WHATS NEW IN GERIATRIC ANESTHESIA

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WHATS NEW IN GERIATRIC ANESTHESIA?

• Raymond C. Roy, PhD, MD
• Professor Chair of Anesthesiology
• Wake Forest University School of Medicine
• Winston-Salem, North Carolina 27157-1009
• rroy_at_wfubmc.edu

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If she were born today, what would be her life
expectancy?
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LIFE EXPECTANCY AT BIRTH USA - 2002

• WOMEN Caucasian 80.3 yrs
• African-American 75.7
• MEN Caucasian 75.3
• African-American 68.9

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Obesity in Older Men with BMI gt 29.2Flegal.
JAMA 2002 2881723
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Obesity A Potential Decline in Life Expectancy
in the U.S. in the 21st Century
Olshansky et al N Engl J Med 2005 3521139-45
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AGE LIMITS

• Reproductive (women) lt 50 yrs
• Life expectancy (USA) 70-80
• Premature death (trauma, disease)
• Life span 85-100
• Natural death (no trauma, disease)
• Maximum length of life 120

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Anesthetics per 100 Population per YearClergue
et al Anesthesiology 1999 911509 (Fr)
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IN-HOSPITAL DEATH RATESELECTIVE, NON-CARDIAC,
SURGICAL PATIENTSPolanczyk et al Ann Int Med
2001 134637
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EPIDEMIOLOGIC CONCLUSIONS

• Increasing
• life-expectancies
• and older patients
• anesthetics with ? age
• Mortality Morbidity with ? age
• Significant evidence that we can reduce this M M

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PREOPERATIVE PREPARATIONMortality Morbidity
Reduction

• ß-blockers, statins
• Diastolic dysfunction
• Digoxin
• Contrast nephropathy
• Diabetes mellitus

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MI AFTER AAA SURGERYKertai et al.
Anesthesiology 2004 1004-7
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CLINICAL RISK FACTORS

• Age 70 yrs
• Angina
• Past MI
• CHF

• Past CVA
• DM
• CRI
• COPD

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MYOCARDIAL INFARCTION AFTER AAA SURGERY ( 3
RISK FACTORS)Kertai et al. Anesthesiology 2004
1004-7
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EFFECT OF ß-BLOCKERS ON TROPONIN RELEASE DURING
MAJOR NONCARDIAC SURGERY IN PATIENTS WITH
ISCHEMIC HEART DISEASE

• Elevated troponin I
• Atenolol - 22 (9/40)
• No atenolol 42 (8/19)
• troponin I appeared during surgery
• Zaugg Anesthesiology 1999 911674

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DEATH BY 42 DAYS () VS TROPONIN I RELEASE IN
PATIENTS WITHOUT ST ELEVATIONS
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CONCLUSIONS HIGH RISK

• Clear benefit to ß-blockers
• pre-/intra-/post-op
• targets HR 55-65, SBP gt100
• Auerbach JAMA 2002 2871435
• esmolol boluses intra-op insufficient
• Statins pre-/post-op?

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REVISED CARDIAC RISK INDEX

• RCRI - one point each for
• High risk surgery
• Intrathoracic, intraperitoneal, suprainguinal
  vascular
• Ischemic heart disease
• Cerebrovascular disease
• Renal insufficiency
• Diabetes mellitus
• Lindenauer et al N Engl J Med 2005 353349-61

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Adjusted Odds Ratio for Death Associated with
Perioperative ß-Blockade in Patients Undergoing
Major Noncardiac Surgery
RCRI Revised Cardiac Risk Index
Lindenauer et al N Engl J Med 2005 353349-61
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CONCLUSIONS LOW RISK

• ß-blocker controversy
• No benefit Juul AHA Abstract 2004
• 921 diabetic patients, non-cardiac surgery,
  metoprolol
• Harm Lindenauer et al N Engl J Med 2005
  353349-61 ( gt600,000 patients)
• Two ongoing randomized trials (results in 4 yrs)
• POISE Perioperative Ischemic Evaluation
  10,000 patients
• DECREASE IV 6000 patients
• Recommendation still yes to ß-blockers
• Poldermans, Boersma N Engl J Med 2005 353412-4
  (Editorial)

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STATIN MYOPATHIC SYNDROMESThompson et al JAMA
2003 2891681

• MYOPATHY
• Any muscle complaint coincident with start of
  statin therapy
• MYALGIA
• CK normal
• MYOSITIS
• CK elevated
• RHABDOMYOLYSIS
• CK gt 10 x normal

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PREOPERATIVE PREPARATIONMortality Morbidity
Reduction

• ß-blockers, statins
• Diastolic dysfunction
• Digoxin
• Contrast nephropathy
• Diabetes mellitus
• Preoperative testing

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Groban J Cardiothorac Vasc Anesth 2005
19228-36
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DIASTOLIC DYSFUNCTION vs AGERedfield et al
JAMA 2003 289194
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DIASTOLIC DYSFUNCTION DIAGNOSIS

• Symptoms of left ventricular heart failure
• Flash pulmonary edema
• Normal ejection fraction (gt 50)
• Elevated B-type natriuretic peptide (BNP)
• Normal lt DD without failure lt DD with failure
• Enlarged left atrium
• Increased diastolic filling pressure
• Echocardiographic surrogates for invasive
  measurement
• isovolemic relaxation time
• E to A ratio
• atrial flow reversal

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NEW DIAGNOSTIC TEST FOR CHFBNP

• Congestive Heart Failure
• A-type natriuretic peptide - secreted by atria in
  response to chamber dilation
• B-type natriuretic peptide - secreted by
  ventricles in response to increased end-diastolic
  pressure and volume expansion
• Maisel. N Engl J Med 2002 347163
• Differentiates dyspnea cardiac vs. pulmonary

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B-type Natriuretic Peptide Plasma LevelsMaisel.
N Engl J Med 2002 347163
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DIASTOLIC DYSFUNCTION TREATMENT

• Treat exacerbating factors
• ischemic heart disease, hypertension
• Be careful with nitrates
• Maintain slow (60-70 bpm) sinus rhythm
• Prevent volume overload
• but do not run too dry
• Be careful with diuretics
• Prevent/reduce hypertrophy

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PREOPERATIVE PREPARATIONMortality Morbidity
Reduction

• ß-blockers, statins
• Diastolic dysfunction
• Digoxin
• Contrast nephropathy
• Diabetes mellitus
• Preoperative testing

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All Cause Mortality Rates vs. Serum Digoxin
Concentration
Rathore et al JAMA 2003 289871-8
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NEW (LOWER) THERAPEUTIC LEVELS FOR DIGOXIN

• Patients with CHF
• Therapeutic 0.5-0.8 ng/ml
• Placebo 0.8-1.2 ng/ml
• Increased M M gt 1.2 ng/ml
• Rathmore JAMA 2004 289871

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PREOPERATIVE PREPARATIONMortality Morbidity
Reduction

• ß-blockers, statins
• Diastolic dysfunction
• Digoxin
• Contrast nephropathy
• Diabetes mellitus
• Preoperative testing

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CONTRAST NEPHROPATHY DEFINITION

• INCREASE IN SERUM CREATININE
• Criteria variable from study to study
• 0.5 mg/dl, 1.0 mg/dl, 25, or 50
• WITHIN 7 DAYS OF CONTRAST STUDY
• Peak 1-5 days (usually 2-3 days)
• Duration 2 weeks

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CONTRAST NEPHROPATHY INCIDENCE

• If normal creatinine lt 2
• If elevated creatinine 12-50
• Incidence vs. osmolality
• High gt Low gt Iso-osmolar
• 1st generation gt 2nd gt 3rd
• Demonstrated in patients with increased
  creatinine
• Sandler N Engl J Med 2003 348551

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CONTRAST NEPHROPATHY POTENTIAL CONSEQUENCES

• Disease state requiring contrast study
• Contrast study nephropathy
• More likely if
• pre-existing renal injury or disease
• concomitant nephrotoxic drug administration
• hypotension, hypovolemia, low CO
• Acute renal failure

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CONTRAST NEPHROPATHY PREVENTION

• Normovolemia
• MAP 90-110 mmHg
• Palmer N Engl J Med 2002 348491
• Sodium bicarbonate infusion
• Merten et al JAMA 2004 2912328
• Controversial vs ineffective
• Diuretics, dopamine, fenoldopam, adenosine
  antgonists, N-acetylcysteine, hemofiltration
• Chertow JAMA 2004 2912376.

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Appropriate Blood Pressure for Patients with
Contrast Nephropathy
Palmer N Engl J Med 2002 348491
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CONTRAST NEPHROPATHY WHAT TO DO?

• Ideally - postpone surgery
• Creatinine returns to baseline (1-2 weeks)
• If have to proceed
• Normovolemia, MAP 90-110 mmHg, normal CO
  (dopamine infusion if low), cis-atracurium
• Avoid nephrotoxic drugs
• metformin, NSAIDs, ACE inhibitors, methicillin,
  sevoflurane (?), succinylcholine (?)
• Price Br J Anaesth 2003 91909

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PREOPERATIVE PREPARATIONMortality Morbidity
Reduction

• ß-blockers, statins
• Diastolic dysfunction
• Digoxin
• Contrast nephropathy
• Diabetes mellitus 10 older patients
• Preoperative testing

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PROBLEMS WITH ORAL HYPOGLYCEMIC AGENTSGu
Anesthesiology 2003 981359

• Sulfonylureas discontinue
• Predispose to myocardial ischemia
• Metformin discontinue
• Lactic acidosis
• Thiazolidinediones continue?
• Actos, Avandia
• Sensitize response to insulin
• Better intraoperative control?
• Kersten et al Anesthesiology 2005 103677-8

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DIABETES MELLITUSTight Control of GlucoseGu.
Anesthesiology 2003 981359

• Perioperative insulin infusions
• Glucose 80-150 mg/dl intraop
• Glucose 80-110 mg/dl postop
• Reduces ICU mortality by 40
• Improves outcome from acute MI
• Decreases infections

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Ouattara et al Poor intraoperative blood
glucose control is associated with a worsened
hospital outcome after cardiac surgery in
diabetic patients. Anesthesiology 2005
103687-94.

• Attempted tight glycemic control in all patients
• 18 insulin resistance ? poor control
• Morbidity
• Poor control 37 (odds ratio 7.2)
• Tight control 10
• Could not predict poor control preop
• Identifies vs. responsible for higher risk?

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INTRAOPERATIVE BLOOD GLUCOSE CONCENTRATIONS IN
DIABETIC CARDIAC SURGERY PATIENTS WITH SAME
INSULIN REGIMEN
Ouattara et al Anesthesiology 2005 103687-94
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IN-HOSPITAL MORBIDITY VERSUS INTRAOPERATIVE
GLUCOSE CONTROL
Ouattara et al Anesthesiology 2005 103687-94
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Kersten, Warltier, Pagel Aggressive control of
intraoperative glucose concentration. A shifting
paradigm? Anesthesiology 2005 103677-8
(Editorial)

• strong evidence exists to indicate
  hyperglycemia alone, with or without diabetes,
  contributes to morbidity and mortality in
  patients at risk for myocardial ischemia and
  reperfusion injury
• Speculated thiazolidinedione insulin
  sensitizing agents may improve patient outcome by
  enhancing degree to which tight control of blood
  glucose concentrations may be achieved with
  exogenous insulin. Actos, Avandia

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PREOPERATIVE PREPARATIONMortality Morbidity
Reduction

• ß-blockers, statins
• Diastolic dysfunction
• Digoxin
• Contrast nephropathy
• Diabetes mellitus
• Preoperative testing

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OBTAIN PREOPERATIVE TESTS?

• Screening NO
• Except urinalysis if hip surgery or acutely ill
• Cook Anesth Analg 2003 961823
• Treatment effectiveness MAYBE
• Yes, if recently started, change of symptoms
• No, if long term
• Baseline MAYBE, but overused
• Risk Assessment - YES

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PREOPERATIVE TESTING BEFORE LOW RISK SURGERY

• 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.
• Schein N Engl J Med 2000 342168

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INTRAOPERATIVE CONSIDERATIONS

• Intravenous anesthesia drug doses
• MAC appropriate anesthetic depth
• Neuromuscular blocking agents

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INTRAOPERATIVE CONSIDERATIONS

• Intravenous anesthesia drug doses
• MAC appropriate anesthetic depth
• Neuromuscular blocking agents

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MAC AGENickalls. Br J Anaesth 2003 91170
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Most of Us Overdose Elderly

• Gas monitors
• Assume patient is 40 yrs old
• Do not know opioids lower MAC
• Do not know spinals epidurals lower MAC
• Underestimate brain concentration on emergence
• BIS 45-60 better than BIS lt 45?

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I believe Terri Monk!

• Monk et al Anesthetic management and one-year
  mortality after noncardiac surgery. Anesth Analg
  2005 1004-10
• Patient comorbidity
• Cumulative deep hypnotic time (BIS lt 45)
• Intraoperative systolic hypotension
• Cohen NH Anesthetic depth is not (yet) a
  predictor of mortality! Anesth Analg 2005
  1001-3 Editorial

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MY USUAL MAINTENANCE REGIMEN

• lt 0.8 MAC inhaled agent
• BIS 45-60
• Rocuronium or cisatracurium
• Dose based on lean body weight
• Fentanyl up to 250 µg, then morphine
• Preemptive analgesia
• Mg, low dose ketamine, lidocaine infusion (1
  mg/min)
• Hemodynamic control
• ? BP phenylephrine infusion (DBP gt 60 mmHg)
• ?HR ?BP - ß-blockers (labetalol, metoprololgt
  esmolol)

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INTRAOPERATIVE CONSIDERATIONS

• Intravenous anesthesia drug doses
• MAC appropriate anesthetic depth
• Neuromuscular blocking agents

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NEUROMUSCULAR BLOCKING AGENTS IN THE ELDERLY

• Same initial dose as in younger
• Longer onset times with
• Advanced age
• Vecuronium vs rocuronium
• Tullock. Anesth Analg 1990 7086
• Esmolol infusions
• Szmuk. Anesth Analg 2000 901217

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RELAXANT ONSET TIME (sec) INCREASES WITH
ADVANCING AGE Koscielniak-Nelson Anesthesiology
1993 79229
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NEUROMUSCULAR BLOCKING AGENTS IN THE ELDERLY

• Longer duration
• Advanced age (except cisatracurium)
• Intraoperative hypothermia (34.7o C)
• Diabetes mellitus (10 of elderly)
• Obesity, if dose mg/kg total body weight

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Temperature Time-to-25-Recovery from
Vecuronium 0.1 mg/kg Caldwell. Anesthesiology
2000 92 84
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Time (min) to Reappearance of T1 - T4 after
Vecuronium 0.1 mg/kg in Patients with DMSaito
Br J Anaesth 2003 90480
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Rocuronium gt Vecuronium gt 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 gt rocuronium if renal
  insufficiency

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POSTOPERATIVE CARDIAC CONSIDERATIONS

• Myocardial ischemia vs. infarction
• New T-wave inversions

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Typical Progression of Coronary Atherosclerosis
Abrams N Engl J Med 2005 3522524-33

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MYOCARDIAL INFARCTIONversus ISCHEMIA

• ISCHEMIA
• OXYEN DEMAND gt SUPPLY
• STABLE ATHEROSCLEROTIC PLAQUE
• ASYMPTOMATIC lt gt STABLE ANGINA lt gt ? non-Q-wave,
  non-ST elevation INFARCTION ?
• Q-WAVE INFARCTION
• OCCLUDING THROMBUS
• RUPTURE OF UNSTABLE PLAQUE
• ACUTE CORONARY SYNDROME

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Timing of Perioperative MI in Non-cardiac Surgery
Patients (18/323)Badner. Anesthesiology 1998
88561
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WHAT IS THE INCIDENCE AND TIMING OF PERIOPERATIVE
MYOCARDIAL INFARCTIONS?

• Since the 1970s the timing and character of
  perioperative myocardial infarction has shifted
  from a predominance of Q-wave myocardial
  infarction peaking between postoperative days 2
  and 3 with a high mortality (25-50) to
  earlier-occurring non-Q-wave myocardial
  infarction with a lower mortality
• London Anesthesiology 2004 100170.

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DIAGNOSING MYOCARDIAL INFARCTIONS

• Decreasing order of sensitivity specificity
• 1. Cardiac troponins new standard
• 2. CK-MB
• 3. ECG old standard

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CARDIAC TROPONINS VS CK-MB

• Cardiac troponins I or T
• Microinfarctions can produce elevations in
  cardiac troponins in blood that are not
  associated with elevations of the CK-MB
• Silent infarctions
• Non-ST elevation infarctions
• Non-Q-wave infarctions
• MB fraction of creatine kinase (CK-MB)
• ST elevation infarctions
• Q-wave infarctions

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POSTOPERATIVE CARDIAC CONSIDERATIONS

• Myocardial ischemia vs. infarction
• New T-wave inversions

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FREQUENCY OF NEW T-WAVE CHANGES IN PACU

• 18 of 394 consecutive patients
• Breslow. Anesthesiology 1986 64 398
• Young old, regional general
• 46 flattening 25 - inversion
• No S/S of myocardial ischemia
• 21 of 206 TURP patients
• Ashton. J Am Geriatr Soc 1991 39 575
• No S/S of myocardial ischemia
• No elevations of CK-MB
• Before troponin

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NEW T-WAVE CHANGES IN PACU WHAT TO DO

• Usually benign, transient
• Aggressively work up if
• Pulmonary edema or CHF
• LV hypertrophy, aortic stenosis, or ASH (IHSS)
• Significant HR, BP changes from preop
• Cardiac work up includes
• Serial troponin, CK-MB, BNP
• 12-lead ECG, physical exam
• ECHO (?), CXR (?), cardiology consult (?)

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TEN WAYS TO IMPROVE ANESTHESIA IN OLDER PATIENTS

• Administer ß-blockers ( statins)
• Check digoxin levels
• Beware of contrast nephropathy
• Timely antibiotic administration
• Tighter control of blood glucose levels

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TEN WAYS TO IMPROVE ANESTHESIA IN OLDER PATIENTS

• 6. Tighter control of fluid administration
• Administer less anesthesia
• Rocuronium or cisatracurium
• Diastolic pressure gt 60 mmHg
• 10. Aggressively treat myocardial ischemia