Geriatric Anesthesia

SC 李侑珊
石博元
VS 鄭雅蓉
Brief History
 99 y/o female with
1. Large bedsore for 5 months s/p debridement
2. Old right femoral fracture s/p Moore hemiart
hroplasty on 1995
3. Osteoporosis
4. Dementia

No other systemic illness

CXR
Anesthesia record
Anesthesia record

Agent Given dose Regular dose

fentanyl 1 ml 2 ml
propofol 50 mg 80-90 mg
rocuronium 20 mg 40 mg
atropine 0.4 mg 0.4 mg
Enlon 28 mg 32-40 mg
Age, Minimum Alveolar Anesthetic C
oncentration, and Minimum Alveol
ar Anesthetic Concentration-Awak
e
Eger, Edmond I II, MD

Anesth Analg. 2001 Oct;93(4):947-53

Geriatric Anesthesia
Age related anatomic &
Physiologic Changes
Cardiovascular system and
Autonomic Nervous System
(1)
1. Decline in the responsiveness of β- receptors
- plasma catecholamine level unchanged
- decrease in beta-adrenergic receptors density(?)
- 75y/o vs. 25y/o, 20% decrease of maximal HR
2. Progressive replacement of supple, functional car
diac and vascular tissue (a. &v) by stiff, fibrotic m
aterial
- elevated afterload
- elevated systolic BP
- LV hypertrophy
Cardiovascular system and
Autonomic Nervous System
(2)
3. Decreased cardiac output
4. Decreased baroreceptor reflex

These factors render the elderly patients

less capable of defending their CO and BP
against the usual periop challenges.
Respiratory System (1)

1. a decline in elasticity of the bony thorax

• Increased residual volume
• Decreased vital capacity
• Increased dead space
2. a loss of muscle mass with weakening of
the muscles of respiration
• FEV1 decreases progressively with aging
• ratio of FEV to TLC of the elderly decreases.
(70% vs. >80%)
Respiratory system (2)

1. a decrease in alveolar gas exchange surf

ace
2. a decrease in central nervous system res
ponsiveness
• Ventilatory response to hypercapnia and hy
poxia is blunted in the elderly (1/2 of 25y/o)
• Thus, we need to increase FIO2 and tidal vo
lume (watch out for oxygen toxicity and bar
otrauma)
Renal System
1. Decreased renal mass, mainly in the corte
x
2. Decreased renal blood flow
 Due to glomerulosclerosis
 RPF and GFR↓
3. Decreased tubular function
 impaired fluid handling
 decreased concentrating ability
 decreased diluting capacity
 impaired sodium handling
 decreased drug excretion
Liver

1. There is a lack of correlation

between structural and functional
data concerning the aging liver, as a
decline in organ volume does not
necessarily reflect impaired metabolic
function.
2. Reduced hepatic drug clearance is
common in the elderly
Nervous System (1)
Effects of aging on the nervous system
include:
 a general loss of neuronal substance
 a decrease in the number of peripheral neur
ons
 muscles innvervated by fewer axons, leadin
g to possible denervation atrophy
 conduction velocity is slightly affected by agi
ng (slower)
Nervous System (2)

 increased sensitivity to opioid analgesi

cs
 decreased cell density, lower cerebral
oxygen consumption and lower cerebr
al blood flow
Geriatric Anesthesia
Age related pharmacologic
changes
Pharmacokinetic and pharmacodynamic d
ifferences in the elderly (1)

 Protein binding:
– Circulating level of serum protein (especially
albumin) decreases in quantity
– 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.
Pharmacokinetic and pharmacodynami
c differences in the elderly (2)
 Changes in body compartment
– Age-related changes in body composition
include a loss of skeletal muscle and an
increase in percentage of body fat.
– Increased availability of lipid storage sites,
this will leads a gradual elution of these
agents from the storage sites.
Pharmacokinetic and pharmacodyn
amic differences in the elderly (3)

 Heaptic and renal function

– Hepatic and renal function are reduced about 1
% per year beyond 30.

Elimination half-life
Drug Young adult Old adult
Fentanyl 250min 925min
Diazepam 24hrs 72hrs
midazolam 2.8hrs 4.3hrs
vecuronium 16min 45min
Induction Agent (1)
 Thiopental
– Administration of IV barbiturates produces the p
eripheral vasodilatation with a moderate BP dec
rease.
– With a decreased baroreceptor reflex and increa
sed 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.
Induction Agent (2)

 Methohexial
– Methohexial is rapid acting and has a high
er hepatic clearance rate and shorter elim
ination time than thiopental.
– More suitable for outpatient surgery.
Induction Agent (3)
 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 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)
Muscle Relaxant (1)

 Aging affects the neuromuscular junc

tion in many ways:
1. The distance of the junction ↑
2. The number of ACh vesicle ↓
3. Receptors of ACh ↓
4. Sensitivity of ACh receptors —
Muscle Relaxant (2)

 Succinylcholine
– This agent is metabolized by pseudocholi
nesterase which is not affected by the agi
ng process.
– The response of succinylcholine is unalter
d with aging.
Muscle Relaxant (3)

Non-depolarizing muscle relaxant

 Long-acting agents:
– Metocurine, pancuronium (renal)↑
– Doxacurium, pipecuronium (renal) —
 Intermediate-acting agents
– Vecuronium, rocuronium ↑
– Atracurium, cisatracurium (Hoffmann elim
ination)—
Muscle Relaxant (4)

 The use of the intermediate-acting

agent is prudent, because even the
duration of one single dose of long-
acting agent may be too prolonged for
the planned surgery.
 Fewer dose of non-depolarizing
muscle relaxant will be required.
Opioids (1)

 Increases in potency for alfentanil, fen

tanyl, and remifentanil were demonstr
ated in EEG studies.
 A reduction in dosage in the elderly wo
uld be recommended.
Opioids (2)

 Fentanyl
– Dose should be reduced to ½ to achieve t
he same effect.
 Alfentanil
– Same recommendation as fentanyl.
Volatile agents (1)

 Ventilation perfusion mismatch will

decrease the rate of action.
 Decreased cardiac output will make
the onset of the action more rapid.
 Recovery from anesthesia with a
volatile agent may be prolonged
because of an increased volume of
distribution (increased body fat).
Volatile agents (2)
 The MAC of inhalational agents is reduced
by 6% per decade of age over 40 years.
 The lower lipid-solubility of sevoflurane a
nd desflurane has advantage in the elderl
y:
– More rapid control of anesthetic depth than higher li
pid-solubility agents.
– A faster emergence from anesthesia. (desflurane vs.
isoflurane: 5.4 vs. 7 mins)
Summary
Anesthesia Record

Agent Given dose Regular dose

fentanyl 1 ml 2 ml
propofol 50 mg 80-90 mg
rocuronium 20 mg 40 mg
atropine 0.4 mg 0.4 mg
Enlon 28 mg 32-40 mg
Thank you for your
Attention