Health Articles

Controlling postoperative pain in Ihe elderly can be difficult. The major goal of such control is paCieni comfort; a secondary goal is decreased morbidity and mortality. Adequate analgesia may improve cardiovascular and pulmonary function. By preventing Ihe stress response to postoperative pain, adequate analgesia may also lower the incidence of postoperative myocardial events.
Much of the decrease in ventilatory function after thoracic and abdominal surgeries results from surgical trauma and splinting from postoperative pain. Postoperative analgesia cannot undo the decrease in ventilatory function produced by surgical trauma or lung resection. However, anesthesiologists and surgeons can help prevent splinting by providing adequate analgesia, thus helping patients breathe deeply and cough, improving mucous removal and avoiding atelectasis. Ry avoiding atelectasis, patients also reduce the risk of postoperative pneumonia and hypoxia.
Patients who receive adequate postoperative pain relief generally walk earlier and are discharged sooner than those who do not. Thus, adequate analgesia helps in achieving the overall goal of most surgical procedures: to return the patient to an improved functional state in the community, which benefits both Ihe patient and society. Also, by shortening the hospital stay, adequate analgesia reduces the cost of medical care.
To achieve postoperative analgesia, an anesthesiologist may use a narcotic, a nonsteroidal anti-inflammatory drug, or a regional anes-Ihelic method. Each choice has its advantages and disadvantages as a modality for analgesia in the elderly (see also Ch. 12).

Obtaining vascular access to use monitoring devices and to administer drugs, fluids, and blood can be a challenge in the elderly. Arthritic changes can make inlubalion and positioning for surgery difficult. Also, increased skin fragility makes the elderly person prone to injury from restraining devices, tape, Bovie pads, and adhesive monitoring devices such as HCG electrodes. Extra padding should be placed on operating tables, and care should be exercised in positioning extremities to avoid injury.
The elderly also have significant problems with perioperative temperature regulation. Heal production is reduced as a result of their lower basal metabolic rate. Thinning of the skin and loss of subcutaneous fat make the skin a less effective insulator, so that body heat conservation is also impaired. The relative increase in body surface area wilh respect to body mass and the impaired vasomotor response in oldcrpersons predispose them to heat loss. Duringanesthesia, the thermoregulatory center in the hypothalamus is anesthetized; patients are pharmacologically paralyzed and given sympathetic blocking agents. Thus, heat production is prevented, and heat loss is promoted. A major sequela of hypothermia is Ihe surge in oxygen consumption that occurs with shivering during the re warming period. IT oxygen demand exceeds supply, hypoxemia, acidosis, and circulatory changes occur, and the elderly patient may be unable to compensate. To minimize the risk of hypothermia and its sequelae, the operating room, inspired gases. IV solutions, and antibacterial solutions used to prepare the surgical site should be warmed. Forced-air warming blankets help prevent heat loss and should be used, especially when patients are hypothermic.

Anesthesia
Depending on the circumstances, the anesthesiologist may provide monitored anesthesia care, regional anesthesia, or general anesthesia.
Monitored anesthesia care: When patients do not need analgesia for a procedure or when the surgeon administers it, the anesthesiologist provides monitored anesthesia care, which consists of monitoring the pa-tient”s vital signs and providing sedation as needed. Procedures such as cataract surgery, pacemaker placement, inguinal hernia repair, and extracorporeal shock wave lithotripsy are often done with monitored anesthesia care.
Regional anesthesia: This type of anesthesia includes spinal anesthesia, epidural anesthesia, and blockade of other major nerves such as the cervical or brachial plexus. Procedures of the lower abdomen, pelvis, and legs can be done wilh spinal or epidural anesthesia in certain patients. Spinal or epidural blockade produces profound sympathetic block, which can precipitate hypotension in patients with inadequate volume status. In the elderly, epidural anesthetics have a faster onset and a greater spread; the duration of action can be prolonged because of reduced clearance. Whenever possible, adjuvant therapy with anticholinergics should be avoided because of the high risk of inducing delirium and other complications.
General anesthesia: General anesthesia provides loss of consciousness, amnesia, analgesia, and a variable degree of muscle relaxation. Generally, the patient’s airway is secured with an endotracheal lube, and ventilation is controlled. Most of the general anesthetics are potent myocardial depressants and vasodilators. The metabolism of these drugs is governed by the pharmacokinetic factors described above.
The dosage requirements for the induction agents propofol, midazolam, and thiopental arc significantly reduced in the elderly. Ketamine and elomidate have been suggested as induction agcnls of choice for geriatric patients because of their minimal effects on the cardiovascular system, but little information is available about the effect of age on exact dose requirement. The volatile anesihelics halothane. enflurane.
and isoflurane impair the already allenuated chemoreceptor response in the elderly. Also, the minimal alveolar concentration of these agents decreases linearly with age.
The muscle relaxants pancuronium and tubocurarine have an increased duration of action in Ihe elderly because the termination of their activity depends largely on renal and hepatic clearance. This is not true of the shorter-acling neuromuscular blockers atracurium and vecuronium. Few data are available on the effects of aging on succinyl-choline activity, but it is commonly held that the longer circulatory time in the elderly allows more time for hydrolysis of the drug, so that a larger initial dose may be necessary.
The duration of action of opioids is also prolonged in the elderly because clearance is decreased and sensitivily to these drugs is increased. The sedative and respiratory depressant efl’ccls of opioids may contribute to the postoperative pulmonary complications frequently observed in this age group.
In hip fracture surgery, both regional and general anesthesia are used, and considerable debate exists over which is the best technique with respect to early and late survival and the incidence of postoperative thromboembolic disease and confusion. Investigators have found no difference in the incidence of postoperative confusion between elderly patients who had regional anesthesia and those who had general anesthesia for hip fracture repair. The current consensus is that spinal anesthesia has no advantage over general anesthesia in improving either short-term or long-term outcomes in elderly patients undergoing surgical hip repair. Regional anesthesia does provide some protection against deep venous thrombophlebitis, but it is not associated with a sustained improvement in outcome.

Many anesthesiologists avoid preoperative sedation for elderly patients because it further reduces the alrcudj compromised ventilatory response to hypoxia and hypercapnia. The muscarinic anticholinergics, such as atropine and scopolamine, are generally not needed to decrease oral secretions because newer anesthetics cause fewer seerelion problems in the airways. Besides producing an unpleasantly dry mouth, atropine and scopolamine can cause CNS side effects. Atropine, usually considered stimulatory, may produce excitement and delirium; scopolamine, a sedative amnestic, can cause agitation, restlessness. and hallucinations in elderly patients. If an anticholinergic is necessary, glycopyrrolale, which is poorly lipid soluble and does not cross the blood brain barrier, is the drug of choice.

Most elderly patients have existing medical problems, which are superimposed on age-related physiologic changes, complicating management for the anesthesiologist. A thorough history and physical examination is an inlegral part of forniulaling an anesthesia plan lor the elderly patient. A review of previous hospital records or an interview with family members or friends can help define the patient’s medical history. A list of the patient’s medications can also provide important information about disease processes. The conditions of particular importance to the anesthesiologist are described in TABLE 28-3.
One of the best sources of information is the elderly patient’s primary care physician, who may have records of past medical history, functional status, medications, and allergies. Frequently, lest results obtained to prepare a patient for anesthesia can be compared wilh earlier results available from the primary care physician.
The most important question the anesthesiologist has to answer is not whether the patienl is in perfect condition but whether the patient is in optimal condition for the anticipated surgery. Several authorities have tried to identify predictors of adverse outcome. In 1977, Goldman retrospectively identified a number of variables associated wilh cardiac risk and assigned each a relative weight. He found that nol only cardiac problems but also a patient’s age and Ihc type of surgery affected cardiac outcome (see TABLE 28-4). Several investigators have since applied the Goldman Cardiac Risk Index prospectively and found that it is not useful in predicting adverse outcome; however, it remains a commonly used index. Nearly all of the studies agree that a prior myocardial infarction (especially a recent one) or a reduced cardiac functional capacity greatly increases Ihe risk of a postoperative adverse cardiac event. Perioperative optimization of medical prohlems docs improve outcome, and the patient’s own physician, by virtue of an established relationship, can besl determine that cardiovascular status and respiratory function are optimized, thai blood pressure and blood glucose level are well controlled, and that the doses of medication are appropriate for the patienl’s current condition.
The anesthesiologist may request specific studies (o better evaluate a patient’s ability to undergo anesthesia and the surgical procedure These studies may include an exercise stress lest or cardiac catheterization. When the requested data are available, the anesthesiologist can formulate an anesthesia plan that best fits the patient’s needs.

The risk of urinary tract infection is higher in geriatric surgical patients and is particularly associated with catheterization of the lower genitourinary tract during surgery. The usual symp-lomsand signs of a urinary Iract infection may appear days later, especially in older men with bladder outlet obstruction from benign prostatic hyperplasia.

Disruption of either the skin or fascial closure. Skin dehiscence delays complete skin healing but has little significance otherwise. Fascial dehiscence, however, is usually associated with evisceration or herniation of intraperitoneal organs and is a life-threatening condition.
Dehiscence of an abdominal incision often is heralded by profuse discharge of clear fluid from the incision. In nearly all cases of fascial dehiscence, resulure of the incision is necessary. The only treatment for evisceration is placing sterile towels over the exposed bowel and immediately returning the patient to the operating room for fascial closure. In fascial dehiscence, late hernia formation is common.