Anesthetic ManagementAnesthetic Managementof The Elderly Patientsof The Elderly Patients

Presented by:Presented by:Tia Sabrina, S,KedTia Sabrina, S,Ked

Citra Seftiani, S.KedCitra Seftiani, S.KedThavamalar Silvarajoo, S.KedThavamalar Silvarajoo, S.Ked

Indah Kencana, S.KedIndah Kencana, S.Ked

Supervisor:Dr. Endang Melati Maas , Sp.An

Introduction Introduction BackgroundBackground

Aging process is a process that converts healthy Aging process is a process that converts healthy adults into frail accompanied by a decrease in adults into frail accompanied by a decrease in reserves almost all physiological systems and reserves almost all physiological systems and accompanied by increased susceptibility to accompanied by increased susceptibility to disease and death. disease and death. Approach and management of the operation and Approach and management of the operation and anesthesia on geriatric patients are different and anesthesia on geriatric patients are different and often more complex than in younger patients.often more complex than in younger patients.

PurposePurpose

To identify the management of anesthesia To identify the management of anesthesia in geriatric patients, so it can reduce in geriatric patients, so it can reduce mortality and morbidity risk in geriatric mortality and morbidity risk in geriatric patients during surgery.patients during surgery.

Age-Related Anatomic & Age-Related Anatomic & Physiological ChangesPhysiological Changes

Cardiovascular SystemCardiovascular SystemReduced arterial compliance results in Reduced arterial compliance results in

increased afterload, elevated systolic increased afterload, elevated systolic blood pressure, and left ventricular blood pressure, and left ventricular hypertrophy. hypertrophy.

The left ventricular wall thickens at the The left ventricular wall thickens at the expense of the left ventricular cavity. expense of the left ventricular cavity.

Some myocardial fibrosis and calcification Some myocardial fibrosis and calcification of the valves are common. of the valves are common.

Baroreceptor function is depressed Baroreceptor function is depressed Cardiac output typically declines with age Cardiac output typically declines with age Increased vagal tone and decreased Increased vagal tone and decreased

sensitivity of adrenergic receptors lead to sensitivity of adrenergic receptors lead to a decline in heart rate; maximal heart rate a decline in heart rate; maximal heart rate declines by approximately one beat per declines by approximately one beat per minute per year of age over 50 minute per year of age over 50

Fibrosis of the conduction system and loss Fibrosis of the conduction system and loss of sinoatrial node cells increase the of sinoatrial node cells increase the incidence of dysrhythmias, particularly incidence of dysrhythmias, particularly atrial fibrillation and flutter atrial fibrillation and flutter

Diminished cardiac reserve in many Diminished cardiac reserve in many elderly patients may be manifested as elderly patients may be manifested as exaggerated drops in blood pressure exaggerated drops in blood pressure during induction of general anesthesia during induction of general anesthesia

Like infants, elderly patients have less Like infants, elderly patients have less ability to respond to hypovolemia, ability to respond to hypovolemia, hypotension, or hypoxia with an increase hypotension, or hypoxia with an increase in heart rate in heart rate

Respiratory System Respiratory System Elasticity is decreased in lung tissue, Elasticity is decreased in lung tissue,

allowing overdistention of alveoli and allowing overdistention of alveoli and collapse of small airways collapse of small airways

The former reduces the alveolar surface The former reduces the alveolar surface area, which decreases the efficiency of area, which decreases the efficiency of gas exchange gas exchange

Airway collapse increases residual volume Airway collapse increases residual volume and closing capacityand closing capacity

Some airways close during part of normal Some airways close during part of normal tidal breathing, resulting in a mismatch of tidal breathing, resulting in a mismatch of ventilation and perfusion. ventilation and perfusion.

Decrease arterial oxygen tension by an Decrease arterial oxygen tension by an average rate of 0.35 mm Hg per year. average rate of 0.35 mm Hg per year.

Both anatomic and physiological dead Both anatomic and physiological dead space increase. space increase.

Prevention of perioperative hypoxia includes:Prevention of perioperative hypoxia includes:

a longer preoxygenation period prior to a longer preoxygenation period prior to inductioninduction

a higher inspired oxygen concentrations a higher inspired oxygen concentrations during anesthesiaduring anesthesia

small increments of positive end-expiratory small increments of positive end-expiratory pressure pressure

Metabolic & Endocrine Function Metabolic & Endocrine Function Basal and maximal oxygen consumption Basal and maximal oxygen consumption

declines with age. declines with age. Heat production decreases, heat loss Heat production decreases, heat loss

increases, and hypothalamic temperature-increases, and hypothalamic temperature-regulating centers may reset at a lower regulating centers may reset at a lower level. level.

Increasing insulin resistance leads to a Increasing insulin resistance leads to a progressive decrease in the ability to progressive decrease in the ability to handle glucose loads. handle glucose loads.

The neuroendocrine response to stress The neuroendocrine response to stress appears to be preserved or slightly appears to be preserved or slightly decreased in most healthy elderly patients.decreased in most healthy elderly patients.

Aging is associated with a decreasing Aging is associated with a decreasing

response to -adrenergic agents response to -adrenergic agents ("endogenous -blockade") ("endogenous -blockade")

Circulating norepinephrine levels are Circulating norepinephrine levels are reported to be elevated in elderly patients. reported to be elevated in elderly patients.

Renal Function Renal Function Renal blood flow and kidney mass (eg, Renal blood flow and kidney mass (eg,

glomerular number and tubular length) glomerular number and tubular length) decrease with age decrease with age

Renal function as determined by Renal function as determined by glomerular filtration rate and creatinine glomerular filtration rate and creatinine clearance is reduced clearance is reduced

Impairment of sodium handling, Impairment of sodium handling, concentrating ability, and diluting capacity concentrating ability, and diluting capacity predisposes elderly patients to predisposes elderly patients to dehydration or fluid overload. dehydration or fluid overload.

The response to antidiuretic hormone and The response to antidiuretic hormone and aldosterone is reduced. aldosterone is reduced.

The ability to reabsorb glucose is The ability to reabsorb glucose is decreased. decreased.

The combination of reduced renal blood The combination of reduced renal blood flow and decreased nephron mass flow and decreased nephron mass increases the risk of elderly patients for increases the risk of elderly patients for acute renal failure in the postoperative acute renal failure in the postoperative period. period.

As renal function declines, so does the As renal function declines, so does the kidney's ability to excrete drugs kidney's ability to excrete drugs

The decreased capacity to handle water The decreased capacity to handle water and electrolyte loads makes proper fluid and electrolyte loads makes proper fluid management more critical, elderly patients management more critical, elderly patients are more predisposed to developing are more predisposed to developing hypokalemia and hyperkalemia. hypokalemia and hyperkalemia.

Gastrointestinal FunctionGastrointestinal FunctionLiver mass declines as a person ages, Liver mass declines as a person ages,

with a corresponding decrease in hepatic with a corresponding decrease in hepatic blood flow. blood flow. Hepatic function (reserves) Hepatic function (reserves) declines declines

The rate of biotransformation and albumin The rate of biotransformation and albumin production decreases. production decreases.

Plasma cholinesterase levels are reduced Plasma cholinesterase levels are reduced in elderly men. in elderly men.

Gastric pH tends to rise, whereas gastric Gastric pH tends to rise, whereas gastric emptying is prolonged emptying is prolonged

Nervous System Nervous System Brain mass decreases with age; neuronal Brain mass decreases with age; neuronal

loss is prominent in the cerebral cortex, loss is prominent in the cerebral cortex, particularly the frontal lobes. particularly the frontal lobes.

Cerebral blood flow also decreases about Cerebral blood flow also decreases about 10–20% in proportion to neuronal losses. 10–20% in proportion to neuronal losses.

The synthesis of some neurotransmitters, The synthesis of some neurotransmitters, such as dopamine, and the number of such as dopamine, and the number of their receptors are reduced. their receptors are reduced.

Serotonergic, adrenergic, and -Serotonergic, adrenergic, and -aminobutyric acid (GABA) binding sites aminobutyric acid (GABA) binding sites are also reduced. are also reduced.

Astrocytes and microglial cells increase in Astrocytes and microglial cells increase in number. number.

Degeneration of peripheral nerve cells Degeneration of peripheral nerve cells results in prolonged conduction velocity results in prolonged conduction velocity and skeletal muscle atrophy. and skeletal muscle atrophy.

Aging is associated with an increasing Aging is associated with an increasing threshold for nearly all sensory modalities, threshold for nearly all sensory modalities, including touch, temperature sensation, including touch, temperature sensation, proprioception, hearing, and vision. proprioception, hearing, and vision.

Dosage requirements for local (Cm: Dosage requirements for local (Cm: minimum anesthetic concentration) and minimum anesthetic concentration) and general (MAC: minimum alveolar general (MAC: minimum alveolar concentration) anesthetics are reduced. concentration) anesthetics are reduced.

A longer duration of action should be A longer duration of action should be expected from a spinal anesthetic. expected from a spinal anesthetic.

Elderly patients often take more time to Elderly patients often take more time to recover completely from the central recover completely from the central nervous system effects of general nervous system effects of general anesthesia, particularly if they were anesthesia, particularly if they were confused or disoriented preoperatively. confused or disoriented preoperatively.

The incidence of postoperative delirium The incidence of postoperative delirium appears similar with both regional and appears similar with both regional and general anesthesia general anesthesia

MusculoskeletalMusculoskeletalMuscle mass is reduced. Muscle mass is reduced. Neuromuscular junctions thicken. Neuromuscular junctions thicken. Skin atrophies with age and is prone to Skin atrophies with age and is prone to

trauma from adhesive tape, electrocautery trauma from adhesive tape, electrocautery pads, and electrocardiographic electrodes. pads, and electrocardiographic electrodes.

Veins are often frail and easily ruptured by Veins are often frail and easily ruptured by intravenous infusions. intravenous infusions.

Degenerative cervical spine disease can Degenerative cervical spine disease can limit neck extension potentially making limit neck extension potentially making intubation difficult. intubation difficult.

Anesthetic Management of The Anesthetic Management of The Elderly PatientsElderly Patients

Preoperative Assessment ofthe Elderly

The preoperative evaluation has served two primary functions:

to alert the perioperativecare providers to physiologic conditions that may alter perioperative management

to determine if medical intervention is indicated before proceeding.

to provide an index of risk, therefore contributing to decisions about the most appropriate intervention,

and to provide baseline data on which the success of a surgical intervention might be judged.

Pre-operative AssesmentPre-operative Assesment

1. Assesment:1. Assesment: A full history of patientA full history of patientClinical assessment - cardiac, respiratory Clinical assessment - cardiac, respiratory

and renal disease and renal disease ECGECGChest X-rayChest X-ray

2. Resuscitation/optimisation pre-operatively

3. Consider day case surgery 4. Decision to operate.

Monitoring

Some aspects that consider perioperative Some aspects that consider perioperative care in elderly patients:care in elderly patients:- Rehydration, if there is dehydration- Rehydration, if there is dehydration- Gastrointestinal disorders resolved- Gastrointestinal disorders resolved- Overcoming sepsis- Overcoming sepsis- Overcoming hemorrhage (blood loss), if any- Overcoming hemorrhage (blood loss), if any- Overcoming edema in congestive heart - Overcoming edema in congestive heart failurefailure

Age-Related Pharmacological Age-Related Pharmacological Changes Changes

The reduced volume of distribution for water-The reduced volume of distribution for water-soluble drugs can lead to higher plasma soluble drugs can lead to higher plasma concentrations; conversely, an increased concentrations; conversely, an increased volume of distribution for lipid-soluble drugs volume of distribution for lipid-soluble drugs can lower their plasma concentration. can lower their plasma concentration.

Because renal and hepatic functions decline Because renal and hepatic functions decline with age, reductions in clearance prolong the with age, reductions in clearance prolong the duration of action for many drugs. duration of action for many drugs.

Distribution and elimination are also Distribution and elimination are also affected by altered plasma protein binding affected by altered plasma protein binding Albumin, which tends to bind acidic drugs Albumin, which tends to bind acidic drugs (eg, barbiturates, benzodiazepines, opioid (eg, barbiturates, benzodiazepines, opioid agonists), typically decreases with age. agonists), typically decreases with age.

The principal pharmacodynamic change The principal pharmacodynamic change associated with aging is a reduced associated with aging is a reduced anesthetic requirement, represented by a anesthetic requirement, represented by a lower MAC. lower MAC.

Inhalational AnestheticsInhalational Anesthetics The MAC for inhalational agents is reduced by The MAC for inhalational agents is reduced by

4% per decade of age over 40 years. 4% per decade of age over 40 years.

Onset of action will be more rapid if cardiac Onset of action will be more rapid if cardiac output is depressed, whereas it will be delayed if output is depressed, whereas it will be delayed if there is a significant ventilation/perfusion there is a significant ventilation/perfusion abnormality abnormality

The myocardial depressant effects of volatile The myocardial depressant effects of volatile anesthetics are exaggerated in elderly patients, anesthetics are exaggerated in elderly patients, whereas the tachycardiac tendencies of whereas the tachycardiac tendencies of isoflurane and desflurane are attenuated isoflurane and desflurane are attenuated

Thus, in contrast to its effects on younger patients, Thus, in contrast to its effects on younger patients, isoflurane reduces cardiac output and heart rate in isoflurane reduces cardiac output and heart rate in elderly patients. elderly patients.

Recovery from anesthesia with a volatile anesthetic Recovery from anesthesia with a volatile anesthetic may be prolonged because of an increased volume may be prolonged because of an increased volume of distribution (increased body fat), decreased of distribution (increased body fat), decreased hepatic function (decreased halothane metabolism), hepatic function (decreased halothane metabolism), and decreased pulmonary gas exchange. and decreased pulmonary gas exchange.

The rapid elimination of desflurane may make it the The rapid elimination of desflurane may make it the inhalation anesthetic of choice for elderly patients. inhalation anesthetic of choice for elderly patients.

Nonvolatile Anesthetic AgentsNonvolatile Anesthetic Agents In general, elderly patients display a lower In general, elderly patients display a lower

dose requirement for propofol, etomidate, dose requirement for propofol, etomidate, barbiturates, opioids, and benzodiazepines. barbiturates, opioids, and benzodiazepines.

Although propofol may be close to an ideal Although propofol may be close to an ideal induction agent for elderly patients because induction agent for elderly patients because of its rapid elimination, it is more likely to of its rapid elimination, it is more likely to cause apnea and hypotension than in cause apnea and hypotension than in younger patients. younger patients.

Concomitant administration of midazolam, Concomitant administration of midazolam, opioids, or ketamine further decreases opioids, or ketamine further decreases propofol requirements propofol requirements

In the case of thiopental, enhanced In the case of thiopental, enhanced sensitivity appears to be primarily due to sensitivity appears to be primarily due to pharmacokinetics factors. pharmacokinetics factors.

The initial volume of distribution for The initial volume of distribution for etomidate significantly decreases with etomidate significantly decreases with aging aging

Pharmacokinetics for these opioids are not Pharmacokinetics for these opioids are not significantly affected by age. Dose significantly affected by age. Dose requirements for the same EEG end point requirements for the same EEG end point using fentanyl and alfentanil are 50% using fentanyl and alfentanil are 50% lower in elderly patients. lower in elderly patients.

Aging increases the volume of distribution Aging increases the volume of distribution for all benzodiazepines, which effectively for all benzodiazepines, which effectively prolongs their elimination half-lives. prolongs their elimination half-lives.

Muscle Relaxants Muscle Relaxants The response to succinylcholine and The response to succinylcholine and

nondepolarizing agents is unaltered with aging. nondepolarizing agents is unaltered with aging. Decreased cardiac output and slow muscle Decreased cardiac output and slow muscle

blood flow, however, may cause up to a 2-fold blood flow, however, may cause up to a 2-fold prolongation in onset of neuromuscular blockade prolongation in onset of neuromuscular blockade in elderly patients. in elderly patients.

Recovery from nondepolarizing muscle relaxants Recovery from nondepolarizing muscle relaxants that depend on renal excretion (eg, metocurine, that depend on renal excretion (eg, metocurine, pancuronium, doxacurium, tubocurarine) may be pancuronium, doxacurium, tubocurarine) may be delayed due to decreased drug clearance. delayed due to decreased drug clearance.

Decreased hepatic excretion from a loss of Decreased hepatic excretion from a loss of liver mass prolongs the elimination half-life liver mass prolongs the elimination half-life and duration of action of rocuronium and and duration of action of rocuronium and vecuronium. vecuronium.

The pharmacological profiles of atracurium The pharmacological profiles of atracurium and pipecuronium are not significantly and pipecuronium are not significantly affected by age. affected by age.

Elderly men—but not elderly women—may Elderly men—but not elderly women—may display a slightly prolonged effect from display a slightly prolonged effect from succinylcholine due to lower plasma succinylcholine due to lower plasma cholinesterase levels. cholinesterase levels.

Fluid ManagementFluid Management Careful peri-operative fluid balance is mandatory in the

elderly. Patients are more often underfilled than overloaded,

although care should be taken to avoid fluid overload: excess fluids in an elderly patient, especially in the presence of renal failure, can cause pulmonary oedema.

Conversely, dehydration, which can be difficult to assess in the elderly, can precipitate renal failure.

Regular review of fluid therapy is essential after major surgery.

Conclusion Conclusion Physiological changes occur in the elderly patients Physiological changes occur in the elderly patients Management of anesthesia in geriatric patients Management of anesthesia in geriatric patients

differ from younger patientsdiffer from younger patientsDrug selection and dose determination of Drug selection and dose determination of

anesthesia must also be adjusted with the anesthesia must also be adjusted with the conditions of geriatric patients. conditions of geriatric patients.

Fluid therapy should be considered more carefully Fluid therapy should be considered more carefully considering cardiac function and renal function. considering cardiac function and renal function.

ReferencesReferences http://medlinux.blogspot.com/2007/09/anastesi-pada-geriatri.html diakses pada diakses pada tanggal 14 Juli 2010tanggal 14 Juli 2010 Silverstein JH, Rooke GA, Reves JG, McLeskey CH. The Practice of Geriatric Silverstein JH, Rooke GA, Reves JG, McLeskey CH. The Practice of Geriatric

Anesthesia. In: Silverstein JH, ed. Anesthesia. In: Silverstein JH, ed. Geriatric anesthesiologyGeriatric anesthesiology 2nd ed. USA: Springer 2nd ed. USA: Springer Science+Business Media; 2008.Science+Business Media; 2008.

Morgan GE, Mikhail MS, Murray MJ. Geriatric anesthesia. In: Morgan GE, ed. Morgan GE, Mikhail MS, Murray MJ. Geriatric anesthesia. In: Morgan GE, ed. Clinical Clinical Anesthesia Anesthesia 4th ed. USA: The McGraw-Hill Companies; 2007. 4th ed. USA: The McGraw-Hill Companies; 2007.

DeFrances CJ, Podgornik MN. 2004 National Discharge Survey. 371. 5-4-2006. DeFrances CJ, Podgornik MN. 2004 National Discharge Survey. 371. 5-4-2006. Hyattsville, MD: National Center for Health Statistics. Advance Data from Vital and Hyattsville, MD: National Center for Health Statistics. Advance Data from Vital and Health Statistics.Health Statistics.

Mangano DT. Preoperative risk assessment: many studies,few solutions. Is a cardiac Mangano DT. Preoperative risk assessment: many studies,few solutions. Is a cardiac risk assessment paradigm possible?Anesthesiology 1995;83:897–901.risk assessment paradigm possible?Anesthesiology 1995;83:897–901.

Silverstein JH, Rooke GA, Reves JG, McLeskey CH. Research Priorities in Geriatric Silverstein JH, Rooke GA, Reves JG, McLeskey CH. Research Priorities in Geriatric Anesthesiology. In: Jankowski CJ, Cook DJ,ed. Anesthesiology. In: Jankowski CJ, Cook DJ,ed. Geriatric anesthesiologyGeriatric anesthesiology 2nd ed. USA: 2nd ed. USA: Springer Science+Business Media; 2008.Springer Science+Business Media; 2008.

http://www.asahq.org/clinical/geriatrics/perio_comp.htm diakses pada tanggal 19 Juli http://www.asahq.org/clinical/geriatrics/perio_comp.htm diakses pada tanggal 19 Juli 20102010

http://update.anaesthesiologists.org/wp-content/uploads/2009/08/Elderly-Patients-and-Anaesthesia.pdf diakses pada 20 juli 2010 diakses pada 20 juli 2010

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