Anaesthesia for Geriatricians

Richard Griffiths MD FRCA

Peterborough & Stamford Hospitals NHS Trust

Talk Outline

1. Types of anaesthesia

2. Risk Assessment

3. Elective v Emergency

4. Wish list for future training

Anaesthesia

When ever a surgical procedure is planned always ask the following;

Can it be performed with;

1. General anaesthesia

2. Regional anaesthesia

3. Local anaesthesia

Pharmacology

Intravenous agents

Volatile agents

Local anaesthetics (used locally, regionally or intravenously)

Opioids

Adjuvants (ketamine, NSAIDs, paracetamol)

DELIRIUM

Clinical Example

Ankle fracture in 85 year old female

Could do

GA

Spinal anaesthesia (regional)

Local blocks? A possibility if patient is particularly unwell

COLORECTAL

Analgesia

Risk Assessment

Must be performed for all elective cases

Should be performed for all emergency cases

What tools are available?

Risk Assessment- ASA Classification

First described in 1940-41, first example of risk stratification

Modified in 1963

There are 5 classes, E means emergency

Arabic numerals, not Roman (original paper 1941)

ASA Classification

Must be recorded for all cases

Often dispute about grades

Obesity, smoking cause controversy

Used in many national registries, NHFD, NJR

Elective Surgery

Risk Assessment

Donati et al BJA 2004

National Surgical Quality Improvement Programme Calculator

Free

NSQIP Calculator

http://riskcalculator.facs.org/RiskCalculator/PatientInfo.jsp

Emergency

Elective Cases chance to get patient in the best possible condition for surgery and the recovery period

EMERGENCY may have only a matter of minutes to “optimise” the patient

NCEPOD

RISK ASSESSMENT

Very important in emergency cases

Surgical outcome risk tool (SORT) (NCEPOD)

Nottingham Hip Fracture Score (NHFS)

Both available on app store

Also

Cardiff Surgical Risk Score (Possum based)

RISK ASSESSMENT

Emergency Cases

National Emergency Laparotomy Audit (NELA)

Availability of HDU/ITU post operatively

NB P-Possum tends to over estimate mortality at higher levels

http://www.riskprediction.org.uk/index-pp.php

Regional V General Debate

Endless arguments

No evidence that general is better

Little evidence that regional is better

Lots of evidence that regional causes less harm

Wish List

Hip Fracture Anaesthesia Fellowships

Geriatricians spending time in theatre, HDU/ITU, post anaesthesia care units

Anaesthetists (with an interest) spending time on wards, clinics, community

richardgriffiths1@nhs.net

Be nice to each other

Help your colleagues