Anesthetic Management of the Elderly Patient

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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
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Hayflicks 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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Older Americans

• 2000 2030
• gt 65 yrs 12.4 19.6
• 35 mil 71 mil
• gt 80 yrs 9.3 mil 19.5 mil

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The Oldest..

• MAN 120 yrs
• WOMAN 122
• Guinness Book of Records
• GENERAL ANESTHETIC 113
• Br J Anaesth 2000 84260

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Life Expectancy at birth USA - 1997

• WOMEN Caucasian 79.9 yrs
• African-American 74.7
• MEN Caucasian 74.3
• African-American 67.2

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Life Expectancy, Life Span, Maximum Length of
Life

• Maximum Length of Life gt 120 yrs
• Life Span 85-100
• Natural death (no trauma or disease)
• Life Expectancy (USA) 67-80
• Premature death (trauma, disease)

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Oldest Surgical Patient?Oliver. Br J Anaesth
2000 84260

• Woman, 113 yrs, femoral fracture
• General anesthesia
• CVP, no arterial-line
• Extubation in ICU after 5h
• Hospital discharge POD 23

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Anesthetics per 100 Population?Clergue.
Anesthesiology 1999 911509 (France)
Ages (yrs) Men Women
35 44 8.9 13.2
55 - 64 17.7 14.6
75 - 84 30.2 23.6
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Vascular Surgery Mortality vs AgeFleisher.
Anesth Analg 1999 89849
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Perioperative Complication Rates in Medicare
Patients

• Intermediate Risk Surgery - 42
• Silber, Anesthesiology 2000 93152
• 217,440 general orthopedic surgery
• Low Risk Surgery - 3
• Schein, N Engl J Med 2000 342168
• 18,901 cataract surgery

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Age Perioperative Outcome

• With advancing age
• More surgery
• Morbidity increases
• Mortality increases
• Cause - disease vs age ?
• Disease gt age when lt 85 yrs
• Age may disease when gt 85 yrs
• Increase ASA PS when gt 85 yrs

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Preoperative Considerations

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

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Why Obtain Preoperative Tests?

• Screening NO with one exception
• Urinalysis if hip surgery or acutely ill
• Cook Rooke, Anesth Analg 2003 961823
• Treatment effectiveness - YES
• Baseline MAYBE, but overused
• Risk Assessment - YES

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Value of Preoperative Testing Before Low Risk
SurgerySchein. N Engl J Med 2000 342168
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Value of Preoperative Testing Before Low Risk
Surgery Schein. N Engl J Med 2000 342168

• 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.

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Intermediate Risk Noncardiac Surgery (Mortality gt
1, lt 5)

• CAROTID
• HEAD NECK
• INTRAPERITONEAL
• INTRATHORACIC
• ORTHOPEDIC
• PROSTATE

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Preoperative Tests - Prevalence of Abnormal
Results544 consecutive intermediate risk
non-cardiac surgical patients gt 69 yrs - Dzankic.
Anesth Analg 2001 93301

• 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

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Outcomes of Patients with No Laboratory
Assessment for Intermediate Risk Surgery N
1,044 Narr. Mayo Clin Proc 1997 72505

• Patients assessed by history and physical
  examination safely undergo operation with
  tests drawn only as indicated intraoperatively
  and postoperatively.

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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

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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 27910

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INTERMEDIATE CLINICAL PREDICTORS

• MILD STABLE ANGINA
• PRIOR MI
• COMPENSATED CHF
• PRIOR CHF
• DIABETES MELLITUS

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FUNCTIONAL CAPACITY

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

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Estimated Energy Requirements for Activities of
Daily Living - 1

• 1 MET -------------------------gt 4 METs
• eat, dress, use toilet
• walk indoors around house
• walk 1-2 blocks on level ground
• light house work

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Estimated Energy Requirements for Activities of
Daily Living - 2

• 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

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Most Difficult ROUTINE Preoperative Tests to
Justify

• Chest X-ray
• PT and aPTT (if no heparin or warfarin)
• Liver Function Tests

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4 Statin Myopathic SyndromesThompson. JAMA 2003
2891681

• STATIN MYOPATHY
• Any muscle complaint with onset coincident with
  start of statin therapy
• MYALGIA with normal CK
• MYOSITIS with elevated CK
• RHABDOMYOLYSIS

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of Older Patients with Diastolic Dysfunction
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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

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Problems with Oral Hypoglycemic AgentsGu.
Anesthesiology 2003 981359

• 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

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Diabetes Mellitus Tight Control of Glucose Gu.
Anesthesiology 2003 981359

• 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

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Beta-adrenergic Blocking Agents Perioperative
Administration

• Reduces myocardial ischemia
• Reduces myocardial infarction
• Secondary Observations
• Zaugg. Anesthesiology 1999 911674
• Decrease anesthetic administration
• Enable faster emergence
• Decrease post-op analgesic requirement

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Perioperative Myocardial IschemiaWallace.
Anesthesiology 1998 887
MYOCARDIAL ISCHEMIA ATENOLOL (N 99) PLACEBO (N 101)
POD 0 - 2 17 34 p 0.008
POD 0 - 7 24 39 p 0.029
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Perioperative Beta-Blockade - Therapeutic Target
Auerbach. JAMA 2002 2871435

• HEART RATE 55 65 bpm
• SYSTOLIC gt100 mm Hg
• Before, during, and after surgery

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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)

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General Anesthesia

• Anesthetic depth
• Neuromuscular blocking agents
• Diastolic pressure
• Transfusion trigger
• Regional vs general anesthesia

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MAC AgeNickalls. Br J Anaesth 2003 91170
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Nitrous Oxide MAC AgeNickalls. Br J Anaesth
2003 91170
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End-tidal Isoflurane to Provide MAC with N2O in
80 Year OldsNickalls. Br J Anaesth 2003 91170
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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

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End-tidal Concentrations Under-estimate Brain
Concentrations During Emergence from
IsofluraneLockhart. Anesthesiology 1991 74575
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PROPOFOL INDUCTIONS IN 25 81 YR-OLDSSchnider.
Anesthesiology 1999 901502

• Propofol 2 mg/kg lt 65 yrs 1 mg/kg gt 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

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PROPOFOL INDUCTIONS 20 84 YRSKazama.
Anesthesiology 1999 901517

• HALF-TIME FOR NADIR IN BP
• 20 29 yrs 5.7 min
• 70 85 yrs 10.2 min

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PROPOFOL INDUCTIONS gt 65 YRSHabib. Br J Anaesth
2002 88430

• Glycopyrrolate, propofol 1 mg/kg, and either
  alfentanil 10 µg/kg or remifentanil 0.5 µg/kg
  0.1 µg/kg/min
• SBP lt 100 mmHg 50, lt 80 mmHg 8

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RECOMMENDED PROPOFOL DOSE FOR INDUCTION IF gt 65
yrs old

• IF BOLUS (lt 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 lt 1.0 mg/kg

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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

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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 7086
• Esmolol
• Szmuk. Anesth Analg 2000 901217

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Onset Time (sec) Increases with Advancing Age
Koscielniak-Nelson. Anesthesiology 1993 79229
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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

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Obesity in Older Men with BMI gt 29.2Flegal.
JAMA 2002 2881723
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Obesity in Older Women with BMI gt 29.2Flegal.
JAMA 2002 2881723
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Times to Reappearance of T1, T2, T3, T4 after
Vecuronium 0.1 mg/kg in Patients with Diabetes
MellitusSaito. Br J Anaesth 2003 90480
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Effect of Hypothermia on Time-to-25-Recovery
from Vecuronium 0.1 mg/kg Caldwell.
Anesthesiology 2000 92 84
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Rocuronium gt Vecuronium gt 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 gt rocuronium if renal
  insufficiency

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Transfusion Trigger for ElderlyHgb 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

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Minimum Diastolic PressurePauca 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

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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 lt GENERAL
• Real world , BP, HR not tightly controlled
• Included combined regional-general in regional
  group
• Rogers et al. Br Med J 20003211493

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Postoperative Considerations

• Postoperative Analgesia
• Postoperative Delirium

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Postoperative Titration of Intravenous Morphine
in Elderly Patients Abrun. Anesthesiology 2002
9617

• Bolus q 5 min to VAS 30 (max 100)
• 2 mg if lt60 kg 3 mg if gt 60 kg
• Total mg/kg dose young old
• Young (lt 70, mean 45) vs Old (gt 70, mean 76)
• Morbidity young old
• adverse opioid effects, sedation, stopped
  titrations

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Age is not an Impediment to Effective Use of PCA
Gagliese. Anesthesiology 2000 93601

• Initial Dose for Pain Relief
• young old
• Total Dose
• old lt young

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Postoperative Delirium in 5-50That Appears on
PODs 1-3Cook. Anesth Analg 2003 961823

• 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

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Ten Ways to Improve Anesthesia in Older Patients

1. H P gt Pre-op Testing gt 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

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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