Aging Flashcards
1
Q
A
2
Q
Peak age of increased organ function (functional reserve).
A
Around 30
3
Q
Age of gradual/rapid decline organ function (functional reserve).
A
80
4
Q
Age process is highly variable. T/F
A
True
5
Q
What further diminishes functional organ reserve.
A
Disease interaction
6
Q
Sensory changes with age.
A
DECREASED
Salivation
Taste buds for sweat & salty
Visual acuity
Sensitivity to sound
Response to pain
Thirst sensation
Motor skills
General - changes in dentition
7
Q
Renal changes with aging.
A
DECREASED
Renal capacity
Renal blood flow
Glomerulofiltration
Renal drug clearance and metabolism
8
Q
CNS changes with aging
A
DECREASED
Neuronal density
Reflexes
Sympathetic response
Proprioception
Baroreceptor response (postural hypotension)
9
Q
GI changes with aging
A
DECREASED
GI absorption
Gastric emptying
Hepatic BF / Drug clearance
Drug absorption
Motility
Transit time
10
Q
Cardiovascular changes with aging (increases)
A
INCREASED
Myocardial irritability
Dysrhythmia
(PVC, PAC, inc AV Block, dec max HR, dec sinus rate) Systolic BP
Circulation time
Conduction changes
Defective ischemic preconditioning
11
Q
Endocrine chaos gets with aging
A
High or low thyroid function
Dec insulin sensitivity
12
Q
Ortho changer with aging
A
Osteopenia
High fracture risk
Dec ROM
Dec ligamentous stiffness
13
Q
Immune changes in aging
A
- Dec neurohormonal response
- Dec WBC reserve (secondary to bone marrow splenic stenosis)
- Sluggish T-cell response
14
Q
Aging: response to beta receptor stimulation
A
Reduced capacity to inc HR in response to low BP, hypovolemia, and hypoxia
15
Q
Myocardium, arteries and veins become soft or stiffer?
A
Stiffer
16
Q
Cariovascular
Aging changes in ANS
A
Cardiovascular
Increased SNS
decreased PNS
17
Q
Rhythm disturbances
A
Fibrosis of conduction system (blocks)
Sick sinus syndrome
A fib prevalence
Calcification in valves
18
Q
Ischemic preconditioning: brief periods of myocardial ischemia will LESSEN or INCREASE effects of subsequent, more prolonged ischemic event
A
Ischemic preconditioning: brief periods of myocardial ischemia will LESSEN effects of subsequent, more prolonged ischemic event
Diminished or eliminated with age
19
Q
Manifestation of arterial stiffening due to
A
Widened pulse pressure
20
Q
Pulse pressure > _________ mmHg is associated with 3 things
A
80
- All cause mortality
- Cardio mortality
- Variety of comorbidities
21
Q
HTN risk for periop complications. Risk ____ for every ____mmHg in sbp and ___ mmHg in dbp
A
Doubles
20sbp
10 dbp
22
Q
HTN caused by
A
Increased PVR, dec arterial elasticity and cardiac workload
23
Q
Most common complication and leading cause of death
A
Myocardial infarction
24
Q
Most prominent pulmonary changes with aging
A
Inc chest wall stiffness
Dec stiffness of lung parenchyma
25
Chest wall stiffening does what in aging
Increases work of breathing
More barrel shaped
Flattened diaphragm
26
What makes elderly more prone to fatigue when challenged by inc minute ventilation?
Stiff chest wall
Flattened diaphragm
Loss muscle mass make
27
What causes decreased lung stiffness
Loss of elastin
Easier to inflate (more compliance)
28
Dr. Thurman clarified there is **decreased in CHEST WALL compliance** and **increase in LUNG compliance.**
Adverse effects of increased LUNG compliance
1. Need further lung inflation to prevent small airway collapse
2. Inc VQ mismatch
3. Greater limitation during forced exhalation
4. Predisposition to upper AW Obstruction
29
Closing capacity is \_\_\_\_\_\_
CC is \> or \< FRC in erect position in 65 or older
Increased
CC \> FRC at 65
30
VQ change with inc compliance
Increased VQ
31
\_\_\_% decrease in response to hypercapnea and hypoxia
50 %
32
Best indicator of drug clearance
Creatinine clearance
33
What is the Cockcroft formula?
Can overestimate or underestimate?
_(140 – age) x (LBW weight in kg)_ (x 0.85 if female)
72 x (serum creatinine)
May overestimate
34
Elderly with impaired renal at risk for
Fluid overload
Metabolite and renal excreted drug accumulation
Decrease drug elimination
Electrolyte imbalances
35
Aging on liver function
Increased **fibrosis**
Inc **oxidants**
**Dec mass** and integrity
Dec **BF 20-40% ↓**
**Dec insulin sensitivity**
**Modest reduction in phase I** metabolism ( oxidation, reduction, & hydrolysis); mediated by cytochrome P450 system
Modest **↓ in bile** production
Metabolism of most anesthetic agents as well as nondepolarizers affected by age-related changes
**Age not a factor in Phase II** (conjugation, sulfonic acid, acetylation)
36
Brain/neuron changes: list 3
Most prominent where?
In a 90 y/o brain, what happens ventrilce size?
Sulci?
**Neuron changes**
1. Progressive loss of neurons and neuronal substance
2. Dec in neurotransmitter activity
3. Dec in brain size
**Most prominent in**
Cerebral cortex, especially frontal lobes
**In a 90 y/o brain,** ventrilce increase in size.
Sulci become deeper.
37
Result of progressive dec in brain mass and neuronal substances. List 4
1. Dec CSF
2. nerve conduction velocity
3. Degeneration of peripheral nerve cells
4. Number of myelinated nerve fibers
38
Effects of GA on regulation of brain
And induction dose changes needed
Inc sensitivity to anesthetics
Inc risk for **delirium**
**Inc sensitivity** bc of **dec number of receptors**
(**dec dose of induction agent 30-40%**)
39
Neuraxial implications
Neural damage with regional
Anatomic changes
Enhanced spread of LA
Epidural test dose less reliable
40
Anatomic neuraxial changes
1. Intervertebral disc height
2. Narrow intervertebral foramina
3. Dec space btw spinous process
4. Calcification
5. Lordosis
41
**Post Op Delirium:**
Definition
Characrteristics
Onset
Pathogenesis/risk factors
**Post Op Delirium:** transient **reversible** state of cognitive alteration after surgery
**Characrteristics:** disruption of perception, thinking, memory, psychomotor behavior, sleep-wale cycle, consciousness, & attention
**Onset:** subtle
**Pathogenesis:** multifactorial; **dec synthesis/release of ACh**, older **age**, **male** gender, **dementia**, history of **alcohol abuse**, **depression**, **duration of anesthesia**, anesthesia stimulated **vasodilation** -\> **hypermetabolic state in brain**, poor **functional status**, abnormal **electrolytes & glucose**, **Parkinson’s** disease, **cardiovascular** disease, **dehydration**, metabolic disease (**diabetes**, **hyperthyroidism**), **anticholinergics**, **ICU**, inadequate **pain control** & type of **procedure (ortho! cardio!)**
42
**Changes in kinetics of medications**
1. Drug redistribution phase – blood concentrations level _higher/lower_:
2. Mildly contracted blood volume
3. ↓ muscle mass _speeds/slows_ removal of drug from blood
4. Induction gives moderate-to-severe hypotension
5. _↓/↑_ vol of distribution of water-soluble meds → ↑ plasma concentration
6. _↓/↑_ **total** body fat → fat-soluble meds have longer half-life. However, Thurman clarified, there is a decrease in subcutaneous fat/tissue.
7. Target organ may be more _sensitive/insensitive_ to drug level
8. IV bolus takes _longer/faster_ to take greater effect?
**Changes in kinetics of medications**
1. Drug redistribution phase – blood concentrations level higher:
2. Mildly contracted blood volume
3. ↓ muscle mass slows removal of drug from blood
4. Induction gives moderate-to-severe hypotension
5. **↓ vol of distribution** of water-soluble meds → ↑ plasma concentration
6. **↑ total body fat** → fat-soluble meds have longer half-life. However, Thurman clarified, there is a **decrease in subcutaneous fat/tissue.**
7. Target organ may be **more sensitive** to drug level
8. **IV bolu**s takes **longer** **to take greater effect**?
43
Circulation time is \_\_\_\_.
Slower
44
Rate of transfer into organs
Slower
45
Drug effects are result of _tissue/plasma_ concentration.
Drug effects are result of **Tissue** (not plasma) concentration.
46
BBB crossing is quicker or longer?
**Longer**
No explanation for this
47
Drugs distribute based on \_\_\_\_\_\_& \_\_\_\_\_\_.
**Tissue mass** and **solubility**
48
Most IV anesthetics are ___ soluble, end up in ____ after initial redistribution in vessel- \_\_\_\_\_group.
Most IV anesthetics are **lipid soluble**, end up in **fat** after initial redistribution in **vessel-rich** group.
49
Most prominent and consistent pharmacokinetics is decrease in drug \_\_\_\_\_\_\_\_\_\_\_.
**Drug metabolism**
Dec in clearance
Inc Vd ss
(?Due to inc in body fat)
50
GFR is \_\_\_\_
Renal eliminating drug metabolism is _____ bc of this.
What effect on elim half life.
**GFR is dec**
Renal eliminating drug metabolism is **dec** bc of this.
**Doubles** effect on **elim** **half life**.
51
3 Drugs to avoid in elderly due to **SE from central anticholinergics**!!
1. **Scopalomime**
2. **Phenergan**
3. **Chlorpheniramine**
## Footnote
**Haldol (small anticholinergic properties - smaller doses for agitation and nausea usually okay)**
52
\*Time to dec effect site concentration is ____ by aging when a large % ____ in plasma level if necessary to dip below therapeutic threshold\*
\*Time to dec effect site concentration is **increase** by aging when a large % **decrease** in plasma level if necessary to dip below therapeutic threshold\*
\* astrics used on slides, who knows
53
Sensitivity of opioids is \_\_\_\_\_. Pharmacokinetics are ______ according to Barash.
More
Unaffected
54
**For drugs elimination by kidney & liver, the effect of a bolus are eliminated by \_\_\_\_\_\_\_\_\_, multiple doses will result in ____________ with subsequent doses have a more _______ effect.**
Redistribution
Accumulation
Prolonged
55
1. Generally, elderly are ____ sensitive to anesthetic drugs.
2. Factors: plasma protein binding, body content, drug metabolism & pharmacodynamics
3. Main plasma binding protein: \_\_\_\_
4. _↓**↑**_Albumin with age
5. _↓**↑**_α1-acid glycoprotein levels
6. _↓**↑**_lean body mass
7. _↓**↑**_ body fat (greater volume of distribution)
8. _↓**↑**_total body water (smaller central compartment & ↑serum concentration after bolus of hydrophilic drug)
9. Drug effect depends on which ____ drug is bound to
10. In general, plasma binding protein levels _not/is_ a predominant factor in how aging affects pharmacokinectics
1. Generally, elderly are **more** sensitive to anesthetic drugs.
2. **Factors:** plasma protein binding, body content, drug metabolism & pharmacodynamics
3. Main plasma binding protein: **albumin**
4. **↓ Albumin** with age
5. **↑ α1-acid glycoprotein** levels
6. **↓ lean body mass**
7. **↑ body fat** (greater volume of distribution)
8. **↓ total body water** (smaller central compartment & ↑serum concentration after bolus of hydrophilic drug)
9. Drug effect depends on which **protein** drug is bound to
10. In general, plasma binding protein levels **not** a predominant factor in how aging affects pharmacokinectics
56
Hemodynamic response results of interactions with aging ______ and \_\_\_\_\_\_\_\_\_.
**Hemodynamic response** results of interactions with **aging heart and vasculature.**
57
Compensatory or reflex responses are blunted or absent T/F?
**Compensatory or reflex responses** are **blunted or absent T/**F?
58
Mac is decreased approx \_\_% per \_\_\_\_\_\_.
**MAC dec 6% per decade**
59
Altered activity of neuronal ion channels are associated with what receptors.
Nicotinic
ACh
GABA
Glutamate
60
Thiopental changes seen
**No change** **in brain sensitivity** with
61
Most common 3 system complications
neuro
pulm
cardiac
62
Relative risk for 90 day mortality for any ADL and IADL impairment (instrumental ADL)
ADL - RR 1.9
IADL - RR 2.4
63
ADLs - 5 of them
bathing
dressing
toileting
transferring
eating
64
Instrumental ADLs - 7 of these
telephone
use public transportation
use shopping
meal prep
housekeeping
taking meds
properly managing finances
65
Multisystem loss of physiologic reserve; vulnerable to disability after stress
**Frailty**
prognostic factor for poor outcomes
66
Components of **Frailty**
mobility
muscle weakness
poor exercise tolerance
unstable balance
body composition factors
(weight loss, malnutrition, & muscle wasting)
**Chronic inflammation & endocrine dysregulation "key drivers"**
67
**5 Criteria** used to define
**Frailty**
(Which is a prognostic factor for poor outcomes - thought I'd throw that in there)
Weight loss
Exhaustion
Physical activity
Walk time
Grip strength
68
Quesioning weight loss criterion.
“In the last year, have you lost more than 10 lb unintentionally (i.e., not as a result of dieting or exercise)?” Patients answering “Yes” are categorized as frail by the weight loss criterion.
69
Questioning exhaustion criterion
The patient is read the following two statements: (1) I felt that everything I did was an effort; (2) I could not get going. The question is asked, “How often in the last week did you feel this way?” The patient’s response is rated as follows: 0 = rarely or none of the time (\<1 day); 1 = some or little of the time (1 to 2 days); 2 = a moderate amount of the time (3 to 4 days); or 3 = most of the time. Patients **answering “2” or “3” are categorized as frail by the exhaustion criterion.**
70
Questioning about Physical activity criterion
The patient is asked about **weekly** physical activity.
Patients with low physical activity are categorized as frail by the physical activity criterion.
71
Questions about walk time criterion
The patient is **asked to walk a short distance and** **timed****.**
Patients who are **slow walkers are categorized as frail by the walk time criterion.**
72
Questioning about strength criterion
The patient’s **grip strength is measured**.
Patients with **decreased grip strength are categorized as frail by the grip strength criterion.**
73
Atypical Presentation of Disease
Primarily linked to presence of
**Dementia**
**NOT** a characteristic feature of aging process
74
(Topic: malnutrition, immobility and dehydration)
Which is associated with
↑ morbidity, mortality & length of stay
Malnourishment
75
(Topic: malnutrition, immobility and dehydration)
Which is associated with loss of skeletal muscle, ventricular atrophy, hypovolemia, & orthostatic intolerance
Bedrest
76
(Topic: malnutrition, immobility and dehydration)
Which is associated with hypernatremia & infection
Dehydration
77
Leading cause of unintential falls
Trauma
Primary goal: prevention
Anticoags: highest mortality in head injury
78
(Chronic pain) Most prevalent indication for analgesics
Arthritis
79
Consequence of persistent pain:
depression
sleep disturbance
impaired ambulation
80
Fill in blank
81
Fill in blank
82
No evidence that use of either regional vs general anesthesia can alter 30 day mortality in elderly T/F
True
No alateration in 30 day mortality in studies
83
Specific benefits of regional anesthesia
1) prevent postop inhibition of fibrinolysis
2) ↓ blood loss in pelvic & lower extremity surgery
3) no instrumentation of airway → patients maintain their own airway & level of pulmonary function
4) opiate-sparing effects
5) improved postop pain control
84
Regional anesthesia use
Ortho
prostate
gynecologic
LE vascular
85
Placement of needle for epidural or spinal block may be difficult
1. Calcification of interspinous ligament & ligamentum flavum
2. Narrowing of intervertebral foramina
3. Reduction in flexibility → difficulty positioning
86
Spread of LA in epidural space is exaggerated T/F
True
goes to **higher** **level**
87
Spead in spinal is narrow
False
Wide
Should decrease dose in spinals
88
Most common hemodynamic event in **regional anesthesia.**
**Hypotension**
Exaggerated in pts with HTN
Pretx with crystalloid **NOT** consistent in prevention
89
Hypotension is most likely due to
Vasodilation
Sympathetic Blockade
Decreased SVR
Decreased CVP
Redistribution of blood volume to the extremities from central splanchnic & mesenteric vascular bed.
90
Hypotension is of particular concern in very elderly patients with limited _____ \_\_\_\_\_\_\_\_, and may be exaggerated in patients with baseline hypertension.
**Hypotension is of particular concern** in very elderly patients **with** **limited cardiac** **reserve**, and may be exaggerated in patients with baseline hypertension.
Pretreatment with crystalloid does not consistently offset the hypotension following a spinal block
91
This assessment associated with masking more difficult; laryngoscopy easier
Edentulous
92
Hx of this may limit head & neck manipulation with DL (think basic)
Arthritis
93
This disease may predispose to **cerebral ischemia** during neck manipulation
Vertebrobasilar disease
(can't be rough on trying to get the axis all line up - cerebral ischemia!!)
94
Used to treat exaggerated response to laryngoscopy?
Lidocaine 50 mg IV or short-acting beta-blocker may attenuate
95
Risk of pulmonary aspiration is due to
Decreased pharyngeal responses
96
Prolonged periods of intraop hypotension → ↑ in postop morbidit maintain BP within \_\_\_% of baseline
Prolonged periods of intraop hypotension → ↑ in postop morbidit **maintain BP within 10% of baseline**
97
Propofol implications
1. hemodynamic effects can be greatly exaggerated in elderly
2. ↓ initial dose & time interval between repeated doses
3. Rapid recovery with minimal delayed cognitive effects
4. ↑ brain sensitivity
98
Etomidate implications
* 30-60% of patients develop myoclonus
* Minimal cardiovascular effects
* Excellent for emergencies
* **Volume of distribution ↓ - 50%** **↓ in dose recommended**
99
The hemodynamic effects of propofol can be greatly exaggerated in elderly patients, especially if their intravascular volumes are depleted possibly leading to significant cardiac or cerebral ischemia. Propofol infusion probably provides a more stable hemodynamic course.
no thinking required here just enjoy the paragraph
The hemodynamic effects of propofol can be greatly exaggerated in elderly patients, especially if their intravascular volumes are depleted possibly leading to significant cardiac or cerebral ischemia. Propofol infusion probably provides a more stable hemodynamic course.
100
Etomidate, carboxylated imidazole ring, produces some ________ effects leading to development of myoclonus, in about 30-60% of patients
**Etomidate, carboxylated imidazole ring**, produces some **disinhibitory effects** leading to development of myoclonus, in about 30-60% of patients
101
What do you know about Midazolam for elderly?
* **short** duration, **absence** **of active metabolites** & CV effects
* Pharmacokinetic changes prolong elimination, but **↑ sensitivity** due to pharmacodynamic change in benzodiazepine GABA receptor
* **↓dose 50-75%**; **repeat doses 0.5 mg or less**
* Susceptible to **midazolam-induced apnea**
* Unwanted effects **reversed with flumazenil**
* **Long-acting benzodiazepines** associated with **delirium** in elderly due to **prolonged clearance & active metabolites**
102
Inhaled anesthetics implications
* MAC **↓ 6% every decade after age 20 years**
* MAC **at 90 yo ↓ by 30% compared to 40 yo**
* Due to cerebral atrophy & alterations in neurotransmitter balance
103
Aging does ↑ sensitivity to muscle relaxants at NMJ
T/F
False
Aging does **not** ↑ sensitivity to muscle relaxants at NMJ
104
Muscle relaxant implications
* Other age-related changes may **↑ sensitivity or ↓ elimination** (Thurman said in her experience, MR do not last as long actually)
* **Avoid pancuronium** because **85% eliminated by kidneys**
* Vecuronium & rocuronium less dependent on renal excretion, yet **elim** **t 1/2 is** **proloned**
* Cisatracurium/atracurium not impacted by hepatic/renal function
105
Opioid pharmacodynamic changes account for ↑ sensitivity of brain T/F
True
1. **Sufentanil, alfentanil, fentanyl**, **remi** **2 x as potent** in older adult
2. ↑ in brain sensitivity **(not altered pharmacokinetics)**
3. ↑ brain sensitivity **(½ bolus dose)**
4. Vol of central compartment, Vl & clearance **↓ (1/3 infusion rate)**
106
General opioid implications
1. Pharmacodynamic changes account for **↑ sensitivity of brain**
2. Pharmacokinetics changes on elimination/distribution **less** significant
3. **↓ dose by 50%**
4. Variability of response common among elderly; **titrate to effect**
107
Fentanyl implications
Short-acting lipid-soluble
large VD
↓ dose by 50%
108
Remi implications
1. ultrashort-acting **Mu receptor agonist**
2. Metabolized by **plasma esterases**
3. Bolus & infusion dose reduced & tritrated
109
Morphine implications
1. ↓ VD
2. metabolites morphine **3-glucuronide** & morphine 6-glucuronide eliminated by **kidneys** →potential **accumulation**
110
Meperidine implications
**Not recommended**
*except* for **shivering** with **smaller doses**
**12.5-25 mg**
can cause **delirium**
111
MAC Concept: ______ dose or infusion but _____ interval
MAC Concept: **reduce** dose or infusion but **increase** interval
112
Monitored anesthesia care
Patients are susceptible to what 2 things per Thurman's slides
Monitored anesthesia care
Patients are susceptible to hypoventilation & apnea
113
Tx/Drugs to use for MAC
1. Supplemental O2 & monitoring of ETCO2 recommended
2. Drugs used include benzodiazepines **(midazolam), fentanyl, remifentanil**
3. I include propofol
4. **Ketamine** 10-30 mg IV useful
5. **Dexmedetomidine** (centrally acting α2-agonist) – no adverse respiratory effects; provides analgesia & sedation
6. Side effects of Dex: prolonged sedation, bradycardia, hypotension
114
How to dilute precedex
**Precedex**
Dilute with **sterile saline** to a concentration of
**4 mcg/mL**
(**2 ml of** **precedex** **added to** **48 mL** of saline)
115
**Precedex dosing**
loading
mainenance infusion
adjustment for elderly
**Precedex dose:**
1. 1 mcg/kg IV over 10 minutes for loading dose
2. maintenance infusion of 0.2-0.7 mcg/kg/hr up to 24 hours.
3. Rate of maintenance is titrated to desired level of sedation.
4. Decrease dose for elderly.
116
Look at this
117
Review
118
Review
**The few with No increased brain sensitivity, BUT have dec initial Vd**
Etomidate
Thiopental
**N/A for brain sensitivity**
Panc
Cisatra
Atra
**Few without any decreased clearance issues**
inhaled
sufe
alfe
fenta
atra
cisatra
119
Drugs with decreased clearance in elderly
etomidate
prop
midazolam
morphine
remi
panc
120
Postop mgmt/considerations: what are some key points?
1. **Pulmonary problems** of particular importance
2. **Most important** patient-related factors are **age, ASA status**
3. Greater incidence of postop desaturation
4. **Higher risk for aspiration** due to progressive ↓ **laryngopharyngeal sensory discrimination** & associated **dysfunctional swallowin**g
5. **Urinary retention** more common in older adults
121
**Treatment of Acute Postoperative Pain**
1. Age-related ↓ pain perception (↓ nerve conductivity & receptors)
2. **Postop pain** **asso** **with what 4 things?**
3. Cognitively intact – recommend PCA
4. Cognitively impaired report less pain
**Treatment of Acute Postoperative Pain**
1. Age-related ↓ pain perception (↓ nerve conductivity & receptors)
2. Postop pain asso with **↑ length of stay, ↑ morbidity, pulmonary complications, & delirium**
3. Cognitively intact – recommend PCA
4. Cognitively impaired report less pain
122
**3 Principles** for Tx of acute post op pain:
**3 Principles** for Tx of acute post op pain:
1) mult modalities (acetaminophen, gabapentin)
2) use site-specific analgesia – regional blocks
3) caution with NSAIDS - risk for renal failure & GIB
123
Iatrogenic complications
**Iatrogenic complications**
Adverse **d**rug events
**d**ehydration
**d**elirium
functional **d**ecline
124
**Outcomes**
Goal of surgical intervention to preserve or improve activity & _________ while avoiding \_\_\_\_\_\_\_.
Functional recovery may be challenging & require time
**Outcomes**
Goal of surgical intervention to **preserve or** **improve activity & independence** while avoiding **disability**
Functional recovery may be challenging & require time
125
Age has no effect on duration of motor blockade with bupivacaine T/F
Age has no effect on duration of motor blockade with bupivacaine **T**/F
126
**Neuraxial Anesthesia & Peripheral Nerve Blocks**
1. Age has ____ effect on duration of motor blockade with bupivacaine
2. Time of onset _increased/decreased._
3. Spread is more _diminished/extensive_ with hyperbaric bupivacaine
4. Effect on duration of epidural with bupivacaine not known
5. Ropivacaine \_\_\_\_% for PNB: ____ a major factor in determining duration of motor & sensory block
**Neuraxial Anesthesia & Peripheral Nerve Blocks**
1. Age has **no** effect on duration of motor blockade with bupivacaine
2. Time of onset **↓**
3. **Spread is more extensive** with **hyperbaric bupivacaine**
4. Effect on duration of epidural with bupivacaine not known
5. **Ropivacaine 0.75% for PNB**: **age** a major factor in determining duration of motor & sensory block
127
**Consider shorter acting anesthetics**
1. Shorter-acting opioid, such as \_\_\_\_\_\_.
2. Shorter- acting muscle relaxants
3. No significant difference in recovery profile of cognitive function with ______ \_\_\_\_\_\_.
4. ______ inhalation agent is associated with the most rapid emergence
**Consider shorter acting anesthetics**
1. Shorter-acting opioid, such as **remifentanil**
2. Shorter- acting muscle relaxants
3. No significant difference in recovery profile of cognitive function with inhaled anesthetics
4. **Desflurane** associated with the most rapid emergence
128
Most 5 important risk factors for periop complications (elderly)
1. Age
2. Physiologic status
3. Coexisting disease (ASA)
4. Elective or urgent surgery
5. Type of procedure
129
Chronologic age is _less/more_ important than sum of cormorbidities
Chronologic age is \< important than sum of cormorbidities
130
Independent predictor of adverse events
**Emergency**
| (poor preop and prep)
131
NH considers elderly age at
65 or older
132
**POCD**
1. **characterized by:**
2. **Onset:**
3. **Dx:**
4. **Pathogenesis**:
**POCD**
1. **characterized by:** cognitive imprairments
2. **Onset:** subtle & may not present for weeks to months postop
3. **Dx:** no universal criteria
4. **Pathogenesis**: multifactorial
133
Incidence of POCD is similar with regional vs general.
T/F
True dat
