老年病人的麻醉管理.ppt

Anesthetic Management of the Elderly Patient,Raymond C.Roy,PhD,MDProfessor&Chair of AnesthesiologyWake Forest University Health SciencesWinston-Salem,NC,USA 27157-1009,Education:Annual Meeting American Society of Anesthesiologists,Hayflicks View of Aging,“Because modern humans,unlike feral animals,have learned how to escape death long after reproductive success,we have revealed a process that,teleologically,was never intended for us to experience.”,#Older Americans,20002030 65 yrs12.4%19.6%35 mil71 mil 80 yrs9.3 mil19.5 mil,The Oldest.,MAN120 yrsWOMAN122 Guinness Book of RecordsGENERAL ANESTHETIC113 Br J Anaesth 2000;84:260,Life Expectancy at birth USA-1997,WOMENCaucasian79.9 yrsAfrican-American74.7MENCaucasian74.3African-American67.2,Life Expectancy,Life Span,&Maximum Length of Life,Maximum Length of Life 120 yrsLife Span85-100Natural death(no trauma or disease)Life Expectancy(USA)67-80Premature death(trauma,disease),Oldest Surgical Patient?Oliver.Br J Anaesth 2000;84:260,Woman,113 yrs,femoral fractureGeneral anesthesiaCVP,no arterial-lineExtubation in ICU after 5hHospital discharge POD 23,#Anesthetics per 100 Population?Clergue.Anesthesiology 1999;91:1509(France),Vascular Surgery Mortality vs AgeFleisher.Anesth Analg 1999;89:849,Perioperative Complication Rates in Medicare Patients,Intermediate Risk Surgery-42%Silber,Anesthesiology 2000;93:152217,440 general 342:16818,901 cataract surgery,Age&Perioperative Outcome,With advancing age More surgery Morbidity increases Mortality increasesCause-disease vs age?Disease age when 85 yrs Increase ASA PS when 85 yrs,Preoperative Considerations,Preoperative AssessmentNo routine preoperative testingStatin myopathic syndromesDiastolic dysfunctionDiabetes MellitusTighter glucose control with insulinStop oral hypoglycemic agents,Why Obtain Preoperative Tests?,Screening NO with one exceptionUrinalysis if hip surgery or acutely illCook 96:1823Treatment effectiveness-YESBaseline MAYBE,but overusedRisk Assessment-YES,Value of Preoperative Testing Before Low Risk SurgerySchein.N Engl J Med 2000;342:168,Value of Preoperative Testing Before Low Risk Surgery Schein.N Engl J Med 2000;342:168,“Tests should be ordered only when the history or a finding on a physical examination would have indicated the need for the test even if surgery had not been planned.”,Intermediate Risk Noncardiac Surgery(Mortality 1%,5%),CAROTIDHEAD&NECKINTRAPERITONEALINTRATHORACICORTHOPEDICPROSTATE,Preoperative Tests-Prevalence of Abnormal Results544 consecutive intermediate risk non-cardiac surgical patients 69 yrs-Dzankic.Anesth Analg 2001;93:301,Creatinine 1.5 mg/dL 12%Hemoglobin 200 mg/dL 7%K+5.0 mEq/L 4%Platelets 115,000/ml 2%,Outcomes of Patients with No Laboratory Assessment for Intermediate Risk SurgeryN=1,044 Narr.Mayo Clin Proc 1997;72:505,“Patients assessed by history and physical examination safely undergo operation with tests drawn only as indicated intraoperatively and postoperatively.”,Is ROUTINE Preoperative Testing Indicated?,NO(my opinion),IFFOLLOWED BY PRIMARY CARE MDRELIABLE SYSTEM TO OBTAIN H&PNO“RED FLAGS”IN H&PMODERATE FUNCTIONAL STATUS+INTERMEDIATE RISK SURGERY ORPOOR BUT STABLE FUNCTIONAL STATUS+LOW RISK SURGERY,No Non-invasive or Invasive Cardiac Testing for Intermediate Risk Surgery,MODERATE FUNCTIONAL CAPACITY+INTERMEDIATE CLINICAL PREDICTORSORPOOR FUNCTIONAL CAPACITY+MINOR CLINICAL PREDICTORSJ Am Coll Cardiol 1996;27:910,INTERMEDIATE CLINICAL PREDICTORS,MILD STABLE ANGINAPRIOR MICOMPENSATED CHFPRIOR CHFDIABETES MELLITUS,FUNCTIONAL CAPACITY,MET=metabolic equivalent O2 consumption of 70 kg,40 yr old man in resting state 7 METs-excellent4-7 METs-moderate 4 METs-poorJ Am Coll Cardiol 1996;27:910-48,Estimated Energy Requirements for Activities of Daily Living-1,1 MET-4 METseat,dress,use toiletwalk indoors around housewalk 1-2 blocks on level groundlight house work,Estimated Energy Requirements for Activities of Daily Living-2,4 METs-10 METsclimb flight of stairs,walk up a hillwalk briskly on level groundrun a short distancedo heavy house workgolf,bowling,dancing,doubles tennis,Most Difficult ROUTINE Preoperative Tests to Justify,Chest X-rayPT and aPTT(if no heparin or warfarin)Liver Function Tests,4 Statin Myopathic SyndromesThompson.JAMA 2003;289:1681,STATIN MYOPATHYAny muscle complaint with onset coincident with start of statin therapyMYALGIA with normal CKMYOSITIS with elevated CKRHABDOMYOLYSIS,%of Older Patients with Diastolic Dysfunction,Diabetes Mellitus 8.7%of Elderly,Ischemic heart diseaseProblems with all oral hypoglycemic agentsMore infections pulmonary,woundDecreased pulmonary functionDecreased response to hypoxiaProlonged response to vecuronium,Problems with Oral Hypoglycemic AgentsGu.Anesthesiology 2003;98:1359,Sulfonylureas myocardial ischemia Interfere with K-ATP channels Prevent ischemic preconditioning Eliminate ECG benefit of warm-up Eliminate functional benefit of warm-up Worsen dipyridamole-induced ischemiaMetformin lactic acidosis,Diabetes Mellitus Tight Control of Glucose Gu.Anesthesiology 2003;98:1359,Insulin infusions to maintain glucose:80-150 mg/dl intraoperatively80-110 mg/dl postoperativelyReduce ICU mortality by 40%Improve outcome from acute MIDecrease infections,Beta-adrenergic Blocking Agents Perioperative Administration,Reduces myocardial ischemiaReduces myocardial infarctionSecondary ObservationsZaugg.Anesthesiology 1999;91:1674Decrease anesthetic administrationEnable faster emergenceDecrease post-op analgesic requirement,Perioperative Myocardial IschemiaWallace.Anesthesiology 1998;88:7,Perioperative Beta-Blockade-Therapeutic Target Auerbach.JAMA 2002;287:1435,HEART RATE 55 65 bpmSYSTOLIC 100 mm HgBefore,during,and after surgery,Actual Practice versus Evidenced-based Beta-blockade“Wrong”Answers from ABA Oral Examinees,DID NOT ADD IN PREOP CLINICUSED HR 80 AS TARGET INTRAOPDID NOT ORDER POSTOP(7 days)ASSUMED ESMOLOL-BOLUS=LONG-ACTING PRE-,INTRA-,POSTOP(REACTIVE vs PROPHYLACTIC),General Anesthesia,Anesthetic depthNeuromuscular blocking agentsDiastolic pressureTransfusion triggerRegional vs general anesthesia,MAC 91:170,Nitrous Oxide MAC 91:170,End-tidal Isoflurane to Provide MAC with N2O in 80 Year OldsNickalls.Br J Anaesth 2003;91:170,Most of Us Overdose Elderly,Gas monitorsAssume patient is 40 yrs oldDo not know what other drugs givenDo not know opioids&epidurals lower MACUnderestimate brain concentration on emergenceBIS Index 55-60 with beta-blockers better than BIS Index 35-45,End-tidal Concentrations Under-estimate Brain Concentrations During Emergence from IsofluraneLockhart.Anesthesiology 1991;74:575,PROPOFOL INDUCTIONS IN 25 81 YR-OLDSSchnider.Anesthesiology 1999;90:1502,Propofol:2 mg/kg 65 yrs Injection time 13-24 sLoss of consciousness Young=old=40 sReturn of consciousness 30 yrs 5 min,75 yrs 10 min,PROPOFOL INDUCTIONS 20 84 YRSKazama.Anesthesiology 1999;90:1517,HALF-TIME FOR NADIR IN BP20 29 yrs 5.7 min70 85 yrs10.2 min,PROPOFOL INDUCTIONS 65 YRSHabib.Br J Anaesth 2002;88:430,Glycopyrrolate,propofol 1 mg/kg,and either alfentanil 10 g/kg or remifentanil 0.5 g/kg+0.1 g/kg/minSBP:100 mmHg 50%,80 mmHg 8%,RECOMMENDED PROPOFOL DOSE FOR INDUCTION IF 65 yrs old,IF BOLUS(30 s)No concurrent drugs 1.0-1.5 mg/kgConcurrent drugs 0.5-1.0 mg/kgHYPOTENSIONContinues for 10 min after injectionFentanyl peak 6-8 min,midazolam peak 5 minPREFER SLOWER INJECTION(1 min)Less hypotension if slow with 1.0 mg/kg,Elderly Take Longer to Emerge Than Younger Patients,Lower MACawake and higher pain thresholdHypothermia more likelyEmergence hypertension treated as light anesthesiaReluctance to turn off vaporizerLonger durations of action for drugs in elderlyRelative drug overdosesSynergistic drug interactions,Neuromuscular Blocking Agents in the Elderly-1,Same initial dose as in youngerLonger onset times with:Advanced ageVecuronium vs rocuronium Tullock.Anesth Analg 1990;70:86 Esmolol Szmuk.Anesth Analg 2000;90:1217,Onset Time(sec)Increases with Advancing Age Koscielniak-Nelson.Anesthesiology 1993;79:229,Neuromuscular Blocking Agents in the Elderly-2,Longer duration(except cisatracurium)Advanced ageIntraoperative hypothermia(34.7o C)Diabetes mellitus(8.7%of elderly)Obesity dosing mg/kg,Obesity in Older Men%with BMI 29.2Flegal.JAMA 2002;288:1723,Obesity in Older Women%with BMI 29.2Flegal.JAMA 2002;288:1723,Times to Reappearance of T1,T2,T3,90:480,Effect of Hypothermia on Time-to-25%-Recovery from Vecuronium 0.1 mg/kg Caldwell.Anesthesiology 2000;92:84,Rocuronium Vecuronium Pancuronium(My Practice),Fastest onsetShortest durationLeast inter-patient variabilityEasiest to reverseShortest PACU length of stayFewest post-op pulmonary complicationsCisatracurium rocuronium if renal insufficiency,Transfusion Trigger for ElderlyHgb 10 g/dl or Hct 0.30,Ischemic Heart DiseaseEspecially if reversible ischemia,unstable angina,recent infarction or dysfunctionPulmonary DiseaseIntra-thoracic or intra-abdominal surgeryLeukocyte-reducedWalsh,McClelland,Br J Anaesth 2003;719,Minimum Diastolic PressurePauca Abstract ASA 2003,When treating systolic pressure(SP),pay attention to diastolic pressure(DP)To maintain coronary perfusion,keepDP at least 2/3rd SPDP greater than Pulse PressureDP at least 60 mmHg,Regional vs General Anesthesia Mortality&Morbidity,REGIONAL=GENERALBP,HR tightly controlled in studiesMore interventions to control BP,HR in general anesthesia groupREGIONAL GENERAL“Real world”,BP,HR not tightly controlledIncluded combined regional-general in regional groupRogers et al.Br Med J 2000;321:1493,Postoperative Considerations,Postoperative AnalgesiaPostoperative Delirium,Postoperative Titration of Intravenous Morphine in Elderly Patients Abrun.Anesthesiology 2002;96:17,Bolus q 5 min to VAS=30(max 100)2 mg if 60 kgTotal mg/kg dose:young=oldYoung(70,mean 76)Morbidity young=oldadverse opioid effects,sedation,stopped titrations,Age is not an Impediment to Effective Use of PCA Gagliese.Anesthesiology 2000;93:601,Initial Dose for Pain Relief:young=oldTotal Dose:old young,Postoperative Delirium in 5-50%That Appears on PODs 1-3Cook.Anesth Analg 2003;96:1823,Cellular proteins altered by potent inhaled agentsCentral cholinergic insufficiency,MicroemboliPreexisting subclinical dementia,HypoxiaFever,Infection(UTI,sinusitis,pneumonia)Electrolyte abnormalities,Anemia,PainSleep deprivation,Unfamiliar environment,Ten Ways to Improve Anesthesia in Older Patients,H&P Pre-op Testing CXR,PT,PTTBeta-blockers pre-.intra-,post-opTimely antibiotic administrationLower doses of inhaled&iv agentsRocuronium or cisatracurium,Ten Ways to Improve Anesthesia in Older Patients,6.Higher FIO2 intra-,post-op 7.Transfusion trigger Hct.30 8.Diastolic pressure 60 mmHg 9.Blood glucose-periop 80-150 mg/dl10.Reduce post-op opioid requirements,