Geriatric Anesthesia – Flashcards
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The percent maximum physiologic function decreases with age after _____ years.
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The percent maximum physiologic function decreases with age after 25-32 years (30 years).
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Pulmonary complications with surgery increase in elderly based on :
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Pulmonary complications with surgery increase in elderly based on duration of surgery, obesity and patient age greater than 70. .
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These Increase in geriatric cardiovascular : .
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-LV wall thickness - Left ventricular wall hypertrophy can exist without arterial hypertension. LV wall is thicker and less elastic exhibiting symmetric hypertrophy and an increase in collagen cross linking in the myocardial cytoskeleton. -LV hypertrophy results from chronic increase in afterload to left ventricular ejection imposed by elevations in PVR (decreased arterial compliance) -LV wall tension -Due to chronic increase in afterload seen in elderly; The law of Laplace applies. Stiffer vessels (harder to receive blood) like PVC pipe. Ventricle doing more work. Large arteries and the aorta do not have the ability to store energy during systole (the windkessel effect); this will elevate the ventricular wall tension and cardiac workload -heart size and tissue mass -Afterload - due to decrease in arterial compliance and impedence to LV output increases -Cardiac workload - decrease in arterial compliance results in increases in afterload , systolic pressure, and LV hypertrophy ; -Systemic BP -systolic arterial hypertension due to fibrotic replacement of elastic tissues. (vessels become less compliant); decrease in arterial compliance -Systolic BP - usually seen with increased arterial pulse pressure. Peripheral Vascular Resistance - The increase in peripheral vascular resistance is greater than the decrease seen in cardiac output, because blood vessels are less compliant. Circulation Time - reduced myocardial pump function leads to reduced cardiac output, which prolongs circ time. Conduction system fibrosis - Conduction fibrosis and loss of SA node cells will increase the incidence of dysrhythmias Incidence of dysrhythmia based on Conduction fibrosis and loss of SA node cells. SA node cell loss Do not replicate properly anymore. vagal tone Increases - decrease in sensitivity of adrenergic receptors leads to decreases in heart rate. Symptoms of diastolic dysfunction
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These remained unchanged in geriatric cardiovascular: .
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-Diastolic BP -Resting systolic function -Excitatory-contraction coupling and -metabolism of ionized calcium are unchanged. -Ionized calcium -cardiac Contractile proteins
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These decrease in geriatric: cardiovascular :
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-Cardiac reserve - Manifested as exaggerated drops in BP -myocardial reserve -Cardiac output - related to the aging process and an increase in afterload. -Maximum cardiac output -Cardiac index - An appropriate response to reduced requirements for perfusion and metabolism that results due to age related atrophy etc. -Resting HR - due to a increase in vagal tone and decreased sensitivity of adrenergic receptors; normal aging loss of one beat per minute for each year over 50. Heart rate - maximum -LV compliance - Based on stiffer (less compliant) myocardial fibers and replacement of these fibers with non-muscle connective tissue. The left ventricle thickens and becomes less elastic with age -Arterial compliance -Stroke volume - a decreased myocardial pump fx leads to decreased stroke volume and decreased cardiac output. -Coronary blood flow -Perfusion to vital organs -Organs with a major blood supply atrophy as you age. Loss of tissue mass in many organs. -Chronotropic and ionotropic response - a decrease in adrenrgic receptor quality. -Baroreceptor function - due to decreased sensitivity of stretch receptors owing to normal aging processes. -Adrenergic sensitivity - a decrease in adrenergic receptor quality.
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Arterial compliance
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Reduced arterial elasticity caused by fibrosis of the media results in a reduction in arterial compliance which may cause an increase in afterload, elevated systolic blood pressure, and eventually left ventricu¬lar hypertrophy
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Does the heart atrophy?
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The heart does not atrophy with age; size and tissue mass increase
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Because of diastolic dysfunction what are the elderly the elderly more dependent upon?
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Age-related diastolic dysfunction causes the elderly to be more dependent on atrial contraction (atrial kick)
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What increases the incidence of dysrhythmias in the elderly?
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Fibrolysis of the conduction system and loss of sinoatrial nodal cells increase the incidence of dysrhythmias in the elderly?
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Cardiac contractile proteins at the cellular level in the elderly?
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There is no change in cardiac contractile proteins at the cellular level
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Diastolic dysfunction in the elderly can be detected how? What are the symptoms of Diastolic dysfunction in the elderly?
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Diastolic dysfunction can be detected with Doppler echocardiography; Symptoms are systemic hypertension, coronary artery disease, cardiomyopathies, and valvular heart disease, especially aortic stenosis
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What can Diastolic dysfunction lead to in the elderly? .
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Diastolic dysfunction results in large increases in ventricular end-diastolic pressure with small changes in left ventricular volume. This may lead to atrial enlargement with subsequent atrial fibrillation and congestive heart failure
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What leads to exaggerated drops in blood pressure during induction of anesthesia in the elderly?
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Decreased cardiac reserves may result in exaggerated drops in blood pressure during induction of anesthesia
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How does prolonged circulation time (takes longer) affect intravenous drugs in the elderly?
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Prolonged circulation time (takes longer) delays the onset of intravenous drugs, but speeds induction with inhalation agents.
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How does prolonged circulation time (takes longer) affect inhalation agents in the elderly?
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Prolonged circulation time (takes longer) delays the onset of intravenous drugs, but speeds induction with inhalation agents.
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Elderly patients (and infants) have a diminished ability to increase or decrease heart rate in response to hypovolemia, hypotension, or hypoxia.
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Elderly patients (and infants) have a diminished ability to increase heart rate in response to hypovolemia, hypotension, or hypoxia.
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The elderly have a contracted state of the vasculature that may result in a higher than expected ?
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The elderly have a contracted state of the vasculature that may result in a higher than expected plasma concentration of drugs.
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The elderly have increased or decreased lipid storage sites?
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The elderly have increased lipid storage sites that lead to a greater reservoir for lipid soluble drugs.
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Younger pts. shiver at ____ C , pts over 80 shiver at ____C.
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Younger pts shiver at 36.1°C , pts over 80 shiver at 35°C. Shivering increases O2 consumption 400% which leads to hypoxia, acidosis, and cardiopulmonary compromise.
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Cardiac function declines by _____%
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50% (20-80 years old)
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Why are arteries less compliant in the elderly? .
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Peripheral vasculature has increased wall thickness, increased diameter, and consequent stiffening of the aorta and lg arteries, leading to less ability to vasodilate.
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T or F Elderly have loss of elasticity throughout arterial tree along with loss of arterial distensibility.
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True
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Systemic hypertension is common in the elderly due ______________?
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Systemic hypertension is common due to poorly compliant blood vessels, decreases in CO and increases in peripheral vascular resistance.
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Myocardial changes in the elderly include: ?
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Myocardial changes in the elderly include: increased left ventricular wall thickness, decreased myocardial compliance, and thicjkening of aortic valve cusps, producing midsystolic ejection murmur.
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Left ventricular hypertrophy results from ?
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Left ventricular hypertrophy results from increased afterload, secondary to elevated peripheral vascular resistance.
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Prolonged circulation time is a result of ?
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Prolonged circulation time is a result of impaired myocardial pump function and reduced cardiac output.
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Increased circulation time has what implications for the elderly? .
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Increased circulation time causes a decreased perfusion to vessel rich organs like brain, heart, and liver. Delay onset of drugs and slow onset of effects.
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When the elderly need an increase in cardiac output they depend on what?
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They are more dependent on an increase in end diastolic volume than an increased heart rate to produce an increase in CO. They are more prone to CHF when large volumes of IV fluids are given in the presence of anesthesia induced myocardial depression and hypotension.
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What happens to the aging myocardium in the elderly?
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The aging Myocardium becomes thicker in both systole and diastole, increases in the size (hypertrophy) and number (hyperplasia) of individual myocytes occurs and adipose tissue infiltrates as well.
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Atrial contraction accounts for ______ of left ventricular end-diastolic volume. Loss of atrial kick will result in decreased BP.
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Atrial contraction accounts for 20% of left ventricular end-diastolic volume. Loss of atrial kick will result in decreased BP.
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T or F There is a decrease in chronotropic and inotropic cardiac function.
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True There is a decrease in chronotropic and inotropic cardiac function.
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How is contractility affected in the elderly ?
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Catecholamine effects that enhance calcium ion transport (contractility) are less pronounced in the elderly.
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Discuss Elderly and increased risk for aspiration: .
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Vocal cord stimulation for closure: Increased The stimulus needed for vocal cord closure (protection) is markedly elevated. Airway obstruction - Increased The normal aging process naturally decreases the sensitivity of the need to clear secretions, food, etc. The naturally occurring decrease in laryngeal reflexes compounds the problem. Risk of aspiration - Increased Due to vocal cord stimulation being elevated, thus putting the patient at risk for aspiration. Also, chest wall rigidity increases while muscle strength decreases. The ability to cough is decreased, as is maximal breathing capacity. Pulmonary complications - Increased Aspiration pneumonia is common and life-threatening due to a decrease in protective laryngeal reflexes with age. Also, the decreased ability to cough adds to increased pulmonary complications.
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Discuss Elderly and Physiologic dead space
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Physiologic dead space - Increased Breakdown of alveolar septae reduces total alveolar surface area, increasing both anatomic and physiologic dead space. These changes disrupt the normal matching of ventilation and perfusion within the lungs, increasing both shunting and deadspacing.
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Discuss Elderly and Work of breathing
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Work of breathing - Increased Skeletal calcification and increased airway resistance increase the work of breathing in subjects who are elderly and predisposes them to acute postoperative ventilatory failure.
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Discuss Elderly and Potential for hypoxia
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Potential for hypoxia - Increased The causes are multiple. It starts with decreased elasticity of lung tis¬sues, which reduces alveolar surface area and decreases the effi¬ciency of gas exchange. There is airway collapse, a decrease in normal oxygen tension, ventilation-perfusion mismatch, and increase in preoxygenation time and higher inspired oxygen concentration.
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Discuss Elderly and FRC
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Increase of FRC (modest) - Increased Approximately 30% of alveolar wall tissue is lost between ages 20 to 80 years, diminishing elastic recoil and parenchymal traction that maintains airway patency (loss of interdependence). This produces increased residual volume, closing volume, and functional residual capacity. Like a little oxygen tank that they are carrying around. Elderly need a bigger tank.
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Discuss Elderly and Closing volume & closing capacity
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Closing volume & closing capacity (dramatic increase) - Increased closing capacity is caused by airway collapse and the distribution of tidal volume to areas of the lung that are less perfused.
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Discuss Elderly and Alveolar compliance
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Alveolar compliance - Increased This increase is caused by the absorption of connective tissue and this results in a loss of "protective netting" to restrict or limit the expansion of the alveoli.
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Discuss Elderly and Respiratory depression with opioids
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Respiratory depression with opioids - Increased Along with the normal respiratory changes due to aging, opioids produce changes ranging from respiratory depression to apnea in a dose-dependent manner.
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Describe geriatric lung tissue:
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Normally sclerotic lung tissue, not very compliant. Have alveoli compliance, blows up readily, but no recoil, not as elastic. Chest wall is not compliant. .
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Elastin fibers in the elderly?
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Elastin fibers (reduced elasticity) Normal process in aging
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Elderly Chest wall and tissue elasticity.
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Tissue elasticity As noted above, and in a tissue-dependent manner, some muscle is replaced with adipose tissue and less-elastic components. Lung recoil - The chest wall is less compliant (stiffer, less elastic); if the chest wall does not expand upward and outward, the lung will not expand fully, nor recoil fully.
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Ability to cough in the elderly?
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Ability to cough - Decreased muscle strength decreases the ability to cough, and it takes more stimulation to cough.
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Alveolar surface area in the elderly?
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Alveolar surface area (functional) - Alveolar wall tissue decreased, and there is a loss of recoil, therefore there is decreased airway patency.
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Chest wall compliance in the elderly?
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Chest wall compliance - Cartilage and connective tissues become stiffer (less compliant). Increased stiffness of the thoracic cage and progressive dorsal kyphosis are accompanied by upward and anterior rotation of the ribs and sternum, which lead to an increase in the anterior-posterior diameter of the chest and restricted chest expansion.
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Vital capacity, expiratory reserve volume, and inspiratory reserve volume in the elderly?
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Vital capacity, expiratory reserve volume, and inspiratory reserve volume - As residual lung volume increases, there is a decrease in vital capacity, expiratory reserve volume, and inspiratory reserve volumes
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Response to hypoxia & hypercapnia in the elderly?
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Response to hypoxia & hypercapnia - There is a decreased respiratory response to hypoxia and hypercapnia.
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Protective reflexes in the elderly?
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Protective reflexes - Laryngeal responses are blunted in the elderly.
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Cervical spine & TMJ mobility in the elderly?
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Cervical spine & TMJ mobility - Inability to flex or extend the neck and a small mouth opening can make intubation challenging.
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Ease of mask ventilation in the elderly?
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Ease of mask ventilation - Often the geriatric patient is edentulous and there is no support for a tight face mask fit.
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Indicate how the following lung parameters changes with aging .
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RV increased ERV decreased FRC increased CC increased IC decreased VC decreased TLC decreased (TV): tidal volume changes minimnally with aging.
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Elastin and collagen in the geriatric lung? By 70 years of age how much decrease in functional alveolar surface area?
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The reduction in elastic tissue along with an increased amount of collagen = 15% reduction of functional alveolar surface area by 70 years of age.
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The changes in chest wall and lung _________ impair matching of ventilation and perfusion in the elderly?
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The changes in chest wall and lung compliances impair matching of ventilation and perfusion. Physiologic shunt is increased and the efficacy of oxygen exchange is reduced at the cellular level.
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What changes in FEV1 and Forced Vital capacity (FVC) are seen in the elderly. What causes the changes?
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Progressive decreases in forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) is caused by loss of elastic tissue around the alveoli and alveolar ducts. These changes cause the alveoli to remain more distended at rest (air trapping) and less distensible upon inspiration.
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What happens during forced expiratory maneuvers in the elderly?? The volume of gas that can subsequently be exhaled is the ________. _____________ is the closing volume plus the residual volume.
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During forced expiratory maneuvers, airways begin to close. The volume of gas that can subsequently be exhaled is the closing volume. The closing capacity is the closing volume plus the residual volume.
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As closing volume increases in the elderly, the greater or less the amount of gas that "remains behind" in the alveoli and airways. .
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As closing volume increases, the greater the amount of gas that "remains behind" in the alveoli and airways. .
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Closing capacity is greater than functional residual capacity in anesthetized elderly patients.
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Closing capacity is greater than functional residual capacity in anesthetized elderly patients. More dependent airways are collapsed and more of the tidal volume is distributed to areas of the lung that are underperfused. This combination manifests as atelectasis in dependent lung regions. .
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Total lung capacity (TLC) and the geriatric pt? Why?
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Total lung capacity (TLC) declines about 10% by age 70, reflecting a loss in height due to deterioration of intervertebral disks. .
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Increase in A-P diameter of the chest and restricted chest expansion in the elderly is due to ?
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Increased stiffness (greater elasticity) of the thoracic cage and dorsal kyphosis will cause anterior and upward rotation of the ribs and sternum, leading to an increase in A-P diameter of the chest and restricted chest expansion. .
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Contributors to a decline in gas exchange in the elderly include:
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Other contributors to a decline in gas exchange include: reduction in alveolar surface area, increased alveolocapillary membrane thickness, and reduction in pulmonary capillary blood volume. Taken together, arterial oxygen tension declines with age. .
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Alveolar-arterial oxygen difference (A-a gradient) increases from ___ mm-Hg at 20 years of age to more than ___ mm-Hg at 70 years of age. .
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Alveolar-arterial oxygen difference (A-a gradient) increases from 8 mm-Hg at 20 years of age to more than 20 mm-Hg at 70 years of age.
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Pa02 decreases ______ per year after 20 years of age. T or F There is a decrease in reactivity of protective airway reflexes, such as coughing and swallowing, due to diminished laryngeal and pharyngeal reflexes.
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Pa02 decreases 0.5 mm-Hg per year after 20 years of age. You may need to watch for hypoxia and hypercarbia postoperatively. The elderly may require higher inspired oxygen concentrations because of lower Pa02 levels and reduced efficiency of gas exchange. There is a decrease in reactivity of protective airway reflexes, such as coughing and swallowing, due to diminished laryngeal and pharyngeal reflexes. The risk of pulmonary aspiration increases.
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Problems with induction in the elderly: .
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A difficult fit of the anesthesia mask on edentulous patients may occur. Intubation may be difficult based on limited neck flexion and extension, cervical arthritis, and osteoarthritis.
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Insulin resistance and the elderly? Why? .
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Decreased Pancreatic function declines and diabetes mellitus increases (glucose metabolism is impaired). Mechanisms responsible for elevelated blood glucose: ■ sluggish insulin response to hyperglycemia. ■ resistance to the effects of insulin at peripheral receptors. Frequent intraoperative blood glucose monitoring may be beneficial to patient status.
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Heat loss and the elderly?
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Increases Heat production decreases, heat loss increases, hypothalamic temperature regulating centers may reset to a lower level, predisposing the patient to hypothermia.
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Heat production and the elderly?
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Decreased Heat production decreases, heat loss increases, hypothalamic temperature regulating centers may reset to a lower level, predisposing the patient to hyperthermia.
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Basal oxygen consumption and the elderly? .
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Decreased Basal and maximal oxygen consumption decline as one ages due to general loss of lean body mass
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Hypothalamic temperature regulation and the elderly? .
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Decreased Heat production decreases, heat loss increases, hypothalamic temperature regulating centers may reset to a lower level, predisposing the patient to hyperthermia.
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Liver mass and the elderly?
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Decreased Hepatic blood flow decreases with age, but the hepatocellular function changes very little. Reduced hepatic blood flow and a potential reduction in microsomal enzyme (P450) function impairs the liver's ability to metabolize anesthetics and nondepolarizing neuromuscular blocking drugs. Reduced liver tissue mass and blood flow are responsible for inadequate perioperative hepatic function in the geriatric surgical patient. Plasma clearance of drugs metabolized by the liver liver is reduced.
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Hepatic blood flow and the elderly?
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Decreased Hepatic blood flow decreases with age, but the hepatocellular function changes very little. Reduced hepatic blood flow and a potential reduction in microsomal enzyme (P450) function impairs the liver's ability to metabolize anesthetics and nondepolarizing neuromuscular blocking drugs. Reduced liver tissue mass and blood flow are responsible for inadequate perioperative hepatic function in the geriatric surgical patient.
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Liver metabolism and the elderly?
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Decreased Hepatic blood flow decreases with age, but the hepatocellular function changes very little. Reduced hepatic blood flow and a potential reduction in microsomal enzyme (P450) function impairs the liver's ability to metabolize anesthetics and nondepolarizing neuromuscular blocking drugs. Reduced liver tissue mass and blood flow are responsible for inadequate perioperative hepatic function in the geriatric surgical patient.
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Metabolism of benzodiazepines in the elderly?
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Metabolism of benzodiazepines in men is decreased. Plasma cholinesterase levels are reduced in elderly men.
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Synthesized plasma cholinesterases and the elderly?
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Decreased Plasma cholinesterase levels are reduced in elderly men.
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Basal oxygen consumption and the elderly?
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Decreased
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Gastric pH and the elderly?
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Gastric pH rises (more alkaline), gastric emptying is prolonged and decreased, concern for full stomach.
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Biotransformation and the elderly?
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Decreased Liver function is dereased.
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Albumin production and the elderly?
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Decreased
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Cerebral cortex neuron loss CSF Degeneration of peripheral nerve cells Spinal duration of action Sensory block with spinals in the elderly. Epidural volume cephalad spread •
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Cerebral cortex neuron loss CSF Degeneration of peripheral nerve cells Spinal duration of action Sensory block with spinals Epidural volume cephalad spread • T8 for turp
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Proprioception threshold Hearing threshold Temperature threshold Touch threshold in the elderly?
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Proprioception threshold Hearing threshold Temperature threshold Touch threshold Vision threshold
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Skeletal muscle in the elderly
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skeletal muscle atrophy
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Intracranial volume Gray matter Brain mass in the elderly.
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Cerebral blood flow Intracranial volume Gray matter Brain mass
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Skeletal muscle steadiness, Skeletal muscle strength and Skeletal muscle control in the elderly?
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Skeletal muscle steadiness Skeletal muscle strength Skeletal muscle control
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Dose for general anesthetics* Dose for locals * Epidural segment dosing * Duration of epidural action * Epidural motor blocks * in the elderly. .
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Dose for general anesthetics* Dose for locals * Epidural segment dosing * Duration of epidural action * Epidural motor blocks *
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What level for a turp?
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T-8
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Cerebral blood flow autoregulation in the elderly? .
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No change in Cerebral blood flow autoregulation.
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Cerebral blood flow and brain mass increase or decrease about ____ with age, neuronal loss prominent in cerebral cortex, especially frontal lobes
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Cerebral blood flow and brain mass decrease about 20% with age, neuronal loss prominent in cerebral cortex, especially frontal lobes
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Intracranial volume increases or decreases from 92% to 82%, most rapid reduction in gray matter and greatest increase in cerebral ,spinal fluid.
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Intracranial volume decreases from 92%-82%, most rapid reduction in gray matter and greatest increase in cerebral spinal fluid.
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Neurons and nerve conduction in the elderly?
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Some neurons decrease in size and lose some synapses. Nerve conduction velocity decreases by 0.15 m/ sec/yr. Skeletal muscle strength, control, and steadiness decrease by 20%-50%.
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Neurotransmitters and receptors in the elderly? .
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Synthesis of some neurotransmitters and the number of their receptors are reduced
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Decreased CNS activity is related to a decrease in neuronal density, decrease in cerebral metabolic oxygen consumption, decrease in blood flow, decrease in neurotransmitters receptors and decrease in the rate of neurotransmitters synthesis .
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Decreased CNS activity is related to a decrease in neuronal density, decrease in cerebral metabolic oxygen consumption, decrease in blood flow, decrease in neurotransmitters receptors and decrease in the rate of neurotransmitters synthesis
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Review general surgery, spinals, epiduals and local anesthesia for the elderly. .
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Spinal anesthetics have a longer duration of action Sensory block increase with spinals; Decrease segmental dose for epidurals Epidural volume tends to result in more extensive cephalad spread of anesthetics, but accompanied by a shorter duration of analgesia and motor block. Doses for local and general anesthetics are reduced. Mac decreases Dosing decreases for local anesthetics, opiods, barbituates, benzodiazepine, and many other agents
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True or False Cerebral auto-regulation of blood flow is preserved.
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Cerebral auto-regulation of blood flow is preserved.
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Dosing increases or decreases for local anesthetics, opiods, barbituates, benzodiazepine, and many other agents
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Mac decreases Dosing decreases for local anesthetics, opiods, barbituates, benzodiazepine, and many other agents
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Post-op delirium and postoperative cognitive dysfunction in the elderly. .
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Post-op delirium and postoperative cognitive dysfunction is a factor with the elderly.
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BUN in the elderly
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BUN - 3. Serum creatinine level is unchanged, owing to a decrease muscle mass and reduced creatinine production. BUN gradually increases.
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ADH function in the elderly?
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ADH response to hypertonic saline load - Elderly release large amounts of ADH in response to hypertonic saline loads. Watch your fluids!!
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Hyperkalemia and hypokalemia in the elderly. .
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Ability to develop hyperkalemia Ability to develop hypokalemia
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Serum Creatinine in the elderly?
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Serum creatinine level is unchanged, owing to a decrease muscle mass and reduced creatinine production. BUN gradually increases. .
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Kidney mass, Muscle mass, Decreased renal (nephron) mass, Renal blood flow. Renal plasma flow, Renal function (GFR and creatinine clearance) in the elderly.
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Kidney mass - kidney mass decrease with age Muscle mass, More prominent in cortex of kidney, which is replaced by fat and fibrotic tissue Decreased renal (nephron) mass Renal blood flow - decreases 50%, about 10% per decade. Renal plasma flow - decreases Renal function (GFR and creatinine clearance) is reduced. GFR - decreases
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Fluid handling, Sodium handling, Concentrating ability, Response to ADH, Response to aldosterone, Response to aldosterone, and Creatinine production in the elderly? .
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Elderly patients may experience impaired sodium handling, concentrating ability, and diluting capacity, predisposing them to dehydration or fluid overload. Fluid handling - decreases Sodium handling - decreases Concentrating ability - decreases Response to ADH - decreases Response to aldosterone - decreases Response to aldosterone - decreases Creatinine production - decreases
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_____________ is the most sensitive indicator of renal function in the elderly.
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Creatinine clearance is the most sensitive indicator of renal function in the elderly
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Elderly patients may experience impaired sodium handling, concentrating ability, and diluting capacity, predisposing them to ______________________?
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Elderly patients may experience impaired sodium handling, concentrating ability, and diluting capacity, predisposing them to dehydration or fluid overload.
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May develop acute renal failure postop due to ? .
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May develop acute renal failure postoperatively due to reduced renal blood flow and decreased renal (nephron) mass
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As renal function declines, what happens to ability to excrete drugs?
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As renal function declines, so does the ability to excrete drugs.
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Hypokalemia and hyperkalemia in elderly patients, Why? .
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Predisposed to develop hypokalemia and hyperkalemia
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Why would you monitor serum electrolytes, cardiac filling pressure, and urinary output?
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Monitor serum electrolytes, cardiac filling pressure, and urinary output.
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Elderly and: Circulation time? Body fat? Vd for lipid-soluble drugs? Recovery from volatile anesthetics?
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Circulation time Body fat - (lipid fraction increases) Vd for lipid-soluble drugs Recovery from volatile anesthetics
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Elderly and: Extracellular fluid volume Plasma volume Red cell mass
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Extracellular fluid volume Plasma volume Red cell mass Response to muscle relaxants
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Elderly and: Basal metabolic requirements Body heat production Core body temperature .
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Basal metabolic requirements Body heat production Core body temperature
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Elderly and: -Total body water: Progressive decrease in muscle mass (greater in males) -Increase in body fat (lipid fraction increases) result in -decreased total body water (TBW). -Vd for water-soluble drugs -Dosing for barbiturates, opioid .
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Total body water - Progressive decrease in muscle mass (greater in males) and increase in body fat (lipid fraction increases) result in decreased total body water (TBW). Vd for water-soluble drugs Dosing for barbiturates, opioid antagonists, and benzodiazepines.
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Elderly and Mac?
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MAC decreases in the elderly.
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Elderly and muscle mass?
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Progressive decrease in muscle mass (greater in males)
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Elderly and body fat?
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Increase in body fat (lipid fraction increases)
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Elderly and TBW, volume of distribution for water-soluble drugs,
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Decreased TBW results in smaller volume of distribution for water-soluble drugs and may lead to a concentrated drug and quick effects.
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Elderly and volume of distribution for lipid-soluble drugs?
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An increased volume of distribution for lipid-soluble drugs can lower their plasma concentration and decrease the rate of elimination
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***MAC is reduced by ___ per decade of age over 40 years.
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MAC is reduced by 4% per decade of age over 40 years.
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Elderly and Inhalation agent uptake?
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Inhalation agent uptake is more rapid if cardiac output is decreased. May also be delayed if there is significant ventilation/perfusion abnormality.
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Elderly and Recovery from anesthesia with a volatile anesthetic, volume of distribution, hepatic function, pulmonary gas exchange?
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Recovery from anesthesia with a volatile anesthetic may be prolonged because of an increased volume of distribution (increased body fat), decreased hepatic function (decreased halothane metabolism), and decreased pulmonary gas exchange.
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Elderly and dose requirement for barbiturates, opioid antagonists, and benzodiazepineses.
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In general, elderly patients display a lower dose requirement for barbiturates, opioid antagonists, and benzodiazepines.
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Typical eighty year old requires what induction dose of pentothal.
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Typical eighty year old requires less than half the induction dose of pentothal.
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Elderly and Anectine (succinylcholine) and nondepolarizing agents?
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Response to Anectine (succinylcholine) and nondepolarizing agents is unaltered with aging. Remember: IV delivery may be prolonged (increased circulation time - takes longer for one whole-body transit).
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Changes in body composition will reduce basal metabolic requirements during aging by ?
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Changes in body composition will reduce basal metabolic requirements during aging by 10%-15%.
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Elderly and body heat production, core body temperature?
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Hypothermia due to decreased body heat production Elderly decrease core body temperature at almost one degree centigrade per hour. This is twice the rate of young people
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Elderly and Plasma volume, red cell mass, and extracellular fluid volumes?
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Plasma volume, red cell mass, and extracellular fluid volumes are normally maintained in physically active elderly patients
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IV drugs are administered on a schedule adjusted to ? If you give a lipid-soluble drug (inhalational agents, benzodiazepines, barbiturates), you may see what type of recovery?
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IV drugs are administered on a schedule adjusted to total body weight. If you give a lipid-soluble drug (inhalational agents, benzodiazepines, barbiturates), you may see a delayed recovery
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Lipid soluble drugs in the elderly? .
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Lipid soluble drugs in adipose tissues will have a prolonged elimination (increased Volume of distribution)
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Barbituate induction dose in the elderly is reduced ?
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Barbituate induction dose is reduced 30-40%.
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Elderly and benzodiazepines?
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Elderly women metabolize benzodiazepines at rates closer to those in young women; men do not.
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Elderly and benzodiazepines, barbiturates and opiod agonists?
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Elderly in general have lower dose requirement for benzodiazepines, barbiturates and opiod agonists
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Potent inhalational agents in the elderly?
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Decrease inspired concentration; MAC down 30%; faster induction and emergence
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Barbiturates, etomidate, and Ketamine in the elderly?
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Use with caution; seizures, hallucinations, mental disturbances
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Opioids in the elderly?
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Marked decrease in initial dose, increased duration of systemic and epidural effects, greater incidence or rigidity, increased res¬piratory depression
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Fentanyl, Sufenta, alfentanil in the elderly?
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Induction dose reduced by 50%, maintenance dose reduced by 30% - 50%
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Local anesthetics used for in the elderly?neuraxial anesthesia
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Small to moderate decrease in segmental dose requirements; anticipate prolonged effects
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Benzodiazepines in the elderly?
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Modest decrease in initial dose, anticipate marked increase in duration (except Versed)
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Succinylcholine in the elderly?
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Slightly reduced dose in elderly men; prolonged block in con¬junction with metoclopramide
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Nondepolarizing relaxants in the elderly?
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Same or slight increase in initial dose; anticipate increased duration (except atracurium or mivacurium)
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Neostigmine, edrophonium in the elderly?
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No change in dose efficacy, though larger doses are often necessary; slightly prolonged effect
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Atropine in the elderly?
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Increased dose for equal heart rate response; anticipate central anticholinergic syndrome
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Isoproterenol, other beta agonists in the elderly? .
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Increased dose for equal cardiovascular responses
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***Thiopental in the elderly?
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• Induction dose reduced by 15% (2.1 mg/kg IV); same maintenance dose
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***Propofol in the elderly?
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Induction dose reduced by 20%; 80 year old = 1.7 mg/kg IV
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***Midazolam in the elderly?
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Sedation/induction dose reduced by 50%; 80 year old = 0.02 -0.03 mg/kg IV; maintenance dose reduced by 25%
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***Etomidate in the elderly?
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Induction dose reduced by 20%; 80year old = 0.2 mg/kg IV
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...
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Administration of a water soluble drug may lead to a concentrated drug and quick effects. The volume of distribution is small. However, if you give a lipid soluble drug to the same patient, you will get a lower plasma concentration and a decreased rate of elimination. When you study the age-related changes in the elderly, drug activity must be pondered.
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Decreased/contracted vascular volume. .
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Results in high initial plasma concentration
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Decreased protein binding
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Increased availability of free drug
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Increased lipid storage sites
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Prolonged action of lipid soluble drugs.
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Decreased renal and hepatic blood flow
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Prolonged action of drugs dependent on kidneys and liver for elimination.
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Which drugs have no change in dosing in the elderly? .
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Atracurium, Neostigmine, edrophonium
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Which drugs have increase in dosing in the elderly? .
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Atropine, Isoproterenol, other beta agonists
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1. Which of the following physiologic changes occurs in the geriatric patient? a. Decreased lung compliance b. Decreased chest wall compliance c. Decreased residual volume d. Decreased closing capacity
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b. Decreased chest wall compliance
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2. Geriatric cardiovascular changes that occur include all except: a. Elevated afterload b. Left ventricular hypertrophy c. Elevated systolic blood pressure d. increased arterial elasticity
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d. increased arterial elasticity
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3. The geriatric population has renal changes. As renal function declines, so does the kidneys ability to: a. Modify the glomerular filtration rate b. Maintain potassium level c. Excrete drugs d. Handle diuretics
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a. Modify the glomerular filtration rate
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4. The principle pharmacodynamic change associated with aging is: a. Arthritis b. Pulmonary changes c. Lipid solubility d. Reduced anesthetic requirements
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d. Reduced anesthetic requirements
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5. The onset of drug action in the elderly is determined mainly by: a. Alveolar ventilation b. Lipid solubility c. Increased circulation time d. Decreased circulation time
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c. Increased circulation time
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6. Aged men have a prolonged effect with Anectine but aged women do not. What explains this? a. Lipid solubility. b. Water solubility c. Lower plasma cholinesterase concentration d. Fewer motor end-plates
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c. Lower plasma cholinesterase concentration
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7. Which MAC number would be appropriate for a 65-year-old person receiving Desflurane? a. 10 b. 9 c. 8 d. 4
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d. 4
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8. The geriatric patient needs special attention while positioning. Which joint is most vulnerable? a. Hip /leg b. Knee c. Arms/brachial plexus d. Neck
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d. Neck
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9. The onset of muscle relaxants in the elderly is prolonged because of: a. Increased cardiac output b. Low muscle blood flow c. Decreased kidney clearance d. Decreased hepatic function
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b. Low muscle blood flow
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10. Which drug would have prolonged action in the geriatric patient? a. Fat soluble drug b. Water soluble drug c. Both fat soluble and water soluble drugs d. Makes no difference
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a. Fat soluble drug
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11. All of the following contribute to increased pulmonary complications in the elderly undergoing surgery EXCEPT: a type of surgery b. duration of surgery c. fat content (obesity) d. age greater than 70 years old
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a type of surgery
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12. A short-term increase in cardiac output in the elderly is due to all of the following EXCEPT: a. increase in heart rate b. increased left ventricular end-diastolic volume c. larger stoke volumes d. decreased pre-load
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d. decreased pre-load
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13. Which of the following statements best describes desflurane in an elderly patient? a. uptake will be slower b. build-up will occur first in the brain c. It works slower because of bradycardia d. It is very blood-soluble.
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b. build-up will occur first in the brai
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14. Choose the correct change in lung parameters in the elderly. FRC Vital Capacity a. Increases Increases b. Increases Decreased c. Decreases Increases d. Decreases Decreases
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b. Increases Decreased
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15. The most sensitive indicator of renal function in the elderly is: a. BUN b. creatinine production c. serum creatinine levels d. Creatinine clearance
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d. Creatinine clearance
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16. Which of the following physiologic changes occurs in the geriatric person? a. decreased lung compliance b. increased chest wall compliance c. decreased residual volume d. increased closing capacity
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d. increased closing capacity
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17. Which of the following physiologic changes occurs in the geriatric person? a. BUN b. Creatine production c. ability to excrete drugs d. ability to handle diuretics
answer
a. BUN
