Best practice & research. Clinical anaesthesiology
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The number of aged individuals is growing, and consequently the demands on resources for cardiac surgery will increase in the elderly. Even in the absence of obvious coexisting diseases, advanced age is always accompanied by a general decline in organ functions, and specifically by changes in structure and function of the heart and vasculature that will ultimately affect cardiovascular performance (e.g. hypertension, ischaemic heart disease, etc.). These alterations have to be taken into account when older patients require anaesthesia for cardiac surgery. ⋯ Essential monitoring should include pulmonary artery catheterization and/or transoesophageal echocardiography. During cardiac surgery the risk for elderly individuals is increased; in particular, the central nervous system is more often compromised in the elderly than in younger patients. However, elderly patients without significant co-morbidity have a mortality rate comparable to that of younger patients.
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Best Pract Res Clin Anaesthesiol · Jun 2003
ReviewCognitive function after anaesthesia in the elderly.
Despite advances in peri operative care, a significant percentage of elderly patients experience transient post operative delirium and/or long-term post-operative cognitive dysfunction (POCD). This chapter reviews the aetiology, clinical features, preventive strategies and treatment of these syndromes. Pre-operative, intra-operative, and post-operative risk factors for delirium and POCD following cardiac and non-cardiac surgery are discussed. ⋯ Currently there is no single therapy that can be recommended for treating post-operative cognitive deterioration. Primary prevention of delirium and POCD is probably the most effective treatment strategy. Several large clinical trials show the effectiveness of multicomponent intervention protocols that are designed to target well-documented risk factors in order to reduce the incidence of post-operative delirium and, possibly, POCD in the elderly.
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Elderly patients represent the majority of the surgical population scheduled for ophthalmological surgery. Eye surgery is usually minimally invasive, enabling most of the procedures to be performed as day-case surgery despite the high co-morbidity of these patients. This, however, requires a specific perioperative anaesthetic strategy. In this chapter we address features of perioperative care in the geriatric population undergoing eye surgery, from pre-medication and pre-operative testing, to choice and performance of anaesthesia, and finally to post-anaesthesia care.
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An overview is given of the influence of age on the pharmacodynamics of drugs used during general and locoregional anaesthesia. For some groups of agents a distinct separation into age-related changes in the pharmacokinetics and pharmacodynamics is possible, whereas for others the literature indicates only that responses in the elderly are enhanced. I start with an overview of the influence of age on cardiovascular and neuroendocrine function and include a short account of the state-of-the-art in pharmacodynamic modelling. ⋯ For opioids and local anaesthetics applied for blockade of the central nervous system, the pharmacodynamic involvement is not always clear. For neuromuscular blocking agents, pharmacodynamic involvement appears to be nearly absent in the reduced dose requirements seen with age--so that the latter appear to be caused by altered pharmacokinetics. Future studies, using pharmacokinetic-pharmacodynamic (PK-PD) mixed-effects modelling, should further explore this area to obtain clinically applicable data for improving our insight into the delivery of anaesthetics to the elderly and improving the quality of anaesthesia in this fast-growing population.