Anaesthesia for the elderly outpatient: preoperative assessment and evaluation, anaesthetic technique and postoperative pain management

Risk Factors of In-Hospital Venous Thromboembolism and Prognosis After Emergent Ventral Hernia Repair

Background: The risk factors and association of venous thromboembolism (VTE) following emergent ventral hernia repair (EVHR) remains uncertain. This aim of the study aims was to establish the predictors of VTE after EVHR and its influence on the long-term outcomes. Methods: A total of 2093 patients from the MIMIC-IV database who underwent EVHR were recruited. Multivariate logistic regression and nomogram models were developed to predict in-hospital VTE and mortality. Calibration and receiver operating characteristic (ROC) curves were utilized to assess the model's effectiveness and reliability. Decision curve analysis (DCA) was performed to evaluate the net clinical benefits of the model. Results: The rate of in-hospital VTE was 1.6% (33/2093) after EVHR. Four independent potential factors were established after multivariate analysis, and the abovementioned risk factors fit into the nomogram. The prediction model presented good performance metrics (C-index: 0.857), the calibration and ROC curves demonstrated the accurate prediction power, and DCA indicated the superior net benefit of the established model. In-hospital and 1-year mortality rates were 0.8% (17/2093) and 4.1% (86/2076) after EVHR. The potential factors were included in the mortality prediction nomogram. The prediction model presented good performance metrics (C-index of 0.957 and 0.828, respectively), the calibration and ROC curves were consistent with the actual results, and DCA indicated the superior net benefit of the established model. Conclusion: The nomogram, derived from the logistic regression model, demonstrated excellent predictive performance for VTE occurrence and prognosis in patients following EVHR. This model could serve as a valuable reference for clinical decision-making regarding VTE prevention and for enhancing post-EVHR prognosis.

Efficacy and complications of microvascular decompression in patients over 70 years with trigeminal neuralgia

OBJECTIVE

Treatment of choice for trigeminal neuralgia (TN) by neurovascular conflict in case of failure of medical treatment is microvascular decompression (MVD). It is a safe and effective technique in the short and long term. But what about older patients who are considered more fragile anesthetically and surgically? Our Objective is to demonstrate the efficacy and complication rate of microvascular decompression (MVD) for older and younger patients with trigeminal neuralgia (TN) due to neurovascular conflict.

METHODS

102 patients with TN due to neurovascular conflict were included (June 2005-December 2016) in a single Regional hospital. 25 were included in the group composed of ≥ 70-year-old patients (G1), while 77 were included in the < 70-year-old group (G2). The patients were operated on by the same surgical team using a retro-sigmoid approach to access the neurovascular conflict. The epidemiologic, clinical, anesthetic, and surgical data were extracted.

RESULTS

The immediate efficacy of surgical treatment (BNI pain intensity = I) was 96% in G1 and 96.10% in the G2 group (p = 0.71). At 3-year follow-up, the efficacy rate was 89% and 86%, respectively (p = 0.93). At 5 years, it was 92% and 92% (p = 0.98). Complication rates were comparable between the two groups (20% versus 27%; p = 0.47) and no deaths occurred despite the fact that G1 group had worst preoperative anesthetic score (ASA-NYHA).

CONCLUSION

MVD is a durable procedure in patients over 70 years of age diagnosed with essential TN. The complication rate and immediate-, medium-, and long-term efficacy were similar to those of younger patients.

Association of Nutritional Risk Index With Postoperative Pain Outcomes in Elderly Patients Undergoing Gastrointestinal Surgeries: A Retrospective Cohort Study

Background: Malnutrition is a major health problem, which is common in hospitalized elderly patients and is associated with an increased risk of morbidity and mortality. However, studies on malnutrition and its effect on postoperative pain outcomes in elderly patients have been largely neglected. Here we investigated the relationship between nutritional risk and postoperative pain outcomes in elderly patients.

Methods: Between April 1, 2012, and August 31, 2015, 734 elderly patients (≥65 years) who underwent gastrointestinal surgeries were recruited and assigned into two groups according to geriatric nutritional risk index (GNRI). All patients received standard anesthesia procedures and postoperative patient-controlled analgesia for 48 h. The preoperative epidemiology data and postoperative outcome data including pain intensities at rest and movement, the cumulative consumption of analgesics and its common side effects were recorded.

Results: The total number of patients with high nutritional risk (GNRI < 92) was 533 out of 734 (72.62%). When compared with low nutritional risk individuals (GNRI ≥ 92), the incidence of inadequate analgesia was significantly higher in elderly patients with GNRI < 92 at different time points. In addition, the cumulative consumption of analgesics was also significantly higher in elderly patients with GNRI < 92 at 0–6 h postoperatively. Through logistic regression analysis, high nutritional risk (OR = 3.113, 95% CI: 1.661–5.834, P < 0.001) and female gender (OR = 0.606, 95% CI: 0.394–0.932, P = 0.023) were identified as significant predictors for postoperative inadequate analgesia. Further sensitivity analyses showed high nutritional risk as a predictor for postoperative inadequate analgesia was more prominent in female patients and early elderly patients. Moreover, 88 was determined as an optimal cut-off value of GNRI for postoperative inadequate analgesia using receiver operating characteristic curve analysis.

Conclusion: High nutritional risk is associated with poor postoperative pain outcomes in gastrointestinal elderly patients. Preoperative nutritional evaluation using simple nutritional screening instruments (e.g., GNRI) with the new suggested cut-off value (GNRI = 88) might be included as a standard procedure in routine clinical practice among these patients for postoperative analgesia.

Chronic pain and substance abuse disorders: Preoperative assessment and optimization strategies

There is an ever-increasing number of opioid users among chronic pain patients and safely managing them can be challenging for surgeons, anesthesiologists, pain experts, and addiction specialists. Healthcare providers must be familiar with phenomena typical of opioid users and abusers, including tolerance, physical dependence, hyperalgesia, and addiction. Insufficient pain management is very common in these patients. Patient-centered preoperative communication is integral to setting realistic expectations for postoperative pain, developing successful nonopioid analgesic regimens, minimizing opioid consumption during the postoperative period, and decreasing the number of opioid pills at the risk of diversion. Preoperative evaluation should identify comorbidities and identify risk factors for substance abuse and withdrawal. Intraoperative and postoperative strategies can ensure safe and effective pain management and minimize the potential for morbidity and mortality in this high-risk patient population.

A New Robot-assisted Billroth-I Reconstruction: Details of the Technique and Early Results

BACKGROUND

Laparoscopic surgery for gastric tumor is considered a demanding procedure because of lymph node dissection and reconstruction. Billroth-I (B-I) reconstruction after laparoscopic distal gastrectomy is commonly performed extracorporeally because of the complexity of an intracorporeal procedure. Robotic surgery overcomes some limitations of laparoscopy, allowing to reproduce the basic maneuvers of open surgery. We describe a new technique to perform robotic B-I anastomosis.

METHODS

Between January 2012 and February 2015, 5 patients underwent distal gastrectomy with intracorporeal B-I-stapled anastomosis. Patient demographics, tumor characteristics, histopathologic features, and perioperative data were analyzed.

RESULTS

Median operative time was 170 minutes (145 to 180 min). There were no conversions. Contrast swallow was routinely performed on the third postoperative day. Median postoperative hospitalization was 7 days (range: 6 to 8). No major complications or mortality were observed.

CONCLUSIONS

Robotic distal gastrectomy with intracorporeal B-I anastomosis is a safe and promising technique in selected cases of gastric tumors.

Enhanced Recovery After Surgery in Laparoscopic Surgery

BACKGROUND

As part of an effort to maximize value in the perioperative setting, a paradigm shift is underway in the way that patients are cared for preoperatively, on the day of surgery, and postoperatively-a setting collectively known as the perioperative care. Enhanced Recovery After Surgery (ERAS^®) is an evidence-based, patient-centered team approach to delivering high-quality perioperative care to surgical patients.

METHODS

This review focuses on anesthesiologists, with their unique purview of perioperative setting, who are important drivers of change in the delivery of valuable perioperative care. ERAS care pathways begin in the preoperative setting by both preparing the patient for the psychological stress of surgery and optimizing the patient's medical and physiologic status so the body is ready for the physical demands of surgery.

RESULTS

Minimization of perioperative fasting is important to maintain volume status-decreasing reliance on intravenous fluid administration, and to reduce protein catabolism around the time of surgery. Intraoperative management in ERAS pathways relies on goal-directed fluid therapy and opioid-sparing multimodal analgesia. Postoperatively, early feeding and ambulation, as well as discontinuation of extraneous lines and catheters facilitate patients' functional recovery.

CONCLUSION

The laparoscopic approach to surgery, when possible, compliments ERAS techniques by reducing abdominal wall trauma and the resultant milieu of inflammatory, neurohumoral, and pain responses. Anesthesiologists driving change in the perioperative setting, in collaboration with surgeons and other disciplines, can improve value in healthcare and provide optimal outcomes that matter most to patients and healthcare providers alike.

Perioperative Care of Elderly Surgical Outpatients

The ambulatory setting offers potential advantages for elderly patients undergoing elective surgery due to the advancement in both surgical and anesthetic techniques resulting in quicker recovery times, fewer complications, higher patient satisfaction, and reduced costs of care. This review article aims to provide a practical guide to anesthetic management of elderly outpatients. Important considerations in the preoperative evaluation of elderly outpatients with co-existing diseases, as well as the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and recommendations regarding the management of common postoperative complications (e.g., pain, postoperative nausea and vomiting [PONV], delirium and cognitive dysfunction, and gastrointestinal dysfunction) are discussed. The role of anesthesiologists as perioperative physicians is important for optimizing surgical outcomes for elderly patients undergoing ambulatory surgery. The implementation of high-quality, evidence-based perioperative care programs for the elderly on an ambulatory basis has assumed increased importance. Optimal management of perioperative pain using opioid-sparing multimodal analgesic techniques and preventing PONV using prophylactic antiemetics are key elements for achieving enhanced recovery after surgery.

Serial Analgesic Consumptions and Predictors of Intravenous Patient-controlled Analgesia with Cluster Analysis

Objectives:

To elucidate the dynamics of analgesic consumption regarding intravenous patient controlled analgesia (IVPCA) during postoperative period is rather complex partly due to between-patient variation and partly due to within-patient variation. A statistical method was proposed to classify serial analgesic consumption into different classifications that were further taken as the multiple outcomes on which to explore the associated predictors.

Methods:

We retrospectively included 3284 patients administrated by IVPCA for 3 days after surgery. A repeated measurement design corresponding to serial analgesic consumption variables defined as six-hour total analgesic consumptions was adopted. After determining the numbers of clusters, serial analgesic consumptions were classified into several homogeneous subgroups. Factors associated with new classifications were identified and quantified with a multinominal logistic regression model.

Results:

Three distinct analgesic classifications were aggregated, including “high”, ”middle” and “low” level of analgesic consumption of IVPCA. The mean analgesic consumptions on 12 successive analgesic consumptions at 6-hour interval of each classification consistently revealed a decreasing trend. As the trends were almost parallel with time, this suggests the time-invariant proportionality of analgesic consumption between the levels of analgesic consumption of IVPCA. Patient’s characteristics, like age, gender, weight, height, and cancer status, were significant factors associated with analgesic classifications. Surgical sites had great impacts on analgesic classifications.

Discussion:

The serial analgesic consumptions were simplified into 3 analgesic consumptions classifications. The identified predictors are useful to recognize patient’s analgesic classifications before using IVPCA. This study explored a new approach to analysing dynamic changes of postoperative analgesic consumptions.

[Unilateral spinal anesthesia : Literature review and recommendations]

Unilateral spinal anesthesia is a cost-effective and rapidly performed anesthetic technique. An exclusively unilateral block only affects the sensory, motor and sympathetic functions on one side of the body and offers the advantages of a spinal block without the typical adverse side effects seen with a bilateral block. The lack of hypotension, in particular, makes unilateral spinal anesthesia suitable for patients with cardiovascular risk factors e. g. aortic valve stenosis or coronary artery disease. Increasing numbers of surgical procedures are now being performed on an outpatient basis. Until now, spinal anesthesia has been considered unsuitable for this, not only because of the high incidence of intraoperative hypotension and postoperative urinary retention but also because of the prolonged postoperative stay before home discharge. This is not the case with unilateral spinal anesthesia: motor function returns rapidly, the incidence of urinary retention is extremely low, and patients are usually eligible for home discharge sooner than after bilateral spinal anesthesia or general anesthesia. The success of the technique depends on a number of factors. In addition to the local anesthetic, its concentration and dose, and the baricity of the injected solution, the shape of the spinal needle, the injection speed, the patient's position during injection, and the time the patient remains in this position after injection are equally important parameters. A number of intrathecally applied adjuvant drugs are used to give a more intense and/or longer-lasting block. For this review, we collated the published data on unilateral spinal anesthesia from journals with an impact factor greater than 1.0 and defined an optimized method for performing the technique. In order to achieve an exclusively unilateral block one should use 0.5 % hyperbaric bupivacaine injected at a rate of 0.33 ml/min or slower. During the injection and the following 20 min the patient should lie in the lateral decubitus position on the side intended for surgery with knees drawn to the chest. An injection of 5 mg (1 ml) hyperbaric bupivacaine 0.5 % provides an hour-long block to T 12, and a dose of 7.5 to 10 mg (1.5-2.0 ml) extends the block to T 6. Adding clonidine (0.5 to 1.0 µg/kg BW) to the injection prolongs the duration of the block to approximately two to three hours. During the 20-minute fixation period, the cephalad spread of the block can be influenced to a certain extent by raising or lowering the head of the table.

Use of direct oral anticoagulants with regional anesthesia in orthopedic patients

The use of direct oral anticoagulants including apixaban, rivaroxaban, and dabigatran, which are approved for several therapeutic indications, can simplify perioperative and postoperative management of anticoagulation. Utilization of regional neuraxial anesthesia in patients receiving anticoagulants carries a relatively small risk of hematoma, the serious complications of which must be acknowledged. Given the extensive use of regional anesthesia in surgery and the increasing number of patients receiving direct oral anticoagulants, it is crucial to understand the current clinical data on the risk of hemorrhagic complications in this setting, particularly for anesthesiologists. We discuss current data, guideline recommendations, and best practice advice on effective management of the direct oral anticoagulants and regional anesthesia, including in specific clinical situations, such as patients undergoing major orthopedic surgery at high risk of a thromboembolic event, or patients with renal impairment at an increased risk of bleeding.

Validation of a frailty index in patients undergoing curative surgery for urologic malignancy and comparison with other risk stratification tools

OBJECTIVE

To retrospectively validate and compare a modified frailty index predicting adverse outcomes and other risk stratification tools among patients undergoing urologic oncological surgeries.

MATERIALS AND METHODS

The American College of Surgeons National Surgical Quality Improvement Program was queried from 2005 to 2013 to identify patients undergoing cystectomy, prostatectomy, nephrectomy, and nephroureterectomy. Using the Canadian Study of Health and Aging Frailty Index, 11 variables were matched to the database; 4 were also added because of their relevance in oncology patients. The incidence of mortality, Clavien-Dindo IV complications, and adverse events were assessed with patients grouped according to their modified frailty index score.

RESULTS

We identified 41,681 patients who were undergoing surgery for presumed urologic malignancy. Patients with a high frailty index score of >0.20 had a 3.70 odds of a Clavien-Dindo IV event (CI: 2.865-4.788, P<0.0005) and a 5.95 odds of 30-day mortality (CI: 3.72-9.51, P<0.0005) in comparison with nonfrail patients after adjusting for race, sex, age, smoking history, and procedure. Using C-statistics to compare the sensitivity and specificity of the predictive ability of different models per risk stratification tool and the Akaike information criteria to assess for the fit of the models with the data, the modified frailty index was comparable or superior to the Charlson comorbidity index but inferior to the American Society of Anesthesiologists Risk Class in predicting 30-day mortality or Clavien-Dindo IV events. When the modified frailty index was augmented with the American Society of Anesthesiologists Risk Class, the new index was superior in all aspects in comparison to other risk stratification tools.

CONCLUSION

Existing risk stratification tools may be improved by incorporating variables in our 15-point modified frailty index as well as other factors such as walking speed, exhaustion, and sarcopenia to fully assess frailty. This is relevant in diseases such as kidney and prostate cancer, where surveillance and other nonsurgical interventions exist as alternatives to a potentially complicated surgery. In these scenarios, our modified frailty index augmented by the American Society of Anesthesiologists Risk Class may help inform which patients have increased surgical complications that may outweigh the benefit of surgery although this index needs prospective validation.

Anesthesia for the elderly outpatient

PURPOSE OF REVIEW

As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly patients will assume increased importance.

RECENT FINDINGS

Increasing evidence supports the expanded use of ambulatory surgery for managing elderly patients undergoing elective surgery procedures.

SUMMARY

This review article describes the demographics of ambulatory surgery in the elderly population. This review article describes the effects of aging on the responses of geriatric patients to anesthetic and analgesic drugs used during ambulatory surgery. Important considerations in the preoperative evaluation of elderly outpatients with co-existing diseases, as well as the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and recommendations regarding the management of common postoperative side-effects (including delirium and cognitive dysfunction, fatigue, dizziness, pain, and gastrointestinal dysfunction) after ambulatory surgery. Finally, we discuss the future challenges related to the continued expansion of ambulatory surgery practice in this growing segment of our surgical population. The role of anesthesiologists as perioperative physicians is of critical importance for optimizing surgical outcomes for elderly patients undergoing ambulatory surgery. Providing high-quality, evidence-based anesthetic and analgesic care for elderly patients undergoing elective operations on an ambulatory basis will assume greater importance in the future.

The implication of frailty on preoperative risk assessment

PURPOSE OF REVIEW

Frailty, a state of decreased homeostatic reserve, is characterized by dysregulation across multiple physiologic and molecular pathways. It is particularly relevant to the perioperative period, during which patients are subject to high levels of stress and inflammation. This review aims to familiarize the anesthesiologist with the most current concepts regarding frailty and its emerging role in preoperative assessment and risk stratification.

RECENT FINDINGS

Current literature has established frailty as a significant predictor of operative complications, institutionalization, and death among elderly surgical patients. A variety of scoring systems have been proposed to preoperatively identify and assess frail patients, though they differ in their clinical utility and prognostic ability. Additionally, evidence suggests an evolving potential for preoperative intervention and modification of the frailty syndrome.

SUMMARY

The elderly are medically complex and heterogeneous with respect to operative risk. Recent advances in the concept of frailty provide an evidence-based framework to guide the anesthesiologist in the perioperative management, evaluation, and risk stratification of older surgical patients.

Monitored anesthesia care without endotracheal intubation is safe and efficacious for single-balloon enteroscopy

BACKGROUND

General endotracheal (GET) anesthesia is often used during single-balloon enteroscopy (SBE). However, there is currently limited data regarding monitored anesthesia care (MAC) without endotracheal intubation for this procedure.

AIMS

The aim of the study was to determine the safety and efficacy of MAC sedation during SBE and to identify risk factors for adverse events.

METHODS

All patients who underwent SBE and SBE-assisted endoscopic retrograde cholangiopancreatography between June 2011 and July 2013 at a tertiary-care referral center were studied in a retrospective analysis of a prospectively collected database. Patients received MAC anesthesia or GET. The main outcome measurements were sedation-related adverse events, diagnostic yield, and therapeutic yield.

RESULTS

Of the 178 cases in the study, 166 cases (93 %) were performed with MAC and 12 (7 %) with GET. Intra-procedure sedation-related adverse events occurred in 17 % of cases. The most frequent event was transient hypotension requiring pharmacologic intervention in 11.8 % of procedures. In MAC cases, the diagnostic yield was 58.4 % and the therapeutic yield was 30.1 %. Anesthesia duration was strongly associated with the occurrence of a sedation-related adverse event (P = 0.005).

CONCLUSIONS

MAC is a safe and efficacious sedation approach for most patients undergoing SBE. Sedation-related complications in SBE are uncommon, but are more frequent in longer procedures.

Management of postoperative complications: cardiovascular disease and volume management

Postoperative cardiovascular complications are common, predictable, and typically treatable in geriatric patients who have sustained fractures. Although intervention-specific data are sparse, observational evidence from high-performing geriatric fracture centers coupled with an understanding of geriatric principles can serve as a basis for treatment guidelines. Many patients can be safely and effectively managed with close attention to intravascular volume status, heart rate control, and minimization of other physiologic stresses, including pain and delirium. Many chronic cardiovascular therapies may be harmful in the immediate postoperative period, and can usually be safely omitted or attenuated until hemodynamic stability and mobility have been restored.

Perioperative multimodal anesthesia using regional techniques in the aging surgical patient

Background. Elderly patients have unique age-related comorbidities that may lead to an increase in postoperative complications involving neurological, pulmonary, cardiac, and endocrine systems. There has been an increase in the number of elderly patients undergoing surgery as this portion of the population is increasing in numbers. Despite advances in perioperative anesthesia and analgesia along with improved delivery systems, monotherapy with opioids continues to be the mainstay for treatment of postop pain. Reliance on only opioids can oftentimes lead to inadequate pain control or increase in the incidence of adverse events. Multimodal analgesia incorporating regional anesthesia is a promising alternative that may reduce needs for high doses and dependence on opioids along with any potential associated adverse effects. Methods. The following databases were searched for relevant published trials: Cochrane Central Register of Controlled Trials and PubMed. Textbooks and meeting supplements were also utilized. The authors assessed trial quality and extracted data. Conclusions. Multimodal drug therapy and perioperative regional techniques can be very effective to perioperative pain management in the elderly. Regional anesthesia as part of multimodal perioperative treatment can often reduce postoperative neurological, pulmonary, cardiac, and endocrine complications. Regional anesthesia/analgesia has not been proven to improve long-term morbidity but does benefit immediate postoperative pain control. In addition, multimodal drug therapy utilizes a variety of nonopioid analgesic medications in order to minimize dosages and adverse effects from opioids while maximizing analgesic effect and benefit.

Systematic review of the efficacy of pre-surgical mind-body based therapies on post-operative outcome measures

OBJECTIVES

A large body of research has demonstrated that patient factors are strong predictors of recovery from surgery. Mind-body therapies are increasingly targeted at pre-operative psychological factors. The objective of this paper was to evaluate the efficacy of pre-operative mind-body based interventions on post-operative outcome measures amongst elective surgical patients.

METHODS

A systematic review of the published literature was conducted using the electronic databases MEDLINE, CINAHL and PsychINFO. Randomised controlled trials (RCTs) with a prospective before-after surgery design were included.

RESULTS

Twenty studies involving 1297 patients were included. Mind-body therapies were categorised into relaxation, guided imagery and hypnotic interventions. The majority of studies did not adequately account for the risk of bias thus undermining the quality of the evidence. Relaxation was assessed in eight studies, with partial support for improvements in psychological well-being measures, and a lack of evidence for beneficial effects for analgesic intake and length of hospital stay. Guided imagery was examined in eight studies, with strong evidence for improvements in psychological well-being measures and moderate support for the efficacy of reducing analgesic intake. Hypnosis was investigated in four studies, with partial support for improvements in psychological well-being measures. Evidence for the effect of mind-body therapies on physiological indices was limited, with minimal effects on vital signs, and inconsistent changes in endocrine measures reported.

CONCLUSIONS

This review demonstrated that the quality of evidence for the efficacy of mind-body therapies for improving post-surgical outcomes is limited. Recommendations have been made for future RCTs.

Surgical pleth index-guided remifentanil administration reduces remifentanil and propofol consumption and shortens recovery times in outpatient anaesthesia

BACKGROUND

The surgical pleth index (SPI) is an index based on changes in plethysmographic characteristics that correlate with the balance between the sympathetic and parasympathetic nervous system. It has been proposed as a measure of the balance between nociception and anti-nociception. The goal of this study was to test whether it could be used to titrate remifentanil in day-case anaesthesia.

METHODS

A total of 170 outpatients were given total i.v. anaesthesia with propofol and remifentanil. The patients were randomized to have the remifentanil dose either adjusted according to the SPI (SPI group) or to clinical parameters (control group). The propofol dose was adjusted according to entropy in both groups. The consumption of anaesthetic drugs, recovery times, and complications were compared.

RESULTS

The mean [standard deviation (SD)] remifentanil and propofol infusion rates in the SPI and control groups were 0.06 (0.04) vs 0.08 (0.05) µg kg(-1) min(-1) and 6.0 (2.1) vs 7.5 (2.2) mg kg(-1) h(-1), respectively (both P<0.05). The mean (SD) times to eye opening were -0.08 (4.4) and 3.5 (4.3) min and to extubation were 1.2 (4.4) and 4.4 (4.5) min in the SPI and control groups, respectively (both P<0.05). There was no difference between the groups with regard to satisfaction with the anaesthetic or intensity of postoperative pain. No patient reported intraoperative awareness.

CONCLUSIONS

Adjusting the remifentanil dosage according to the SPI in outpatient anaesthesia reduced the consumption of both remifentanil and propofol and resulted in faster recovery.

Preoperative geriatric assessment: comprehensive, multidisciplinary and proactive

With the changing global demographic pattern, our health care systems increasingly have to deal with a greater number of elderly patients, which consequently also takes its toll on our surgical services. The elderly are not simply older adults. They represent a heterogeneous branch of the population with specific physiological, psychological, functional and social issues that require individualised attention prior to surgery. Increased acknowledgement that chronological age alone is not an exclusion criterion, along with advances in surgical and anaesthetic techniques have today lead to decreased reluctance to deny the elderly surgical treatment. In order to ensure a safe perioperative period, we believe that a comprehensive, multidisciplinary and proactive preoperative assessment will be helpful to detect the multiple risk factors and comorbidities common in older patients, to assess functional status and simultaneously allow room for early preoperative interventions and planning of the intra- and postoperative period. In this review we outline the currently available preoperative geriatric risk assessment tools and provide an insight on how a comprehensive, multidisciplinary and proactive approach can help improve perioperative outcome.

Perioperative care for the older outpatient undergoing ambulatory surgery

As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly will assume increased importance. Given the recent advances in anesthesia, surgery, and monitoring technology, the ambulatory setting offers potential advantages for elderly patients undergoing elective surgery. In this review article we summarize the physiologic and pharmacologic effects of aging and their influence on anesthetic drugs, the important considerations in the preoperative evaluation of elderly outpatients with coexisting diseases, the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and offer recommendations regarding the management of common postoperative side effects (including delirium and cognitive dysfunction, fatigue, dizziness, pain, and gastrointestinal dysfunction) after ambulatory surgery. We conclude with a discussion of future challenges related to the growth of ambulatory surgery practice in this segment of our surgical population. When information specifically for the elderly population was not available in the peer-reviewed literature, we drew from relevant information in other ambulatory surgery populations.