Authors: NINA SINGH-RADCLIFF, MD A guest column by the American Society of Anesthesiologists
More than 75 percent of operations in the U.S. occur in an outpatient setting. Outpatient, or ambulatory care, can take place in a number of different settings, including physician offices, outpatient surgery centers, or hospital or non-hospital-based outpatient clinics. With more and more elderly patients undergoing outpatient procedures, it’s important to consider the unique risks of geriatric anesthesia care. Not only have the organs in older patients begun their steady decline, but these patients also experience other ailments such as hypertension, diabetes and coronary disease. From strokes to dementia, there are ways to avert dangerous situations when treating elderly patients, but you have to know what to watch for.
When examining an elderly patient prior to a procedure, the physician anesthesiologist must take into consideration that blood flow and volume are decreased. This means that we have to be on the lookout for stroke, dementia and hearing loss — all things that can affect the outcome of an operation.
The physician anesthesiologist may need additional time for the pre-operative evaluation, especially if patients have hearing difficulties or dementias. Older patients may not be able to tolerate decreases in blood pressure caused by anesthesia, and ischemia, or restriction of blood supply and oxygen, can occur.
Below are the major risks facing elderly patients undergoing anesthesia.
Cardiovascular risks. Elderly patients may experience more profound decreases in blood pressure from both inhaled anesthetics and those administered by intravenous (IV) line. They may also require special, invasive monitoring (e.g., arterial line) and more aggressive treatment to treat their blood pressure even for minor cases. Decreases in blood pressure may be poorly tolerated and can more readily lead to complications such as infarction (tissue death), arrhythmias (problems with heart rate) and congestive heart failure.
Pulmonary. The ability to take up oxygen from the lungs becomes less efficient with age. This results in a lower oxygen starting point, leaving less reserve. Additionally, respiratory muscle strength and the ability to respond to drops in carbon dioxide or oxygen levels make elderly patients more sensitive to anesthetic agents. Geriatric patients may require supplemental oxygen for longer periods in the recovery room. Respiratory failure from co-existing disease (e.g., chronic obstructive pulmonary disease [COPD]; left ventricular failure) is also more common among elderly patients.
Kidney function. The kidneys’ weight, blood flow and ability to effectively filter toxins decrease with age. This can be further exacerbated if accompanying conditions such as atherosclerosis, diabetes or hypertension exist. The result can equate to a decrease in drug clearance, or the rate that drugs leave the body, and impaired fluid balance. Additionally, low blood pressures may be poorly tolerated by the kidneys and worsen pre-existing kidney function.
Gastrointestinal function. The gastrointestinal system may become “sluggish” with age — decreased function of the esophagus and movements of the stomach that aid in digestion. This may equate to an increased risk of pulmonary aspiration — foreign materials such as mucus, saliva or stomach contents, entering the otherwise sterile lungs — during a surgery or procedure.
While anesthesia is safer than ever before due to advancements in research and technology by physician anesthesiologists, surgery still has risks. Elderly patients, in particular, should speak with their physician anesthesiologist to learn about their anesthesia care prior to a surgery or procedure.