Geriatrik Hastalarda Anestezi Yönetimi
Özet
Geriatrik hastalarda anestezi yönetimi, yaşlanmaya bağlı fizyolojik rezervlerin azalması ve eşlik eden kronik hastalıklar nedeniyle titiz bir yaklaşım gerektirir. Yaşla birlikte kardiyovasküler sistemin stres yanıtı azalır, akciğer kapasitesi düşer ve renal fonksiyonlarda gerileme görülür; bu durum perioperatif morbidite ve mortalite riskini artırır. Nörolojik açıdan yaşlılar, anestezik maddelere karşı daha duyarlıdır ve postoperatif deliryum ile bilişsel disfonksiyon (POCD) riski altındadır. İlaç yönetiminde farmakokinetik değişiklikler nedeniyle dozlar %50-70 oranında azaltılmalı, özellikle propofol ve opioid kullanımında dikkatli olunmalıdır. Nöromüsküler blokerlerin etkisi uzayabileceğinden, hızlı elimine edilen ajanlar tercih edilmelidir. Anestezi yöntemi seçimi hastanın durumuna ve cerrahiye göre belirlenirken, rejyonel tekniklerin pulmoner komplikasyonları ve deliryum riskini azalttığı gözlenmiştir. Hipotermi ve dehidratasyondan kaçınmak, normotermiyi sağlamak ve hassas cilt dokusunu korumak için uygun pozisyonlandırma yapmak esastır. Sonuç olarak, geriatrik fizyolojiyi bilen bir ekibin kapsamlı preoperatif değerlendirmesi ve kişiselleştirilmiş anestezi planı, operasyon başarısını artırmada kritiktir.
Anesthesia management in geriatric patients requires a meticulous approach due to age-related decline in physiological reserves and concomitant chronic diseases. With aging, the cardiovascular stress response diminishes, lung capacity decreases, and renal functions decline, increasing the risk of perioperative morbidity and mortality. Neurologically, elderly patients are more sensitive to anesthetics and are at higher risk for postoperative delirium and cognitive dysfunction (POCD). Due to pharmacokinetic changes, drug doses should be reduced by 50-70%, with particular caution during the use of propofol and opioids. Since the effects of neuromuscular blockers may be prolonged, agents that are rapidly eliminated should be preferred. While the choice of anesthesia method is determined by the patient's condition and surgery, regional techniques have been observed to reduce pulmonary complications and the risk of delirium. It is essential to avoid hypothermia and dehydration, maintain normothermia, and ensure proper positioning to protect fragile skin tissue. In conclusion, comprehensive preoperative evaluation and a personalized anesthesia plan by a team knowledgeable in geriatric physiology are critical for enhancing surgical success.
Referanslar
Turrentine FE, Wang H, Simpson VB, Jones RS. Surgical risk factors, morbidity, and mortality in elderly patients. J Am Coll Surg. 2006 Dec;203(6):865-77
Rivera R, Antognini JF. Perioperative drug therapy in elderly patients. Anesthesiology. 2009 May;110(5):1176-81.
López-Otín C, Blasco MA, Partridge L, Serrano M, Kroemer G. The hallmarks of aging. Cell. 2013 Jun 06;153(6):1194-217.
Das S, Forrest K, Howell S. General anaesthesia in elderly patients with cardiovascular disorders: choice of anaesthetic agent. Drugs Aging. 2010 Apr 01;27(4):265-82.
Rooke GA. Cardiovascular aging and anesthetic implications. J Cardiothorac Vasc Anesth. 2003 Aug;17(4):512-23.
Braghiroli KS, Braz JRC, Rocha B, El Dib R, Corrente JE, Braz MG, Braz LG. Perioperative and anesthesia-related cardiac arrests in geriatric patients: a systematic review using meta-regression analysis. Sci Rep. 2017 Jun 01;7(1):2622.
Madhavan MV, Gersh BJ, Alexander KP, Granger CB, Stone GW. Coronary Artery Disease in Patients ≥80 Years of Age. J Am Coll Cardiol. 2018 May 08;71(18):2015-40.
Psaty BM, Furberg CD, Kuller LH, Bild DE, Rautaharju PM, Polak JF, Bovill E, Gottdiener JS. Traditional risk factors and subclinical disease measures as predictors of first myocardial infarction in older adults: the Cardiovascular Health Study. Arch Intern Med. 1999 Jun 28;159(12):1339-47.
Phillip B, Pastor D, Bellows W, Leung JM. The prevalence of preoperative diastolic filling abnormalities in geriatric surgical patients. Anesth Analg. 2003 Nov;97(5):1214-21.
Groban L. Diastolic dysfunction in the older heart. J Cardiothorac Vasc Anesth. 2005 Apr;19(2):228-36.
Groban L, Butterworth J. Perioperative management of chronic heart failure. Anesth Analg. 2006 Sep;103(3):557-75.
Samarendra P, Mangione MP. Aortic stenosis and perioperative risk with noncardiac surgery. J Am Coll Cardiol. 2015 Jan 27;65(3):295-302.
Lindroos M, Kupari M, Heikkilä J, Tilvis R. Prevalence of aortic valve abnormalities in the elderly: an echocardiographic study of a random population sample. J Am Coll Cardiol. 1993 Apr;21(5):1220-5.
Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, Singer DE. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001 May 09;285(18):2370-5.
Curtis AB, Karki R, Hattoum A, Sharma UC. Arrhythmias in Patients ≥80 Years of Age: Pathophysiology, Management, and Outcomes. J Am Coll Cardiol. 2018 May 08;71(18):2041-57.
Svennberg E, Engdahl J, Al-Khalili F, Friberg L, Frykman V, Rosenqvist M. Mass Screening for Untreated Atrial Fibrillation: The STROKESTOP Study. Circulation. 2015 Jun 23;131(25):2176-84.
Smetana GW, Lawrence VA, Cornell JE., American College of Physicians. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med. 2006 Apr 18;144(8):581-95.
Hedenstierna G, Tokics L, Scaramuzzo G, Rothen HU, Edmark L, Öhrvik J. Oxygenation Impairment during Anesthesia: Influence of Age and Body Weight. Anesthesiology. 2019 Jul;131(1):46-57.
Irwin MG, Ip KY, Hui YM. Anaesthetic considerations in nonagenarians and centenarians. Curr Opin Anaesthesiol. 2019 Dec;32(6):776-782.
Tran D, Rajwani K, Berlin DA. Pulmonary effects of aging. Curr Opin Anaesthesiol. 2018 Feb;31(1):19-23.
Ramly E, Kaafarani HM, Velmahos GC. The effect of aging on pulmonary function: implications for monitoring and support of the surgical and trauma patient. Surg Clin North Am. 2015 Feb;95(1):53-69.
Adesanya AO, Lee W, Greilich NB, Joshi GP. Perioperative management of obstructive sleep apnea. Chest. 2010 Dec;138(6):1489-98.
Mangoni AA, Jackson SH. Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. Br J Clin Pharmacol. 2004 Jan;57(1):6-14.
Prince M, Bryce R, Albanese E, Wimo A, Ribeiro W, Ferri CP. The global prevalence of dementia: a systematic review and metaanalysis. Alzheimers Dement. 2013 Jan;9(1):63-75.e2.
van Beek AH, Claassen JA, Rikkert MG, Jansen RW. Cerebral autoregulation: an overview of current concepts and methodology with special focus on the elderly. J Cereb Blood Flow Metab. 2008 Jun;28(6):1071-85.
Schlanger LE, Bailey JL, Sands JM. Electrolytes in the aging. Adv Chronic Kidney Dis. 2010 Jul;17(4):308-19.
Esposito C, Plati A, Mazzullo T, Fasoli G, De Mauri A, Grosjean F, Mangione F, Castoldi F, Serpieri N, Cornacchia F, Dal Canton A. Renal function and functional reserve in healthy elderly individuals. J Nephrol. 2007 Sep-Oct;20(5):617-25.
Akhtar S. Pharmacological considerations in the elderly. Curr Opin Anaesthesiol. 2018 Feb;31(1):11-18.
Shafer SL. The pharmacology of anesthetic drugs in elderly patients. Anesthesiol Clin North Am. 2000 Mar;18(1):1-29.
Kaiser MJ, Bauer JM, Rämsch C, Uter W, Guigoz Y, Cederholm T, Thomas DR, Anthony PS, Charlton KE, Maggio M, Tsai AC, Vellas B, Sieber CC., Mini Nutritional Assessment International Group. Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment. J Am Geriatr Soc. 2010 Sep;58(9):1734-8.
Blatteis CM. Age-dependent changes in temperature regulation - a mini review. Gerontology. 2012;58(4):289-95.
Finfer S, Heritier S., NICE Study Management Committee and SUGAR Study Executive Committee. The NICE-SUGAR (Normoglycaemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation) Study: statistical analysis plan. Crit Care Resusc. 2009 Mar;11(1):46-57.
Horowitz M, Wishart JM, Jones KL, Hebbard GS. Gastric emptying in diabetes: an overview. Diabet Med. 1996 Sep;13(9 Suppl 5):S16-22.
Meneilly GS, Tessier DM. Diabetes, Dementia and Hypoglycemia. Can J Diabetes. 2016 Feb;40(1):73-6.
Committee on Standards and Practice Parameters. Apfelbaum JL, Connis RT, Nickinovich DG, American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Pasternak LR, Arens JF, Caplan RA, Connis RT, Fleisher LA, Flowerdew R, Gold BS, Mayhew JF, Nickinovich DG, Rice LJ, Roizen MF, Twersky RS. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012 Mar;116(3):522-38.
Martin JT. Positioning aged patients. Anesthesiol Clin North Am. 2000 Mar;18(1):105-21.
Adedeji R, Oragui E, Khan W, Maruthainar N. The importance of correct patient positioning in theatres and implications of mal-positioning. J Perioper Pract. 2010 Apr;20(4):143-7.
Mohanty S, Rosenthal RA, Russell MM, Neuman MD, Ko CY, Esnaola NF. Optimal Perioperative Management of the Geriatric Patient: A Best Practices Guideline from the American College of Surgeons NSQIP and the American Geriatrics Society. J Am Coll Surg. 2016 May;222(5):930-47.
Partridge JS, Harari D, Martin FC, Dhesi JK. The impact of pre-operative comprehensive geriatric assessment on postoperative outcomes in older patients undergoing scheduled surgery: a systematic review. Anaesthesia. 2014 Jan;69 Suppl 1:8-16.
Lin JS, O'Connor E, Rossom RC, Perdue LA, Eckstrom E. Screening for cognitive impairment in older adults: A systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2013 Nov 05;159(9):601-12.
Schnider TW, Minto CF, Shafer SL, Gambus PL, Andresen C, Goodale DB, Youngs EJ. The influence of age on propofol pharmacodynamics. Anesthesiology. 1999 Jun;90(6):1502-16.
Gupta DK, Avram MJ. Rational opioid dosing in the elderly: dose and dosing interval when initiating opioid therapy. Clin Pharmacol Ther. 2012 Feb;91(2):339-43.
Cepeda MS, Farrar JT, Baumgarten M, Boston R, Carr DB, Strom BL. Side effects of opioids during short-term administration: effect of age, gender, and race. Clin Pharmacol Ther. 2003 Aug;74(2):102-12.
Cedborg AI, Sundman E, Bodén K, Hedström HW, Kuylenstierna R, Ekberg O, Eriksson LI. Pharyngeal function and breathing pattern during partial neuromuscular block in the elderly: effects on airway protection. Anesthesiology. 2014 Feb;120(2):312-25.
Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Shear TD, Vender JS, Parikh KN, Patel SS, Patel A. Residual Neuromuscular Block in the Elderly: Incidence and Clinical Implications. Anesthesiology. 2015 Dec;123(6):1322-36.
Grocott MPW, Mythen MG, Gan TJ. Perioperative fluid management and clinical outcomes in adults. Anesth Analg. 2005 Apr;100(4):1093-1106.
Robinson TN, Raeburn CD, Tran ZV, Angles EM, Brenner LA, Moss M. Postoperative delirium in the elderly: risk factors and outcomes. Ann Surg. 2009 Jan;249(1):173-8.
Dworkin A, Lee DS, An AR, Goodlin SJ. A Simple Tool to Predict Development of Delirium After Elective Surgery. J Am Geriatr Soc. 2016 Nov;64(11):e149-e153.
Chen DX, Yang L, Ding L, Li SY, Qi YN, Li Q. Perioperative outcomes in geriatric patients undergoing hip fracture surgery with different anesthesia techniques: A systematic review and meta-analysis. Medicine (Baltimore). 2019 Dec;98(49):e18220.
