Anesthesia for the elderly: selected topics

Anesthesia care in the interventional neuroradiology suite: an update

PURPOSE OF REVIEW

The scope of procedures conducted by neurointerventionalists is expanding quickly, with lacking consensus over the best anesthesia modality. Although the procedures involve all age groups, the interventions may be complex and lengthy and may be provided in hospitals currently not yet familiar with the field. Here we review current literature addressing elective outpatient neurointerventional procedures and aim to provide an update on the management of intervention-specific crises, address special patient populations, and provide key learning points for everyday use in the neurointerventional radiology suite.

RECENT FINDINGS

Various studies have compared the use of different anesthesia modalities and preinterventional and postinterventional care. Monitored anesthesia care is generally recommended for elderly patients, whereas children are preferably treated with general anesthesia. Additional local anesthesia is beneficial for procedures, such as percutaneous kyphoplasty and vascular access.

SUMMARY

Combining different anesthetic modalities is a valuable approach in the neurointerventional radiology suite. More interventional and patient population-specific studies are needed to improve evidence-based perioperative management.

Therapeutic and tectonic keratoplasty with simple cryopreserved remnants of donor corneas: an 11 year retrospective case series

This study sought to describe the use of deep-frozen donor corneal remnants preserved after keratoplasty procedures for therapeutic or tectonic keratoplasty without subsequent optical keratoplasty. This single-center retrospective consecutive case series analyzed the electronic medical records of patients who had undergone therapeutic or tectonic keratoplasty using deep-frozen donor remains preserved in Optisol-GS, for the past 11 years at Keimyung University Dongsan Medical Center. Fifty-five surgical cases in 46 patients were included. Twenty-three surgical cases in 18 patients underwent therapeutic keratoplasty for refractory infectious corneal ulcer. Complete eradication of primary infection was achieved in 14 patients (77.8%). Tectonic keratoplasty were performed 32 cases in 28 patients. Twenty-seven of 28 patients were ultimately able to maintain anatomical integrity (96.4%). Mean uncorrected visual acuity improved from 1.77 ± 0.94 preoperatively to 1.31 ± 0.95 at the last follow-up postoperatively in the tectonic graft group by logarithm of the minimal angle of resolution (P = 0.002). There were no cases of graft rejection. Keratoplasty using cryopreserved donor tissue is a suitable surgical alternative for infectious or non-infectious corneal ulcers in elderly patients or patients with poor general condition. It could be a viable alternative to overcome the shortage of corneal donors.

Differences in Outcomes After Anesthesia-Related Adverse Events in Older and Younger Patients

Because more older adults undergo surgical procedures, it is incumbent on us to learn how to provide them with the safest possible perioperative care. We conducted a retrospective cohort study at a large tertiary care center to determine whether outcomes after anesthesia-related adverse events differed between patients aged 65 years and older versus patients under age 65. One thousand four hundred twenty-four cases were referred to the Performance Improvement committee of the Department of Anesthesiology from the years 2007-2015. After exclusions of cases that were not anesthesia-related, could not be identified, or were duplicates, 747 cases with anesthesia-related adverse events were included in the study. Two hundred eighty-six were aged 65 years and older and 461 were under age 65. Anesthesia-related adverse events occurred more commonly in the postoperative period in older patients relative to younger patients (37.7% vs. 21.9%, p = .001), and older patients had a greater incidence of mortality compared with a propensity-matched group of younger patients (adjusted odds ratio 1.87 [1.14-3.12], p < .05). We concluded that older patients have a greater likelihood of mortality as a result of suffering an anesthesia-related adverse event and may benefit from increased vigilance in the postoperative period.

Predictive Factors of Postoperative Blood Pressure Abnormalities Following a Minor-to-Moderate Surgery

Myocardial ischemic events after non-cardiac surgery is still a serious problem, especially in older, high-risk patients. However, the prevalence and risk factors of blood pressure (BP) abnormalities, which may possibly lead to myocardial ischemic attack, have not been reported. Our aim is to elucidate predictive factors of postoperative BP abnormalities following a minor-to-moderate surgery, employing preoperative left ventricular diastolic function. Patients who underwent cardiac echocardiogram examination and received oral and maxillofacial surgery under general anesthesia were enrolled. The echocardiographic parameters of diastolic function were compared between patients who had postoperative BP abnormalities (hypertension-systolic blood pressure [SBP] ≥ 170 mmHg-or hypotension-SBP < 80 mmHg-episode) that required therapeutic interventions until 7 days after surgery and those who had no BP abnormalities. Of the 173 patients analyzed, 25 (14.4%) had BP abnormalities. BP abnormalities patients were older, having a larger proportion of diabetes mellitus, lower E/A ratio and e', and larger E/e' and left atrial dimension than those without BP abnormalities. Subanalyses revealed that the independent risk factors responsible for hypertension episodes (14 patients) were the mean e' (odd ratio [OR]: 0.434; 95% confidence interval [CI]: 0.229-0.824), diabetes mellitus (OR: 5.018; 95% CI: 1.030-24.436), SBP at hospitalization (OR: 1.099; 95% CI: 1.036-1.165), and operation time (hour; OR: 1.326; 95%CI: 1.109-1.586), while hypotension episodes (11 patients) were associated solely with operation time (OR: 1.206; 95% CI: 1.046-1.391). In conclusion, left ventricular diastolic dysfunction, increased insulin resistance, boosted SBP at hospitalization, and prolonged operation should be taken into consideration as risk factors of postoperative BP abnormalities, especially hypertension, following minor-to-moderate surgery.

Perioperative care in elderly cardiac surgery patients

Introduction

Surgery is an extreme physiological stress for the elderly. Aging is inevitably associated with irreversible and progressive cellular degeneration. Patients above 75 years of age are characterized by impaired responses to operative stress and a very narrow safety margin.

Aim

To evaluate perioperative complications in patients aged ≥ 75 years who underwent cardiac surgery in comparison to outcomes in younger patients.

Material and methods

The study was conducted at the Silesian Centre for Heart Diseases in Zabrze in 2009–2014 after a standard of perioperative care in seniors was implemented to reduce complications, in particular to decrease the duration of mechanical ventilation and reduce postoperative delirium. The study group included 1446 patients.

Results

The mean duration of mechanical ventilation was 13.8 h in patients aged ≥ 75 years and did not differ significantly compared to younger patients. In-hospital mortality among seniors was 3.8%, a value significantly higher than that observed among patients younger than 75 years of age. Patients aged ≥ 75 years undergoing cardiac surgery have significantly more concomitant conditions involving other organs, which affects treatment outcomes (duration of hospital stay, mortality).

Conclusions

The implementation of a standard of perioperative care in this age group reduced the duration of mechanical ventilation and lowered the rate of postoperative delirium.

[Rehabilitation after hip and knee endoprosthetic treatment in the elderly]

Due to current demographic developments with a continuous increase in average life expectancy and improved medical treatment, the number of elderly patients with joint replacement of the lower extremities also has increased in recent years. Most of these patients have not only one but several chronic diseases requiring treatment and medication. Drug-drug interaction and functional restrictions of the elderly additionally reduce the postoperative psychophysical capacity; therefore, special knowledge in rehabilitative treatment and pain management is necessary. Physiotherapy and exercise should include training of mobility, endurance, strength, coordination and training in activities of daily living. The individual constitution and pain during exercise must always be taken into consideration. Rehabilitative outcome is dependent on a functioning cooperation of an interdisciplinary rehabilitation team and requires an organized, holistic treatment approach in interconnected structures, which aims at rapid postoperative mobilization.

Anaesthetic perioperative management of patients with pancreatic cancer

Pancreatic cancer remains a significant and unresolved therapeutic challenge. Currently, the only curative treatment for pancreatic cancer is surgical resection. Pancreatic surgery represents a technically demanding major abdominal procedure that can occasionally lead to a number of pathophysiological alterations resulting in increased morbidity and mortality. Systemic, rather than surgical complications, cause the majority of deaths. Because patients are increasingly referred to surgery with at advanced ages and because pancreatic surgery is extremely complex, anaesthesiologists and surgeons play a crucial role in preoperative evaluations and diagnoses for surgical intervention. The anaesthetist plays a key role in perioperative management and can significantly influence patient outcome. To optimise overall care, patients should be appropriately referred to tertiary centres, where multidisciplinary teams (surgical, medical, radiation oncologists, gastroenterologists, interventional radiologists and anaesthetists) work together and where close cooperation between surgeons and anaesthesiologists promotes the safe performance of major gastrointestinal surgeries with acceptable morbidity and mortality rates. In this review, we sought to provide simple daily recommendations to the clinicians who manage pancreatic surgery patients to make their work easier and suggest a joint approach between surgeons and anaesthesiologists in daily decision making.

Outcome in patients with long-term treatment in a surgical intensive care unit

BACKGROUND

This study aimed to evaluate the outcome of patients with abdominal, thoracic or vascular operations and long-term intensive care unit (ICU) treatment.

PATIENTS AND METHODS

The present retrospective observational cohort study was performed at the authors' surgical ICU at the Marburg University Medical Centre. All patients who stayed at the ICU longer than 48 h and underwent visceral, thoracic or vascular surgery between January 2005 and December 2006 were retrospectively analysed. Patients with an ICU stay of 20 or more days were defined as the long-term study group. Clinical variables were tested for prognostic value.

RESULTS

In 2 years, 852 patients were treated at the intensive care unit. Follow-up was available in 502 patients, with 219 patients treated for two and more days and a median of 16.4 days. Sixty-seven long-term patients were compared to 152 (69.4 %) patients treated between 2 and 20 days. Overall survival after 12 months was 50.2 % (110/219), while 65.8 % (144/219) were discharged from ICU. Older age, longer treatment at the ICU and increased simplified acute physiology score (SAPS) at admission were associated with decreased 12-month survival, while no statistical differences were observed for the underlying and malignant disease by univariate analysis. The risk of death was 29, 56 and 61 % for patients treated 2-4, 5-19 and ≥20 days at the ICU. Decreased survival of patients treated for 5-19 and ≥20 days were confirmed by logrank test (p = 0.001).

CONCLUSIONS

Patients with long-term ICU stay showed decreased survival than patients who are treated less than 5 days but similar survival as patients which stayed between 5 and 19 days. Malignant disease is not associated with an unfavourable 12-month survival while older age, higher SAPS index at discharge and longer stay at ICU are. Long-term ICU survivors have no increased risk to succumb after discharge from ICU.

Titration of sevoflurane in elderly patients: blinded, randomized clinical trial, in non-cardiac surgery after beta-adrenergic blockade

BACKGROUND

Monitoring depth of anesthesia via the processed electroencephalogram (EEG) has been found useful in reducing the amount of anesthetic drugs, optimizing wake-up times, and, in some studies, reducing awareness. Our goal was to determine if titrating sevoflurane as the maintenance anesthetic to a depth of anesthesia monitor (SEDLine™, Masimo, CA) would shorten time to extubation in elderly patients undergoing non-cardiac surgery while on beta-adrenergic blockade. This patient population was selected because the usual cardiovascular signs of inadequate general anesthesia may be masked by beta-blocker therapy.

METHODS

Surgical patients older than 65 years of age receiving beta-adrenergic blockers for a minimum of 24 h preoperatively were randomized to two groups: a group whose titration of sevoflurane was based on SEDLine™ data (SEDLine™ group) and a group whose titration was based on usual clinical criteria (control group) where SEDLine™ data were concealed. The primary endpoint was time from skin closure to time to extubation. Aldrete score, White Fast Track score and QoR-40 were also assessed.

RESULTS

There was no significant difference in time to extubation [12.5 (SD 7.4) min in the control group versus 13.0 (SD 5.9) min for the treatment group]. The control group used more fentanyl [339 mcg (SD 205)] than did the treatment group [238 mcg (SD 123)] (P<0.02). There was no difference in sevoflurane utilization, Aldrete, White Fast Track scores, time to PACU discharge, or QoR-40 assessments between the groups.

CONCLUSION

Use of the SEDLine™ monitor's data to titrate sevoflurane did not improve the time to extubation or change short-term outcome of geriatric surgical patients receiving beta-adrenergic blockers. (ClinicalTrials.gov number, NCT00938782).

Prognosis of patients with hepatocellular carcinoma after hepatic resection: are elderly patients suitable for surgery?

AIM

The indication for hepatectomy is still controversial in elderly patients with hepatocellular carcinoma (HCC). We examined the clinicopathological features and survival of 188 HCC patients who underwent hepatectomy.

PATIENTS/METHODS

Patients were divided into four age groups: Age(<50) group (young patients <50 years of age, n = 9), Age(50-69) group (between 50-69 years, n = 110), Age(70-79) group (70-79 years, n = 57), and Age(≥80) group (≥80 years, n = 12). Physiologic ability and surgical stress (E-PASS) score, including preoperative risk score (PRS), surgical stress score (SSS), and comprehensive risk score (CRS) were assessed.

RESULTS

Proportion of patients of Age(70-79) and Age(≥80) groups increased significantly in the last 5 years (P < 0.01). Co-morbidity, performance status, and American Society of Anesthesiologists score significantly increased with age (P < 0.05). Proportions of patients with irregular findings and necro-inflammatory activity were significantly lower in Age(70-79) and Age(≥80) groups than in other groups (P < 0.05). Systemic postoperative complications were high in Age(70-79) and Age(≥80) groups. PRS increased significantly with age (P < 0.05). Multivariate analysis identified PRS ≥0.32 and age ≥70 years as significant determinants of systemic complications (P < 0.05). There were no significant differences in postoperative survivals among the groups.

CONCLUSIONS

Careful follow-up and proper decision on hepatectomy upon assessment of PRS are important in elderly HCC patients.

General anaesthesia in elderly patients with cardiovascular disorders: choice of anaesthetic agent

Our population is aging; currently 15% of the Western population are aged >65 years, and represent 25% of those undergoing surgery. The proportion of the population aged >or=65 years is rapidly growing, and an increasing number are affected with cardiovascular disease. The older person is a high-risk patient. This is because of their altered physiology and associated co-morbidities, as well as the pharmacokinetic and pharmacodynamic changes that may alter drug responses. There is considerable variability seen in the physical and physiological states of individual patients within the older population. This has an important impact on choosing a safe anaesthetic technique for each individual, which in turn can influence the morbidity and mortality in this population. The physiological changes in the aging cardiovascular system affect the arterial and venous vasculature, myocardium and autonomic nervous system, making the older person more prone to cardiovascular instability. In addition to the physiological changes, the cardiovascular status of the older person tends to be compromised by associated pathological conditions that are more common with increasing age. Pharmacokinetic and pharmacodynamic changes must be taken into account when deciding about drug dosing in this age group. Aspects of dose reduction, titration of drugs, dosing intervals and the pharmacodynamic effects of each class of drug are explained in detail in the text. The major challenge in anaesthesia for the older person with cardiovascular disease is maintenance of haemodynamic stability, particularly in the face of reduced physiological reserve and capability to respond to periods of instability. An appropriate anaesthetic technique must be selected to minimize haemodynamic changes and maintain near normal physiological status. The other key objective is to minimize the incidence of adverse outcomes, such as perioperative myocardial ischaemia/infarction, arrhythmias, heart failure, postoperative cognitive dysfunction and stroke. No single anaesthetic regimen or agent can be advocated. Knowledge of the pharmacokinetic and pharmacodynamic principles of anaesthetic agents and their altered response in elderly patients is essential when selecting an anaesthetic agent. This article provides a practical guide to the selection and use of general anaesthetic agents in older patients with cardiovascular disorders, highlighting the differences among various agents.

A prospective evaluation of 2 different pain management protocols for total hip arthroplasty

Pain management after total hip arthroplasty has improved dramatically in the past decade. However, most protocols use opioid medications for pain control. In the current study, 100 patients were prospectively selected to receive a traditional narcotic-based patient-controlled analgesia protocol or a nonnarcotic oral protocol for pain management after primary total hip arthroplasty. Therapy programs were similar for both groups. Postoperatively, patients were followed daily for opioid use, medication adverse effects, pain control, and overall satisfaction. The nonnarcotic oral group showed lower mean pain scores during the first 24 hours after surgery. The satisfaction rate was high in both groups. Both protocols provided adequate pain control after total hip arthroplasty; the nonnarcotic pain management protocol resulted in significantly decreased opioid consumption and fewer adverse effects.

Perioperative morbidity and mortality in 80 years and older undergoing elective urology surgery - a prospective study

BACKGROUND AND PURPOSE

The number of octogenarians requiring surgery increases constantly. Data regarding perioperative morbidity and mortality in octogenarians is limited. Our aim was to assess surgery-related complications in octogenarians, undergoing urological surgery.

PATIENTS AND METHODS

We prospectively collected data from octogenarians and a control group of younger patients undergoing an elective urological surgery in our institution. Recorded data included: age, gender, American Society of Anesthesiologists (ASA) score, co-morbidities, number of medications, operation extent, anaesthesia type, surgery duration and perioperative morbidity and mortality.

RESULTS

Forty-seven octogenarians and 80 patients with a median age of 59 years (range 19-75) enrolled prospectively. Gender ratio, surgeries extent and median operative time were similar among groups. General anaesthesia was more prevalent in the control group. ASA classification and duration of hospitalization were significantly higher in octogenarians. The rate of intra-operative complications was significantly higher in the octogenarians group 6.38% versus 3.75% (p = 0.007), there was no significant difference in immediate post-operative and post-discharge complications among groups. One octogenarian patient died 2 days post-surgery, no death occurred in the control group.

CONCLUSIONS

Octogenarians have higher rate of intra-operative morbidity, leading to longer hospital stay. More experienced surgeons and anaesthetists should be involved in the operation; and careful surgical technique, tapered anaesthesia and higher level of post-operative monitoring should be applied for patients in this age.

Hypotension induced by lateral decubitus or supine spinal anaesthesia in elderly with low ejection fraction undergone hip surgery

OBJECTIVE

The aim of the study was to assess the effect of low ejection fraction (EF) on hypotension during lateral or supine position of spinal anaesthesia in patients older than 75 years old.

METHODS

We analyzed 41 patients who had undergone hip surgery between August 2000 and October 2001 in the Aydin SSK State Hospital retrospectively. Patients older than 75 years of age and an EF less than 50% were selected and spinal anaesthesia was performed with hyperbaric bupivacaine 0.5%, lateral decubitus or supine position. The patients were divided into two groups: Group I (unilateral group, n = 23) and Group II (supine group, n = 18). History of hypertension, diabetes mellitus, and ASA status, preoperative value of EF and cardiac index, and intraoperative hypotension, bradycardia, ephedrine use, and maximal sensorial block levels were recorded.

RESULTS

The age range of patients was between 75 and 103. The maximal sensorial block level was evaluated due to lower or higher than thoracic sixth segment for each patient in intraoperative period. The sensorial block level higher than thoracic sixth segment were determined 2 patient in Group I and 14 patients in Group II (p = 0.001). Hypotension was observed in five patients in Group I and 10 patients in Group II (p = 0.015). In Group I, the number of ephedrine used patient was lower than Group II (p = 0.015).

CONCLUSIONS

Elderly patients with low EF were more likely to predispose to higher sensorial block level and hypotension was more common during spinal anaesthesia with supine position compared to lateral decubitus position.