000
342168-75 - Johns Hopkins

• Routine vs no testing (ECG, CBC, electrolytes,
  BUN, Cr, glucose, frequently chest x-ray vs no
  tests unless worsening medical condition)
• Exclusion criteria lt 50 yrs, MI lt 3 mos, preop
  tests lt 28 d

41
Schein et al. The value of preoperative testing
before cataract surgery. N Engl J Med 2000
342168-75 - Johns Hopkins
42
Schein et al. The value of preoperative testing
before cataract surgery. N Engl J Med 2000
342168-75 - Johns Hopkins
43
Schein et al. The value of preoperative testing
before cataract surgery. N Engl J Med 2000
342168-75 - Johns Hopkins
44
Schein et al. The value of preoperative testing
before cataract surgery. N Engl J Med 2000
342168-75 - Johns Hopkins

• Perioperative morbidity and mortality are not
  reduced by routine use of commonly ordered
  preoperative medical tests.
• 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.

45
Narr et al. Outcomes of patients with no
laboratory assessment before anesthesia and a
surgical procedure. Mayo Clin Proc 1997 72505-9
N 1,044

• Patients who have been assessed by history and
  physical examination and determined to have no
  preoperative indication for laboratory tests can
  safely undergo anesthesia and operation with
  tests drawn only as indicated intraoperatively
  and postoperatively.

46
CARDIAC RISK STRATIFICATION FOR NONCARDIAC SURGERY

• HIGH (death, MI) gt 5
• Emergent major surgery in elderly
• Aortic and major vascular
• Peripheral vascular
• Prolonged procedures with large fluid shifts
  and/or blood loss
• J Am Coll Cardiol 1996 27910-48

47
CARDIAC RISK STRATIFICATION FOR NONCARDIAC SURGERY

• INTERMEDIATE gt 1, lt 5
• Carotid endarterectomy
• Head neck
• Intraperitoneal
• Intrathoracic
• Orthopedic
• Prostate
• J Am Coll Cardiol 1996 27910-48

48
CARDIAC RISK STRATIFICATION FOR NONCARDIAC SURGERY

• LOW lt 1
• No preoperative cardiac testing
• Endoscopies
• Superficial procedures
• Cataract
• Breast
• J Am Coll Cardiol 1996 27910-48

49
FUNCTIONAL CAPACITY

• MET metabolic equivalent O2 consumption of 70
  kg, 40 y/o man in resting state
• gt 7 METs - excellent
• 4-7 METs - moderate
• lt 4 METs - poor
• J Am Coll Cardiol 1996 27910-48

50
ESTIMATED ENERGY REQUIREMENTS for ADL

• 1 MET -------------------------gt 4 METs
• eat, dress, use toilet
• walk indoors around house
• walk 1-2 blocks on level ground
• light house work
• J Am Coll Cardiol 1996 27910-48

51
ESTIMATED ENERGY REQUIREMENTS for ADL

• 4 METs -------------------gt 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, throwing
  ball
• J Am Coll Cardiol 1996 27910-48

52
MAJOR CLINICAL PREDICTORS

• Unstable coronary syndromes
• Decompensated CHF
• Significant arrhythmias
• Severe valvular disease
• J Am Coll Cardiol 1996 27910-48

53
INTERMEDIATE CLINICAL PREDICTORS

• Mild stable angina
• Prior MI
• Compensated CHF
• Prior CHF
• Diabetes mellitus
• J Am Coll Cardiol 1996 27910-48

54
MINOR CLINICAL PREDICTORS

• Advanced age
• Abnormal ECG
• Rhythm other than sinus
• Low functional capacity
• Stroke history
• Uncontrolled systemic BP
• J Am Coll Cardiol 1996 27910-48

55
NO NONINVASIVE or INVASIVE CARDIAC TESTING for

• INTERMEDIATE RISK SURGERY MODERATE FUNCTIONAL
  CAPACITY if INTERMEDIATE CLINCAL PREDICTORS
• INTERMEDIATE RISK SURGERY POOR FUNCTIONAL
  CAPACITY if MINOR CLINICAL PREDICTORS
• J Am Coll Cardiol 1996 27910-48

56
Roizen. More preoperative assessment by
physicians and less laboratory tests. N Engl Med
2000 342204-5

• Without changes to the system to increase
  preoperative clinical assessment by physicians,
  we may see poorer patient outcomes and higher
  long term costs.

57
ANESTHESIA PREOPERATIVE ASSESSMENT OLD PARADIGM

• Inpatients only
• Day before surgery
• Patients hospital room
• By same one who gives anesthetic
• Routine screening tests
• Anesthesia consent

58
ANESTHESIA PREOPERATIVE ASSESSMENT NEW PARADIGM

• Outpatient, same-day gtgt inpatient
• Days before/day of surgery
• Dedicated clinic
• By one who will NOT give anesthetic
• No routine screening
• Anesthesia request risk disclosure

59
ABCDS of PREOPERATIVE ASSESSMENT

• ASSESSMENT
• BETA- BLOCKERS, other drugs
• COMMUNICATION
• DECISIONS

60
ABCDS of PREOPERATIVE ASSESSMENT

• ASSESSMENT
• Airway anatomy
• Functional capacity
• Laboratory testing ?
• Chest x-ray?
• Noninvasive cardiac ?

61
ABCDS of PREOPERATIVE ASSESSMENT

• BETA BLOCKERS
• Calcium channel blockers
• Other antihypertensives
• OTHER DRUGS
• Oral hypoglycemic agents
• Diuretics
• HERBAL MEDICINES

62
Tsen et al. Alternative medicine use in
presurgical patients. Anesthesiology 2000
93148-51

• HERBAL MEDICINE USE
• 61 - 70 yrs 20
• 71 - 80 yrs 15
• gt 80 yrs 10

63
ABCDS of PREOPERATIVE ASSESSMENT

• COMMUNICATION
• Risk disclosure reassurance
• Preoperative instructions
• Concerns to surgeon
• Preoperative information to attending
  anesthesiologist
• Same anesthetic, pain management plan discussed
  that attending will use

64
ABCDS of PREOPERATIVE ASSESSMENT

• DECISIONS
• Necessary lab tests, consults
• Appropriate schedule
• Preoperative medications
• Anesthetic plan
• Postoperative analgesia
• Discharge plans

65
CONCLUSIONS

• LABORATORY TESTING
• NONE UNLESS NEEDED INDEPENDENT OF SURGERY -
  PREOP, INTRAOP prn
• NOINVASIVE CARDIAC TESTING
• NO - MODERATE FUNCTIONAL CAPACITY, INTERMEDIATE
  RISK SURGERY INTERMEDIATE CLINICAL PREDICTORS
• NO - POOR FUNCTIONAL CAPACITY, LOW RISK SURGERY
  MINOR CLINICAL PREDICTORS
• ADD BETA BLOCKERS