Anaesthesia in Geriatric Patients: What are Some Special Considerations?
M3 India Newsdesk Aug 21, 2024
This article discusses the anaesthetic management of elderly patients, focusing on the impact of age-related physiological changes and comorbidities on surgical outcomes. It emphasises strategies for improving perioperative care and quality of life in geriatric patients.
Ageing is associated with progressive loss of functional reserve in almost all organ systems. An ‘elderly person’ as defined by the World Health Organisation is one aged 65 years or above and ‘oldest old’, that is 85 years and above is considered to be a group of the population where most care is needed for a better outcome after surgery.
The overall aim of anaesthetic management in the elderly is that we should be able to add life to the years not just years to the life. Moreover, perioperative anaesthetic management should not be limited to reducing mortality and morbidity alone but to improving the overall quality of life.
Below is the case management of an elderly patient posted for elective surgery for open ureterolithotomy and vesicular lithotomy at our institute.
Case Report
A 75-year-old male came to our institute with a decreased frequency of urination and straining during voiding for 2 months.
He has been a known diabetic for 5 years under Tab Metformin 500 mg BD, He is a known COPD patient diagnosed 2 months ago under MDI( Tiatropium bromide 9mcg+Formoterol fumarate).
Presently he is under Tab Doxophylline 400mg, Inj Hydrocortisone 100 mg BD iv, Nebulisation Iprasure 6th hourly and Budacort 8th hourly)
On clinical examination, he was conscious and oriented, Ht - 155cms, Wt 52 kgs, PR - 104 bpm, BP - 140/80 mm/hg, Auscultation was normal and his chest was clear.
Airway examination was normal ( MPG 3, TMJ > 6.5cm, mouth opening was adequate) Spine examination was normal.
Investigations
Investigations for the patient as follows:
- Hb 9.7g/dl, CBG - 142mg%
- Coagulation profile - PT - 15
- INR - 1.1
- Viral serology - negative
- RFT: B.urea 23
- S. Creat - 1.0
- S. electrolytes Na+ 139
- K+ was 2.8 after correction it went to 3.3, Cl -94
- LFT -WNL
- CXR - diffuse haziness in left lower lobe.
- ECG - NSR, 2D
- Echo: Concentric LVH Tachycardia during the study. EF -61%
Other investigations
- CT KUB shows 12*8*16 mm sized calculus in the proximal right ureter causing Hydroureteronephrosis.
- Another 9*9 mm sized irregularly shaped calculus in the distal right ureter.
- A cardiologist's opinion was obtained and was given to be moderate risk.
- A pulmonologist opinion was obtained given COPD changes and was advised to give Nebulisation pre and postoperatively Dublin and Budecort.
- Inj Hydrocortisone 100 mg IV was to be given on the day of surgery.
- Preoperatively Syp KCL 10 mL BD was given to correct reduced K+ levels initially after K+ levels improved over 3-4 days. Tab PANTAPRAZOLE 40 mg was given the previous night.
Management
- On the day of surgery, Tab Metformin 500 mg was withheld, and CBG was repeated 116 mg%. Nebulisation with Duolin and Budecort was given on the day of surgery. Antibiotics Inj Amikacin 500mg iv and Inj Meropenem 1g iv was given.
- The patient was shifted into the operating room, 18G IV cannula was secured on the left hand connected with NS with adequate co-loading around and standard ASA monitors connected.
- HR -102 bpm
- BP- 130/80mm/hg
- SpO2 98%IRA
- The plan was to go ahead with combined spinal and epidural (CSE) anaesthesia. In a sitting position, an Epidural catheter was placed at the 9cm mark at L1-L2 level, test dose was given with 4ml of 1.5% lignocaine with adrenaline and the subarachnoid block was given with 3 mL (2.8 mL of 0.75 % Ropivacaine + 0.2ml(60mcg) of buprenorphine) at L3-L4 level.
- The level of anaesthesia was at T6 and surgery was started. In the intraoperative period, Epidural top-up was given with 0.5% Bupivacaine with 150 mcg buprenorphine post 120 mins of skin incision as the level of anaesthesia regressed.
- The surgical time was 3 hours. Intraoperative vitals are maintained and monitored. The air warmer was kept. Pressure points were padded and the position of the patient was initially left lateral and changed to supine and
- The intraoperative period was uneventful. Fluid input was 1300ml, urine output was 250ml and blood loss was 200ml.
- Postoperative advice was given as oxygen supplementation via Hudson’s mask if required, epidural top-up on the same night and as required, adequate fluids correlating with urine output and early ambulation.
Take home points
- Preoperative investigation like ECG and 2D Echo was done and it was co-related subjectively by the patient’s ability to climb a flight of stairs ( to find out METs -metabolic equivalent . >4 METs is the basic requirement to undergo major surgery)
- The choice of anaesthesia ( regional vs general) plays a vital role in deciding the outcome of surgery, especially in the elderly and also to some extent in preventing postoperative cognitive defects.
- Padding of pressure points was essential to prevent neurological injuries due to the change of position during surgery.
- Warmer was placed to prevent intraoperative hypothermia as shivering increases the oxygen consumption to 300%.
- Adequate fluids were given to replace fluid deficit preoperatively and also to tackle intraoperative fluid shifts as well as maintain urine output as elderly patients are more prone to preoperative AKI.
- Early ambulation helps in preventing bed sores and deep vein thrombosis.
Discussion
1. The anaesthetic management in the geriatric should focus mainly on:
- Age-related physiological changes and their perioperative outcome
- Multiple comorbidities
- Polypharmacy
- Assessment of frailty
- Pre and postoperative cognitive deficits
- Prehabilitation
- Nutrition
- The physiological changes related to age affect all the systems in varied proportions
- Respiratory - decreased chest wall compliance, increased lung compliance, decreased respiratory muscle strength and so on.
- Cardiovascular - impaired sinoatrial node function, conduction abnormalities, decreased adrenergic activity and so on.
- Neurological - decreased neural tissue and cerebral blood flow, autonomic dysfunction and decreased central ventilatory response to hypoxia and hypercapnia
- Renal - decreased renal cortical mass, decreased renal cortical blood flow, decreased concentrating effect of kidneys and altered sodium handling.
- Hepatic - decreased liver mass and hepatic blood flow, decreased first-pass metabolism and drug metabolism
2. Other systemic involvements are decreased skeletal muscle mass, increased body fat, decreased glucose homeostasis and anaemia.
- Elderly patients have multiple comorbidities and polypharmacy may indicate multimorbidity which leads to decreased functional reserve, decreased life expectancy and increased length of hospital stay.
- The duration of the co-morbidity and drug intake and also whether it is regular or not play a crucial role.
- They also have impaired pharmacokinetics and pharmacodynamics to drugs, particularly those used for analgesia and anaesthesia.
- Frailty is a clinical condition characterised by an excessive vulnerability of the individual to exogenous and endogenous stressors.
- The signs and symptoms of frailty include involuntary weight loss, exhaustion, slow gait speed, poor hand grip and sedentary behaviour.
- These five characteristics belong to The Frailty Phenotype, each symptom has 1 point and those with greater than 3 are considered frail and 1-2 are pre-frail.
- Frailty identifies the group of individuals vulnerable to their peers which then increases Intra and postoperative expenditure by 15-60%.
- Ageing is associated with neuronal changes that may lead to reduced cognitive reserve or neurocognitive dysfunction.
- The perioperative neurocognitive disorders(PND) include postoperative delirium, delayed neurocognitive recovery and postoperative neurocognitive disorder.
- The baseline cognitive function should be evaluated with an objective screening tool such as a Mini-Cognitive or Mini-mental state examination.
- Prehabilitation measures such as supervised physical training with strength, flexibility, balance and coordination components enhance both strength and function.
- Malnutrition is seen in up to 20% of frail patients. Serum albumin level is an inexpensive indicator and low less (<3g/dl represents a strong predictor of surgical risk and mortality. Vitamin D and protein requirement of 1.5g/kg/day are considered to attenuate sarcopenia loss of muscle mass and function.
The common problems associated with the elderly
- Airway - edentulous teeth and reduced airway tone increase the risk of airway obstruction with sedation
- Respiratory - due to decreased respiratory reserve, respiratory depressants are used with caution. Postoperative apnoeas are common due to reduced central respiratory drive.
- Cardiovascular - hypotension under anaesthesia both general and regional occurs with greater frequency and intensity than in younger patients.
Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.
About the author of this article: Dr Vignesh N, MD (Anaesthesia & Critical Care) is an Assistant Professor at Meenakshi Medical College and Research Institute in Kanchipuram.
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