Mode of anesthesia, mortality and outcome in geriatric patients

Patients risk for mortality at 90 days after proximal femur fracture - a retrospective study in a tertiary care hospital

BACKGROUND

Despite improving the management of proximal femur fractures (PFF) with legal requirements of timing the surgery within 24 h, mortality rates in these patients remain still high. The objective of our study was to analyze potential cofactors which might influence the mortality rate within 90 days after surgery in PFF to avoid adverse events, loss of quality of life and high rates of mortality.

METHODS

In this retrospective, single-center study all patients with PFF aged 65 years and older were included. We recorded gender, age, type of fracture, surgery and anesthesia, time, comorbidities and medication as well as complications and mortality rate at 90 days. Separate logistic regression models were used to assess which parameters were associated with patients' mortality. The mortality rate was neither associated with timing, time and type of surgery nor time and type of anesthesia, but with higher age (OR 1.08 per year; 95% CI 1.034-1.128), lower BMI (OR 0.915 per kg/m2; 95% CI 0.857-0.978), higher CCI (OR 1.170 per point; 95% CI 1.018-1.345), dementia (OR 2.805; 95% CI 1.616-4.869), non-surgical complications (OR 2.276; 95% CI 1.269-4.083) and if mobilization was impossible (OR 10.493; 95% CI 3.612-30.479).

RESULTS

We analyzed a total of 734 patients (age ≥ 65 years) who had a PFF in 2019 and 2020 and received surgery. 129 patients (17.6%) died until 90 days at an median age of 89.7 years (range 65-101 years).

CONCLUSION

The proportion of patients who died until 90 days after surgery is still high. It is less extend influenced by surgical and anaesthesiologic factors than by patient-related factors like age or lower BMI. Physicians should be aware of the importance of avoiding adverse events and the importance of patients' mobilization to reduce mortality and improve patients' outcome.

Orthogeriatric care-outcome of different fragility fractures

INTRODUCTION

Fragility fractures (FF) are associated with increased morbidity and mortality and reflect a dramatic turning point in the life of older adults. The scientific discourse is dominated by proximal femoral fractures, but FF affect multiple parts of the body and often precede hip fractures. Orthogeriatric co-management has multiple shown to improve patient's outcome. We hypothesize that all geriatric patients with FF benefit from orthogeriatric co-management.

MATERIALS AND METHODS

We retrospectively evaluated all patients over 70 years with FF (hip joint, periprosthetic, spine, pelvic ring, and humerus) of our geriatric trauma center for the years 2019-2021, who received orthogeriatric co-management. Demographic data, fracture type, complications, discharge modality and in-hospital mortality were recorded. For patients transferred to geriatrics, the Barthel Index (BI) and the discharge modality were recorded. Primary outcome parameters were discharge modality and BI difference. Secondary outcome parameters were complication rates and in-hospital mortality. Logistic regression analysis was performed.

RESULTS

555 patients (83.8 ± 6.5 years, 182 males, 373 females) were evaluated. 245 (44.1%) patients were referred to geriatrics for further orthogeriatric treatment. Positive predictors were age, surgery, and a high Charlson Comorbidity Index. The overall in-hospital mortality was 8.6% (n = 48) (5.8% (n = 32) during acute trauma care and 6.5% (n = 16) during stay in geriatrics). The mortality rate of nursing home residents was significantly higher compared to patients living at home (10.4% vs. 5.6%). The rate of non-surgical complications was 44.5%. 26.9% of patients living at home were discharged to a nursing home, while 51.3% were able to return home. The risk of admission to a nursing home was reduced for thoracolumbar fractures (OR = 0.22) and increased markedly for periprosthetic fractures (OR = 3.95). During orthogeriatric treatment, all fractures showed a significant increase in BI. Patients living at home benefited more than nursing home residents (20.5 ± 19.5 vs. 8.7 ± 18.0 points). The chance of a BI increase (> 19 points) was increased for hip and pelvic ring fractures. Devastating results showed patients with dementia. In comparison, mentally healthy patients had a 4.5-fold increased chance of increasing their BI (> 19 points).

CONCLUSIONS

Presented data shows that all patients with FF are at high risk for complications and could benefit from standardized orthogeriatric management. Modern patient care requires a holistic orthogeriatric approach to improve patient's outcome.

Goal-directed fluid therapy using uncalibrated pulse contour analysis and balanced crystalloid solutions during hip revision arthroplasty: a quality implementation project

BACKGROUND

To implement a goal-directed fluid therapy (GDFT) protocol using crystalloids in hip revision arthroplasty surgery within a quality management project at a tertiary hospital using a monocentric, prospective observational study.

METHODS

Adult patients scheduled for elective hip revision arthroplasty surgery were screened for inclusion in this prospective study. Intraoperatively stroke volume (SV) was optimized within a previously published protocol using uncalibrated pulse contour analysis and balanced crystalloids. Quality of perioperative GDFT was assessed by protocol adherence, SV increase as well as the rate of perioperative complications. Findings were then compared to two different historical groups of a former trial: one receiving GDFT with colloids (prospective colloid group) and one standard fluid therapy (retrospective control group) throughout surgery. Statistical analysis constitutes exploratory data analyses and results are expressed as median with 25th and 75th percentiles, absolute and relative frequencies, and complication rates are further given with 95% confidence intervals for proportions using the normal approximation without continuity correction.

RESULTS

Sixty-six patients underwent GDFT using balanced crystalloids and were compared to 130 patients with GDFT using balanced colloids and 130 controls without GDFT fluid resuscitation. There was a comparable increase in SV (crystalloids: 65 (54-74 ml; colloids: 67.5 (60-75.25 ml) and total volume infused (crystalloids: 2575 (2000-4210) ml; colloids: 2435 (1760-3480) ml; and controls: 2210 (1658-3000) ml). Overall perioperative complications rates were similar (42.4% (95%CI 30.3-55.2%) for crystalloids and 49.2% (95%CI 40.4-58.1%) for colloids and lower compared to controls: 66.9% (95%CI 58.1-74.9)). Interestingly, a reduced number of hemorrhagic complications was observed within crystalloids: 30% (95%CI 19.6-42.9); colloids: 43% (95%CI 34.4-52.0); and controls: 62% (95%CI 52.6-69.9). There were no differences in the rate of admission to the post-anesthesia care unit or intensive care unit as well as the length of stay.

CONCLUSIONS

Perioperative fluid management using a GDFT protocol with crystalloids in hip revision arthroplasty surgery was successfully implemented in daily clinical routine. Perioperative complications rates were reduced compared to a previous management without GDFT and comparable when using colloids.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01753050.

[Plastic-surgical reconstruction of the lower extremity in senior patients]

The proportion of patients in the population beyond the 7th decade of life is increasing worldwide, especially in highly developed countries. Consequently, there is also an increasing need for complex lower extremity reconstructions after trauma, tumors, or infections in this age group. The reconstruction of soft tissue defects of the lower extremity should be performed according to the principle of the plastic-reconstructive ladder or elevator. The goal of reconstruction is to restore anatomy and function of the lower extremity to enable pain-free and stable standing and walking; however, for older patients in particular, a careful preoperative multidisciplinary planning, detailed preoperative assessment and optimization of comorbidities, such as diabetes, malnutrition or pathological vascular alterations, as well an age-adapted perioperative management are necessary. By implementing these principles, older and very old patients can maintain their mobility and autonomy, which are crucial for a high quality of life.

Do Patients Aged 85 Years and above Benefit from Their Cochlear Implants?

The present study aims to investigate the usage and benefits of cochlear implants (CIs) in elderly patients aged ≥85 years, including their device-handling issues, follow-ups, and the influence on their well-being. The patients answered one questionnaire regarding quality of life, EQ5D-3L, and one questionnaire, obtained from the Swedish CI quality register, regarding usage, handling, satisfaction, remaining difficulties, etc. The medical records were searched for the implantation date, implant model, speech processor model, monosyllabic (MS) word scores, infections over the implant, and compliance regarding scheduled visits to the clinic. The results show that most elderly patients are satisfied full-time users of their implants. Even though most patients had no problems handling their CI, handling issues must be considered. Recurring guidance and training on device operation are needed. We suggest that follow-up visits are essentially needed for this group of patients on a regular basis. CI surgery is considered a safe treatment, even for the elderly. Upgrads to new external equipment (e.g., sound processors) should not be excluded because of their age. The results suggested that the CI positively affected their well-being. This study was approved by the Swedish Ethical Review Authority (5/10-2021, Dnr: 2021-04970).

The relationship between anesthetic technique and thirty-day mortality in patients undergoing noncardiac- and nonneurosurgery: A retrospective, propensity score-matched cohort study

BACKGROUND

Currently, 310 million patients undergo surgery every year worldwide, and there is still controversy over which anesthetic technique to choose for a considerable of surgeries.This study evaluates the association of the anesthetic technique with thirty-day mortality after noncardiac- and nonneurosurgery.

METHODS

Electronic medical records of 90,785 patients who underwent non-cardiac- and nonneurosurgery at the *** General Hospital from January 1, 2012 to October 31, 2016, were subject to secondary retrospective analysis. The principal exposure was regional versus general anesthesia. Outcome measures were death, intensive care unit (ICU) admission and blood transfusion requirement within 30 days after surgery. Propensity-score matching was used to assemble a cohort of patients with similar baseline characteristics.

RESULTS

We identified 90,785 patients, of whom 76,442 received regional anesthesia and 14,343 received general anesthesia. A total of 11,351 patients in the general anesthesia group had propensity scores similar to those of patients who received regional anesthesia and were included in the analyses. In the propensity-score matched cohort, the postoperative 30-day mortality rate was 0.75% (n = 85) in the regional anesthesia group (Odds Ratio, 0.567; 95% CI, 0.434 to 0.741; P = 0.00003) compared with 1.31% (n = 149) in the general anesthesia group. Regional anesthesia was also associated with a reduced rate of ICU admission compared with that of patients who received general anesthesia (0.44% vs. 2.68%; OR, 0.161; 95% CI, 0.119 to 0.217, P < 0.00001). There was a nonsignificant relationship between the anesthetic technique and postoperative blood transfusion (P = 0.082).

CONCLUSIONS

The results of this observational, propensity score-matched cohort study suggest a significant association between regional anesthesia and low thirty-day mortality and a worse postoperative prognosis in patients who underwent noncardiac- and nonneurosurgery, which provides information for anesthetic technique decision making in the clinical setting.

Association of Neuraxial Anesthesia With Postoperative Venous Thromboembolism After Noncardiac Surgery: A Propensity-Matched Analysis of ACS-NSQIP Database

BACKGROUND

Neuraxial anesthesia improves components of the Virchow's triad (hypercoagulability, venous stasis, and endothelial injury) which are key pathogenic contributors to venous thrombosis in surgical patients. However, whether neuraxial anesthesia reduces the incidence of venous thromboembolism (VTE) remain unclear. We therefore tested the primary hypothesis that neuraxial anesthesia reduces the incidence of 30-day VTE in adults recovering from orthopedic surgery. Secondarily, we tested the hypotheses that neuraxial anesthesia reduces 30-day readmission, 30-day mortality, and the duration of postoperative hospitalization.

METHODS

Inpatient orthopedic surgeries from American College of Surgeons National Surgical Quality Improvement Program database (2011-2015) in adults lasting more than 1 hour with either neuraxial or general anesthesia were included. Groups were matched 1:1 by propensity score matching for appropriate confounders. Logistic regression model was used to assess the effect of neuraxial anesthesia on 30-day VTE, 30-day mortality, and readmission, while Cox proportional hazard regression model was used to assess its effect on length of stay.

RESULTS

Neuraxial anesthesia decreased odds of 30-day VTE (odds ratio 0.85, 95% confidence interval, 0.78-0.95; P = .002) corresponding to number-needed-to-treat of 500. Although there was no difference in 30-day mortality, neuraxial anesthesia reduced 30-day readmission (odds ratio 0.90, 98.3% confidence interval, 0.85-0.95; P < .001) corresponding to number-needed-to-treat of 250 and had a shortened hospitalization (2.87 vs 3.11; P < .001).

CONCLUSIONS

Neuraxial anesthesia appears to provide only weak VTE prophylaxis, but can be offered as an adjuvant to current thromboprophylaxis in high-risk patients.

Anesthetic management of geriatric patients

The number of elderly patients who frequently access health care services is increasing worldwide. While anesthesiologists are developing the expertise to care for these elderly patients, areas of concern remain. We conducted a comprehensive search of major international databases (PubMed, Embase, and Cochrane) and a Korean database (KoreaMed) to review preoperative considerations, intraoperative management, and postoperative problems when anesthetizing elderly patients. Preoperative preparation of elderly patients included functional assessment to identify preexisting cognitive impairment or cardiopulmonary reserve, depression, frailty, nutrition, polypharmacy, and anticoagulation issues. Intraoperative management included anesthetic mode and pharmacology, monitoring, intravenous fluid or transfusion management, lung-protective ventilation, and prevention of hypothermia. Postoperative checklists included perioperative analgesia, postoperative delirium and cognitive dysfunction, and other complications. A higher level of perioperative care was required for older surgical patients, as multiple chronic diseases often makes them prone to developing postoperative complications, including functional decline and loss of independence. Although the guiding evidence remains poor so far, elderly patients have to be provided optimal perioperative care through close interdisciplinary, interprofessional, and cross-sectional collaboration to minimize unwanted postoperative outcomes. Furthermore, along with adequate anesthetic care, well-planned postoperative care should begin immediately after surgery and extend until discharge.

Fascia Iliaca Block as an Anesthetic Technique for: Acute Lower Limb Ischemia

Purpose

The purpose of this study is to evaluate the efficacy of preoperative fascia iliaca block (FIB) as a sole anesthetic technique in transfemoral thromboembolectomy of unilateral acute lower limb ischemia compared to unilateral spinal anesthesia (SA) as a primary outcome. Hemodynamic variation, postoperative pain score, and the first demand for analgesia with the total postoperative analgesic required in the 1^st postoperative day were considered as the secondary outcome.

Patients and Methods

This prospective randomized controlled study included two groups of patients aged between 40 and 70 years, who underwent transfemoral thrombectomy for acute unilateral lower limb ischemia. Patients in the spinal group (SA) (n = 56): underwent unilateral SA using 10 mg bupivacaine 0.5% and patients in the group FIB (n = 56): received FIB with 30 mL of 0.25% bupivacaine. Sensory block was evaluated over the incisional area with 3-point scale. If the sensory block did not reach zero grade after 30 min, the patient received general anesthesia.

Results

The incidence of the successful block was 100% in the SA group compared to 80.35% in the FIB group. There was a significant decrease in recorded heart rate and mean blood pressure within the SA group at 3, 10, and 20 min and 3, 20, and 45 min, respectively. Values of visual analog scale decreased significantly in SA group compared to that of the FIB group immediately and 1 h postoperative. However, the time for the first postoperative analgesic requirement and morphine consumption was comparable between the groups.

Conclusion

Preoperative FIB could be considered as a promising alternative anesthetic technique to SA with better hemodynamic parameters in patients undergoing transfemoral thrombectomy for acute lower limb ischemia. It could be also due to limited precautions considered the first choice over SA for patients on perioperative anticoagulants.

Postoperative intensive care unit admission does not affect outcomes in elective surgical patients with severe comorbidity

OBJECTIVE

The impact of postoperative intensive care upon patient outcomes was evaluated by retrospectively investigating the rate of poor outcomes among miscellaneous elective surgical patients with severe comorbidities.

DESIGN

A retrospective cohort study was carried out.

SETTING

University hospital.

PATIENTS

Surgical patients with severe comorbidities.

INTERVENTION

The outcomes of 1218 surgical patients treated in intensive care units (ICUs) and postsurgical wards (ICU group vs. non-ICU group) were reviewed for poor outcomes (i.e., no discharge or death). A propensity score analysis was used to generate 248 matched pairs of ICU-admitted patients and controls.

VARIABLES OF INTEREST

Poor outcome rates on postoperative day 90 and mortality on postoperative days 30 and 90.

RESULTS

No significant between-group differences were observed in terms of poor outcomes on postoperative day 90 [ICU vs. non-ICU: 33/248 (13%) vs. 28/248 (11%), respectively; ICU odds ratio (OR): 1.19, 95% confidence interval (CI), 0.71-2.01, p=0.596] or in between-group differences in terms of mortality on postoperative days 30 and 90 [ICU vs. non-ICU: 4/248 (1.6%) vs. 2/248 (0.8%) on postoperative day 30 and 5/248 (2.0%) vs. 3/248 (1.2%) on day 90, respectively; ICU OR (95% CI), 2.00 (0.37-10.9) and 1.67 (0.40-6.97) for postoperative 30- and 90-day mortality, respectively (p=0.683 and 0.724)]. Low preoperative body weight was negatively correlated to patient outcomes [OR (95% CI): 0.82/10kg (0.70-0.97), p=0.019], whereas regional analgesia combined with general anesthesia was positively correlated to patient outcomes [OR (95% CI): 0.39 (0.69-0.96), p=0.006]. Extra ICU admission was correlated to poor patient outcomes [OR (95% CI): 4.18 (2.23-7.81), p < 0.0001].

CONCLUSIONS

Postoperative ICU admission failed to demonstrate any meaningful benefits in patients with severe comorbidities undergoing miscellaneous elective surgeries.

Effect of anaesthesia type on postoperative mortality and morbidities: a matched analysis of the NSQIP database

BACKGROUND

The anaesthetic technique may influence clinical outcomes, but inherent confounding and small effect sizes makes this challenging to study. We hypothesized that regional anaesthesia (RA) is associated with higher survival and fewer postoperative organ dysfunctions when compared with general anaesthesia (GA).

METHODS

We matched surgical procedures and type of anaesthesia using the US National Surgical Quality Improvement database, in which 264,421 received GA and 64,119 received RA. Procedures were matched according to Current Procedural Terminology (CPT) and ASA physical status classification. Our primary outcome was 30-day postoperative mortality and secondary outcomes were hospital length of stay, and postoperative organ system dysfunction. After matching, multiple regression analysis was used to examine associations between anaesthetic type and outcomes, adjusting for covariates.

RESULTS

After matching and adjusting for covariates, type of anaesthesia did not significantly impact 30-day mortality. RA was significantly associated with increased likelihood of early discharge (HR 1.09; P< 0.001), 47% lower odds of intraoperative complications, and 24% lower odds of respiratory complications. RA was also associated with 16% lower odds of developing deep vein thrombosis and 15% lower odds of developing any one postoperative complication (OR 0.85; P < 0.001). There was no evidence of an effect of anaesthesia technique on postoperative MI, stroke, renal complications, pulmonary embolism or peripheral nerve injury.

CONCLUSIONS

After adjusting for clinical and patient characteristic confounders, RA was associated with significantly lower odds of several postoperative complications, decreased hospital length of stay, but not mortality when compared with GA.

The Fascia Iliaca Block as the Primary Intraoperative Anesthesia for Hip Fracture Surgery: A Preliminary Study

BACKGROUND

Early surgical intervention for hip fractures in the elderly has proven efficacious. However, surgical delays commonly occur in this patient population due to comorbid conditions that put these patients at a high risk for hypotension-related complications of general or neuraxial anesthesia or anticoagulants that delay the safe use of neuraxial anesthesia.

QUESTIONS/PURPOSES

The questions/purposes of this study are (1) to investigate if a fascia iliaca block in conjunction with light to moderate sedation could provide adequate analgesia throughout open surgery for intertrochanteric hip fractures (AO/OTA 31-1) without requiring conversion to general anesthesia with airway support and (2) to assess its perioperative complication profile.

METHODS

A retrospective chart review was conducted to identify patients with intertrochanteric hip fractures who underwent anesthesia with a fascia iliaca block over a 1.5-year period.

RESULTS

In the six patients identified, there were no intraoperative conversions to general anesthesia requiring airway support. Additionally, there were no intraoperative complications, no mortalities within 30 days, 2 patients on anticoagulation who required a blood transfusion, and a single patient who developed a postoperative hospital-acquired pneumonia that resolved with an antibiotic course.

CONCLUSIONS

In this series of patients, we demonstrate that a fascia iliaca block can reliably be utilized as the primary anesthetic for patients undergoing surgical fixation of intertrochanteric hip fractures, with an acceptable perioperative complication profile. Although concomitant sedation was provided with the block, this anesthesia strategy has the potential to reduce preoperative delays and minimize the overall burden of sedative and anesthetic medications in a geriatric population. These initial findings may serve as a basis for future, higher-quality prospective and comparative studies.

Leading Comorbidity associated with 30-day post-anesthetic mortality in geriatric surgical patients in Taiwan: a retrospective study from the health insurance data

Background

Elderly patients with aged physical status and increased underlying disease suffered from more postoperative complication and mortality. We design this retrospective cohort study to investigate the relationship between existing comorbidity of elder patients and 30 day post-anesthetic mortality by using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) from Health Insurance Database.

Methods

Patients aged above 65 years old who received anesthesia between 2000 and 2010 were included from 1 million Longitudinal Health Insurance Database in (LHID) 2005 in Taiwan. We use age, sex, type of surgery to calculate propensity score and match death group and survival one with 1:4 ratio (death: survival = 1401: 5823). Multivariate logistic model with stepwise variable selection was employed to investigate the factors affecting death 30 days after anesthesia.

Results

Thirty seven comorbidities can independently predict the post-anesthetic mortality. In our study, the leading comorbidities predict post-anesthetic mortality is chronic renal disease (OR = 2.806), acute myocardial infarction (OR = 4.58), and intracranial hemorrhage (OR = 3.758).

Conclusions

In this study, we present the leading comorbidity contributing to the postoperative mortality in elderly patients in Taiwan from National Health Insurance Database. Chronic renal failure is the leading contributing comorbidity of 30 days mortality after anesthesia in Taiwan which can be explained by the great number of hemodialysis and prolong life span under National Taiwan Health Insurance. Large scale database can offer enormous information which can help to improve quality of medical care.

Electronic supplementary material

The online version of this article (10.1186/s12877-017-0629-7) contains supplementary material, which is available to authorized users.

[Anesthesiological care of trauma patients in orthogeriatric co-management]

Elderly patients increasingly need to undergo surgery under anesthesia, especially following trauma. A timely interdisciplinary approach to the perioperative management of these patients is decisive for the long-term outcome. Orthogeriatric co-management, which includes geriatricians and anesthesiologists from an early stage, is of great benefit for geriatric patients. Patient age, comorbidities and self-sufficiency in activities of daily life are decisive for an anesthesiological assessment of the state of health and preoperative risk stratification. If necessary additional investigations, such as echocardiography must be carried out, in order to guarantee optimal perioperative anesthesiological management. Certain medical factors can delay the initiation of anesthesia and it is absolutely necessary that these are taken into consideration for surgical management. Not every form of anesthesia is equally suitable for every geriatric patient.

Multimodal analgesia and regional anaesthesia

Multimodal analgesia provides quality analgesia, with fewer side effects due to the use of combined analgesics or analgesic techniques. Regional anaesthesia plays a fundamental role in achieving this goal. The different techniques of regional anaesthesia that include both peripheral and central blocks in either a single dose or in continuous infusion help to modulate the nociceptive stimuli that access the central level. The emergence of the ultrasound as an effective system to perform regional anaesthesia techniques has allowed the development of new regional anaesthesia techniques that formerly could not be carried out since only neurostimulation or skin references were used. It is essential to take into account that even with effective blocking it is advisable to associate other drugs by other routes, in this way we will be able to reduce the required doses individually and attempt to achieve a synergistic, not purely additive, effect.

[Anesthesiological care in orthogeriatric co-management. Perioperative treatment of geriatric trauma patients]

Elderly patients increasingly need to undergo surgery under anesthesia, especially following trauma. A timely interdisciplinary approach to the perioperative management of these patients is decisive for the long-term outcome. Orthogeriatric co-management, which includes geriatricians and anesthesiologists from an early stage, is of great benefit for geriatric patients. Patient age, comorbidities and self-sufficiency in activities of daily life are decisive for an anesthesiological assessment of the state of health and preoperative risk stratification. If necessary additional investigations, such as echocardiography must be carried out, in order to guarantee optimal perioperative anesthesiological management. Certain medical factors can delay the initiation of anesthesia and it is absolutely necessary that these are taken into consideration for surgical management. Not every form of anesthesia is equally suitable for every geriatric patient.

[Proximal femoral fractures in the elderly]

Proximal femoral fractures represent an increasing major healthcare problem due to the demographic changes in this aging population and are associated with the highest mortality among fractures in elderly patients after suffering insufficiency injuries (so-called fragility fractures). The main aim in the treatment of orthogeriatric patients who suffered from a proximal femoral fracture is the preservation of function and independency. Given the high prevalence of comorbidities in these patients, interdisciplinary and interprofessional approaches are required. The use of modern osteosynthesis procedures can provide an improved, individualized surgical treatment with early full weight bearing of the affected extremity. Another aspect is the accompanying geriatric treatment which is associated with a significant reduction of perioperative and postoperative complications. In addition to acute treatment, the organization of secondary fracture prevention is a crucial pillar of treatment. This article provides an overview of the essential elements of orthogeriatric trauma surgery in elderly patients following proximal femoral fractures.

Anesthetic Considerations for Common Procedures in Geriatric Patients: Hip Fracture, Emergency General Surgery, and Transcatheter Aortic Valve Replacement

The elderly population is growing. Geriatric patients undergo a large proportion of surgical procedures and have increased complications, morbidity, and mortality, which may be associated with increased intensive care unit time, length of stay, hospital readmission, and cost. Identification of optimal anesthetic care for these patients, leading to decreased complications and contributing to best possible outcomes, will have great value. This article reviews the anesthetic considerations for intraoperative care of geriatric patients and focus on 3 procedures (hip fractures, emergency abdominal surgery, and transcatheter aortic valve replacement). An approach to evaluation and management of the elderly surgical patient is described.

A rare case of delayed subarachnoid anesthetic blockade effects in a 103-year-old female patient

Background:

The elderly represent a unique challenge for the effects of regional anesthesia, and very few cases of block onset delay have been described. Their delayed response is attributed to a number of factors that include: Physiologic deterioration, musculoskeletal contractures, degenerative joint disease, autonomic regulatory dysfunction, cognitive dysfunction, altered pharmacokinetics, and pharmacodynamics of local anesthetics and adjuvants.

Case Description:

In this report we present the rare case of 45-min delay between the administration and onset of action of a subarachnoid blockade in a 103-year-old female, who was scheduled for left hip pinning, for repair of a femoral neck fracture. Patient received an injection of hyperbaric bupivacaine, 1.5 ml of 0.75% (11.25 mg), with 15 mcg of fentanyl into the subarachnoidal space and underwent the surgical procedure without complications.

Conclusions:

Delayed responses to subarachnoid anesthesia can be expected in extremely elderly patients. Anesthetic procedures should be monitored and managed on a case-by-case basis.

The effect of aging on pulmonary function: implications for monitoring and support of the surgical and trauma patient

Age-related anatomic, physiologic, and immunologic changes to the pulmonary system, as well as a high prevalence of chronic pulmonary diseases, puts the geriatric patient at an especially high risk for postoperative pulmonary complications. Successful perioperative respiratory care of the geriatric patient relies on careful risk assessment and optimization of pulmonary function and support. The success of such efforts aimed at preventing and/or mitigating pulmonary complications in the geriatric patient depends on a thorough, individualized, yet standardized and evidence-based approach to the care of every patient.