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SPECIAL ARTICLES
Anaesthesiology Intensive Therapy
2013, vol. 45, no 2, 5761
ISSN 16425758
DOI: 10.5603/AIT.2013.0013
www.ait.viamedica.pl
Guidelines for general anaesthesia in the elderlyof the Committee on Quality and Safety in Anaesthesia,
Polish Society of Anaesthesiology and Intensive Therapy
Radosaw Owczuk
Department of Anaesthesiology and Intensive Therapy, Medical University of Gdansk, Poland
The prolongation o the human liespan, one o the most
important achievements o modern medicine, has led to
a rapid increase in the number o elderly people (according
to the current denition, this reers to those over 65 years
o age). The incidence o anaesthesia and surgery in elderly
patients is assumed to be our-old higher compared to the
remaining general population [1]. It is estimated that within
the next ten years the demands or invasive procedures
will increase by 25%, whereas the geriatric population will
grow by about 50% [2]. Consequently, the demands or
anaesthesia in the elderly will increase.
Elderly people require specic management adjusted
to the natural processes o ageing, higher prevalence o co-
-existing pathologies, and dierent responses to medicines
used in the perioperative period. The pathophysiological
changes associated with natural ageing aect all the organs
and tissues, especially those in the cardiovascular, respirato-
ry, urinary and central nervous systems. At a rough estimate,
the competence o internal organs diminishes by 1% per
one year o lie over the age o 40 [3].
RISK ASSESSMENT
The decision concerning surgery and anaesthesia should
not be solely based on a patients age; the risk-benet ratio
ought to be assessed. Four main independent risk actors
are considered the indicators o possible risk o surgery in
patients over the age o 65: age, general condition and coexi-
sting illnesses (according to the ASA scale), urgency o surge-
ry (scheduled or emergent), and type o surgical procedure.
Advanced age is a risk actor o possible anaesthetic
complications and major incidents in the post-surgery recu-
peration period [4]. It should be stressed, however, that age
itsel is responsible only or a slight increase in anaesthetic
complications, which are much more related to the urgency
o surgery and severity o other systemic diseases [2, 5].
PATIENT PREPARATION FOR ANAESTHESIA
The success o anaesthetic and surgical procedures de-
pends not only on proper and skilul perormance, but also
on suitable preparation o patients or surgery and anaesthe-
sia, and in particular patients with concomitant diseases.
1. In scheduled procedures, preparation or anaesthesia
should be started early.
2. Strategies to reduce surgery-related cardiovascular com-
plications using -adrenolytics, statins or angiotensin
convertase inhibitors should be optimally introduced
our weeks prior to anaesthesia (seven days as a mini-
mum) [2]; thereore, co-operation between the hospital
personnel and GPs as well as early patient visits to the
anaesthesiological outpatient clinic are required.
3. In cardiovascularly compromised patients, preparation
or surgery/anaesthesia and optimisation o the patients
condition should be consistent with the guidelines o
the European Society o Cardiology and European So-
ciety o Anaesthesiology [2].
4. Optimisation o the patients condition and preparation
o patients with severe chronic diseases should be based
on co-operation with a suitable specialist.
ADDITIONAL TESTS CONDUCTED PRIOR
TO ANAESTHESIA
In the majority o cases, the ollowing tests are recom-
mended:1. Peripheral blood tests, including lymphocyte count (to
evaluate potential malnutrition).
Accepted by members of the Commitee on Quality and Safety
in Anaesthesia, Polish Society of Anaesthesiology and Intensive Therapy:
Janusz Andres (Krakw), Wojciech Gaszyski (Lodz),Przemysaw Jaowiecki (Katowice), Krzysztof Kusza (Bydgoszcz),
Andrzej Nestorowicz (Lublin), Ewa Mayzner-Zawadzka (Olsztyn)
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Anaesthesiol Intensive Ther 2013, vol. 45, no 2, 5761
2. Serum concentrations o sodium, potassium, chlorides,
urea and creatinine.
3. Fasting blood sugar.
4. Resting 12-lead ECG.
5. Chest X-ray.
In individual cases, it is necessary to widen the spectrum
o tests and consultations, depending on the kind and se-
verity o diseases.
Since the muscle mass in the elderly decreases, the renal
unction should be assessed based on serum concentrations
o creatinine and urea as well as renal ltration, which is best
determined by the Cockrot-Gault ormula [6]:
Creatinine
clearance=
[140 age (years)] body mass (kg) C
Serum creatinine (mg dL1) 72
C constant: women = 0.85; men = 1.0.
CONSENT FOR ANAESTHESIA
According to the Medical and Dental Practitioners Act,
the patient should give conscious and voluntary inormed
consent or any medical procedure, including anaesthesia.
In cases o patients incapable o providing such consent due
to quantitative or qualitative consciousness decits, the con-
sent is given by the statutory representative or, in his or her
absence, by the Guardianship Court with jurisdiction over
the place o procedure. It should however be remembered
that i the patient is legally incapacitated, but still able to
consciously communicate his or her will, it is necessary to
obtain an additional consent rom him or her [7].
PREMEDICATION
The available literature does not prove beyond all doubt
that routine premedication is benecial to elderly patients
[8]. Any decision-making concerning administration and
type o premedication in this age group should consider
the ollowing actors:
1. The decision regarding pharmacological premedication
ought to be made on an individual basis, taking into
consideration the physical and psychological condition
o the patient, possible side eects o administered
medicines and their interactions with the drugs already
used by the patient or chronic conditions.
2. Possible premedication-related side eects should be
taken into account, especially paradoxical stimulation
and impaired respiration or circulation (monitoring sho-
uld be provided in the patient's ward).
3. Extremely anxious patients can receive an anxiolytic
(usually a short-action benzodiazepine).
4. Midazolam should be used with great caution due toincreased risk o respiratory depression or arrest, even
at very low doses.
5. In highly aroused patients, oral olanzapine or a small
dose o lorazepam may be considered [9].
6. Since the patients reactions, even to reduced doses o
premedication agents, are unpredictable, enhanced
surveillance ater their administration and during trans-
port to the surgical ward is required.
During the pre-surgery visit, the physician should discuss
not only possible premedication, but also pre-surgical liquid
supply, especially in patients who are not anaesthetised and
operated on rst. There are no contraindications or small
amounts o clear liquids 23 hours prior to anaesthesia,
unless patients suer rom severe diabetes and/or chronic
renal ailure, due to gastropathy that accompanies such
conditions.
INDUCTION OF ANAESTHESIA
Induction o anaesthesia in elderly patients can be par-
ticularly dicult during general anaesthesia. Patients over
65 years o age display high variability in their responses
to induction drugs especially i.v. anaesthetics. Compared
to the younger population, the doses should be lower due
to decreased volume o distribution [1]. It is recommended
to monitor meticulously the patients cardiac parameters
during induction.
1. Due to decreased unctional residual capacity, the pre-
oxygenation period should be longer.
2. Doses o opioids used or induction (entanyl, suentanil)
do not have to be reduced considerably compared to
the doses administered to younger patients [8]. Never-
theless, the utmost care should be taken during admini-
stration o remientanil or the initial dose o remientanil
abandoned due to the risk o circulatory depression and
chest wall rigidity.
3. The Polish Society o Anaesthesiology and Intensive The-
rapy recommends inhaled induction in elderly patients
[11]. Sevofurane is particularly suited or inhaled induc-
tion and it is well tolerated by elderly patients [1214].
4. Irritation o the airway caused by desfurane signican-
tly limits its use in anaesthesia induction. Desfurane
should not be used or induction in patients with in-
creased risk o ischaemic heart disease or in any cases
where increased heart rate and blood pressure are
contraindicated.
5. The slightest circulatory depression is observed ater i.v.
etomidate; however its administration (as with that o
ketamine) should be careully considered, especially in
patients with circulatory instabilities.
6. Doses o thiopental and propool used in anaesthetic
induction should be decreased by 3040% in compari-
son to those used in younger patients.7. Intravenous anaesthetic titration appears to be the opti-
mal method o administration to obtain the required
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Radosaw Owczuk, Guidelines for general anaesthesia in the elderly of the Committee on Quality and Safety in Anaesthesia PTAiIT
clinical eect (e.g. suppression o eyelash refex) or su-
itable BIS value at the lowest dosage possible.
8. The onset o action o non-depolarising muscle relaxants
is delayed in elderly patients, so lung ventilation via a a-
cemask may have to be provided or a longer time [3, 15].
9. When suxametonium is used, its reduced doses are not
required. In patients with low cardiac output, the onset
o drug eects may be delayed. Even though the activity
o butyrylcholinesterase is decreased in elderly patients,
the clinical ndings do not show prolonged block ater
this depolarising agent [16].
In addition to correct selection o all the agents and
pharmaceuticals used or anaesthesia induction, it is neces-
sary to consider the problems that may be associated with
lung ventilation via a acemask and laryngeal intubation.
Decreased mobility o the cervical spine may hinder opti-
mal head placement. In patients with severely obstructed
cervical arteries, and whose cerebral circulation is mainly de-
pendent on the blood fow via the spinal arteries, excessive
head movements should be avoided. Special care must be
taken during laryngeal intubation in patients with moving
or shiting teeth.
The use o a laryngeal mask and other supralarynge-
al airway devices in elderly patients is an alternative sae
method o securing the airways, unless there are specic
contraindications [17]. Compared to propool, sevofurane
used or anaesthesia induction beore the placement o
a laryngeal mask has been demonstrated to reduce the risk
o adverse circulatory eects and apnoea [18].
MAINTENANCE OF ANAESTHESIA
Maintenance o anaesthesia, as with its induction, re-
quires proper adjustment o drug doses to the patients
age and biological condition. The optimal solution inclu-
des anaesthesia depth monitoring (using BIS or entropy)
and administration o the smallest doses that will maintain
the required anaesthesia level with the proper circulatory
unction preserved. It is estimated that a BIS level o 50
60 is optimal or maintaining anaesthesia in the elderly,
compared to that o about 45 which is optimal or younger
patients [6, 19].
1. It appears that anaesthesia maintenance with inhaled
sevofurane, desfurane or isofurane is optimal or el-
derly patients. Moreover, halogen inhaled anaesthe-
tics enable continuous monitoring o anaesthetic end-
-expiratory concentration and have possible protective
eects on vital organs, especially the heart, which results
in decreased perioperative mortality and morbidity [20].
2. MAC and MAC-awake o halogen agents drop by 45%
or every decade o lie over the age o 40, thus theirconcentrations should be adjusted to the patients age
[21, 22].
3. A sudden increase in desfurane concentration in the
inhalation mixture should be avoided due to the risk o
sympathetic nervous system stimulation and resultant
elevated arterial blood pressure and increased myocar-
dial oxygen demand.
4. Desfurane should not be administered to patients with
obstructive diseases (e.g. chronic obstructive pulmonary
disease, asthma) as it can result in bronchospasms.
5. Nitrous oxide should be used or anaesthesia main-
tenance with due caution in patients with impaired
circulatory unction, as its cardiodepressive eects are
likely to decrease arterial blood pressure [3].
6. The maintenance dose o propool should be adequate
to the dose used or anaesthesia induction. The dose is
usually decreased by 50% compared to the maintenance
dose used in younger patients. I the inusion guided by
target concentration is used, the Schniders model, taking
into account the patients age, is recommended [23].
7. The remientanil dose used in inusion should be redu-
ced to 3040% o the dose used in younger patients
due to increased risk o cardiovascular complications,
resulting rom the small volume o distribution o this
opioid, decreased clearance and increased susceptibility
o elderly patients.
8. It is recommended to reduce the doses o other opioids by
4050% compared to the doses used in young patients.
9. Pharmacokinetics o atracurium and cisatracurium does
not change with age, so there is no need to adjust the
dosages. Decreased metabolism o pancuronium, vecu-
ronium and rocuronium is likely to prolong their time
o action [3, 4].
SPECIFIC INTRAOPERATIVE PROBLEMS
1. Elderly patients are more prone to intraoperative hypo-
thermia that increases hospital morbidity and mortality.
Thereore, some preventive measures are required (ma-
intaining proper temperature in the operating room,
patient warming, inusion fuid heating).
2. The strategy o intraoperative fuid therapy based on
administration o balanced fuids should be tailored to
a particular surgical procedure and the patients con-
dition, and to a lesser degree to the patients age [8].
3. The decision to transuse red blood cells or otherwise
should be based on the assessment o myocardial ischa-
emia-related clinical symptoms, including haemodyna-
mic instability, tachycardia or ECG changes. The haemo-
globin concentration and peripheral blood haematocrit
are insucient to make such a decision. Moreover, deter-
minations o haemoglobin oxygen saturation in mixed
venous or superior vena cava blood may prove useul.4. Special procedures, such as controlled hypotension or
normovolemic haemodilution should be used with great
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caution due to possible disturbances in autoregulation
o blood fow in some vital organs resulting in their
ischaemia and secondary ailure.
ANAESTHESIA WITHDRAWAL
The altered physiological conditions, as well as die-
rent pharmacokinetics and pharmacodynamics in elderly
patients, can prolong their recovery rom anaesthesia even
at reduced doses o anaesthetics; in some cases articial
lung ventilation is required in the immediate postoperative
period.
One o the most important problems o the aoremen-
tioned postoperative period is the restoration o proper
neuromuscular junction unction and prevention o resi-
dual paralysis that may cause postoperative pulmonary
complications.
1. It is recommended to use intraoperative monitoring o
the neuromuscular blockage level and to extubate the
trachea ater it has ully subsided.
2. Acetylcholinesterase inhibitors may be saely used in
elderly patients. However, their adverse eects must be
taken into account. Moreover, it should be remembered
that administration o ACE inhibitors and obligatory
atropine might induce postoperative cognitive disorders
and conusion.
3. Reversal o rocuronium-induced neuromuscular block
with sugammadex appears preerable, but this method
is not recommended or patients with renal insu-
ciency [24].
All elderly patients ought to be meticulously observed
and closely monitored in recovery rooms and postoperative
care units.
POSTOPERATIVE PAIN MANAGEMENT
Postoperative pain treatment is a challenging task, due
to a smaller saety margin o analgesics and diculties in
pain assessment associated with patient conusion and
age-related nociceptive disorders.
1. Postoperative pain assessment using routine scales may
be dicult or even impossible in some elderly patients.
2. It is recommended to use specic methods o pain as-
sessment based on observation o patients at rest and
on movement (e.g. the MOBID Scale Mobilisation
Observation Behaviour Intensity Dementia) [25, 26].
3. The detailed principles o postoperative pain manage-
ment should be based on inormation ound in geriatric
anaesthesia and pain medicine handbooks [27, 28].
SPECIFIC POSTOPERATIVE PROBLEMS
Patients over the age o 65 are at a particularly high risko postoperative conusion (delirium) and cognitive disor-
ders (PCD Postoperative Cognitive Dysunction) [29, 30].
CONFUSION
1. Frequency o conusion incidents ranges rom 35% to
70% ater some procedures.
2. An extremely high risk o PCD is associated with mi-
dazolam.3. The other risk actors include hypoxia, anticholinergic
drugs, impaired metabolism o sodium and potassium,
abnormal glucose levels, alcohol abuse, inections, de-
hydration, sleep, visual and auditory disorders.
4. In such cases, the risk actors should be early identi-
ed, reversible causes treated and pharmacotherapy
administered (haloperidol or other neuroleptics such
as olanzapine or risperidone; in some cases, lorazepam
although with caution).
COGNITIVE DISORDERS
1. Cognitive disorders develop during the postoperative
period in about 25% o patients over the age o 65.
2. The most common risk actors are hypoxia, hypotension,
general anaesthesia, increased perioperative stress, glu-
cocorticosteroids and drugs aecting the cholinergic
system.
3. It is essential to avoid situations and drugs that are risk
actors o PCD.
The guidelines presented in this paper set out the ge-
neral rules o anaesthesia in elderly patients. In cases o
age-specic diseases, the guidelines published in geriatric
anaesthesiology handbooks [3, 31, 32] and papers [9, 16,
3335] are recommended. The above guidelines do not co-
verperineural anaesthesia and its useulness in the elderly.
Furthermore, monitored anaesthesiological supervision,
sedation and analgosedation have not been considered.
All these complex issues should be urther analysed and
suitable guidelines designed.
CONFLICT OF INTEREST
This work was supported by AbbVie Poland.
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Corresponding author:
Radosaw Owczuk, MD, PhD
Department of Anaesthesiology and Intensive Therapy
Medical University of Gdansk
ul. Dbinki 7, 80211 Gdask, Poland
e-mail: [email protected]