Best practice & research. Clinical anaesthesiology
-
Best Pract Res Clin Anaesthesiol · Sep 2011
ReviewCognitive decline in the elderly: is anaesthesia implicated?
Postoperative cognitive dysfunction (POCD) was originally thought to be associated with cardiac surgery, but has since been associated with non-cardiac surgery and even sedation for non-invasive procedures such as coronary angiography. The focus of POCD has thus shifted from the type of surgery or anaesthetic to patient susceptibility. The realisation that cognitive impairment, such as mild cognitive impairment (MCI - the prodrome for Alzheimer's disease (AD)), may already exist in many elderly patients who incidentally present for surgery beckons anaesthesia to align cognitive research with that of AD in order to draw valid parallels between the two disciplines. ⋯ In this regard, the use of CSF analysis to diagnose AD many years before symptoms appear may identify susceptible individuals. Furthermore, animal studies indicate that volatile anaesthestics may augment the pathological processes of AD by affecting amyloid-beta processing. Identification of a link between surgery/anaesthesia, POCD, MCI, and AD would create a unique opportunity to fast-track the development of clinical or pharmacological preventive strategies that would benefit a significant proportion of the population.
-
The average age of the world's population is increasing rapidly, with those over 80 years of age the fastest growing subsection of older persons. Consequently, a higher proportion of those presenting for surgery in the future will be older, including greater numbers aged over 100 years. Management of postoperative pain in these patients can be complicated by factors such as age and disease-related changes in physiology, and disease-drug and drug-drug interactions. ⋯ Alterations in pharmacokinetics and pharmacodynamics may influence drugs and techniques used for pain relief. The evidence-base for postoperative pain management in the older population remains limited. However, most commonly used analgesic regimens are suitable for older patients if adapted and titrated appropriately.
-
Best Pract Res Clin Anaesthesiol · Sep 2011
ReviewPerioperative exercise training in elderly subjects.
The association between physical fitness and outcome following major surgery is well described - less fit patients having a higher incidence of perioperative morbidity and mortality. This has led to the idea of physical training (exercise training) as a perioperative intervention with the aim of improving postoperative outcome. Studies have started to explore both preoperative training (prehabilitation) and postoperative training (rehabilitation). ⋯ Prehabilitation using continuous or interval training has been shown to improve fitness but the impact on surgical outcomes remains ill defined. Taken together, these findings are encouraging and support the notion that pre- and postoperative exercise training may be of benefit to patients. There is an urgent need for adequately powered randomised control studies addressing appropriate clinical outcomes in this field.
-
Best Pract Res Clin Anaesthesiol · Sep 2011
ReviewPerioperative cardiopulmonary exercise testing in the elderly.
The elderly constitute an increasingly large segment of the population and of the patients requiring medical attention. Major surgery is associated with a substantial burden of postoperative morbidity and mortality. Advancing age is a particular risk factor for these outcomes. ⋯ There is a consistent association between CPET-derived variables and outcome following major surgery. Furthermore, CPET-derived variables have utility in perioperative risk prediction and identification of patients at high risk of adverse outcome following major surgery. This optimal predictor appears to differ between various surgery types and the incremental benefit of combining CPET with alternative methods of perioperative risk prediction remains poorly defined.
-
Best Pract Res Clin Anaesthesiol · Sep 2011
ReviewRenal injury in the elderly: diagnosis, biomarkers and prevention.
Acute kidney injury (AKI) in the elderly patient is a common iatrogenic complication of major surgery that impacts morbidity, mortality and resource use. Several renal functional and structural changes have been described, including a substantially decreased nephron mass. ⋯ The limitations of serum creatinine are much more pronounced in the elderly, including its dependence on muscle mass and the presence of multiple drug use and co-morbidities. Although it is conceivable that earlier AKI diagnosis and application of classical preventive measurements, including postponement of surgery or preference of medical treatment, optimisation of haemodynamics, euvolaemia, aggressive avoidance of nephrotoxic antibiotics or analgesics may translate into better patient outcomes, much more data are needed in this specific cohort.