Anaesthesia for Geriatric Surgery PDF

‫اﻟﻤﺮﺣﻠﺔ اﻟﺜﺎﻟﺜﺔ‬ ‫ﻗﺴﻢ ﺗﻘﻨﻴﺎت اﻟﺘﺨﺪﻳﺮ واﻟﻌﻨﺎﻳﺔ اﻟﻤﺮﻛﺰة‬ ‫اﻟﻤﺤﺎﺿﺮة اﻟﺴﺎﺑﻌﺔ‬ ‫‪Anaesthesia for geriatric surgery‬‬ ‫اﻟﺘﺨﺪﯾﺮ اﻟﺠﺮاﺣﻲ ﻟﮑﺒﺎر اﻟﺴﻦ‬ ‫‪Translation‬‬ ‫‪:‬‬ ‫ﺣــﺴﻴﻦ ﺣــﺴﻦ‬ Introduction...

‫اﻟﻤﺮﺣﻠﺔ اﻟﺜﺎﻟﺜﺔ‬ ‫ﻗﺴﻢ ﺗﻘﻨﻴﺎت اﻟﺘﺨﺪﻳﺮ واﻟﻌﻨﺎﻳﺔ اﻟﻤﺮﻛﺰة‬ ‫اﻟﻤﺤﺎﺿﺮة اﻟﺴﺎﺑﻌﺔ‬ ‫‪Anaesthesia for geriatric surgery‬‬ ‫اﻟﺘﺨﺪﯾﺮ اﻟﺠﺮاﺣﻲ ﻟﮑﺒﺎر اﻟﺴﻦ‬ ‫‪Translation‬‬ ‫‪:‬‬ ‫ﺣــﺴﻴﻦ ﺣــﺴﻦ‬ Introduction The incidence of perioperative complications is much higher in these patients due to reduced functional reserve and a high incidence of co-morbidity. ‫ وارﺗﻔﺎع ﻣﻌﺪل‬functional reserve ‫إن ﺣﺪوث اﻟﻤﻀﺎﻋﻔﺎت اﻟﻤﺤﻴﻄﺔ ﺑﺎﻟﺠﺮاﺣﺔ أﻋﻠﻰ ﺑﻜﺜﻴﺮ ﻟﺪى ﻫﺆﻻء اﻟﻤﺮﺿﻰ ﺑﺴﺒﺐ اﻧﺨﻔﺎض‬ (‫اﻹﺻﺎﺑﺔ ﺑﺎﻷﻣﺮاض اﻟﻤﺼﺎﺣﺒﺔ )ﻣﺜﻞ ﺗﺼﻠﺐ اﻟﺸﺮاﻳﻴﻦ اﻟﺘﻬﺎب اﻟﻤﻔﺎﺻﻞ‬ but these complications can be minimized by: ‫وﻟﻜﻦ ﻳﻤﻜﻦ اﻟﺘﻘﻠﻴﻞ ﻣﻦ ﻫﺬه اﻟﻤﻀﺎﻋﻔﺎت ﻋﻦ ﻃﺮﻳﻖ‬ careful preoperative assessment, a meticulous anaesthetic technique and good ‫ﺣـ‬ postoperative care. ‫ وﺗﻘﻨﻴﺔ ﺗﺨﺪﻳﺮ دﻗﻴﻘﺔ ورﻋﺎﻳﺔ ﺟﻴﺪة ﺑﻌﺪ اﻟﻌﻤﻠﻴﺔ اﻟﺠﺮاﺣﻴﺔ‬،‫ﺗﻘﻴﻴﻢ دﻗﻴﻖ ﻗﺒﻞ اﻟﺠﺮاﺣﺔ‬ Age related physiological changes ‫ﺴﻴﻦ‬ ‫اﻟﺘﻐﻴﺮات اﻟﻔﺴﻴﻮﻟﻮﺟﻴﺔ اﻟﻤﺮﺗﺒﻄﺔ ﺑﺎﻟﻌﻤﺮ‬ Ageing is a process where progressive cell loss occurs. ‫اﻟﺸﻴﺨﻮﺧﺔ ﻫﻲ ﻋﻤﻠﻴﺔ ﻳﺤﺪث ﻓﻴﻬﺎ ﻓﻘﺪان اﻟﺨﻼﻳﺎ اﻟﺘﺪرﻳﺠﻲ‬ The concept of "functional reserve" is derived from the difference between the basal level of organ function at rest and the maximum level of organ function that can be achieved in response to increased demand, for example during exercise or in response to surgical stress. ‫ﺣـ‬ ‫ﻣﻔﻬﻮم "اﻻﺣﺘﻴﺎﻃﻲ اﻟﻮﻇﻴﻔﻲ" ﻣﺸﺘﻖ ﻣﻦ اﻟﻔﺮق ﺑﻴﻦ اﻟﻤﺴﺘﻮى اﻷﺳﺎﺳﻲ ﻟﻮﻇﻴﻔﺔ اﻟﻌﻀﻮ أﺛﻨﺎء اﻟﺮاﺣﺔ واﻟﺤﺪ اﻷﻗﺼﻰ ﻟﻤﺴﺘﻮى وﻇﻴﻔﺔ‬ ‫ ﻋﻠﻰ ﺳﺒﻴﻞ اﻟﻤﺜﺎل أﺛﻨﺎء اﻟﺘﻤﺮﻳﻦ أو اﺳﺘﺠﺎﺑﺔ ﻟﻺﺟﻬﺎد اﻟﺠﺮاﺣﻲ‬،‫اﻟﻌﻀﻮ اﻟﺬي ﻳﻤﻜﻦ ﺗﺤﻘﻴﻘﻪ اﺳﺘﺠﺎﺑﺔ ﻟﻠﻄﻠﺐ اﻟﻤﺘﺰاﻳﺪ‬ Functional reserve is often reduced in elderly patients, and is thought to be a major factor in the increased morbidity and mortality of the elderly population. ‫ﺴﻦ‬ ‫ وﻳُﻌﺘﻘﺪ أﻧﻪ ﻋﺎﻣﻞ رﺋﻴﺴﻲ ﻓﻲ زﻳﺎدة ﻣﻌﺪﻻت اﻹﺻﺎﺑﺔ ﺑﺎﻷﻣﺮاض واﻟﻮﻓﻴﺎت‬،‫ﻏﺎﻟﺒًﺎ ﻣﺎ ﻳﻨﺨﻔﺾ اﻻﺣﺘﻴﺎﻃﻲ اﻟﻮﻇﻴﻔﻲ ﻟﺪى اﻟﻤﺮﺿﻰ اﻟﻤﺴﻨﻴﻦ‬ ‫ﺑﻴﻦ ﻛﺒﺎر اﻟﺴﻦ‬ Alterations in Organ Function ‫ﺗﻐﻴﻴﺮات ﻓﻲ وﻇﻴﻔﺔ اﻟﺠﻬﺎز‬ Reduction in cardiovascular, pulmonary, renal and central nervous system function may be the most important determinants of outcome from surgical procedures under general or regional anaesthesia. ‫ﻗﺪ ﻳﻜﻮن اﻧﺨﻔﺎض وﻇﺎﺋﻒ اﻟﻘﻠﺐ واﻷوﻋﻴﺔ اﻟﺪﻣﻮﻳﺔ واﻟﺮﺋﺔ واﻟﻜﻠﻰ واﻟﺠﻬﺎز اﻟﻌﺼﺒﻲ اﻟﻤﺮﻛﺰي ﻣﻦ أﻫﻢ اﻟﻌﻮاﻣﻞ اﻟﻤﺤﺪدة ﻟﻨﺘﺎﺋﺞ‬ ‫اﻟﻌﻤﻠﻴﺎت اﻟﺠﺮاﺣﻴﺔ ﺗﺤﺖ اﻟﺘﺨﺪﻳﺮ اﻟﻌﺎم أو اﻟﻤﻨﺎﻃﻴﻘﻲ‬ Cardiovascular system Ischaemic heart disease is common in affluent societies. The net effect on the heart is reduced cardiac output. ‫ﻣﺮض اﻟﻘﻠﺐ اﻹﻗﻔﺎري ﺷﺎﺋﻊ ﻓﻲ اﻟﻤﺠﺘﻤﻌﺎت اﻟﻐﻨﻴﺔ اﻟﺘﺄﺛﻴﺮ اﻟﺼﺎﻓﻲ ﻋﻠﻰ اﻟﻘﻠﺐ ﻫﻮ اﻧﺨﻔﺎض اﻟﻨﺘﺎج اﻟﻘﻠﺒﻲ‬ 1  In contrast, valvular heart disease secondary to rheumatic fever is more commonly seen in developing countries. ً ‫ﺷﻴﻮﻋﺎ ﻓﻲ اﻟﺒﻠﺪان اﻟﻨﺎﻣﻴﺔ‬ ‫ ﻓﺈن ﻣﺮض ﺻﻤﺎﻣﺎت اﻟﻘﻠﺐ اﻟﻨﺎﺗﺞ ﻋﻦ اﻟﺤﻤﻰ اﻟﺮوﻣﺎﺗﻴﺰﻣﻴﺔ أﻛﺜﺮ‬،‫ﻓﻲ اﻟﻤﻘﺎﺑﻞ‬ Over 50% of patients will have mitral valve disease. Aortic lesions are less common. ً ‫ﺷﻴﻮﻋﺎ‬ ‫ أﻗﻞ‬.Aortic lesions ‫ ﻣﻦ اﻟﻤﺮﺿﻰ ﻳﺼﺎﺑﻮن ﺑﻤﺮض اﻟﺼﻤﺎم اﻟﺘﺎﺟﻲ‬%50 ‫أﻛﺜﺮ ﻣﻦ‬ The reduced cardiac output in heart disease compromises blood flow to the kidneys and brain, and therefore both the kidneys and brain are prone to perioperative ischaemia ‫ وﺑﺎﻟﺘﺎﻟﻲ ﺗﻜﻮن اﻟﻜﻠﻰ واﻟﺪﻣﺎغ ﻋﺮﺿﺔ‬،‫ﻳﺆدي اﻧﺨﻔﺎض اﻟﻨﺘﺎج اﻟﻘﻠﺒﻲ ﻓﻲ أﻣﺮاض اﻟﻘﻠﺐ إﻟﻰ إﺿﻌﺎف ﺗﺪﻓﻖ اﻟﺪم إﻟﻰ اﻟﻜﻠﻰ واﻟﺪﻣﺎغ‬ ‫ﻟﻨﻘﺺ اﻟﺘﺮوﻳﺔ اﻟﻤﺤﻴﻄﺔ ﺑﺎﻟﺠﺮاﺣﺔ‬ The physiological response to cardiovascular stressors (such as hypovolaemia) may be blunted due to reduced baroreceptor sensitivity and autonomic function. ‫ﻗﺪ ﺗﻀﻌﻒ اﻻﺳﺘﺠﺎﺑﺔ اﻟﻔﺴﻴﻮﻟﻮﺟﻴﺔ ﻟﻀﻐﻮﻃﺎت اﻟﻘﻠﺐ واﻷوﻋﻴﺔ اﻟﺪﻣﻮﻳﺔ )ﻣﺜﻞ ﻧﻘﺺ ﺣﺠﻢ اﻟﺪم( ﺑﺴﺒﺐ اﻧﺨﻔﺎض ﺣﺴﺎﺳﻴﺔ ﻣﺴﺘﻘﺒﻼت‬ ‫اﻟﻀﻐﻂ واﻟﻮﻇﻴﻔﺔ اﻟﻼإرادﻳﺔ‬ This lack of compensation may be significant if the patient is taking medication such as betablockers or ACE inhibitors. ‫ﻗﺪ ﻳﻜﻮن ﻫﺬا اﻟﻨﻘﺺ ﻓﻲ اﻟﺘﻌﻮﻳﺾ ﻣﻠﺤﻮﻇًﺎ إذا ﻛﺎن اﻟﻤﺮﻳﺾ ﻳﺘﻨﺎول أدوﻳﺔ ﻣﺜﻞ ﺣﺎﺻﺮات ﺑﻴﺘﺎ أو ﻣﺜﺒﻄﺎت اﻹﻧﺰﻳﻢ اﻟﻤﺤﻮل ﻟﻸﻧﺠﻴﻮﺗﻨﺴﻴﻦ‬ Atrial fibrillation (AF) in the elderly population is common. The fast ventricular rate in AF leads to reduced cardiac output. ‫؛‬ ‫( ﺷﺎﺋﻊ ﻟﺪى ﻛﺒﺎر اﻟﺴﻦ ﻳﺆدي ﻣﻌﺪل اﻟﺒﻄﻴﻦ اﻟﺴﺮﻳﻊ ﻓﻲ اﻟﺮﺟﻔﺎن اﻷذﻳﻨﻲ إﻟﻰ اﻧﺨﻔﺎض اﻟﻨﺘﺎج اﻟﻘﻠﺒﻲ‬AF) ‫اﻟﺮﺟﻔﺎن اﻷذﻳﻨﻲ‬ - Preoperatively, a patient in AF should ideally be cardioverted, or controlled to