老年病人的麻醉管理

Anesthetic Management of the Elderly Patient,Raymond C. Roy, PhD, MD Professor & Chair of Anesthesiology Wake Forest University Health Sciences Winston-Salem, NC, USA 27157-1009,/anesthesia 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,2000 2030 65 yrs 12.4% 19.6% 35 mil 71 mil 80 yrs 9.3 mil 19.5 mil,The Oldest,MAN 120 yrs WOMAN 122 Guinness Book of Records GENERAL ANESTHETIC 113 Br J Anaesth 2000; 84:260,Life Expectancy at birth USA - 1997,WOMEN Caucasian 79.9 yrs African-American 74.7 MEN Caucasian 74.3 African-American 67.2,Life Expectancy, Life Span, & Maximum Length of Life,Maximum Length of Life 120 yrs Life Span 85-100 Natural death (no trauma or disease) Life Expectancy (USA) 67-80 Premature death (trauma, disease),Oldest Surgical Patient? Oliver. Br J Anaesth 2000; 84:260,Woman, 113 yrs, femoral fracture General anesthesia CVP, no arterial-line Extubation in ICU after 5h Hospital discharge POD 23,# Anesthetics per 100 Population? Clergue. Anesthesiology 1999; 91:1509 (France),Vascular Surgery Mortality vs Age Fleisher. Anesth Analg 1999; 89:849,Perioperative Complication Rates in Medicare Patients,Intermediate Risk Surgery - 42% Silber, Anesthesiology 2000; 93:152 217,440 general 342:168 18,901 cataract surgery,Age & Perioperative Outcome,With advancing age More surgery Morbidity increases Mortality increases Cause - disease vs age ? Disease age when 85 yrs Increase ASA PS when 85 yrs,Preoperative Considerations,Preoperative Assessment No routine preoperative testing Statin myopathic syndromes Diastolic dysfunction Diabetes Mellitus Tighter glucose control with insulin Stop oral hypoglycemic agents,Why Obtain Preoperative Tests?,Screening NO with one exception Urinalysis if hip surgery or acutely ill Cook 96:1823 Treatment effectiveness - YES Baseline MAYBE, but overused Risk Assessment - YES,Value of Preoperative Testing Before Low Risk Surgery Schein. 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%),CAROTID HEAD & NECK INTRAPERITONEAL INTRATHORACIC ORTHOPEDIC PROSTATE,Preoperative Tests - Prevalence of Abnormal Results 544 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 Surgery N = 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), IF FOLLOWED BY PRIMARY CARE MD RELIABLE SYSTEM TO OBTAIN H & P NO “RED FLAGS” IN H & P MODERATE FUNCTIONAL STATUS + INTERMEDIATE RISK SURGERY OR POOR BUT STABLE FUNCTIONAL STATUS + LOW RISK SURGERY,No Non-invasive or Invasive Cardiac Testing for Intermediate Risk Surgery,MODERATE FUNCTIONAL CAPACITY + INTERMEDIATE CLINICAL PREDICTORS OR POOR FUNCTIONAL CAPACITY + MINOR CLINICAL PREDICTORS J Am Coll Cardiol 1996; 27:910,INTERMEDIATE CLINICAL PREDICTORS,MILD STABLE ANGINA PRIOR MI COMPENSATED CHF PRIOR CHF DIABETES MELLITUS,FUNCTIONAL CAPACITY,MET= metabolic equivalent O2 consumption of 70 kg, 40 yr old man in resting state 7 METs - excellent 4-7 METs - moderate 4 METs - poor J Am Coll Cardiol 1996; 27:910-48,Estimated Energy Requirements for Activities of Daily Living - 1,1 MET - 4 METs eat, dress, use toilet walk indoors around house walk 1-2 blocks on level ground light house work,Estimated Energy Requirements for Activities of Daily Living - 2,4 METs - 10 METs climb flight of stairs, walk up a hill walk briskly on level ground run a short distance do heavy house work golf, bowling, dancing, doubles tennis,Most Difficult ROUTINE Preoperative Tests to Justify,Chest X-ray PT and aPTT (if no heparin or warfarin) Liver Function Tests,4 Statin Myopathic Syndromes Thompson. JAMA 2003; 289:1681,STATIN MYOPATHY Any muscle complaint with onset coincident with start of statin therapy MYALGIA with normal CK MYOSITIS with elevated CK RHABDOMYOLYSIS,% of Older Patients with Diastolic Dysfunction,Diabetes Mellitus 8.7% of Elderly,Ischemic heart disease Problems with all oral hypoglycemic agents More infections pulmonary, wound Decreased pulmonary function Decreased response to hypoxia Prolonged response to vecuronium,Problems with Oral Hypoglycemic Agents Gu. 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 ischemia Metformin lactic acidosis,Diabetes Mellitus Tight Control of Glucose Gu. Anesthesiology 2003; 98:1359,Insulin infusions to maintain glucose: 80-150 mg/dl intraoperatively 80-110 mg/dl postoperatively Reduce ICU mortality by 40% Improve outcome from acute MI Decrease infections,Beta-adrenergic Blocking Agents Perioperative Administration,Reduces myocardial ischemia Reduces myocardial infarction Secondary Observations Zaugg. Anesthesiology 1999; 91:1674 Decrease anesthetic administration Enable faster emergence Decrease post-op analgesic requirement,Perioperative Myocardial Ischemia Wallace. Anesthesiology 1998; 88:7,Perioperative Beta-Blockade - Therapeutic Target Auerbach. JAMA 2002; 287:1435,HEART RATE 55 65 bpm SYSTOLIC 100 mm Hg Before, during, and after surgery,Actual Practice versus Evidenced-based Beta-blockade “Wrong” Answers from ABA Oral Examinees,DID NOT ADD IN PREOP CLINIC USED HR 80 AS TARGET INTRAOP DID NOT ORDER POSTOP (7 days) ASSUMED ESMOLOL-BOLUS = LONG-ACTING PRE-, INTRA-, POSTOP (REACTIVE vs PROPHYLACTIC),General Anesthesia,Anesthetic depth Neuromuscular blocking agents Diastolic pressure Transfusion trigger Regional vs general anesthesia,MAC 91:170,Nitrous Oxide MAC 91:170,End-tidal Isoflurane to Provide MAC with N2O in 80 Year Olds Nickalls. Br J Anaesth 2003; 91:170,Most of Us Overdose Elderly,Gas monitors Assume patient is 40 yrs old Do not know what other drugs given Do not know opioids & epidurals lower MAC Underestimate brain concentration on emergence BIS Index 55-60 with beta-blockers better than BIS Index 35-45,End-tidal Concentrations Under-estimate Brain Concentrations During Emergence from Isoflurane Lockhart. Anesthesiology 1991; 74:575,PROPOFOL INDUCTIONS IN 25 81 YR-OLDS Schnider. Anesthesiology 1999; 90:1502,Propofol: 2 mg/kg 65 yrs Injection time 13-24 s Loss of consciousness Young = old = 40 s Return of consciousness 30 yrs 5 min, 75 yrs 10 min,PROPOFOL INDUCTIONS 20 84 YRS Kazama. Anesthesiology 1999; 90:1517,HALF-TIME FOR NADIR IN BP 20 29 yrs 5.7 min 70 85 yrs 10.2 min,PROPOFOL INDUCTIONS 65 YRS Habib. 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/min SBP: 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/kg Concurrent drugs 0.5-1.0 mg/kg HYPOTENSION Continues for 10 min after injection Fentanyl peak 6-8 min, midazolam peak 5 min PREFER 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 threshold Hypothermia more likely Emergence hypertension treated as light anesthesia Reluctance to turn off vaporizer Longer durations of action for drugs in elderly Relative drug overdoses Synergistic drug interactions,Neuromuscular Blocking Agents in the Elderly - 1,Same initial dose as in younger Longer onset times with: Advanced age Vecuronium 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 age Intraoperative hypothermia (34.7o C) Diabetes mellitus (8.7% of elderly) Obesity dosing mg/kg,Obesity in Older Men % with BMI 29.2 Flegal. JAMA 2002; 288:1723,Obesity in Older Women % with BMI 29.2 Flegal. 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 onset Shortest duration Least inter-patient variability Easiest to reverse Shortest PACU length of stay Fewest post-op pulmonary complications Cisatracurium rocuronium if renal insufficiency,Transfusion Trigger for Elderly Hgb 10 g/dl or Hct 0.30,Ischemic Heart Disease Especially if reversible ischemia, unstable angina, recent infarction or dysfunction Pulmonary Disease Intra-thoracic or intra-abdominal surgery Leukocyte-reduced Walsh, McClelland, Br J Anaesth 2003; 719,Minimum Diastolic Pressure Pauca Abstract ASA 2003,When treating systolic pressure (SP), pay attention to diastolic pressure (DP) To maintain coronary perfusion, keep DP at least 2/3rd SP DP greater than Pulse Pressure DP at least 60 mmHg,Regional vs General Anesthesia Mortality & Morbidity,REGIONAL = GENERAL BP, HR tightly controlled in studies More interventions to control BP, HR in general anesthesia group REGIONAL GENERAL “Real world” , BP, HR not tightly controlled Included combined regional-general in regional group Rogers et al. Br Med J 2000;321:1493,Postoperative Considerations,Postoperative Analgesia Postoperative Delirium,Postoperative Titration of Intravenous Morphine in Elderly Patients Abrun. Anesthesiology 2002; 96