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1、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,http:/www.wfubmc.edu/anesthesia Education: Annual Meeting American Society of Anesthesiologists,Hayflicks View of Aging,“B
2、ecause 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
3、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 yrsAfrican-American 74.7 MEN Caucasian 74.3African-American 67.2,Life Expectancy, Life Span, & Maximum Length of Life,Maximum Length of Life 120 yrs Li
4、fe 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,
5、# 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,
6、901 cataract surgery,Age & Perioperative Outcome,With advancing ageMore surgeryMorbidity increasesMortality increases Cause - disease vs age ?Disease age when 85 yrsIncrease ASA PS when 85 yrs,Preoperative Considerations,Preoperative Assessment No routine preoperative testing Statin myopathic syndro
7、mes 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 Assessme
8、nt - 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 ne
9、ed for the test even if surgery had not been planned.”,Intermediate Risk Noncardiac Surgery (Mortality 1%, 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 7 METs - excellent 4-7 METs - moderate 4 METs - poor J Am Coll Cardiol 199
10、6; 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, wal
11、k 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
12、: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,
