Aging Pearls: Anesthesiology Answer Guide
Carol L. Howe, MD, MLS, College of Medicine, University of Arizona
1. An 85 year old female patient with hypertension and gall bladder disease is scheduled for elective cholecystecomy. She has a creatinine of .9 so you are confident her renal function is fine and feel that fluid management pre, intra and post-operatively is not something you need to monitor. Careful or careless thinking? Please discuss reasons. Careless--
“Aging is accompanied by a progressive decrease in renal blood flow and loss of renal parenchyma. By age 80, half of all older persons may have reduced renal blood flow. This is accompanied by renal cortical atrophy, resulting in a 30% decrease in nephrons by the end of middle age. Furthermore, aging is associated with sclerosis of remaining nephrons so that some of those remaining are dysfunctional. Together, these processes result in a progressive decrease in glomerular capillary surface area and glomerular filtration rate. However, because of loss of muscle mass, aging is not associated with an increase in serum creatinine. This physiologic, and often occult, aspect of senescence has practical implications in the perioperative period.”[1] (p. 13)
2. Regional anesthesia, where feasible, is always a better option that general anesthesia for an elderly surgical patient. True or False? Please discuss reasons. False According to Dr. Barker, (Grand Rounds)[2] there are many advantages including avoidance of cognitive dysfunction, cardio-depression, post-op N & V, decreased blood loss and less chance of spinal headache. There are, however, some cons including inducing the equivalent of a sympathectomy with less ability to compensate for hypotension, sympathetic blockade above sensory level of block and induction of cardioaccelerators at T1-T4, increased dependence on accessory breathing muscles, and contraindication in the presence of hypovolemia, infection, coagulapathy or increased ICP.
3. Given the likelihood that elderly patients have co-morbidities and are taking many medications, it is usually a good idea to slightly undertreat pain to minimize drug-drug interactions and avoid over-sedation and the possibility of delirium. True or False? Please discuss reasons. False Undertreating pain can lead to more respiratory compromise, atelectasis and pneumonia. Using only narcotics can increase respiratory depression, hypoxia and hypercarbia.2 Increased pain can often translate into increased risk for post-op delirium. One study showed that patients with no cognitive impairment at baseline who underwent surgery for hip fracture and had poorly controlled post operative pain were 9 times more likely to develop delirium than patients whose pain was well controlled.[3]
4. In general, it is better to use shorter acting than longer acting drugs (where indicated) during the immediate pre-op, intra-operative and post-operative periods (eg midazolam vs. clonazepam, or esmolol vs. propranolol). True or False? Please discuss reasons. True
Shorter acting drugs can be eliminated much more quickly—if there is an adverse effect or simply repeated if patient is tolerating well.2
Last updated 04/13/2011
[1] Cook DJ. Geriatric anesthesia. In: Solomon DH, LoCicero J, Rosenthal RA, American Geriatrics Society, John A. Hartford Foundation, eds. New Frontiers in Geriatrics Research : An Agenda for Surgical and Related Medical Specialties. New York: American Geriatrics Society; 2004:9-52.
[2] Barker S. Anesthesia for the Elderly. Lecture presented at: Geriatric Grand Rounds (Arizona Geriatric Education Center). 2/15/2007, University of Arizona, Tucson, AZ.
[3] Sieber FE, Barnett SR. Preventing postoperative complications in the elderly. Anesthesiol Clin. 2011 Mar;29(1):83-97.