Transcript No Slide Title

Sheila Ryan Barnett, MD
Associate Professor of Anesthesiology
Harvard Medical School
Beth Israel Deaconess Medical Center
Boston, MA
> 65y
Population
USA
>85 y
year
surgeries per
 60%
of patients of
general surgeons > 65y
 Growth
in specialty
surgery expected: 3547%
Surgery per 100 00
procedures
 16,000,000
Frequency of 12 common
procedures
800
700
600
500
400
300
200
100
0
<15 y
15-44 y 45-64 y >65 y
US 1999 – 2005
Li et al Anesthesiology 2009; 110: 698-9
 Aging
& comorbidities
 Medications – modifications
 Medications – to avoid
 Risk reduction
 Inevitability
Aging involves physiological changes
AND
The pathophysiology of superimposed
disease
Steady Age-related Decline
in Organ Function
DISABILITIES COMMON
> 80y
What is your elderly patient’s
functional reserve?
Goal of the
preanesthetic
assessment
Minor complications poorly tolerated

Vascular stiffening, HTN, loss elasticity

Ventricular
• Increased impedance - wall hypertrophy
• decreased compliance, atrial dependence

Conduction issues:
• Decline in pacemaker cells, increase in atrial ectopy, &
conduction defects

Reduction in maximal HR –
• reduced response to catecholamines

Increased ischemic heart disease
Diastolic E/A : deceleration time / 250 pts /72 y
Diastolic
Function
Classification
%
Normal
Mild to
Moderate
37%
57.9%
Moderate
Severe
3.9%
1.7%
LVEF
54%
54.5%
61.5%
54%
43%
Philip Anesth Analg 2003 ; 97 1214-21

Thorax stiffens:
• reduced chest wall compliance & decreased thoracic
skeletal muscle mass = Increased work of maximal
breathing






Lung volumes change – reduced reserve volume
Decrease in elastic lung recoil – closing volume
increase
More V/Q mismatch & greater P(A-a) O2 gradient
Reduction in hypoxic and hypercarbic drive
Increased narcotic-induced apnea
Decreased pharyngeal reflexes - ? More aspiration
At age 80 paO2 is
about 58 mmHg !
Close to the edge at the start !
•
•
•
Case controlled study of Spinal surgery
patients
Compared patients with & without
Surgical Site Infection (SSI)
Independent risk factors:
– Long surgery OR 4.7 p<0.001
– ASA 3 + OR 9.7 p< 0.001
– Obesity 4.0 p<0.01
– Intraoperative oxygen <50% OR 12 p <0.001
•
Potential impact for elderly ?
Maragakis Anesth 2009; 110:556-62
 Cortical
grey matter attrition –
• starts in middle age
 Cerebral
atrophy – disease vs. aging
 Increased
intracranial CSF
 CBF
and auto regulation largely
maintained
 Postoperative
cognitive dysfunction
1.
2.
3.
4.
Appreciate reduction in reserve
function
Understand age related organ changes
and the impact of common disease
Beware of ‘under-diagnosis’ e.g. DHF &
fluids
Provide supplemental extra oxygen,
(increased risk hypoxemia)
 Dose
reduction
• Pharmacokinetic
• Pharmacodynamic
 Interval
extension
Anesthesiology 2009; 110:1050-1060
What Dose?
Dose response
curve flattened in
the elderly patient
25 -50% reduction
JR Jacobs et al Anesth Analg 1995; 80:143
 50%
reduction in initial doses for fentanyl
 Significant decrease in
pharmacodynamic response
 All
opioids increased risk apnea &
hypercapnia
Increased & delayed hemodynamic impact leading to
hypotension
Anesthesiology 2009; 110:1050-1060
 “Start
low, go slow”
 Benzodiazepines
• Low dosing with Midazolam to start
 Opioids
• Beware respiratory depression
• Titrate to effect
 Reduce
inhalation agent
 Complete reversal of muscle relaxants
•
Anticholinergic side effects
– Central: Falls, delirium, cognitive dysfunction
– Peripheral : Dry mouth, constipation, confusion
• Anticholinergic Risk Scale
– List of drugs with varying anticholinergic properties
– Avoid or limit use if possible
•
Beers Criteria
– Long acting Benzodiazepines
– Multiple medications , many with anticholinergic
properties
•
High risk 3 points
– Atropine products
– Hydroxyzine (Atarax or Visteril)
– Diphenyhydramine (Benadryl)
– Promethazine (Phenergan)
•
Intermediate 2 points
– Prochlorperazine (Compazine)
•
Low 1 point
– Haloperidol
– Metoclopramide ( Reglan)
Rudolph Arch Int Med 2008; 168:508-13
 Active metabolites normeperidine
• Renal excretion
• T ½ 14-21 hrs in elderly up to 30 hrs with CRI
 Causes myoclonus, twitching and
seizures
 Associated with delirium in elderly
 Not recommended: use of meperidine in
patients 75 yrs or older for analgesia is
considered indicator of poor care by the
Assessing Care of vulnerable elderly.
•
Survey of 3000 community dwelling 57-85 y
– 81% minimum of 1 prescription drug (PD)
– 49% used dietary supplements
– 29% used at least 5 PDs
•
•
•
Among PD users 46% also used over the
counter drugs
4% at risk of major drug interaction, half
with non prescription drugs
Anti-coagulants most commonly involved
Unknown true impact on the
perianesthetic course
Qato JAMA 2008; 300 (24) 2876
1.
Avoid meperidine, long acting muscle
relaxants & benzo’s and anticholinergic
2.
Look for Polypharmacy
 Timing
of surgery
 Comprehensive preoperative
assessments
 Beta Blockade … again
 Meta-analysis
of >250,000 hip fx pts
 Mortality at 30 days and 1 year
 When
delayed over 48 hours
• 41% increase 30 d mortality
• 32% all cause mortality
How practical is this?
Shiga et al Can J Anesth 2008; 55:3; 146-154
 120 patients
 CGA
>60 y
• ADLs, IADLs (Barhtel Index) , comorbidity,
nutrition, MMSE
 All
undergoing thoracic surgery
 17%
post op complications
 Predictors
–
• Low Barthel Index
• Surgery >300 mins
• Dementia – low MMSE
Fukuse Chest 2005; 127:886
 400
patients > 70 y
 Admitted to Intervention Ward
• Assessment, prevention treatment education
 Assessment
day 1,3,7
 Delirious patients in the Intervention ward
• Shorter duration: by day 7 30% vs 60% (p 0.001 )
• Shorter LOS: 9 vs 13 days (p 0.001)
• Reduced mortality: 2 vs. 9 patients died (p 0.03)
Lundstrom et al JAGS 2005:53:622
Mangano NEJM 1996;335:1713
•
•
100/200 patients received Atenolol
preop and for 7 days
Atenolol group improved survival 6
months & up to 2 y. Diabetes major
risk
But later data mixed results with
increased stroke and mortality
•
•
Observational study
5158 THR/THR patients
– 19% Beta blockers
• BB for 7 days (740)
• BB DOS & d/c’ed (252) 25%
– No BB (4166)
•
Total 1.5% (77) had POMI
• BB continued -22 POMI; 7 deaths
• BB discontinued -20 POMI; 19 deaths
• No BB – 35 POMI; 28 deaths
•
•
Event rate 3% BB vs. 7.9% for d/c’ed BB
In those discontinued beta blockers 2 fold increase in POMI
and death ( OR 2.0)
Van Klei et al Anesthesiology 2009; 111:117-24
60
50
45,370 patients
eligible for beta
blockade
40
30
20
10
0
65
75
80
85
90
>9
70
-6
5
-7
79
84
89
94
9
4
Vitagliano et al. JAGS 2004: 52:495
1.
2.
3.
4.
Careful preoperative assessment is a
priority
Get to the OR in a timely manner
Risk reduction medication – possible
beta blockers
Role of blood transfusions (not
discussed)
Unanticipated day of surgery deaths
– > 800 000 patients NSQIP - Death rate 0.08%
– Older age 60 vs. 67y and males P<0.0001
•
Complications increased death rate
•
PACU/ICU transfer most unstable
•
Opportunity to improve in 31% (chart
review )
Improvement: hypovolemia, MI and
transport period
•
Bishop Anesth Analg 2008 107: 1924-35
 Veterans
Hospital Data
• 26 648 > 80 y
• 568 263 < 80 y
 30
day mortality 8% vs. 3%, p<0.001
 <2% if > 80y undergoing simple procedures
• TURP, IH, TKR, CEA
 20%
had complications in > 80y
 Once a complication – 26% vs 4% mortality
Hamel et al JAGS 2005; 53:424
 Cardiac
events post non cardiac surgery
 7700 patients, 83 (1%) Cardiac event
 9 independent predictors
 In patients experiencing a cardiac event,
intraoperative data more likely to show
episode of hypotension +/- tachycardia
Kheterpal et al Anesthesiology 2009; 110:58-66
 Avoid
complications
 Hemodynamics
Surgical mortality
Surgical morbidity
Turrentine et al J Am Coll Surg 2006; 203:865
 300
unselected hip fractures
 All received similar multimodal
anesthesia & defined rehabilitation
 Outcomes:
• 30 d mortality 13%
• >30d 7 more died
 Combined
mortality 16%
Foss & Kehlet Br J Anaesth 2005; 94: 24-29
 47
deaths
• 28% (13) unavoidable, terminal cancer or
refused care
• 15% (7) probably unavoidable
• 34% (16) potentially avoidable ; active care
curtailed
• 23% (11) received maximal care ?
Potentially avoidable
Best outcomes if:
Avoid complications
Preoperative optimization
OR without delay (when feasible)
? Beta blockers / transfusions
Age appropriate drug dosing
Postoperative: pain meds, oxygen