Geriatric Anesthesia PDF

Geriatric anesthesia By: Dr.Bassim Mohammed Jabbar anesthesia & intensive care  Who are Geriatric Patients Most of the world countries have accepted the chronological age of 65 and more as a definition of geriatric patients. ( There are three Groups of geriatrics) Elderly ---...

Geriatric anesthesia By: Dr.Bassim Mohammed Jabbar anesthesia & intensive care  Who are Geriatric Patients Most of the world countries have accepted the chronological age of 65 and more as a definition of geriatric patients. ( There are three Groups of geriatrics) Elderly ------ Age 65 to 74 Aged -------- Age 75 to 84 Very Old ---- Age 85 and more Old age is not a disease 30 40 50 60 70 80  ‫ ﻣﻦ اﻷﺷﺨﺎص اﻟﺬﯾﻦ ﺗﺰﯾﺪ أﻋﻤﺎرھﻢ‬٪15 ‫ ﯾﺰﯾﺪ ﻋﻤﺮ أﻛﺜﺮ ﻣﻦ‬،‫ﻓﻲ اﻟﻮﻻﯾﺎت اﻟﻤﺘﺤﺪة وأوروﺑﺎ‬.‫ ﻋﺎﻣﺎ وﻟﻜﻦ ﻓﻲ اﻟﺸﺮق اﻷوﺳﻂ أﻗﻞ‬65 ‫ﻋﻦ‬ In united state and Europe more than 15 % people are > 65 years but in middle east less. * They account for almost of hospital care days * More than 35% of all surgical procedures are performed on patients over the age of 65. * Medical diseases are most common in this group * Demographical data indicate the elderly people are most rapidly growing in population Use of health care services by elderly disproportionately higher than younger patients The mortality rates for patients aged 80-84 is 3 %, 85-90 is 6 % and above 90 year is 10 % in major surgeries But all geriatric patients are not created equal !  AGE RELATED PROBLEMS ◼ Hypertension ◼ Diabetes mellitus ◼ Heart disease ◼ Malignancy ◼ Myocardial ischemia ◼ Cerebral vascular accident ◼ Chronic renal insufficiency, Liver dysfunction ◼ COPD, Pneumonia ‫ ﻣﺮض اﻟﺰھﺎﯾﻤﺮ‬- ‫اﻟﺨﺮف‬ ◼ Dementia- Alzheimer’s disease = 6-8% older than 65 years -Presence of cognitive deficit, agitation -Predictor of postoperative delirium ◼ Parkinson’s disease- 3% older than 65 years -Classic triad= tremor, muscle rigidity, brady- kinesia -postoperative risk of aspiration ◼ Poly-pharmacy- Average patients takes 8 different drugs per day which are directly proportional to adverse drug reactions with incidence of 5%- 35%. ◼ Depression- 10% older than 65 years ◼ Immobility- Decreases muscle mass which influence pulmonary function ‫ﻓﺮط ﺻﻮدﯾﻮم اﻟﺪم‬ ◼ Dehydration- Associated with hypernatremia and infection like pneumonia ◼ Alcoholism- Manifest as accident, postoperative pneumonia PHYSIOLOGICAL CHANGES DURING AGEING  Cardio-Vascular Changes Heart – Cardiac output Decrease 1 % per year after 30 years of age (at 80 year age CO is half that of a 20 year old person), decrease stroke volume, ejection fraction, decreased coronary artery blood flow HR:20% decrease of maximal HR - Blood Pressure – BP increase 1 mm of hg every year after 50 years as a normal consequence of aging. Systolic will increase and Diastolic remains unchanged or increase. elevated afterload - LV hypertrophy, hypertension ( around 50 % are Hypertensive in geriatric age group ) Arteriosclerosis and Coronary Artery Disease Thickening of arterial walls and Loss of elasticity Decreases in arterial compliance results in increased Systemic Vascular Resistance Myocytes death without replacement leading to increase risk of myocardial infarction also cardiac conduction system becomes fibrotic lead to loss of SA nodal cells and prone to dysrrhythmia ▪ Decreased response to beta-receptor stimulation ▪ ECG Slightly increased PR, QRS and Q-T intervals ▪ Loss of contractile strength and efficiency, decreased organ perfusion. ▪ Impaired diastolic filling due to prolonged contraction and a slowed relaxation ▪ Decreased baroreceptor reflex lead to increased risk of orthostatic ‫ﯾﺆدي اﻧﺨﻔﺎض ﻣﻨﻌﻜﺲ ﻣﺴﺘﻘﺒﻼت اﻟﻀﻐﻂ إﻟﻰ زﯾﺎدة ﺧﻄﺮ اﻧﺨﻔﺎض ﺿﻐﻂ اﻟﺪم اﻻﻧﺘﺼﺎﺑﻲ واﻹﻏﻤﺎء‬ hypotension and syncope ▪ Thermoregulation affected by autonomic impairment lead to inadequate heat production and conservation results heat stroke and ‫ﯾﺆدي اﻟﺘﻨﻈﯿﻢ اﻟﺤﺮاري اﻟﻤﺘﺄﺛﺮ ﺑﺎﻟﻀﻌﻒ اﻟﻼإرادي إﻟﻰ ﻋﺪم ﻛﻔﺎﯾﺔ إﻧﺘﺎج اﻟﺤﺮارة وﻧﺘﺎﺋﺞ اﻟﺤﻔﻆ ﺿﺮﺑﺔ‬ hypothermia ‫اﻟﺸﻤﺲ واﻧﺨﻔﺎض ﺣﺮارة اﻟﺠﺴﻢ‬ These factors render the elderly patients less capable of defending their CO and BP against the usual perioperative challenges.  Effects Decrease exercise tolerance leading to easy fatigability Coronary artery Disease Congestive Heart failure Risk of arrhythmias Diminished peripheral pulse and cold extremities Increased blood pressure Postural Hypotension  Anaesthesia Implication Hypotension and Bradycardia should be kept in mind during induction For emergency Anesthesia BP up to 180/110 mm of hg should be allowed Heart Rate up to 50 at rest is allowed for induction Minor ECG changes are not threatening for anesthesia induction Ejection Fraction up to 45 % is normal for geriatric age group without any symptoms Use of Beta blockers and Anti platelets in pre operative period gives more cardio stability in elderly. Remember old heart can not compensate decrease CO or increase heart rate ‫ﺗﺬﻛﺮ أن اﻟﻘﻠﺐ اﻟﻘﺪﯾﻢ ﻻ ﯾﻤﻜﻨﮫ اﻟﺘﻌﻮﯾﺾ ﻋﻦ اﻧﺨﻔﺎض ﺛﺎﻧﻲ أﻛﺴﯿﺪ اﻟﻜﺮﺑﻮن أو زﯾﺎدة ﻣﻌﺪل ﺿﺮﺑﺎت اﻟﻘﻠﺐ‬ Respiratory system changes Changes in Respiratory system occurs as a result of reduction in elastic support of the airways and leads to increased collapsibility of the alveoli and terminal conducting airways. Changes are- 1. Decline in elasticity of the bony thorax 2-Decreased tidal volume 3-Increased residual volume 4-Decreased vital capacity 5-Ratio of RV to TLC increased 6-Increased FRC 7. Decrease in alveolar gas exchange surface leads to Increase in V/Q mismatch plus the increased alveolar dead space 8. Resting PaO2 declines with age at a rate described by PaO2=100- (0.4×age)mmHg Mean PaO2 declines from 95 at age 20 to 73 at age 75 years 9. Decrease in central nervous system responsiveness - Ventilatory response to hypercapnia and hypoxia is blunted in the elderly. Thus we need to increase FiO2 and tidal volume 10. Intra-pleural pressure increases with age 11. Thorax changes shape with age. Fig. 1. Static pressure-volume curves showing changes in the compliance of the chest wall, the lung, and the respiratory system between an ideal 20-year-old (A) and a 60-year-old subject (B). Note increase in RV and FRC and decrease in slope of pressure-volume curve for the respiratory system (rs) in the older subject, illustrating decreased compliance of the respiratory system. Kyphosis leads to increase A-P diameter of the chest  Upper Airway Protective Reflex ◼ Laryngeal, pharyngeal and airway reflexes are less effective in older people due to loss of muscular pharyngeal support lead to upper airway obstruction ◼ Protective reflex of coughing and swallowing are diminished due to loss of cilia resulting in chronic pulmonary inflammation from repeated aspirations lead to aspiration pneumonia ◼ Increased periodic breathing during sleep results more likely to ‫ﯾﺘﻀﺎءل رد اﻟﻔﻌﻞ اﻟﻮﻗﺎﺋﻲ ﻟﻠﺴﻌﺎل واﻟﺒﻠﻊ ﺑﺴﺒﺐ ﻓﻘﺪان اﻷھﺪاب ﻣﻤﺎ ﯾﺆدي إﻟﻰ اﻟﺘﮭﺎب رﺋﻮي‬ apnea and airway obstruction. ‫ﻣﺰﻣﻦ ﻣﻦ اﻟﺘﻄﻠﻌﺎت اﻟﻤﺘﻜﺮرة ﻣﻤﺎ ﯾﺆدي إﻟﻰ اﻻﻟﺘﮭﺎب اﻟﺮﺋﻮي اﻟﻄﻤﻮح‬.‫ﺗﺆدي زﯾﺎدة اﻟﺘﻨﻔﺲ اﻟﺪوري أﺛﻨﺎء اﻟﻨﻮم إﻟﻰ ﺣﺪوث ﺗﻮﻗﻒ اﻟﺘﻨﻔﺲ واﻧﺴﺪاد ﻣﺠﺮى اﻟﮭﻮاء‬  Anesthetic Implications Advice to stop smoking at least 2 weeks before planned surgery and anesthesia Proper Antibiotic & Anti-aspiration prophylaxis Educate older people for deep breathing and coughing reflex preoperatively Oxygen-Oxygen-Oxygen therapy in Pre-Intra- Post anesthesia period Avoid or reduce doses of Opoids tmc 21  C. Nervous System ‫ﻣﺎ ﺑﻌﺪه‬ 1. Brain size decreased by 20% beyond 80 years 2. Decrease in the number of peripheral neurons 3. Depletion of dopamine, norepinephrine, tyrosine, serotonin results depression, loss of memory, motor dysfunction 5. CBF and cerebral oxygen consumption(CMRO2) is decreased in proportion to the decrease in brain mass. 6. Increased latency of sleep, increased periods of wakefulness during ‫ وزﯾﺎدة ﻓﺘﺮات اﻟﯿﻘﻈﺔ ﺧﻼل اﻟﻠﯿﻞ‬،‫زﯾﺎدة زﻣﻦ اﻧﺘﻘﺎل اﻟﻨﻮم‬ Night ‫ ﻗﻠﯿﻼ‬NMB ‫ ﻟﺬﻟﻚ ﯾﺘﻢ زﯾﺎدة ﺟﺮﻋﺔ أدوﯾﺔ‬.‫ اﻧﺨﻔﺎض ﻓﻲ ﻋﺪد وﻛﺜﺎﻓﺔ وﺣﺪات ﻟﻮﺣﺔ ﻧﮭﺎﯾﺔ اﻟﻤﺤﺮك ﺑﺴﺒﺐ زﯾﺎدة ﻣﺴﺘﻘﺒﻼت اﻟﻜﻮﻟﯿﻦ ﺧﺎرج اﻟﻮﺳﺎط ﻏﯿﺮ اﻟﻨﻤﻄﯿﺔ‬.7 7. Decline in number and density of motor end plate units due to increase in atypical extrajunctional cholinergic receptors. So dose of NMB drugs are slightly increased Neuromuscular blocking=M.R 8. CNS is target organ for virtually every anaesthetic agent.  D.Renal System ‫ ھﺬا ﯾﺴﺒﺐ اﻟﺘﺄﺧﯿﺮ‬.GFR ‫ ﻋﺎﻣﺎ ﺑﺸﻜﻞ رﺋﯿﺴﻲ ﻓﻲ اﻟﻘﺸﺮة ﺑﺴﺒﺐ اﻧﺨﻔﺎض اﻟﺘﺼﻠﺐ اﻟﻜﺒﯿﺒﻲ إﻟﻰ اﻧﺨﻔﺎض ﺗﺪﻓﻖ اﻟﺪم اﻟﻜﻠﻮي و‬80 ‫ أﻛﺒﺮ ﻣﻦ‬٪30 ‫زادت اﻟﻜﺘﻠﺔ اﻟﻜﻠﻮﯾﺔ ﺑﻨﺴﺒﺔ‬ ‫ﻓﻲ إزاﻟﺔ اﻷدوﯾﺔ وﯾﻄﯿﻞ اﻵﺛﺎر اﻟﺴﺮﯾﺮﯾﺔ ﻟﻸدوﯾﺔ‬ ‫ اﻧﺨﻔﺎض اﺣﺘﯿﺎطﻲ اﻟﻮظﯿﻔﺔ اﻷﻧﺒﻮﺑﯿﺔ‬.2 ‫ اﻧﺨﻔﺎض اﻟﻘﺪرات ﻋﻠﻰ ﺗﺮﻛﯿﺰ اﻟﺒﻮل أو اﻟﺤﻔﺎظ ﻋﻠﻰ اﻟﺼﻮدﯾﻮم‬.3 ‫ ﺗﻨﺨﻔﺾ اﻷوﻋﯿﺔ اﻟﺪﻣﻮﯾﺔ اﻟﻜﻠﻮﯾﺔ وﯾﺘﻢ إﻋﺎدة ﺗﻮزﯾﻊ ﺛﺎﻧﻲ أﻛﺴﯿﺪ اﻟﻜﺮﺑﻮن ﻣﻤﺎ ﯾﺆھﺐ ﻟﻨﻘﺺ اﻟﺘﺮوﯾﺔ اﻟﻜﻠﻮﯾﺔ ﻓﻲ ﻓﺘﺮة اﻟﺘﺨﺪﯾﺮ‬.4 1. Decreased renal mass by 30% older than 80 years mainly in the cortex due to glomerulosclerosis results decreased renal blood flow and GFR. This causes delay in drug clearance and prolong the clinical effects of drugs 2. Decreased tubular function reserve 3. Reduced abilities to concentrate urine or conserve sodium 4. Renal vascularity reduced and CO is redistributed predisposing to renal ischemia in peri-anaesthetic period  F. Changes in body composition 1.Decreased in lean body mass and total body water lead to smaller central compartment and increased serum concentration of drug. G. Musculo skeletal system ‫ وﺿﻌﻒ ﺗﻮرم اﻟﺠﻠﺪ‬،‫ واﻧﺨﻔﺎض اﻟﺪھﻮن ﺗﺤﺖ اﻟﺠﻠﺪ‬،‫اﻟﺠﻠﺪ اﻟﮭﺶ‬ 1. Fragile skin, decreased subcutaneous fat, poor skin turgor 2. Functional impairment of bones and joints, Osteoporosis 3. Frequent fractures of hip, Injury to surgical positioning H. Haematological and Immune system 1. Reduced spleen size and bone marrow production 2. Reduced haematopoietic response to imposed anaemia lead to life threatening infections J. Thermoregulation 1.Diminished vasoconstriction and metabolic heat production 2.Both inhalational and intravenous like propofol, alfentanil alter the regulatory threshold that fall body temperature by 4°C 3. Risks of intraoperative hypothermia – MI, surgical wound infection, increased blood loss, impaired drug metabolism  K. Protein binding 1. Circulating level of serum protein (especially albumin) decreases in quantity results acid drugs that bind to albumin like diazepam, pethidine have reduced dose requirement 2. Qualitative change of serum protein reduce the binding effectiveness of the available protein. This will lead to higher free drug levels and an enhanced delivery of the drug to the brain  Clinical Pharmacology of Drugs ◼ Inhaled anaesthetic: Reduced MAC ◼ rapid induction and prolonged recovery due to altered ion channels, synaptic activity or receptor sensitivity. ◼ Intravenous anaesthetic: Thiopentone sodium=Administration of IV barbiturates produces the peripheral vasodilatation with a moderate BP decrease. -With a decreased baroreceptor reflex and increased vascular wall rigidity, the drug may cause a dangerous drop in BP. -In the elderly, elimination half-life is 13-25 hrs(6-12 hrs in the young) -The thiopental dose requirement may decrease 25-75 percent. Etomidate= An imidazole IV hypnotic drug associated with haemodynamic stability -May offer advantage for induction of anaesthesia in elderly patients specially in those with limited cardiovascular reserve Propofol= Propofol produces greater decrease in systemic BP than thiopental. -Injecting the propofol slowly with sufficient time can minimize the effect of cardiovascular depression. -Studies show patients older than 80 years exhibit less post- anesthetic mental impairment with propofol than other agents. -Induction: using 1.2-1.7 mg/kg in the elderly (versus 2.0-2.5 mg/kg in younger patients) ❑ Benzodiazepines: Due to decreased drug clearance and increased brain sensitivity the dose decreases to 75%. ❑ Opioids: Twice as potent in elderly patients, so short acting opioids like fentanyl, sufentanil, alfentanil, remifentanil are better choices. 1/2 the bolus dose and 1/3 the infusion rate required. ‫ اﻟﻤﻮاد اﻷﻓﯿﻮﻧﯿﺔ ﻗﺼﯿﺮة‬،‫ﺿﻌﻒ ﻗﻮة اﻟﻤﺮﺿﻰ اﻟﻤﺴﻨﯿﻦ‬ ‫ رﯾﻤﯿﻔﻨﺘﺎﻧﯿﻞ‬،‫ اﻟﻔﻨﺘﺎﻧﯿﻞ‬،‫ اﻟﺴﻮﻓﻨﺘﺎﻧﯿﻞ‬،‫اﻟﻤﻔﻌﻮل ﻣﺜﻞ اﻟﻔﻨﺘﺎﻧﯿﻞ‬.‫ھﻲ ﺧﯿﺎرات أﻓﻀﻞ‬ ◼ Muscle relaxants: Succinylcholine- This agent is metabolized by pseudocholinesterase which is not affected by the aging process. -The response of succinylcholine is unaltered with aging. Non-depolarizing muscle relaxant -Long-acting agents: Metocurine, pancuronium (renal) Doxacurium, pipecuronium (renal) -Intermediate-acting agents Vecuronium, rocuronium (renal) Atracurium, cisatracurium (Hoffmann elimination) Due to decrease in renal or hepatic reserve , the duration of action prolonged..‫ طﺎﻟﺖ ﻣﺪة اﻟﻌﻤﻞ‬،‫ﺑﺴﺒﺐ اﻧﺨﻔﺎض اﻻﺣﺘﯿﺎطﻲ اﻟﻜﻠﻮي أو اﻟﻜﺒﺪي‬  ‫ زادت ﺟﺮﻋﺔ‬،‫ﺑﺴﺒﺐ اﻧﺨﻔﺎض اﻟﺘﺪﻓﻖ اﻟﻤﺒﮭﻢ وﺣﺴﺎﺳﯿﺔ ﻣﺴﺘﻘﺒﻼت ﺑﯿﺘﺎ‬.‫اﻷﺗﺮوﺑﯿﻦ أو اﻷدرﯾﻨﺎﻟﯿﻦ أو اﻷدوﯾﺔ اﻷدرﯾﻨﺎﻟﯿﺔ اﻷﺧﺮى‬ ◼ Other drugs: Due to decrease in vagal outflow and beta receptor sensitivity, dose of atropine, adrenaline or other adrenergic drugs increased. ◼ Neuraxial anaesthesia: the time of onset is decreased and spread is more extensive with bupivacaine (H).Reduction in plasma clearance lead to prolong motor and sensory blockade. ‫ ﯾﺘﻢ ﺗﻘﻠﯿﻞ وﻗﺖ اﻟﺒﺪاﯾﺔ وﯾﻜﻮن اﻻﻧﺘﺸﺎر أﻛﺜﺮ‬:‫اﻟﺘﺨﺪﯾﺮ اﻟﻌﺼﺒﻲ اﻟﻤﺤﻮري‬ ‫ ﯾﺆدي اﻧﺨﻔﺎض إزاﻟﺔ اﻟﺒﻼزﻣﺎ إﻟﻰ إطﺎﻟﺔ‬.(H) ‫اﺗﺴﺎﻋﺎ ﻣﻊ اﻟﺒﻮﺑﯿﻔﺎﻛﺎﯾﯿﻦ‬ ‫اﻟﺤﺼﺎر اﻟﺤﺮﻛﻲ واﻟﺤﺴﻲ‬  Preoperative assessment: 1. history and physical examination 2. Cognitive status, personality disturbances 3. Review for implanted devices- dentures, hearing aid, spectacles 4. Lab. and diagnostic studies= BUN, creatinine, glucose, Hb, coagulation profile, nutritional status, review of ECG, chest X- ray,2D-ECHO, PFT 5. Review Current medication regimen 6. Informed consent  INTRAOPERATIVE MANAGEMENT ◼ Elderly patients require lower doses of premedication ◼ Opioid premedication may be valuable ◼ Pretreatment with H2 antagonist, metoclopramide may be used ◼ Anxiety relief by benzodiazepine ◼ Smaller doses are needed in comparision to young adults for induction ◼ Etomidate produces less hypotension than propofol. ◼ Hypo or hypertension or both may occur during induction, intubation or postintubation, so performed standard technique carefully. ◼ α-agonist used with fluid administration in hypovolemia ◼ Protective gag reflex is weakened  PERIOPERATIVE COMPLICATIONS ◼ Cardiovascular- MI, cardiac arrest, AF, hypertension ◼ pulmonary- pneumonia, prolonged intubation, re-intubation ◼ central nervous system- Stroke, TIA, Postoperative cognitive decline ◼ Renal dysfunction –Due to drugs such as Aminoglycosides, ACEI , NSAIDS or hypovolemia / cardiac dysfunction ◼ wound infection  intubation ◼ Placement of ET tube is difficult in elderly ◼ Facial shape is altered, TM joint dysfunction, loose teeth/without teeth with cervical arthritis makes exposure of larynx more difficult ◼ Care should be taken during laryngoscopic examination to avoid over extension of neck ◼ When rapid sequence intubation is performed cricoid pressure should be applied ◼ ETT have adverse effects on muco-ciliary clearance and swallowing than laryngeal mask, but ETT provide a large tidal volume and PEEP to prevent atelectasis.  POSTOPERATIVE CARE ◼ The major goal is to good pain relief by achieving adequate analgesia. ◼ Opioids is the mainstay of postoperative analgesia, but it producing same adverse outcome like respiratory depression, sedation, delirium, ileus. ◼ NSAIDS which reduce opioids requirement and some of its adverse effects. ◼ Epidural analgesia is superior than IV therapy due to improved cardiopulmonary outcome, more rapid return of bowel function, earlier mobilization, better nutritional status. ،‫ واﻟﻌﻮدة اﻷﺳﺮع ﻟﻮظﯿﻔﺔ اﻷﻣﻌﺎء‬،‫اﻟﺘﺴﻜﯿﻦ ﻓﻮق اﻟﺠﺎﻓﯿﺔ أﻋﻠﻰ ﻣﻦ اﻟﻌﻼج اﻟﺮاﺑﻊ ﺑﺴﺒﺐ ﺗﺤﺴﯿﻦ اﻟﻨﺘﺎﺋﺞ اﻟﻘﻠﺒﯿﺔ اﻟﺮﺋﻮﯾﺔ‬.‫ وﺗﺤﺴﯿﻦ اﻟﺤﺎﻟﺔ اﻟﻐﺬاﺋﯿﺔ‬،‫واﻟﺘﻌﺒﺌﺔ اﻟﻤﺒﻜﺮة‬ ◼ ECG, hourly urine output, BP must be monitored.Direct intra- arterial pressure and CVP in high risk patients. ◼ Arrhythmia –common in elderly patients due to metabolic disturbances such as hyperventilation, hypokalemia, hypocalcemia, hypoxia, hypercarbia. ◼ Postoperative hypothermia common in elderly. ◼ Perioperative hypothermia aggravates surgical bleeding due to impaired platelet function, reduced intrinsic and extinsic clotting, increased fibrinolysis. ◼ Postoperative delirium= 10% after major surgery.GA ‫ﯾﻘﻠﻞ اﺳﺘﺨﺪام اﻟﺘﮭﺎب اﻟﻤﻔﺎﺻﻞ اﻟﺮوﻣﺎﺗﻮﯾﺪي ﻣﻦ ﺣﺪوث اﻟﺨﻠﻞ اﻟﻤﻌﺮﻓﻲ ﺑﻌﺪ اﻟﻌﻤﻠﯿﺔ اﻟﺠﺮاﺣﯿﺔ ﻣﻘﺎرﻧﺔ ب‬ ‫ وﺑﺎﻟﺘﺎﻟﻲ‬.‫ﯾﺆﺛﺮ اﻟﺘﮭﺎب اﻟﻤﻔﺎﺻﻞ اﻟﺮوﻣﺎﺗﻮﯾﺪي ﻋﻠﻰ ﻧﻈﺎم اﻟﺘﺨﺜﺮ ﻋﻦ طﺮﯾﻖ ﻣﻨﻊ ﺗﺜﺒﯿﻂ اﻧﺤﻼل اﻟﻔﯿﺒﺮﯾﻦ ﺑﻌﺪ اﻟﻌﻤﻠﯿﺔ اﻟﺠﺮاﺣﯿﺔ‬ ‫ اﻟﻤﺮﺗﺒﻄﺔ ﺑﺎﻧﺨﻔﺎض ﻓﻘﺪان اﻟﺪم ﻓﻲ ﺟﺮاﺣﺔ اﻟﺤﻮض واﻷطﺮاف‬RA ‫ اﻵﺛﺎر اﻟﺪﯾﻨﺎﻣﯿﻜﯿﺔ اﻟﺪﻣﻮﯾﺔ ل‬.PE‫ و‬DVT ‫ﺗﻘﻠﯿﻞ ﺣﺪوث‬ ‫ اﻟﺤﻔﺎظ ﻋﻠﻰ ﻣﺠﺮى اﻟﮭﻮاء وﻣﺴﺘﻮى‬.pt ،‫اﻟﺴﻔﻠﯿﺔ واﻧﺨﻔﺎض ﺧﻄﺮ ﻧﻘﺺ اﻷﻛﺴﺠﺔ ﻓﻲ اﻟﺪم ﻓﻲ اﻟﺘﮭﺎب اﻟﻤﻔﺎﺻﻞ اﻟﺮوﻣﺎﺗﻮﯾﺪي‬.‫اﻟﻮظﯿﻔﺔ اﻟﺮﺋﻮﯾﺔ‬ Regional versus General anaesthesia: ❑ Use of RA decrease the incidence of postoperative cognitive dysfunction compared with GA. ❑ RA affects the coagulation system by preventing postoperative inhibition of fibrinolysis. Thus decrease incidence of DVT and PE. ❑ Haemodynamic effects of RA associated with decreased blood loss in pelvic and lower extremity surgery and lower risk of hypoxemia ❑ In RA, pt. maintain their own airway and level of pulmonary function.  ‫طﺮق ﻟﺘﺤﺴﯿﻦ اﻟﺘﺨﺪﯾﺮ ﻟﺪى اﻟﻤﺮﺿﻰ اﻷﻛﺒﺮ ﺳﻨﺎ‬ WAYS TO IMPROVE ANAESTHESIA IN OLDER PATIENTS ‫اﻟﺘﻘﯿﯿﻢ اﻟﻤﻨﺎﺳﺐ ﻗﺒﻞ اﻟﺠﺮاﺣﺔ‬ ‫ ﻛﻦ ﻋﻠﻰ دراﯾﺔ ﺑﺎﻟﺤﺠﻢ اﻟﻤﺘﻌﺎﻗﺪ واﻧﺨﻔﺎض ﺿﻐﻂ اﻟﺪم ﻋﻨﺪ اﻟﺤﺚ‬.2 1. Proper preoperative evaluation ‫ اﻓﺘﺮض اﻟﺨﻠﻞ اﻻﻧﺒﺴﺎطﻲ‬.3 2. Be aware of contracted volume and hypotension on induction ‫ ﺑﻌﺪ اﻟﻌﻤﻠﯿﺔ اﻟﺠﺮاﺣﯿﺔ‬/ ‫ داﺧﻞ‬/ ‫ إدارة ﻣﺎﻧﻊ ﺑﯿﺘﺎ ﻗﺒﻞ‬.4 3. Assume diastolic dysfunction ‫ اﻟﻜﺒﺪ‬/ ‫ اﺑﺤﺚ ﻋﻦ وظﺎﺋﻒ اﻟﻜﻠﻰ‬.5 4. Administer beta blocker pre/intra/postoperative ‫ اﻟﺘﺤﻜﻢ اﻟﺼﺎرم ﻓﻲ اﻟﺠﻠﻮﻛﻮز‬.6 5. Look for renal/ hepatic function ‫ اﺳﺘﺨﺪم ﺟﺮﻋﺎت أﻗﻞ ﻣﻦ ﻋﻮاﻣﻞ اﻟﺘﺨﺪﯾﺮ‬.7 6. Tight glucose control ‫ اﻟﻤﺮاﻗﺒﺔ اﻟﯿﻘﻮﻧﺔ أﺛﻨﺎء اﻟﻌﻤﻠﯿﺔ اﻟﺠﺮاﺣﯿﺔ‬.8 7. Use lower doses of anaesthetic agents‫ إدارة اﻟﮭﺬﯾﺎن‬،‫ اﻟﺴﯿﻄﺮة ﻋﻠﻰ اﻷﻟﻢ ﺑﻌﺪ اﻟﻌﻤﻠﯿﺔ اﻟﺠﺮاﺣﯿﺔ‬.٩ 8. Vigilant intraoperative monitoring ،‫ اﺧﺘﯿﺎر اﻟﺪواء ﺑﻌﻨﺎﯾﺔ وﻣﻌﺎﯾﺮة اﻟﺠﺮﻋﺔ‬.10 9. Postoperative pain control , delirium ،‫اﻟﺪﻗﯿﻖ‬ management ‫ ﻋﻼج اﻟﺴﻮاﺋﻞ‬.١١ 10. Careful drug selection & dosage titration, ١٢. RA ‫ أﻓﻀﻞ ﻣﻦ‬GA 11. Careful fluid therapy, 12. RA better than GA  Chronological age is a poor predictor of physiologic age Geriatric Anesthesiology Charles H. McLeskey