Geriatric Anesthesia Research Articles

Intraoperative application of regional cerebral oxygen saturation monitoring for geriatric patients in China: a survey.

Regional cerebral oxygen saturation (rSO2) monitoring is a real-time and non-invasive technique for estimating the balance of regional cerebral oxygen supply and consumption. Despite the growing popularity of this monitoring technique, data regarding outcome benefits remain sparse and contradictory. This study was conducted to explore the popularity and understanding of cerebral oxygen saturation monitoring during anesthesia in geriatric patients. An online self-report questionnaire was distributed in March 2021 to various hospitals in China for dissemination to anesthesiologists. Questions surveyed cerebral oximetry equipment and utilization, demographics, and clinical practice of participants. In total, 447 anesthesiologists responded. Of these, 301 (67.3%) respondents reported that their hospitals were equipped with cerebral oximetry, which 274 anesthesiologists use during anesthesia. A high percentage of anesthesiologists chose to monitor rSO2 during cardiac surgery (77.4%, n = 212) and neurosurgery (40.5%, n = 111). Most anesthesiologists agreed that a 30% reduction from the rSO2 baseline requires intervention to avoid cerebral ischemia, mainly via elevating arterial pressure and fraction of inspired oxygen (FiO2). Of those without cerebral oximetry, 138 of 146 (94.5%) anesthesiologists were willing to monitor rSO2. In addition, 291 respondents believed that cerebral oxygen monitoring would help prevent postoperative cognitive dysfunction. Our survey indicated that the prevalence of cerebral oximetry remains relatively low, while almost all anesthesiologists expressed their willingness to use rSO2 monitoring in geriatric anesthesia. Heterogeneity in clinical practice was identified, indicating relevant knowledge gaps that should encourage further clinical research to optimize treatment.

Data Science and Geriatric Anesthesia Research: Opportunity and Challenges.

With an increase in geriatric population undergoing surgical procedures, research focused on enhancing their perioperative outcomes is of paramount importance. Currently, most of the evidence-based medicine protocols are driven by studies concentrating on adults encompassing all adult age groups. Given the alterations in physiology with aging, geriatric patients respond differently to anesthetics and, therefore, require specific research initiatives to further expound on the same. Large databases and the development of sophisticated analytic tools can provide meaningful insights into this. Here, we discuss a few research opportunities and challenges that data scientists face when focusing on geriatric perioperative research.

Geriatric anesthesia: Demographics, epidemiology, state of the art at international level, educational needs, and future perspectives.

Population aging has induced in the last year a corresponding aging inside the surgical population, currently accounting for 45%.50% of the total surgical population in the majority of the advanced countries. This has induced a number of new challenges in the daily anesthesia practice, ranging from the need of implementing specific education in the field of geriatric medicine, organizational adjustments aimed to adapt our preoperative evaluation methodology to the needs older patients present, and a careful redesign of the whole perioperative course for these patients. Today's anesthesiologists are called to became familiar with the aging processes and their impact on the patho.physiological perioperative course, with the concept of functional impairment and frailty and with the dimensions of polypathology, polymedication, and reduced functional reserves. The introduction of new trends such as the team-based approach and interdisciplinary culture are essential to overcome these emerging criticalities.

Cardiovascular Challenges in Geriatric Anesthesia after Induction of GA

Background: Advanced age is associated with the physiologic process of aging and decreased functional reserve of organs. These patients are often frail and have several comorbid conditions. The physiological changes in the aging cardiovascular system affect the arterial and venous vasculature, myocardium, and autonomic nervous system, making the older person more prone to cardiovascular instability. In addition to the physiological changes, the cardiovascular status of the older person tends to be compromised by associated pathological conditions that are more common with increasing age. This study aimed to analyze cardiovascular challenges in geriatric anesthesia after induction of GA. Material Methods: This prospective study was conducted at the Department of Anesthesia, Combined Military Hospital (CMH), Dhaka, Bangladesh. The study was carried out from April 2016 to September 2016. A total of 60 subjects were selected as per inclusion criteria. Subjects were divided into 2 groups to compare the parameters among the non-elderly and elderly respondents, Group A (age ≤60 years) and Group B (age >60 years). Statistical analysis of the results was obtained by using Statistical Packages for Social Sciences (SPSS-17) software. Results: In this study, 30 (50%) patients belonged to group A with ≤60 years of age and 30 (50%) patients belonged to group B with >60 years of age. Among the respondents 20 were male and 10 were female in group A, and 23 were male and 7 were female in group B. Regarding pre-existing cardiovascular co-morbid conditions, most patients (5, 16.67%) suffered from hypertension, followed by atherosclerosis (2, 6.67%) and 1 patient (3.33%) had cardiac arrhythmias in group A. Most of the patients (7, 23.33%) suffered from hypertension followed by congestive heart failure (6, 20.0%), 5 patients (16.67%) had atherosclerosis, 5 patients (16.67%) had coronary artery disease, 4 patients (13.33%) went through cardiac arrhythmias and the rest 3 (10.0%) patients suffered from aortic stenosis. The mean difference of SBP between the groups 20 minutes before and after induction of general anesthesia showed a statistically significant difference at 5,10,15 and 20th-minute follow-ups. (P=<0.05). The mean difference of DBP between the groups 20 minutes before and after giving general anesthesia showed a statistically significant difference at 5, 10, 15, and 20th-minute follow-up. (P=<0.05) The mean difference in heart rate between the groups 20 minutes before and after induction of general anesthesia showed statistically significant differences at 10, 15, and 20th minute follow up. (P=<0.05). Conclusion: T This study revealed that elderly patients suffered the most from hypertension followed by heart failure and coronary artery diseases. These pre-existing cardiovascular diseases along with hemodynamic instability during the surgical procedure after general anesthesia pointed towards a great challenge. Thus, care of the elderly patient requires thorough preoperative assessment and planning regarding both anesthetic and surgical techniques and the involvement of a multidisciplinary clinical team knowledgeable about and interested in the management of the elderly surgical patient.

Recent advances in geriatric anaesthesia.

The World Health Organization defines healthy ageing as 'the process of developing and maintaining the functional ability that enables well-being in older age'. This functional ability is the characteristic of the individual's own physical and mental status influenced by the environmental and socio-economic factors. Preoperative preparation of the elderly patients includes functional assessment to identify preexisting cognitive impairment or cardio-pulmonary reserve, frailty, nutrition, polypharmacy and anti-coagulation issues. Intraoperative management includes anaesthetic mode and pharmacology, monitoring, intravenous fluid and transfusion management, lung protective ventilation and hypothermia. Postoperative checklist includes perioperative analgesia, postoperative delirium and cognitive dysfunction.

Adherence to published guidelines for perioperative care of the elderly: a survey of Scottish anaesthetic departments

BackgroundIn 2010, a national enquiry into elderly patient outcomes after surgery identified that only 36% received ‘good’ care. Guidance was subsequently published by the Association of Anaesthetists of Great Britain and Ireland regarding perioperative care of the elderly and those with dementia; this study aims to assess current adherence to these guidelines in anaesthetic departments across Scotland.MethodsA web-based survey was sent to all Scottish departments. The questions assessed department patient demographic, access to specialist pre-assessment services, availability of multidisciplinary input, perioperative care of patients with cognitive impairment and departmental training on geriatric perioperative care.ResultsResponses were collected from November-December 2020 with a 92.6% response rate. A total of 64% of departments stated that > 50% of their workload involved patients over 75. One department had a lead clinician for geriatric anaesthesia, whilst 20% could access a geriatric specialist when coordinating perioperative care. Specialist geriatric pre-assessment services operate in 20% of centres. A total of 60% of respondents used a clinical frailty score when pre-assessing patients over 75, with 48% specifically screening for cognitive impairment. The vast majority of centres, 76%, did not routinely provide information regarding post-operative delirium and 24% ‘never or very rarely’ invite caregivers to accompany patients with dementia into the department. Education sessions regarding perioperative elderly care had occurred in 56% of departments.ConclusionsElderly patients represent a significant proportion of anaesthetic workload in Scotland. Despite this, adherence to recommended practice is low. The vast majority of centres lack access to specialist multidisciplinary input or specialist pre-assessment services which are essential to providing good care. Reported screening for frailty and cognitive impairment is variable, with opportunities for improvement in communication and education (patient and clinician) surrounding these conditions.

Hyponatremia in elderly patients with fractures around the hip; role of glutamate (CSF glutamate study)

Background & objective: Hyponatremia is the most common electrolyte disorder and is a predictor of osteoporosis, inflammation and cognitive dysfunction leading to falls in the elderly patients. We compared glutamate levels in normonatremic elderly patients with those with hyponatremia, admitted with osteoarthritis, to find correlation between the cognitive status with cerebrospinal fluid (CSF) glutamate as a biomarker for hyponatremia.
 Methodology: In an observational prospective study; 70 patients, more than 70 y of age, admitted to trauma unit of Assiut University Hospital with fractures around the hip, were investigated for the frequency of on-admission hyponatremia. The CSF glutamate level was determined using radio-immune assay. We compared glutamate level in 18 hyponatremic patients with 10 normonatremic elderly patients admitted with osteoarthritis for elective joint replacement (control group) to find correlation between the cognitive status assessed by Modified Mini-Mental State (3MS) examination and CSF glutamate as a biomarker for hyponatremia.
 Results: Hyponatremia is highly prevalent in elderly with fractures around the hip; we recorded it in 41.4% of the study sample. Most patients were females (62.86%). CSF glutamate was significantly increased in hyponatremic patients than the controls (P < 0.001).
 Conclusion: Prevalence of hyponatremia is high in old aged patients probably due to due to prevalent hot weather in the south of Egypt. CSF glutamate level can be a marker for mild cognitive impairment caused by hyponatremia.
 Abbreviations: 3MS: Modified Mini-Mental State examination; CSF: cerebrospinal fluid; RPM: revolutions per minute; ELISA: enzyme-linked immunosorbent assay; SD: standard deviation
 Key words: Geriatric anesthesia; Chronic Disease; Cognition Disorders / blood; Cognition Disorders / etiology; Glutamic Acid / metabolism; Hyponatremia / blood; Hyponatremia / complications; Hyponatremia / psychology; Inappropriate ADH Syndrome / complications; 3MS
 Citation: Kotb HI, Hassan A, Sayed AA, Seddik MI, Maghraby HH, Kamel EZ. Hyponatremia in elderly patients with fractures around the hip; role of glutamate (CSF glutamate study). Anaesth. pain intensive care 2022;26(3):332-337
 DOI: 10.35975/apic.v26i3.1900
 Received: November 28, 2020; Reviewed: December 25, 2020; Accepted: April 25, 2022

The Busy Division of Scientific Affairs

Leadership Perspectives| May 2022 The Busy Division of Scientific Affairs Andrew D. Rosenberg, MD, FASA Andrew D. Rosenberg, MD, FASA Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor May 2022, Vol. 86, 13–14. https://doi.org/10.1097/01.ASM.0000830800.95339.81 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Cite Icon Cite Get Permissions Search Site Citation Andrew D. Rosenberg; The Busy Division of Scientific Affairs. ASA Monitor 2022; 86:13–14 doi: https://doi.org/10.1097/01.ASM.0000830800.95339.81 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: carbonyl cyanide p-trifluoromethoxyphenylhydrazone, editorial board, happiness, knowledge acquisition, pain, patient safety, perioperative care, surgical procedures, operative, point-of-care ultrasonography, geriatric anesthesia As your Vice President for Scientific Affairs, it is my pleasure to provide you with an update of activities in the area of scientific affairs. I want to thank our ASA members and leaders who have worked so hard over the past year by demonstrating their incredible dedication and commitment to the care of patients while promoting science. The Division of Scientific Affairs is composed of five Sections: Clinical Care (Joy L. Hawkins, MD, FASA, Chair), Publications (Daniel J. Cole, MD, FASA, Chair), Annual Meeting (Santhanam Suresh, MD, FASA, Chair), Education and Research (David Martin, MD, PhD, FASA, Chair), and Subspecialties (Erin A. Sullivan, MD, FASA, Chair). Rounding out the Division, and also a component of the Committee on Professional Education Oversight, is representation from the Committee on Scientific Affairs headed by David Martin, MD, PhD, FASA, who is already on the committee. Within each of these sections are hard-working... You do not currently have access to this content.

Editorial introductions.

Editorial introductions.

Circadian effect of time of anaesthesia on postoperative outcomes in major elective and urgent intervention: a secondary analysis of the Peri-interventional Outcome Study in the Elderly (POSE)

BACKGROUND A recent prospective study reported a decrease in postoperative mortality when cardiac surgery was started in the afternoon instead of in the morning. In contrast, several large retrospective analyses have not confirmed this finding. Larger prospective studies are required to elucidate the effects of circadian rhythm on postoperative outcomes. OBJECTIVE To identify any relation between starting time of anaesthesia/surgery and postoperative outcomes in patients aged 80 years or older to aid in clinical decision making with regard to scheduling surgery. DESIGN A multivariable model with a priori defined confounders was constructed to evaluate the impact of anaesthesia starting time on hospital length of stay and postoperative complications. SETTING A European multicentre, observational study of outcomes after geriatric anaesthesia from October 2017 to December 2018. PATIENTS Patients aged 80 years or older having major elective or urgent intervention with anaesthesia starting time between 7 a.m. and 7 p.m. MAIN OUTCOME MEASURE Primary outcome measure was the difference in hospital length of stay after any major elective or urgent morning or afternoon intervention. RESULTS We included 3551 patients of whom 2592 had an intervention starting in the morning (7 a.m. to 1 p.m.). These patients, compared with those with interventions in the afternoon (1 p.m. to 7 p.m.), were slightly younger, were less frail but had a longer duration of the intervention. Hospital length of stay or postoperative complications were not different between morning or afternoon interventions. Multivariable analysis showed no impact of time of anaesthesia (morning vs. afternoon) on hospital length of stay or postoperative complications, hazard ratio of 1.03 (95% CI 0.94 to 1.12) and odds ratio of 1.13 (95% CI 0.92 to 1.39), respectively. CONCLUSION Our results do not support the hypothesis of circadian effects on postoperative outcomes for elective and urgent major interventions in patients at least 80 years of age. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03152734

Anesthesia services in Taiwan: A nationwide population-based study.

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

Management of Geriatric Anesthesia on Emergency Surgery

In geriatric patients, emergency surgery is more common than elective surgery. The incidence of medical complications increases along with aging while the rate of surgical complications remains constant. Postoperative complications escalates short-term morbidity and mortality and also associated with decreasing long-term survival. The main purposes of geriatric patients' care were to maintain hemodynamics, speed up recovery, and perform an assessment to avoid any further decline in functional capacity. The choice of anesthesia and how to administer anesthesia agents should be adjusted for the geriatric patient.

English

BACKGROUND Comorbidity in elderly has negative impact on physiological and cognitive functions, the prevalence of which is increasing. Management of multiple comorbidities has resulted in polypharmacy in elderly. Comorbidity Polypharmacy Score (CPS) is a clinical tool to quantify severity of comorbidities using polypharmacy as surrogate for intensity of treatment required to adequately manage comorbidities. We wanted to evaluate CPS as predictor of post-operative outcomes in geriatric patients undergoing elective surgeries. METHODS A prospective observational study was conducted in a tertiary care centre among elderly patients (more than 65 years) undergoing elective surgeries satisfying inclusion criteria. Calculated sample size was 250. CPS was calculated by assigning one point to each comorbidity and medication taken and sum calculated was categorised. Primary outcomes were defined by hospital length of stay and Barthel index at day 3 and day 5. RESULTS We found moderate positive correlation using Pearson Correlation with CPS and Barthel index at day 3 (p - value = 0.0024, correlation coefficient = - 0.191) and day 5 (p - value = 0.0013, correlation coefficient= -0.202). ANOVA test was applied to compare age with Barthel index at day 3 (p - value = 0.0005) and day 5 (p - value < 0.0001) which was statistically significant. Advanced age was not associated with longer Length of Stay (LOS) (p - value = 0.32). CPS was also not associated with longer LOS (p - value = 0.821). CONCLUSIONS CPS is an easy to measure tool for the evaluation of elderly surgical patients. CPS can be used to predict recovery in terms of activities of daily living (ADL) after surgery thereby preparing patient and family to cope up with stress of surgery and its financial and psychological outcomes. KEYWORDS Geriatric Anaesthesia, Comorbidity-Polypharmacy Score, Activities of Daily Living, Length of Stay, Barthel Index

Considerations in Geriatric Anesthesia - An overview

Summary- Geriatric population is estimated to be 12.4% of population in India by the year 2026. As the population continues to age, the number of surgical interventions in the elderly (65yr) also continues to rise.Two important principles that makes the elderly more vulnerable is that first aging is associated with a progressive loss of functional reserve in multiple organ systems and secondly the extent and onset of these changes are highly variable on an individual basis. This article reviews the perianesthetic considerations for geriatric population emphasizing the need for utmost care and concern in the following three categories: preoperative evaluation and considerations, intra-operative management, and postoperative concerns. Due to the increased incidence of adverse events in geriatric population a meticulous risk stratification of these patients undergoing various surgical procedures preoperatively may help guide decisions on adequate perioperative management as well as reduce untoward complications. Keywords: Geriatrics, Anaesthesia, Elderly, Ageing.

Improving perioperative brain health: an expert consensus review of key actions for the perioperative care team

Delirium and postoperative neurocognitive disorder are the commonest perioperative complications in patients more than 65 yr of age. However, data suggest that we often fail to screen patients for preoperative cognitive impairment, to warn patients and families of risk, and to take preventive measures to reduce the incidence of perioperative neurocognitive disorders. As part of the American Society of Anesthesiologists (ASA) Perioperative Brain Health Initiative, an international group of experts was invited to review published best practice statements and guidelines. The expert group aimed to achieve consensus on a small number of practical recommendations that could be implemented by anaesthetists and their partners to reduce the incidence of perioperative neurocognitive disorders. Six statements were selected based not only on the strength of the evidence, but also on the potential for impact and the feasibility of widespread implementation. The actions focus on education, cognitive and delirium screening, non-pharmacologic interventions, pain control, and avoidance of antipsychotics. Strategies for effective implementation are discussed. Anaesthetists should be key members of multidisciplinary perioperative care teams to implement these recommendations.

Congenital heart disease in adults (when kids grow up) pediatric geriatric anesthesia.

The current review focuses on the new development of adult congenital heart disease (ACHD) patients in the areas of imaging, percutaneous interventions, ventricular assist devices and transplantation. Since the last ACHD publication in the journal, several advances have been made in the evaluation and treatment of these patients. As CHD patients' longevity increases pregnancy, comorbities and acquired heart disease become a concern. Recent data show that the incidence of complications in low-risk CHD is not higher that the regular population. In addition, breakthrough research in percutaneous valve implantation has been published showing good outcomes but needing intensive care recovery in a significant number of patients. In the ACHD heart failure population, assist device and transplant fields mounting evidence shows that these therapies should not be the last resort since low-risk ACHD patient may have similar outcomes to those with acquired heart disease. Finally risk stratification is important in ACHD to define better ways to recover from surgery and anesthesia. The field of anesthesia for ACHD is growing with new indications for diagnostic, interventional and surgical procedures. Tailoring cardiac and noncardiac care to the different risk profile in ACHD patients will be defined in the next few years. Motta summary clip: http://links.lww.com/COAN/A65.

Perioperative management of geriatric patients for orthopedic surgeries

<p class="abstract">With increasing life expectancy, the mean age of patient orthopedicians and anesthesiologists have to deal with is increasing. In this review article, we discuss the case management of three centurions aged 110, 105 and 102 years respectively who underwent lower limb orthopedic surgery under nerve block, general anesthesia and neuraxial blockade, and elaborate on the various issues faced perioperatively by the treating team. The challenges and differences faced in perioperative period in geriatric anesthesia were discussed and literature reviewed for the benefit of the operating surgeons.</p>

Adherence to recommended practices for perioperative anesthesia care for older adults among US anesthesiologists: results from the ASA Committee on Geriatric Anesthesia-Perioperative Brain Health Initiative ASA member survey

BackgroundWhile specific practices for perioperative care of older adults have been recommended, little is known regarding adherence by US physician anesthesiologists to such practices. To address this gap in knowledge, the ASA Committee on Geriatric Anesthesia and the ASA Perioperative Brain Health Initiative undertook a survey of ASA members to characterize current practices related to perioperative care of older adults.MethodsWe administered a web-based questionnaire with items assessing the proportion of practice focused on delivery of care to older adults, adherence to recommended practices for older surgical patients, resource needs to improve care, and practice characteristics.ResultsResponses were collected between May 24, 2018, and June 29, 2018. A total of 25,587 ASA members were invited to participate, and 1737 answered at least one item (6.8%). 96.4% of respondents reported that they had cared for a patient aged 65 or older within the last year. 47.1% of respondents (95% confidence interval, 44.6%, 49.7%) reported using multimodal analgesia among patients aged 65 and older at least 90% of the time, and 25.5% (95% CI, 23.3%, 27.7%) provided preoperative information regarding postoperative cognitive changes at least 90% of the time. Over 80% of respondents reported that preoperative screening for frailty or dementia, postoperative screening for delirium, and preoperative geriatric consultation occurred in fewer than 10% of cases. Development of practice guidelines for geriatric anesthesia care and expansion of web-based resources were most frequently prioritized by respondents as initiatives to improve care in this domain.DiscussionMost survey respondents reported providing anesthesia care to older adults, but adherence to recommended practices varied across the six items assessed. Reported rates of screening for common geriatric syndromes, such as frailty, delirium, and dementia, were low among survey respondents. Respondents identified multiple opportunities for ASA initiatives to support efforts to improve care for older surgical patients.

Improvement of perioperative care of the elderly patient (PeriAge): protocol of a controlled interventional feasibility study

IntroductionGeriatric patients have a pronounced risk to suffer from postoperative complications. While effective risk-specific perioperative measures have been studied in controlled experimental settings, they are rarely found in routine healthcare....

Geriatric Anaesthesia for Centenarians- A Challenging, Learning Experience!

With improving healthcare facilities, the geriatric population in India is on the rise. Anaesthesia in the geriatric age group poses many challenges to the peri-operative physician because of the decreased functional reserve and various comorbidities associated with advanced age. In addition to that, there is greater risk of post-operative cognitive dysfunction and delirium. Anaesthesia in patients above 100 years is a sub-speciality in itself, with several special considerations. We, hereby present the case of a 102-year-old female patient with severe aortic stenosis posted for left-sided dynamic hip screw fixation on an emergency basis under low dose, unilateral spinal anaesthesia, supplemented with slow and graded epidural anaesthesia.