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Geriatric Patient

Considerations

  • ↑ post-op morbidity and mortality

  • Screen for dementia → try prevent post-op delirium & POCD with:

    • ↓ anesthetic doses

    • employ BIS/EEG monitoring to titrate minimum anesthetic

  • MSK Δ's with aging predispose to ↑ risk of nerve, joint & skin injury

  • Pre-operative frailty assessment tool can risk stratify patients much better than just using "age"

  • Multiple co-morbid conditions + potential for polypharmacy

  • Pharmacologic considerations:

    • ↓ dose requirements for IV anesthesics

    • ↑ sensitivity to opioids

    • ↑ duration of neuromuscular blockers except cis-atracurium

    • Avoid ketamine to avoid risk of post-op delirium

    • Undesirable side-effects from diphenhydramine, anti-cholinergics, benzos, metoclopramide, NSAIDs, meperidine

  • Consider neuraxial anesthesia > GA to:

    • ↓ risk of post-op delirium & POCD

    • ↓ post-op pulmonary complications

  • Decreased physiologic reserve and Δ's in all organ systems

    • CVS

      • ↓ tachycardic response to hypotension → CO is preload dependent

      • ↓ baroreceptor sensitivity → limited response to hypovolemia & ↓ contractility

      • Rigid arteries → wider pulse pressure + labile blood pressures

      • Increasing prevalence of:

        • LV hypertrophy

        • CAD

        • Aortic valve disease

        • Arrhythmias esp. afib

    • Resp

      • ↑ WOB with age

      • Emphysematous-like changes → VQ mismatching

      • ↓ FRC, ↑CC → ↑shunting

      • PFTs: ↓FEV1, ↓DLCO, ↑A-a gradient

      • Weaker pharyngeal muscles and ↓ effective cough → ↑aspiration risk

    • CNS

      • ↓ MAC requirements

      • ↓ requirements of all IV anesthetics

      • ↑ duration of action of most medications

      • Avoid: diphenhydramine, anti-cholinergics, benzos, metoclopramide, NSAIDs, meperidine

      • ↑ prevalence of dementia

      • ↑ risk of post-op delirium and POCD

    • Renal

      • eGFR ↓ with age

      • ↑ prevalence of: HTN, DM, vascular dz → ↓ renal dysfunction

    • Endo

      • Malnutrition is common & ↑ morbidity & mortality

      • Impaired thermoregulation → ↑risk of hypothermia

      • ↑ prevalence of T2DM

References

  • Staheli B, Rondeau B. Anesthetic Considerations In The Geriatric Population. [Updated 2022 Jun 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572137/

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