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The Anaesthetic Assessment of an Elderly Surgical Patient

The Anaesthetic Assessment of an Elderly Surgical Patient. Dr. Irwin Foo Consultant Anaesthetist and Honorary Clinical Senior Lecturer Department of Anaesthesia Western General Hospital Edinburgh. Scope of the lecture. Anaesthetic definition of elderly and workload

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The Anaesthetic Assessment of an Elderly Surgical Patient

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  1. The Anaesthetic Assessment of an Elderly Surgical Patient Dr. Irwin Foo Consultant Anaesthetist and Honorary Clinical Senior Lecturer Department of Anaesthesia Western General Hospital Edinburgh

  2. Scope of the lecture • Anaesthetic definition of elderly and workload • How elderly patients differ from younger counterparts • The current state of affairs and why there is room for improvement • Importance of good anaesthetic assessment • Concept of functional reserve/capacity • Perioperative management

  3. Anaesthetic Definition of ‘Elderly’ • AAGBI document (2001) • > 80 yrs = elderly • Physiological changes/functional decline most marked after 80 years • Chronological vs biological age • Chronological age - poor discriminator of individual surgical risk • ‘old’ 60 yr old vs ‘young’ 80 yr old • Heterogenecity - most consistent feature in the elderly population

  4. % ORGAN FUNCTION ‘YOUNG’ ‘AVERAGE’ ‘OLD’ AGE (YEARS) Variability of organ function with age

  5. Size of the problem • Increasing numbers • > 80’s -fastest growing section of the population • 2005- >20% of population 65 yrs and over • increasing workload • 50% of elderly will require anaesthesia for surgical intervention in their lifetime • surgical/anaesthetic advances

  6. Anaesthetic/Surgical Workload in the Elderly Population (%) Anaesthetised population Resident population (YEAR) Klopfenstein CE et al. Anesth Analg 1998; 86:1165-70

  7. How do elderly surgical patients differ from younger counterparts ? • Anaesthetising the elderly………. • “Applied clinical pharmacology with enough patho-physiology included to confuse the picture”

  8. No preoperative problems (20%) % of patients n = 288 CVS RS CNS Vaz FG et al. Age and Ageing 1989; 18: 309-315 Comorbidity in the elderly • Increasing medical conditions with age

  9. Type of surgery Mortality after 2 days (%) Mortality after 30 days (%) Major vascular 20.0 20.0 Thoracotomy 12.5 37.5 Biliary, liver 6.7 26.7 Bowel, rectal, anal 3.8 23.8 Hip 2.7 8.2 TURP, eye 0.0 0.0 Extent of surgical stress(patients > 90 yrs; n = 301) Warner et al, Ann Surg 1988; 207: 380 -386

  10. % ORGAN FUNCTION ‘YOUNG’ ‘AVERAGE’ ‘OLD’ AGE (YEARS) Variable physiological ageing in the elderly

  11. The main risk factors determining outcome in the elderly • Severity of co-existing disease • Surgical procedure • Physiological age

  12. How are we doing?

  13. The Good News…………

  14. Outcome of Anaesthesia and Surgery in people > 100yrs and olderWarner et al JAGS 1998; 46:988 • Retrospective study • n = 31 (100-107yrs) • GA 39% RA 35% Sedation 26% • 1 major complication within 48hrs • Mortality rates • 48hrs 0% • 30 day 16% • 1 year 36%

  15. The Bad News……….

  16. Highest incidence of mortality and morbidity- NCEPOD data

  17. Remained constant despite advances in anaesthesia/surgical techniques • NCEPOD 1998/1999 -

  18. Likely Explanations • British surgical patients have on average a worse ASA status than 10yrs ago • ASA Physical Status categories: • Class 1: a normally healthy patient • Class 2: patient with mild systemic disease • Class 3: patient with moderate to severe disease that is not incapacitating • Class 4: patient with incapacitating disease that is a constant threat to life • Class 5: moribund patient- not expected to survive 24 hrs with or without an operation

  19. Likely Explanations • 9 out of 10 patients aged > 60yrs receiving GA have ASA status of 2 and over • 21% > 65yrs developed one or more in-hospital postoperative complications

  20. Relevance of postoperative complications • Hospital postoperative complications shortens long-term survival (Manku et al, 2003) • 7 x  risk in the first 3 months after surgery • (3 x without complications) • In-hospital risk factors:- pulmonary and renal complications • Other factors:- history of cancer, ASA>II, age, history of neurological disease

  21. Relative risk of mortality: 0-3 months 3-12 months > 12 months No complications 2.9 (1.8-4.6) 1.3 (1.04-1.7) 2.3 (1.7-3.2) With complications 7.3 (3.8-14) 2.4 (1.2-4.6) 1.9 (1.2-3.1) Age > 80 yrs 1.1 (0.84-1.6) No complications 1.7 (0.8-3.8) 1.6 (0.98-2.5) With complications 6.2 (2.6-14.9) 2.4 (1.06-5.3) 2.1 (1.2-3.6) Hospital postoperative complications shorten long-term survival

  22. Room for improvement?

  23. NCEPOD report- extremes of ages 1999 Recommendations • lack of senior multidisciplinary care • poor fluid management • matching of experience of surgeon/anaesthetist to physical status of elderly patient • Appropriate postoperative care • Effective pain management

  24. Scottish Audit of Surgical Mortality - Case Assessments Booklet - 2004 • Four hourly bags of iv fluids can drown an elderly patient • Elderly patients have limited physiological reserve • Cardiovascular collapse during orthopaedic surgery • Unnecessary laparotomy on elderly patient

  25. How we can improve the management of the elderly surgical patient ? • Adequate anaesthetic assessment • identification of failing integrated responses/functional reserve of individual organs • plan appropriate anaesthetic technique • Optimisation preoperatively – multidisciplinary approach • Estimate likely outcome of proposed surgery (alter if necessary) • ? day or inpatient surgery • Postoperative placement

  26. Preoperative Assessment • Assessment of damaging effects of concurrent medical conditions • Influence of normal ageing processes • Functional reserve/capacity assessment: both intergrated and individual organs • Specific elderly issues e.g. postoperative cognitive dysfunction (POCD)

  27. % Maximal Organ Function Maximal Functional Reserve Basal The effects of ageing • Progressive loss of functional reserve in all integrated and single organ systems • Invisible loss until 70-80% loss of reserve has occurred • Anaesthesia/surgical insult often utilises 50% or more of functional reserve

  28. The effects of ageing • Clinical signs of failure in any organ system indicates complete loss of functional reserve • Confusion/delirium developing postoperatively suggests poor cognitive reserve • Preoperative assessment aim is to identify systems at risk of failure and to try and minimise risk (if possible)

  29. History of presenting illness Medical/Surgical history Physical examination Investigations Diagnosis and Mx plan Immune system CNS CVS RS UGS GI Traditional diagnostic approach

  30. Medical and surgical history Activity level and quality Physical examination Investigations Assessment of organ system reserve Immune system CNS CVS RS UGS GI Organ-system based approach for preoperative assessment

  31. Brief reminder of age-related changes

  32. Age-related cardiovascular changes • Reduced autonomic responsiveness • SNS activity ;Parasympathetic  • Baroreceptor reflex activity  • -adrenoceptor responsiveness  • Decreased maximum heart rate • Frank-Starling mechanism- major mechanism for maintaining stroke volume

  33. Priebe H-J. BJA 2000; 85:763 - 78

  34. Age-related cardiovascular changes • Increased vascular stiffness •  systolic BP • widening of pulse pressure • Left ventricular wall thickening •  compliance: impairment of diastolic function • Greater dependence on atrial function for ventricular filling • contribute up to 30% of SV

  35. Priebe H-J. BJA 2000; 85:763 - 78

  36. Age-related respiratory changes •  Vital capacity /  Residual volume •  strength and mobility of muscles • lung elastic recoil  • chest wall compliance  • spinal collapse (anterior wedging) •  closing volume/capacity •  V/Q abnormalities →  gas exchange

  37. Effect of age on closing capacity and FRC Lung volume (L) FRC, upright FRC, supine Closing capacity Age (years)

  38. Postoperative PaO2 in the Elderly Postoperative PaO2(mmHg) Oxygen by facemask No Oxygen supplement Age (years) Patients with no preexisting pulmonary disease

  39. Age-related respiratory changes •  hypoxic and hypercapnic reflex control • Poor upper airway tone • snoring almost universal • Poor cough (7 fold reduction in sensitivity of cough reflex) •  risk of aspiration (silent!!) • Chest wall rigidity  more dependent on the diaphragm

  40. Age-related neurological changes •  brain cell mass (10-30% by age 80) • loss of central cholinergic and dopaminergic cells • 70-80% loss of dopaminergic function required before symptoms seen in Parkinson’s disease • ‘Crystallised’ intelligence better preserved than ‘liquid’ intelligence • Poor reflex control • baroreceptor , thermoregulation

  41. Age-related neurological changes • Blindness • cataracts, glaucoma • problem with visual analogue scales • Deafness • problems with comprehension • may be denied by patient • Cognitive impairment • dementia present in 22% of over 80’s • (life expectancy-50% in 5yrs)

  42. Age-related hepatic changes •  liver mass and blood flow • 1% loss/yr after 30 yrs • minor changes in cytochrome P450 activity • variable effect on Phase I reactions; Phase II not affected • Drugs which are flow-limited affected greater than capacity limited • lignocaine/bupivacaine, opioids • Reduced albumin: altered drug binding

  43. Age-related renal changes • Marked decline in RBF and GFR (1% loss of function/yr after 30yrs) • Plasma creatinine: not good guide of renal function bec. of reduced muscle mass • Response to Na concn impaired; less able to excrete Na load • Reduced ability to dilute/concentrate urine •  thirst perception • fear of incontinence • locomotor problems-inability to get to fluids

  44. Age-related musculoskeletal changes • Osteoarthritis/Osteoporosis • immobile   venous stagnation • limits ability to exercise • Poor stability/balance •  risk of accidents esp. in unfamiliar surroundings • Ligamental laxity • cervical vertebrae slip

  45. Functional Reserve/Capacity Assessment

  46. Integrated functional reserve • Metabolic equivalence • attempt to quantify metabolic (O2 delivery) capacity of the patient • estimates the likely outcome of surgery • predicts the likelihood of postoperative complications • patients unable to reach 4 METS

  47. Examples of metabolic equivalents Score Activity 1 Eat and dress, walk indoors around the house 2 Walk a block on the level, do light work around the house 4 Climb a flight of stairs or walk uphill, heavy domestic work, run a short distance 6 Moderate recreational activities e.g. dancing, golf, doubles tennis 10 Strenuous sports e.g. swimming

  48. Integrated functional reserve • METS-dependent on patient history • McGlade et al. Anaesth Intensive Care 2001; 29:520-6 • compared reliability of patients as historians • used a questionnaire and a simple exercise test • 14% of patients who claimed they could climb a flight of stairs declined to do so • watching them climb a flight of stairs more reliable

  49. Cardiopulmonary Exercise Testing in elderly patients undergoing major surgery Older et al. Chest 1999;116:355-62

  50. CPX testing: gold standard for identifying high-risk patients • bicycle ergometer/ metabolic cart • computerised analysis of gas exchange data/ 12 lead ECG data • anaerobic threshold (AT) • AT < 11ml/min/kg equivalent to less than 4 METs

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