Priorities in perioperative geriatrics

Comparison of Minimally Invasive Chevron Akin and Open Lapidus Surgery in Older Patients at a Minimum 1-Year Follow-Up

Background

Hallux valgus deformity affects more than 35% of people aged ≥65 years. Surgical correction in this population can be more complicated because of poor bone quality, worse deformity, and postoperative recovery challenges. The purpose of this study was to compare the radiographic and clinical outcomes of patients aged ≥65 years who underwent either open Lapidus or minimally invasive chevron Akin osteotomy for bunion correction.

Methods

A retrospective review identified 62 patients aged ≥65 years who were treated surgically for hallux valgus with at least 1-year postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores (physical function and pain interference). Preoperative and at least 6-month postoperative radiographs were measured for the hallux valgus angle and intermetatarsal angle. PROMIS scores were obtained preoperatively and at 1 and/or 2 years postoperatively. Differences in demographic, clinical, and radiographic outcomes were assessed using the Mann Whitney U test and P values were adjusted for a false discovery rate of 5%.

Results

There was no difference between the MIS and open cohorts in pre- or postoperative radiographic measurements or clinical outcomes at any time point. At 1 year postoperatively, both groups had statistically significant improvements in the PROMIS pain interference domain but only the MIS group had a statistically significant improvement in the PROMIS physical function domain. Clinical significance was equivocal. At 2 years postoperatively, there were clinically and statistically significant improvements in the PROMIS pain interference and physical function domains for the open and MIS groups.

Conclusion

Patients in both surgical groups had improvement in radiographic measurements and 2-year PROMIS scores, although there was no clinical or statistical difference found between groups. MIS and open surgical techniques appear to be safe and effective in correcting hallux valgus in older patients; however, patients may need to be counseled that maximum improvement after surgery may take more than 1 year.

Level of Evidence

Level III, retrospective cohort study.

Could epidural analgesia be safely used for acute postoperative pain in older adults to enhance recovery?

Epidural analgesia is often considered cornerstone in multimodal analgesia when used in major surgeries. However, its role in managing acute postoperative pain in elderly patients is debatable because of its known potential complications. Furthermore, postoperative pain in elderly patients is under-treated because of complex comorbidities, and they are more prone to adverse events related to pain therapies. All systemic analgesic drugs have pharmacological limitations and precautions in elderly people. Recent meta-analyses showed that epidural analgesia provided better postoperative pain control compared to intravenous opioids. Interestingly, peripheral nerve blocks had no superior control of pain over epidural analgesia. In addition, epidural analgesia has shown to positively affect perioperative morbidities and mortalities, and reduce opioid-related side effects because of its non-analgesic effects on each organ system. When tailored in a specific multimodal approach, it shortens the intensive care and hospital stays. In conclusion, if complications are identified and treated early, and contraindications are ruled out, epidural analgesia can achieve sufficient postoperative pain management with insignificant adverse events in this population.

Comparison of rotational and standard methods of i-gel® insertion in patients of advanced age undergoing general anesthesia: a randomized clinical trial

OBJECTIVE

This study was performed to compare the performance of rotational versus standard insertion of the i-gel® (Intersurgical, Wokingham, Berkshire, England) in patients of advanced age.

METHODS

This single-center, randomized, double-blind trial involved 140 patients of advanced age undergoing general anesthesia. The patients were randomized into the standard group and rotational group. The primary objective of this study was to compare the success rate of the first attempt. The secondary outcome indicators were the insertion time and postoperative complications.

RESULTS

The placement success rate on the first attempt was significantly higher in the rotational group than in the standard group (92% vs. 73%, respectively). The overall success rate was 100% for the rotational method and 95% for the standard method. The mean ± standard deviation insertion times were similar (15 ± 7.34 vs. 14 ± 7.26 s, respectively). The incidence rates of blood staining of the i-gel®, hoarseness, and sore throat did not increase with the rotational technique and were not significantly different from those of the standard method.

CONCLUSION

Compared with the standard method, the rotational method of i-gel® insertion had a higher success rate and did not increase the insertion time and complications in patients of advanced age.Trial registration: This trial was registered at the Chinese Clinical Trial Registry (ChiCTR2000038763, Date of registration: 30/09/2020).

Anesthesia services in Taiwan: A nationwide population-based study

BACKGROUND

This study was conducted to provide an overview of anesthesia services in Taiwan from 2001 to 2010.

METHODS

A retrospective population-based analysis was performed using data from Taiwan's National Health Insurance Research Database for the period 2001 to 2010. The results were stratified by patient sex, patient age, anesthesia type, and hospital setting. Categorical data are presented as totals and percentages. Linear regression was performed to analyze the anesthesia trends.

RESULTS

The annual use of anesthesia increased continually from 964,440 instances in 2001 to 1,073,160 in 2010, totaling 10,076,600 cases with a total cost of 25.4 billion USD. The overwhelming majority (83.9%) of anesthesia cases was for anesthesia in an inpatient setting; general anesthesia accounted for 73.8% of anesthesia cases, and female patients outnumbered male patients (52.4% vs 47.6%). The average number of anesthesia cases was 44.2 per thousand of the population annually, but this percentage was much higher in elderly people (100.9 cases per thousand people annually). The annual number of anesthesia cases per thousand of the population increased from 104.4 in 2001 to 113.0 in 2010 in the oldest group (>80 years). By contrast, a considerable decline in use of anesthesia was discovered over the study period among those aged younger than 18 years.

CONCLUSION

The use of anesthesia services in Taiwan has increased over the years. The relationships of age with anesthesia volume and cost were found to follow an inverse U-shaped pattern. Elderly people used anesthesia services more frequently. The planning of geriatric anesthesia services deserves attention, especially in continually aging societies such as Taiwan.

Robotic Major Hepatectomy: Influence of Age on Clinical Outcomes

BACKGROUND

This study was undertaken to determine if age influences postoperative outcomes for patients undergoing robotic major hepatectomy.

METHODS

Ninety-four patients undergoing robotic major hepatectomy were prospectively followed. With regression analysis, demographic data and postoperative outcomes were compared to age. Data are presented as median (mean ± SD).

RESULTS

Overall, the patients were of age 62 (61 ± 13) years, body mass index (BMI) of 29 (29 ± 5.9) kg/m², and American Society of Anesthesiologists (ASA) class of 3 (3 ± 0.5). The mass size was 5 (5 ± 3.0) cm. The operative duration was 252 (276 ± 106) minutes with an estimated blood loss (EBL) of 175 (249 ± 275.9) mL. One operation was converted to "open" due to bleeding, accounting for the only intraoperative complication. Nine patients required intensive care unit (ICU) admission. Postoperatively, 7 patients had complications with no in-hospital mortalities, and a length of stay (LOS) of 4 (5 ± 2.6) days. Thirteen patients were readmitted within 30 days with 0 deaths within 30 days.A significant relationship was found between age and ASA class (P = .001) and LOS (P = .03). No correlation was found when comparing age to operative duration, EBL, ICU admission, ICU duration, complications, and readmission within 30 days.

CONCLUSION

For patients undergoing robotic major hepatectomy, there was no significant correlation between age and perioperative outcomes, with the exception of LOS. Increasing age is not associated with increased morbidity or perioperative mortality. With the application of innovative technology, that is, the robotic approach, surgeons should be encouraged to undertake major hepatectomy in elderly patients deemed candidates for surgery.

Dural sac cross-sectional area is a highly effective parameter for spinal anesthesia in geriatric patients undergoing transurethral resection of the prostate: a prospective, double blinded, randomized study

Background

Spinal anesthesia is optimal choice for transurethral resection of the prostate (TURP), but the sensory block should not cross the T10 level. With advancing age, the sensory blockade level increases after spinal injection in some patients with spinal canal stenosis. We optimize the dose of spinal anesthesia according to the decreased ratio of the dural sac cross-sectional area (DSCSA), the purpose of this study is to hypothesis that if DSCSA is an effective parameter to modify the dosage of spinal anesthetics to achieve a T10 blockade in geriatric patients undergoing TURP.

Methods

Sixty geriatric patients schedule for TURP surgery were enrolled in this study. All subjects were randomized divided into two groups, the ultrasound (group U) and the control (group C) groups, patient receive either a dose of 2 ml of 0.5% isobaric bupivacaine in group C, or a modified dose of 0.5% isobaric bupivacaine in group U. We measured the sagittal anteroposterior diameter (D) of the dural sac at the L3–4 level with ultrasound, and calculated the approximate DSCSA (A) according to the following formula: A = π(D/2)², ( π = 3.14). The modified dosage of bupivacaine was adjusted according to the decreased ratio of the DSCSA.

Results

The cephalad spread of the sensory blockade level was significantly lower (P < 0.001) in group U (T10, range T7–T12) compared with group C (T3, range T2–T9). The dosage of bupivacaine was significantly decreased in group U compared with group C (P < 0.001). The regression times of the two segments were delay in group U compared with group C (P < 0.001). The maximal decrease in MAP was significantly higher in the group C than in group U after spinal injection (P < 0.001), without any modifications HR in either group. Eight patients in group C and two patients in group U required ephedrine (P = 0.038).

Conclusions

The DSCSA is a highly effective parameter for spinal anesthesia in geriatric patients undergoing TURP, a modified dose of local anesthetic is a critical factor for controlling the sensory level.

Trial registration

This study was registered in the Chinese Clinical Trial Registry (Registration number: ChiCTR1800015566).on 8, April, 2018.

The Growing Challenge of the Older Surgical Population

The population of older adults is rapidly growing. With the continued advancement of medical and surgical interventions, the average age of this population will continue to increase. Nearly one-third of surgical procedures are performed in older adults. Physiologic changes, multiple comorbidities, frailty, and postoperative cognitive dysfunction affect an elderly patient's postoperative recovery. Anesthesia providers can play a key role in creating perioperative geriatric pathways. The perioperative care of a geriatric patient is associated with unique and anesthetic risks. Perioperative care must be tailored to individual patients to reduce perioperative complications in this important, vulnerable population.

Lung ultrasound score-based perioperative assessment of pressure-controlled ventilation-volume guaranteed or volume-controlled ventilation in geriatrics: a prospective randomized controlled trial

Purpose

Recent studies have shown the potential benefits of pressure-controlled ventilation-volume guaranteed (PCV-VG) compared to volume-controlled ventilation (VCV), but the results were not impressive. We assessed the effects of PCV-VG versus VCV in elderly patients by using lung ultrasound score (LUS).

Patients and methods

Elderly patients (aged 65-90 years) scheduled for hip joint surgery were randomly assigned to either the PCV-VG or VCV group during general anesthesia. LUS and mechanical ventilator parameters were evaluated before induction, 30 mins after a semi-lateral position change, during supine repositioning before awakening, and 15 mins after arrival to the post-anesthesia care unit (PACU). Pulmonary function tests were performed before and after surgery. Other recovery indicators were also assessed in the PACU.

Results

A total of 76 patients (40 for PCV-VG and 36 for VCV) were included this study. Demographic data showed no significant difference between the two groups. In both groups, LUSs before induction were significantly lower than those at other time points. LUSs of the VCV group were significantly increased during perioperative periods compared with the PCV-VG group (p=0.049). Visualized LUS modeling suggested an intuitive difference in the two groups and unequal distribution in lung aeration. Higher dynamic compliance and lower inspiratory peak pressure were observed in the PVC-VG group compared to the VCV group (33.54 vs 27.36, p<0.001; 18.93 vs 21.19, p<0.001, respectively). Postoperative forced vital capacity of the VCV group was lower than that of PCV-VG group, but this result was not significant (2.06 vs 1.79, respectively; p=0.091). The other respiratory data are comparable between the two groups.

Conclusion

The PCV-VG group showed better LUS compared with the VCV group. Moreover, LUS modeling in both groups suggests non-homogeneous and positional change in lung aerations during surgery.

Clinical trial registration

This study was registered at the UMIN clinical trials registry (unique trial number: UMIN000029355; registration number: R000033510).

Determination of the median effective dose (ED50) of bupivacaine and ropivacaine unilateral spinal anesthesia : Prospective, double blinded, randomized dose-response trial

BACKGROUND

Unilateral spinal anesthesia (USpA) has been reported to potentiate spinal anaesthesia and is used in geriatric patients. The purpose of this study was to determine the median effective dose (ED₅₀) of 0.5% hypobaric bupivacaine and 0.5% hypobaric ropivacaine USpA for geriatric patients (age ≥ 70 years) undergoing elective hip replacement surgery.

METHODS

A total of 60 geriatric patients (age ≥ 70 years) undergoing elective hip replacement surgery were enrolled in this study. The patients were randomized into 2 groups to receive either intrathecal 0.5% hypobaric bupivacaine USpA (group B) or 0.5% hypobaric ropivacaine USpA (group R). Effective anesthesia was defined as a T10 sensory blockade level maintained for more than 60 min, and a Bromage score of 3 on the operation side within 10 min after injection with no additional epidural anesthetic required during surgery. The ED₅₀ of 0.5% hypobaric bupivacaine and 0.5% hypobaric ropivacaine was calculated using the Dixon and Massey formula.

RESULTS

No significant differences were found between the two groups in terms of demographic data. The ED₅₀ of 0.5% hypobaric bupivacaine USpA was 4.66 mg (95% confidence interval CI 4.69-4.63 mg) mg and that of 0.5% hypobaric ropivacaine USpA was 6.43 mg (95% CI 6.47-6.39 mg) for geriatric patients undergoing hip replacement surgery.

CONCLUSION

We find the ED₅₀ were lower, and the ED50 of 0.5% hypobaric bupivacaine and ropivacaine was 4.66 mg (95% CI 4.69-4.63 mg) and 6.43 mg (95% CI 6.47-6.39 mg), respectively, for USpA in geriatric patients (age ≥ 70 years) undergoing elective hip replacement surgery.

Perioperative hypotension and discharge outcomes in non-critically injured trauma patients, a single centre retrospective cohort study

BACKGROUND

There is a lack of information on the effect of age on perioperative care and outcomes after minor trauma in the elderly. We examined the association between perioperative hypotension and discharge outcome among non-critically injured adult patients.

METHODS

We conducted a retrospective study of non-critically ill patients (ISS <9 or discharged within less than 24h) who received anaesthesia care for surgery and Recovery Room care at a level-1 trauma centre between 5/1/2012 and 11/30/2013. Perioperative hypotension was defined as systolic blood pressure (SBP) <90mmHg (traditional measure) for all patients, and SBP <110mmHg (strict measure) for patients ≥65years. Poor outcome was defined as death or discharge to skilled nursing facility/hospice.

RESULTS

1744 patients with mean ISS 4.4 across age groups were included; 169 (10%) were ≥65years. Among patients≥65years, intraoperative hypotension occurred in >75% (131/169, traditional measure) and in >95% (162/169, strict measure); recovery room hypotension occurred in 2% (4/169) and 29% (49/169), respectively. Mean age-adjusted anaesthetic agent concentration (MAC) was similar across age groups. Opioid use decreased from 9.3 (SD 5.7) mg/h morphine equivalents in patients <55years to 6.2 (SD 4.0) mg/h in patients over 85 years. Adjusted for gender, ASA score, anaesthesia duration, morphine equivalent/hr, fluid balance, MAC and surgery type, and using traditional definition, older patients were more likely than patients <55 to experience perioperative hypotension: aRR 1.21, 95% CI 1.11-1.30 for 55-64 and aRR 1.19, 95% CI 1.07-1.32 for ages 65-74. Perioperative hypotension was associated with poor discharge outcome (aRR 1.55; 95% CI 1.04-2.31 and aRR 1.87; 95% CI 1.17-2.98, respectively).

CONCLUSION

Despite age related reduction in doses of volatile anaesthetic and opioids administered during anaesthesia care, and regardless of hypotension definition used, non-critically injured patients undergoing surgery experience a large perioperative hypotension burden. This burden is higher for patients 55-74 years and older and is a risk factor for poor discharge outcomes, independent of age and ASA status.

Pharmacologic Considerations of Anesthetic Agents in Geriatric Patients

Aging is a natural process of declining organ function and reserve. Census data show that the geriatric population is expected to grow to nearly 30%. More than half of geriatric patients have 1 or more surgical procedures in their lifetimes. Moreover, this is the population at greatest risk of morbidity and mortality with any given complication. There is remarkable variability in health across the age spectrum, from fit to frail and compromised. This variability requires a unique approach to anesthetic delivery and drug dosing on an individual basis to avoid complications such as postoperative cognitive dysfunction and delirium.

Prevalence of positive screening test for cognitive impairment among elderly urogynecologic patients

BACKGROUND

Impaired cognition has been correlated with adverse postoperative outcomes, such as an increased incidence of delirium, a longer length of hospital stay, and higher 6 month mortality. The incidence of cognitive impairment in the elderly is high. Per the Centers for Disease Control and Prevention, 1 in 8 adults aged 60 years and older deal with memory loss and confusion, and less than 20% inform their health care providers. Most studies in the elderly or cognitively impaired have been conducted at Veterans Administration hospitals, in which the majority of patients are male. As the female patient population ages, it is increasingly important to describe the prevalence of cognitive impairment in this specific population as well as identify and manage risk factors for cognitive decline in the ambulatory and perioperative setting.

OBJECTIVE

The objective of the study was to determine the prevalence of positive screening for cognitive impairment in a urogynecology ambulatory population and to establish the feasibility of using standardized, validated screening questionnaires in a tertiary care setting.

STUDY DESIGN

After institutional review board approval, all English-speaking patients 65 years old or older presenting to our ambulatory urogynecology clinic were invited to participate. Cognitive impairment was assessed using both the validated Mini-Cog test and the Eight-Item Interview to Differentiate Aging and Dementia screen for mild dementia. A Mini-Cog score <3 suggests cognitive impairment, whereas an Eight-Item Interview to Differentiate Aging and Dementia score of ≥2 discriminates dementia from normal cognition. Because of the association of depression and cognition in the elderly, the Geriatric Depression Scale (short form of 15 items) was administered, with a score >5 suggesting depression. Demographic and medical history were abstracted from the medical record.

RESULTS

A total of 371 subjects were asked to participate (39 were excluded and 37 declined); 295 subjects (79.5%) were included in the study. Mean subject age was 74.5 years, and 96.6% were white, with an average of 4.1 chronic medical comorbidities. Cognitive impairment was identified in all age groups per the Mini-Cog as follows: 65-74 years, 5.3%; 75-84 years, 13.7%; and 85 years and older, 30%. There was a significant difference in the positive screen for cognitive impairment between ages 65-74 vs >75 (P ≤ .001). According to the Eight-Item Interview to Differentiate Aging and Dementia, all 3 age groups perceived themselves to have early cognitive changes: 65-74 years, 25.9%; 75-84 years, 31.9%; and 85 years and older, 40% (P = .231). The most commonly identified areas of impairment were having daily problems with thinking and memory (62%), problems with judgment (52%), and trouble learning new tools or gadgets (44%). There was no difference in the number of patients who screened positive for depression across age groups: 65-74 years, 5.9%; 75-84 years, 6.3%; and 85 years and older, 10% (P = .697).

CONCLUSION

In our study population positive screening for cognitive impairment, as measured by validated questionnaires, was prevalent among women aged >75 years. Screening for potential cognitive impairment in an ambulatory urogynecology population is feasible and useful in clinical practice. Our subjects were interested in cognitive screening because a third of them self-reported early cognitive changes. These tools are effective in screening for previously unrecognized impaired cognition, a definitive diagnosis, and hence treatment requires additional evaluation. Future studies could evaluate which screening tools for cognitive impairment would be most helpful in assessing patients prior to surgery in an effort to further decrease perioperative morbidity in elderly woman.

Prophylactic phenylephrine infusion for the prevention of hypotension after spinal anesthesia in the elderly: a randomized controlled clinical trial

STUDY OBJECTIVE

Hypotension frequently occurs during spinal anesthesia (SA), especially in the elderly. Phenylephrine is effective to prevent SA-induced hypotension during cesarean delivery. The objective of this study was to evaluate the efficacy and safety of prophylactic infusion of phenylephrine after SA for orthopedic surgery in the elderly.

DESIGN

This prospective, randomized, double-blind, and placebo-controlled study included 54 patients older than 60 years undergoing elective lower limb surgery under SA (injection of 10 mg of isobaric bupivacaine with 5 μg of sufentanyl).

INTERVENTION

Patients were randomized to group P (100-μg/mL solution of phenylephrine solution at 1 mL/min after placement of SA) or the control group C (0.9% isotonic sodium chloride solution). The flow of the infusion was stopped if the mean arterial blood pressure (MAP) was higher than the baseline MAP and maintained or restarted at 1 mL/min if MAP was equal to or lower than the baseline MAP. Heart rate and MAP were collected throughout the case.

MEASUREMENTS

Hypotension was defined by a 20% decrease and hypertension as a 20% increase from baseline MAP. Bradycardia was defined as a heart rate lower than 50 beats per minute.

MAIN RESULTS

Twenty-eight patients were randomized to group P and 26 patients to group C. MAP was higher in group P than in group C (92 ± 2 vs 82 ± 2 mm Hg, mean ± SD, P< .001). The number of hypotensive episodes per patient was higher in group C compared with group P (9 [0-39] vs 1 [0-10], median [extremes], P< .01), but the number of hypotensive patients was similar between groups (19 [73%] vs 20 [71%], P= 1). The time to onset of the first hypotension was shorter in group C (3 [1-13] vs 15 [1-95] minutes, P= .004). The proportion of patients without hypotension (cumulative survival) was better in group P (P= .04). The number of hypertensive episodes per patient and the number of bradycardic episodes per patient were similar between groups (P= not significant).

CONCLUSION

Prophylactic phenylephrine infusion is an effective method of reducing SA-induced hypotension in the elderly. Compared with a control group, it delays the time to onset of hypotension and decreases the number of hypotensive episodes per patient. More data are needed to evaluate clinical outcomes of such a strategy.

Aortic aneurysm trials in octogenarians: Are we really measuring the outcomes that matter?

Purpose

This study is a systematic review to determine the types of outcomes reported in abdominal aortic aneurysm (AAA) studies of patients aged 80 and over. Specifically, it determines the types of patient-centered outcomes reported.

Method

MEDLINE and EMBASE were searched from 2000 to 2014 for studies on AAA surgery with outcome data on patients aged 80 and over. Outcomes were categorized according to Donabedian’s framework for health quality indicators, with further classification as procedural, complication, resource or patient-centered outcome indicators.

Findings

Forty studies were reviewed. Patient-centered outcomes were infrequently reported (13%, n=5), with limited outcomes specifically relevant to older patients. No studies reported physical function, activities of daily living or cognition using validated assessment methods. Short-term mortality (95%, n=38) and complications (85%, n=34) were reported most frequently.

Conclusion

Reporting of aortic surgery outcomes in patients aged 80 and over requires a focus upon outcomes of primary importance to people of this age.

Clinical efficacy of the classic laryngeal mask airway in elderly patients: a comparison with young adult patients

Background

The elderly have been reported to show anatomical and physiologic changes in the upper airway, which might affect the supraglottic airway (SGA) performance in geriatric populations. This study aimed to evaluate the clinical efficacy of the classic laryngeal mask airway (LMA-C) in the elderly compared with young adult patients.

Methods

Fifty patients aged 65-85 years (elderly group) and 50 patients aged 20-40 years (young group) who were scheduled for surgery using the LMA-C for general anesthesia were enrolled in this prospective, non-randomized, comparative study. Manipulations required during insertion, success rate, insertion time, oropharyngeal leak pressure, gastric insufflation, and intraoperative inadequate ventilation with the LMA-C were assessed. Fiberoptic evaluation was used to determine the position of the LMA-C.

Results

In the elderly group, the insertion success rate on the first attempt was significantly lower than that in the young group (84 vs. 96%, P = 0.02). The insertion time in the elderly group was significantly longer than that in the young group (28.5 ± 19.6 vs. 22.2 ± 6.4 seconds, P = 0.001). However, there was no difference in oropharyngeal leak pressure or fiberoptic grade between the two groups after proper placement of the LMA-C. During the surgery, inadequate ventilation events occurred more frequently in the elderly group than in the young group (31.3 vs. 4.0%, P < 0.001).

Conclusions

The clinical efficacy of the LMA-C in elderly patients was inferior to that in young adult patients. Therefore, further studies are required to determine the type of SGA that can provide excellent clinical efficacy in the geriatric population.

Critical Care Issues of the Geriatric Patient

Medical care of the geriatric patient is an important area of focus as the population ages and life expectancy increases. In particular, critical care of the geriatric patient will be especially affected, because geriatric patients will consume most critical care beds in the future and subsequently require increased use of resources. This review focuses on the physiologic effects of aging on all body systems. Focus on frailty and its effect on recovery from critical illness and its potential to modify the course of patient care will be important areas of research in the future.

The History of Geriatric Anesthesia in the United States and the Society for the Advancement of Geriatric Anesthesia

Creation of the American Society of Anesthesiologists Committee on Geriatric Anesthesia provided an opportunity for individuals to interact, strategize, and work with medical organizations outside of anesthesiology. These opportunities expanded with creation of the Society for the Advancement of Geriatric Anesthesia. The American Geriatrics Society provided a major boost when they realized it was important for surgical and related specialties to take an active role in the care of older patients. From this have come educational grants to improve residency training and establishment of a major research grant program now managed by the National Institutes of Health. Nevertheless, for improved care of the older patient, the level of involvement has to increase.

Effects of propofol or desflurane on post-operative spirometry in elderly after knee surgery: a double-blind randomised study

BACKGROUND

Intravenous or volatile agents reduce respiratory function, which can result in respiratory complications in geriatric patients. We hypothesised that there would be no differences in lung function between anaesthesia established using either drug.

METHODS

Elderly patients were randomly assigned to receive either propofol with remifentanil (n = 48) or desflurane (DES) with remifentanil (n = 52) for knee surgery. Spirometry tests including forced expiratory volume in 1 s (FEV1 ), forced vital capacity (FVC), forced mid-expiratory flow (FEF25-75), and FEV1 /FVC ratio were performed preoperatively, and 30 min, 60 min, and 24 h after awakening. Emergence time and post-operative pain scores were also measured.

RESULTS

Time to emergence was significantly longer in the propofol than in the DES group (17.0 vs. 12.5 min, P = 0.04). Post-operative FEV1 (1.6 or 1.4 l, P = 0.68 between groups) were significantly lower than preoperative values (2.1 or 2.0 l, P = 0.001 vs. post-operative values, respectively) in both groups. Reduced FEV1 lasted for 24 h after surgery (1.7 or 1.6 l, P = 0.001 vs. preoperative values, respectively). Post-operative FVC or FEF25-75 were lower than preoperative values. FEV1 /FVC ratio did not change during the study period in both groups. There was no difference in FEV1 , FVC, FEF25-75, FEV1 /FVC, and post-operative pain between the two anaesthetic techniques.

CONCLUSIONS

Although there is a delay in awakening when using propofol, the effects of propofol on post-operative spirometry parameters are similar to those of DES when anaesthesia duration is approximately 3 h. Decreased respiratory parameters persisted up to 24 h after anaesthesia, irrespective of the choice of anaesthetic.

One year of anaesthesia in France: A comprehensive survey based on the national medical information (PMSI) database. Part 1: In-hospital patients

Anaesthesia has evolved in France since the last epidemiologic survey in 1996. The national database program for medical information systems (the PMSI) can be used to track specific knowledge concerning anaesthesia for a selected period of time. The goal of this study was to perform a contemporary epidemiological description of anaesthesia in France for the year 2010.

METHODS

The data concerning private or public hospital stays were collected from the national PMSI database. All surgical/medical institutions performing anaesthesia in France and French Overseas Departments and Territories were queried concerning the number of anaesthesias, patient age, sex ratios, institution characteristics, hospitalization types, the duration of hospital stays, and the surgical procedures performed.

RESULTS

In 2010, the number of anaesthesia procedures performed was 11,323,630 during 8,568,630 hospital stays. We found that 9,544,326 (84.3%) anaesthetic procedures were performed in adults (> 18 years of age; excluding childbirth), 845,568 (7.5%) were related to childbirth and 933,736 (8.2%) were acts in children (up to 18 years of age). The mean duration of hospital stay was 5.7±8.2 days. 56.5% of adults and 39.5% of children were managed as inpatient hospital stays. The male/female sex ratio and mean age were 42/58 and 54±19 years, respectively. In adults, anaesthesia was predominantly performed for abdominal surgery (24.5%), orthopaedics (16.7%), gynaecology (10.3%), ophthalmology (9.7%) and vascular surgeries (7.1%). For paediatric populations, the main surgical activities were Ear-Nose-Throat surgery (43.1%), orthopaedic surgery (15.1%) and urological surgeries (12.8%).

DISCUSSION

The number of anaesthesias performed in France has dramatically increased (42.7%) since the last major epidemiological survey. Anaesthesia in the 21th century has been adapted to associated demographic changes: an older population with more comorbidities and fewer in-hospital procedures.

A randomized controlled trial comparing haemodynamic stability in elderly patients undergoing spinal anaesthesia at L5, S1 versus spinal anaesthesia at L3, 4 at a tertiary African hospital

BACKGROUND

Spinal anaesthesia is a routinely used anaesthetic technique in elderly patients (> 60 years) undergoing operations involving the lower limbs, lower abdomen, pelvis and the perineum. Spinal anaesthesia has several advantages over general anaesthesia including stable haemodynamic variables, less blood loss, less post-operative pain, faster recovery time and less post-operative confusion. Despite these advantages, the sympathetic blockade induced by spinal anaesthesia can result in hypotension, bradycardia, dysrhythmias and cardiac arrests. Conventionally, spinal anaesthesia is performed at the level of L3,4 interspace; with a reported incidence of hypotension in the elderly ranging between 65% and 69%. A possible strategy for reducing spinal induced hypotension would be to minimize the peak block height to as low as possible for the planned procedure.

OBJECTIVE

To determine the difference in haemodynamic stability between elderly patients undergoing spinal anaesthesia at L5, S1 interspace compared to those at L3, 4.

METHODS

Thirty two elderly patients scheduled for lower limb or pelvic surgery under spinal anaesthesia were randomized into 2 groups (control group and intervention group) using a computer generated table of numbers. Control group; received 2.5 mls 0.5% hyperbaric bupivacaine injected intrathecally at the L3, 4 interspace and Intervention group; 2.5mls 0.5% hyperbaric bupivacaine injected intrathecally at the L5, S1 interspace.

RESULTS

The two groups had similar baseline characteristics in age, sex, body mass index and use of anti-hypertensive medications. There was 68.8% proportion of hypotension in the control group and 75% in the intervention group. The difference was not found to be statistically significant (p= 0.694). During the study period, there were 106 episodes of hypotension, out of which, 65 were in the control group and 41 in the intervention group (p=0.004).. Linear regression analysis of the decrease in mean arterial pressures (MAP) showed a higher decrease in MAP in the control group (p 0.018). There were more crystalloids used in the control group (1006mls ± 374) than in the intervention group (606mls ±211) with a p< 0.0001. There was no difference in the amounts of vasopressors used between the two groups (p=0.288). There was no difference in the change in heart rates, conversion to general anaesthesia, use of supplementary intravenous fentanyl and the peak maximum block level achieved. The time to peak maximum sensory block level was 9.06min and 13.07min in the control group and intervention groups, respectively (p<0.0001).

CONCLUSION

Among this population, there was no difference in the proportion of those with hypotension between the elderly patients who received their spinal anaesthesia at L3,4 and those who received spinal anaesthesia at L5,S1. The intervention group had better outcomes with significantly less episodes of hypotension. It took a longer time to achieve a maximum peak sensory block in the intervention group. Performing spinal anaesthesia at the level of L5,S1 was found to provide an adequate sensory block for a wide range of pelvic, perineal and lower limb surgeries.

Single shot spinal anesthesia with very low hyperbaric bupivacaine dose (3.75 mg) for hip fracture repair surgery in the elderly. A randomized, double blinded study

PURPOSE

Single shot spinal anesthesia is used worldwide for hip fracture repair surgery in the elderly. Arterial hypotension is a frequent adverse effect. We hypothesized that lowering local anesthetics dose could decrease the incidence of arterial hypotension, while maintaining quality of surgical anesthesia.

METHODS

In a randomized double blinded study, 66 patients over the age of 65 years, with hip fracture needing surgical repair, were assigned to B0.5 group 7.5mg hyperbaric bupivacaine 5mg/ml (control group), and B0.25 group 3.75mg hyperbaric bupivacaine 2.5mg/ml (study group). Sensory and motor block level, and hemodynamic parameters including blood presure, heart rate and vasopressor dose administration were registered, along with rescue anesthesia needs, the feasibility of surgery, its duration, and regression time of sensory anesthesia to T12.

RESULTS

After exclusions, 61 patients were included in the final analysis. Arterial hypotension incidence was lower in the B0.25 group (at the 5, 10, and 15min determinations), and a lower amount of vasopressor drugs was needed (mean accumulated ephedrine dose 1.6mg vs. 8.7mg in the B0.5 group, p<0.002). Sensory block regression time to T12 was shorter in the B0.25 group, mean 78.6±23.6 (95% CI 51.7-110.2)min vs. 125.5±37.9 (95% CI 101.7-169.4)min in the B0.5 group, p=0.033. All but one patient in the B0.25 group were operated on under the anesthetic procedure first intended. No rescue anesthesia was needed.

CONCLUSION

Lowering bupivacaine dose for single shot spinal anesthesia for hip fracture repair surgery in elderly patients was effective in decreasing the occurrence of arterial hypotension and vasopressor use, while intraoperative quality remained.

Single shot spinal anaesthesia with hypobaric bupivacaine for hip fracture repair surgery in the elderly. Randomized, double blinded comparison of 3.75 mg vs. 7.5 mg

BACKGROUND

Arterial hypotension is the most frequent adverse effect of subarachnoid anaesthesia in the elderly sustaining a femoral proximal fracture. Decreasing the local anaesthetic dose reduces the incidence of hypotension but shortens sensory block duration that could be insufficient in some surgical procedures. Sensory block duration could be prolonged using hypobaric local anaesthetics. We evaluated whether low hypobaric bupivacaine doses were adequate for this type of surgery while maintaining the haemodynamic stability.

METHODS

A prospective, randomized, double blinded study was designed. Patients over 65 years old, sustaining traumatic hip fracture, were assigned to one of two groups: B0.5 group, hypobaric bupivacaine 7.5mg 5mg/ml (control group), and B0.25 group, hypobaric bupivacaine 3.75 mg 2.5mg/ml (study group). After subarachnoid injection, sensory level and motor blockade degree were registered, as were blood pressure, and heart rate at basal time and at 2, 5, 10, 15, 20 and 30 min after injection. The doses of vasopressor needed were registered as well. Surgical conditions and the duration of the surgical procedure-whether rescue analgesia or anaesthesia was needed-and sensory level regression to T12, were registered as well.

RESULTS

Sixty four patients was the calculated sample size. The study was stopped in an interim analysis because an elevated number of patients in the B0.25 group needed iv rescue anaesthesia. In the analyzed cases, blood pressure was significantly lower in the B0.5 group at the 15 and 30 min measurements. Vasopressor drugs needs were similar between groups [ephedrine accumulated mean (SD) doses 11.4 (5.2) mg vs. 9.1 (2.7) mg, p=0.045)]. Sensory block regression to T12 was faster in the B0.25 group, [(mean (SD) 68.2 (29.0) min vs. 112.8 (17.3) min in the B0.5 group, p<0.05]. Five out of 19 patients in the B0.25 group needed intravenous anaesthesia rescue before surgery started.

CONCLUSION

Lowering hypobaric bupivacaine dose to 3.75 mg in subarachnoid anaesthesia for hip fracture repair surgery in elderly patients decrease intraoperative blood pressure, but in an important number of patients intravenous anaesthesia rescue was needed and preclude recommendation.

Influence of changing trends in anaesthetic practice on morbidity and mortality in elderly patients undergoing lower limb surgery

Background and Aims:

Several changes in the management protocols of anaesthesia for geriatric patients were introduced into clinical practice to improve the outcome. Very few studies have evaluated the impact of these management protocols. The aim of our study was to evaluate impact of some of the changes in the peri-operative management protocols of geriatric patients undergoing elective orthopaedic lower limb surgeries on the outcomes.

Methods:

A retrospective chart review of thirty-eight surgical patients from 1999 (Group 1999) before the introduction of changes and 107 patients from 2007 (Group 2007) after establishing changes was performed and data of peri-operative variables were collected and analysed. The primary outcome measured was in-hospital mortality. The secondary outcomes were occurrence of intra-operative and post-operative complications. Comparison of continuous variables between the two groups was performed using independent sample T test and categorical variables using Chi-square test. Multivariate logistic regression was done to identify independent predictors of mortality.

Results:

The use of beta blockers, deep vein thrombosis prophylaxis with low molecular weight heparin and epidural technique for post-operative analgesia was higher in group 2007. Despite higher prevalence of patients with electrocardiographic changes and anaemia, the incidence of intra-operative or post-operative complications was lower in 2007, though the mortality rate in both the groups was comparable. The independent risk factors for mortality in these geriatric patients were intra-operative hypotension (Odds Ratio (OR) =11.33) and post-operative myocardial ischaemia (OR = 34.5), pulmonary embolism (OR = 17.1) and neurologic changes (OR = 17.1).

Conclusions:

Implementation of new management practices had significantly reduced the incidence of intra- and post-operative complications.

Pain management in the ICU

Pain management in the intensive care unit (ICU) is a complex process. Both the experience of pain as well as its treatment can have consequences relating to the overall outcome of the patient. Further, lack of the ability of many patients in the ICU to communicate their distress makes it even more critical for the ICU practitioner to understand the typical causes of pain in this setting and the applicability of many pain management regimens.

[Anesthesia in the elderly]

A growing number of old or very old patients benefits from a surgical procedure. Age is an independent risk factor of postoperative mortality and postoperative complications including cognitive dysfunction. The choice of anesthetic technique does not significantly modify this risk. Preventive strategies and preoperative procedures can be implemented. A multidisciplinary management involving all care providers around the patient is essential to reduce the risk of dependence after surgery which is higher in this population. Early postoperative rehabilitation is recommended in the elderly to improve the prognosis.

[Hip fracture surgery in the elderly patient: epidemiological data and risk factors]

Health care administration is concerned about the escalating cost of geriatric trauma care and more specifically hip fracture (HF). By 2050, the wordwide annual incidence of HF among elderly people will be 4.5 million (predictible incidence in France: 150,000) and prevention will be more important than ever. The risk of hip fracture in older people increases exponentially with age. The main other risk factors are osteoporosis and osteopenia, gender, weight, physical activity. The most important cause of osteoporosis is the gradual bone loss that occurs after the menopause. Similarly, there is a strong association with gender: the female-to-male ratio of HF is greater than 2/1 in people over 50 years of age (mean age: 83.2 yrs in female and 79.6 yrs in male in France). One year mortality after hip fracture is remarkably high, around 20 to 30%.

Pneumonia in older people

The incidence of pneumonia is higher in older than younger people, due to both an increase in factors facilitating entry of infectious agents into the lungs, and attenuated functioning of the immune system. Classic features of presentation of pneumonia may be absent. The most common signs of pneumonia in old age are tachypnoea and tachycardia. Aetiology is established in only 50% of older patients. The empirical treatment of community-aquired pneumonia (CAP) should be aimed at its most common cause,Streptococcus pneumoniae. The empirical treatment of health care-associated pneumonia (HCAP) should be targeted at Gram-negative agents. Choice of antibiotic must include consideration of potential drug interactions.

Medical management of hip fracture

The United States population at the greatest risk for hip fracture, those aged 65 years and older, is steadily increasing in size. Today, the incidence of hip fracture is approximately 250,000 per year and it is expected to double in the next 30 years. Hip fracture patients are comorbid at baseline, and there are complications inherent to hip fractures that can occur in almost a predictable fashion. Overall, one in four hip fracture patients will die within one year of injury. Medical comanagement of hip fracture patients offers the best chance for successful outcome.

Geriatric surgery is about disease, not age

Maintaining life span and quality of life remains a valid aim of surgery in elderly people. Surgery can be an effective way of restoring both length and quality of life to older people. Minimally invasive techniques and surgery under local anaesthesia make fewer demands on geriatric physiology; given that co-morbidity is a stronger predictor of outcome from surgery than age, this is a significant consideration.

Cardiac anesthesia and surgery in geriatric patients

The average age of US population is steadily increasing, with more than 15 million people aged 80 and older. Coronary artery disease and degenerative cardiovascular diseases are particularly prevalent in this population. Consequently, an increasing number of elderly patients are referred for surgical intervention. Advanced age is associated with decreased physiologic reserve and significant comorbidity. Thorough preoperative assessment, identification of the risk factors for perioperative morbidity and mortality, and optimal preparation are critical in these patients. Age-related changes in comorbidities and altered pharmacokinetics and pharmacodynamics impacts anesthetic management, perioperative monitoring, postoperative care, and outcome. This article updates the age-related changes in organ subsystems relevant to cardiac anesthesia, perioperative issues, and intraoperative management. Early and late operative outcome in octogenarians undergoing cardiac surgery are reviewed. The data clearly indicate that no patient group is "too old" for cardiac surgery and that excellent outcomes can be achieved in selected group of elderly patients.

The elderly patient and postoperative pain treatment

The management of postoperative pain in elderly patients can be a difficult task. Older patients have co-existing diseases and concurrent medications, diminished functional status and physiological reserve and age-related pharmacodynamic and pharmacokinetic changes. Pain assessment presents numerous problems arising from differences in reporting cognitive impairment and difficulties in measurement. The elderly are also at higher risk of adverse consequences from surgery and unrelieved or undertreated pain. Selection of analgesic therapy needs to balance the potential efficacy with the incidence of interactions, complications or side effects in the post-operative period. Drug titration in the post-anaesthesia care unit should be encouraged together with analgesia on request in the wards. Multimodal analgesia, using acetaminophen, non-steroidal anti-inflammatory drugs or other non opioid drugs, is the best way to decrease opioid consumption and thus opioid-related adverse events. Sophisticated analgesic methods like PCA, regional analgesia and PCEA are not contraindicated in the elderly but pain relief and side effects should be monitored.

Hip fractures--a joint effort

More than 350,000 hip fractures occur in the United States every year, and the number will double by 2050 as baby boomers advance in age. Hip fractures remain one of the most common injuries of the geriatric cohort, where 9 of 10 patients with a hip fracture are 65 years of age or older and have multiple medical problems. A coordinated approach to care that emphasizes early ambulation, prevention of complications, and patient/family involvement is essential. This article describes the efforts of a interdisciplinary team to develop and implement a hip fracture protocol that directs the care of patients from admission in the emergency room to a planned discharge. The ideal process of care is driven by quality measures and evidence-based practice consisting of early medical screening, early surgical intervention and ambulation, physical therapy, deep vein thrombosis prophylaxis, and appropriate discharge planning.

Evidence-Based Perianesthesia Care: Accelerated Postoperative Recovery Programs

Prolonged stress response after surgery can cause numerous adverse effects, including gastrointestinal dysfunction, muscle wasting, impaired cognition, and cardiopulmonary, infectious, and thromboembolic complications. These events can delay hospital discharge, extend convalescence, and negatively impact long-term prognosis. Recent advances in perioperative management practices have allowed better control of the stress response and improved outcomes for patients undergoing surgery. At the center of the current focus on improved outcomes are evidence-based fast-track surgical techniques and what is commonly referred to as "accelerated postoperative recovery programs." These programs require a multidisciplinary, coordinated effort, and nurses are essential to their successful implementation.

Octogenarians Undergoing Coronary Artery Bypass Graft Surgery: Resource Utilization, Postoperative Mortality, and Morbidity

OBJECTIVE

The purpose of the present study was to examine resource utilization in octogenarians undergoing coronary artery bypass grafting (CABG) and compare it with usage in their younger cohorts at a tertiary care heart center. The resources examined were time to extubation, packed red blood cell transfusions, intensive care unit (ICU) length of stay (LOS), and preoperative and postoperative LOS. The study also examined differences in postoperative morbidity and mortality.

DESIGN

Retrospective hospital follow-up study of consecutive patients undergoing CABG using a prospectively designed database.

SETTING

University teaching tertiary care referral center for cardiac surgery.

PARTICIPANTS

Seventeen hundred forty-six male and female patients undergoing CABG surgery, including 155 octogenarians and 1591 patients younger than 80 years.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographic, mortality, morbidity, and resource utilization data were collected from the records of patients undergoing CABG at the authors' institution over 3 years. There were 1746 patients: 155 octogenarians and 1591 nonoctogenarians. Octogenarians had a significantly higher incidence of preoperative stroke, peripheral vascular disease, chronic obstructive lung disease, congestive heart failure, and left main disease. They weighed significantly less, and had lower preoperative and postoperative hematocrit. There was a significantly higher percentage of women in the octogenarian group. Mean time from the end of surgery to endotracheal extubation was 9.3 hours for octogenarians and 6.3 hours for their younger cohorts (p < 0.001). Blood transfusion was required in 88.4% of octogenarians compared with 58.6% of nonoctogenarians (p < 0.001). Mean ICU LOS was 1.9 days for octogenarians and 1.4 days for nonoctogenarians (p < 0.001). Mean postoperative LOS was 8.7 days for octogenarians and 5.8 days for nonoctogenarians (p < 0.001). Clinical and demographic variables were correlated with age 80 years or older. Multivariate linear and logistic regression models were constructed to show the combined effects of age and comorbid conditions on outcomes. Octogenarians had a significantly higher incidence of postoperative renal failure and neurologic complications. The 30-day mortality rate was 9.0% for the octogenarian group v 1.2% for the younger group (p < 0.001). Age 80 years or older was significantly associated with outcome, and was an independent predictor of increased resource utilization and postoperative mortality and morbidity.

CONCLUSIONS

The results demonstrated that octogenarians undergoing CABG required increased resource utilization and had significantly higher morbidity, with increased incidence of postoperative renal failure, neurologic complications, and 30- day mortality. Age 80 years or older was an independent predictor of increased resource utilization, postoperative morbidity, and mortality.

[Pharmacological peculiarities and problems with older patients]

Because of demographic developments, the fraction of the German population over 65 years of age in the year 2025 will have risen to 20% and will continue to rise so that in 2030 this number will have doubled compared to today's numbers. This has a huge impact on the requirements for anaesthesiologic procedures. In addition to the frequent multi-morbidity in this age group, physiologic changes also occur in the elderly which have to be taken into consideration during the entire perioperative management of these patients. Renal, cardiovascular and hepatic function are impaired in many elderly patients. A major concern in addition to cardiovascular and operative complications is the postoperative cognitive dysfunction (POCD), not only because of its implications for the patient but also because of economical consequences. Regional anaesthesia has some benefits when compared to general anaesthesia as it leads to a reduction in thromboembolic and respiratory complications.

Risk factors for delirium in acutely admitted elderly patients: a prospective cohort study

Background

Delirium is a neuropsychiatric syndrome frequently observed in elderly hospitalised patients and can be found in any medical condition. Due to the severe consequences, early recognition of delirium is important in order to start treatment in time. Despite the high incidence rate, the occurrence of delirium is not always identified as such. Knowledge of potential risk factors is important. The aim of the current study is to determine factors associated with the occurrence of a prevalent delirium among elderly patients acutely admitted to an internal medicine ward.

Methods

All consecutive patients of 65 years and over acutely admitted to the Department of Internal Medicine of the Academic Medical Centre, Amsterdam, a university hospital, were asked to participate. The presence of delirium was determined within 48 hrs after admission by an experienced geriatrician.

Results

In total, 126 patients were included, 29% had a prevalent delirium after acute admission. Compared to patients without delirium, patients with delirium were older, more often were cognitively and physically impaired, more often were admitted due to water and electrolyte disturbances, and were less often admitted due to malignancy or gastrointestinal bleeding. Independent risk factors for having a prevalent delirium after acute admission were premorbid cognitive impairment, functional impairment, an elevated urea nitrogen level, and the number of leucocytes.

Conclusions

In this study, the most important independent risk factors for a prevalent delirium after acute admission were cognitive and physical impairment, and a high serum urea nitrogen concentration. These observations might contribute to an earlier identification and treatment of delirium in acutely admitted elderly patients.

Anaesthesia in the older patient

PURPOSE OF REVIEW

Clinical anaesthesia and analgesia address a growing number of elderly surgical patients. Ageing modifies physiology, pharmacokinetics and pharmacodynamics, and comorbidity is a common occurrence in the elderly. Therefore, based on recent information regarding perioperative outcome, indications and techniques should be individualized.

RECENT FINDINGS

Clinical studies have highlighted the occurrence of postoperative cognitive dysfunction in elderly patients, and have given some information on its risk factors. As pain was found to be one of the most important of these, this review is also focused on the management of perioperative pain. Recently published studies have compared epidural analgesia and parenteral analgesics; others have described the handling of parenteral opioids for postoperative analgesia in elderly patients, and the opioid-sparing effect of multimodal analgesia.

SUMMARY

Postoperative cognitive dysfunction (POCD) is quite frequent. If late POCD seemed not related to the type of anaesthesia and analgesia provided, early POCD (interval delirium) was found to be related to perioperative haematocrit and transfusion requirement and to postoperative pain. Epidural analgesia using local anaesthetics and/or opioids was found to be probably better than parenteral opioids for the control of postoperative pain and the prevention of postoperative morbidity and mortality. However, well implemented protocols of parenteral analgesics could be nearly as efficient.

Peri-operative management of ablative and reconstructive surgery for invasive bladder cancer in the elderly

INTRODUCTION AND OBJECTIVES

Radical cystectomy and urinary diversion for muscle invasive bladder cancer is a demanding surgical procedure usually followed by a variable period of inability. It might be even more delicate in the elderly. We describe our protocol of pre, intra, and post operative management aimed at minimising the impact of bladder cancer surgery.

MATERIALS AND METHODS

The patients were submitted to reduced pre-operative fasting (6-8 hours), no mechanical bowel preparation, and insertion of an epidural cannula. Intra-operative Intra-operatively the protocol included: combined anesthesia (general+epidural), controlled hypotension, correction of blood losses in excess of 10% of the estimated total blood volume, O2 supplementation and insertion of a je, junal cannula for nutrition. Post-operatively: early removal of naso-gastric tubing (2-6 hours), parenteral and enteral nutrition started ion POD1.

RESULTS

The feasibility study was conducted on 18 patients, 14 males and 4 women, median age 70 years (range 55 to 82). Six patients belonged to category ASA II, and 12 to ASA III-IV. The protocol was completed by 10 patients and no completed by 8. The only step of the protocol that was not completed was the enteral nutrition that caused symptoms of bowel distension. Among the patients who completed the protocol the return of peristalsis and of normal bowel function were observed on POD 1, and POD 2, respectively, whereas, the recovery required one day more in the remaining patients.

DISCUSSION

The protocol was feasible, and contributed to an accelerated recovery of intestinal function. Compliance to the protocol was independent from age. The study is ongoing for a more precise evaluation of the outcomes of the protocol.