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Principles of Anesthesia II - Fall 2024 > Anesthesia Implications for Geriatrics - Exam 2 > Flashcards

Anesthesia Implications for Geriatrics - Exam 2 Flashcards

1
Q

Nervous System

Memory decline is r/t ________, ________, and the aging brain.

A
  • dementia
  • alzheimer’s
    elderly more active & read = less cog. decline
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2
Q

Nervous System

What are the 3 neuro structural changes in the elderly?

A
  1. Cerebral atrophy
  2. decreased gray matter (neuronal shrinkage)
  3. decreased white matter (increase ventricle size)

progressive loss of memory, imbalance, mobility

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3
Q

Nervous System

What are 4 reasons why elderly need less doses of LA in neuraxial?

A
  1. decreased epidural space
  2. increased permeability of dura
  3. decreased CSF volume
  4. decreased diameter/# of myelinated fibers in dorsal & ventral nerve roots
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4
Q

Nervous System

Peripheral nervous system
________ - ________ cell distance is decreased.

Why is conduction velocity decreased?

What does this make elderly more sensitive to?

A
  • inter-schwann cell
  • decreased myelination across nerve fibers
  • Neuraxial & PNB
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5
Q

Cardiac

What 2 types of cells decrease in #?

A
  1. Myocytes
  2. SA node cells - susceptible to tachy & brady
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6
Q

Cardiac

Why do the elderly have LV wall thickness?

A
  • increased afterload from years of HTN
    more pressure the heart has to pump against = L heart strain
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7
Q

Cardiac

What happens to SVR and vascular compliance w/ aging?

A
  • increased SVR (afterload)
  • decreased vascular compliance
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8
Q

Cardiac

What happens w/ the aortic valve and aging?

A
  • becomes thick & calcified = aortic stenosis
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9
Q

Cardiac

What does LV hypertrophy cause contractility to do? (increase/decrease)

What does the increased LV stiffness lead to?

A
  • contractility decreases
  • higher LV filling pressures (LVEDP) ventricle does not stretch w/ more volume
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10
Q

Cardiac

What happens w/ beta-adrenergic sensitivity and the elderly?

A
  • pts have a decreased response to beta stimulation
  • they can’t increase HR and EF in stress
  • more prone to decompensation - neuraxial esp.
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11
Q

Cardiac

Why do the elderly have increased vascular stiffness?

A
  • b/c of breakdown of collagen & elastin
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12
Q

Cardiac

What does a reduction in the levels of endogenous NO lead to?

A
  • less NO related vasodilation
  • coronaries can’t dilate optimally in times of stress
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13
Q

Cardiac

Increased vasc. stiffness leads to an early ________ ____ ________.

What does this mean?

A
  • pressure wave deflection
  • pressure travels through stiff vessels faster - returns to heart in systole instead of diastole
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14
Q

Cardiac

What effects does an early pressure wave deflection have on afterload and diastolic function?

A
  • increased afterload
  • less diastolic blood flow - less support for DBP - less coronary perfusion
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15
Q

Pulmonary

What are the 3 main structural changes that happen w/ aging?

A
  1. loss of elastic recoil & surfactant
  2. enlarged bronchioles and alveolar ducts
  3. loss of vertebral height, calcification of vertebrae and intercostal cartilage
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16
Q

Pulmonary

The loss of elastic recoil causes lung compliance to do what?

A
  • increase
  • easier to get air in lungs/harder to get air out b/c collapse of small airways
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17
Q

Pulmonary

Enlarged bronchioles and alveolar ducts happen as a result of what?

This leads to an increased ________ ________, and impaired ____ ________.

A
  • early collapse of small airways in exhalation
  • increased closing capacity
  • impaired gas exchange

increased physiological DS (alveolar)

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18
Q

Pulmonary

What changes does loss of vertebral height & calcification of vetebrae/intercostal cartilage cause?

A
  • barrel chest
  • diaphragm flattening
  • CW stiffness
  • SOB on exertion
  • increased WOB
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19
Q

Pulmonary

What are the 5 main functional changes that happen w/ the pulmonary system and aging?

A
  1. decreased VC
  2. increased CC
  3. increased RV
  4. decreased muscle mass
  5. weaker pharyngeal muscles
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20
Q

Pulmonary

VC =

A

IRV + Vt + ERV

amount of air that can be moved in and out of the lungs

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21
Q

Pulmonary

CC =

What happens w/ FEV1 in response to decreased muscle mass & increased closing capacity?

A

CC = CV + RV
* the point at which the small airways close
* FEV1 decreases 6-8% per decade

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22
Q

Pulmonary

What happens w/ TLC?

A
  • stays the same d/t compensation over time
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23
Q

Pulmonary

What does weaker pharyngeal muscles cause w/ aging?

A
  1. decreased clearance of secretions
  2. less efficient coughing
  3. aspiration risk d/t decreased esophageal motility
  4. less protective upper airway reflexes
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24
Q

Pulmonary

What causes a VQ mismatch w/ aging?

A
  • FRC increases, BUT CC increases more
  • airways can close in normal Vt
  • shunt increases = less arterial oxygenation
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25
Q

Renal

How much does GFR decrease by?

What conditions exacerbate a decline in renal function?

A
  • GFR decreases by 1mL/min/m2/yr or 10mL/min/m2/decade after 30y/o
  • DM, HTN, drugs, IVP contrast, dehydration
26
Q

Renal

Elderly pts have a decreased response to what 3 hormones?

A
  1. aldosterone = hyponatremia
  2. vasopressin (ADH) increased = dilutional hyponatremia
  3. renin

trouble balancing F/E

27
Q

GI & Hepatic

What phase of liver drug metabolism is affected more by aging?

A
  • phase 1 (oxidation, reduction, hydrolysis) - CYP450
  • phase II - not affected (acetylation, conjugation)
28
Q

GI & Hepatic

What drugs that we commonly give are metabolized w/ phase I?

A
  • narcotics & anesthetics
  • prolonged effects in elderly
29
Q

GI & Hepatic

Do elderly have less or more PONV?

What drugs should we avoid?

A
  • less
  • avoid Prochlorperazine (Compazine), Phenergan, Reglan b/c SE
30
Q

Musculoskeletal

What are the 4 main changes that happen w/ the MS system and aging?

A
  1. muscle mass & strength decline
  2. subQ fat thins - less ability to thermoregulate
  3. impaired wound healing
  4. OA
31
Q

Thermoregulation

Why are the elderly more prone to hypothermia?

A
  • Vasoconstriction threshold lowers
  • they won’t vasoconstrict until they get to a lower temp
  • 1 degree C less for adults 60-80
32
Q

What 3 things can we do to optimize surgical healing in elderly?

A
  1. ensure adequate hydration
  2. maintain normothermia
  3. ensure good tissue oxygenation
33
Q

What are the significant predictors of 6 month - 1 yr mortality in elderly?

A
  1. impaired cognition
  2. recent fall
  3. hypoalbuminemia - compromised healing
  4. anemia - tissue oxygenation
  5. functional dep. to do ADLs
  6. comorbidities
34
Q

Neurotoxicity

What are the 4 substances involved in the pathogenesis of dementia?

A
  1. amyloid B
  2. Tau
  3. Calcium
  4. Neuroinflammation (TNF, IL)
35
Q

Neurotoxicity

What is amyloid B?

What is its relationship w/ neurotoxicity/dementia?

A
  • protein fragment - develops when synapse breaks down
  • accumulates extracellularly in amyloid plaques
  • may disrupt cell membranes
  • does not build up permanently
36
Q

Neurotoxicity

How is amyloid B neurotoxic?

A
  • interferes w/ synaptic fx
  • impairs neurotransmission
  • cog decline
37
Q

Neurotoxicity

What is Tau?

A
  • protein that normally stabilizes microtubules (neurons)
38
Q

Neurotoxicity

How does Tau contribute to neurotoxicity/dementia?

A
  • it is hyperphosphorylated and aggreated into Tau chunks
  • disrupts the internal structure of neurons - cell death
39
Q

Neurotoxicity

What is the relationship b/w temp and Tau?

A
  • decrease in temp 2-3 deg. C = increased Tau
  • Tau is not cleared w/ severe hypothermia
40
Q

Neurotoxicity

What are the anesthesia precautions w/ Tau?

A
  • repeated exposure to Halothane, Iso, & Sevo = increased phosphorylation of Tau
41
Q

Neurotoxicity

How does Calcium release cause neurotoxicity?

A
  • exaggerated release (ryanodine or IP3 receptors)
  • MH - genetic predisposition w/ volatiles or succ
  • causes - mitochondrial damage, cell death, neuronal dysfunction & death
42
Q

Neurotoxicity

How does neuroinflammation contribute to cog. decline?

A
  • release of inflammatory factors
  • cytokines
  • IL-6
  • TNfa
43
Q

Neurotoxicity

What are possible drugs for anti-inflammatory prophylaxis?

A
  • dexamethasone
  • lidocaine
  • toradol
44
Q

Anesthesia & Brain

What anesthetic agents are most associated w/ cog decline?

A
  • Iso > Des > Prop

TIVA maintenance of choice

45
Q

Risk Factors for the development of POCD: (6)

A
  1. increasing age
  2. duration of anesthesia
  3. lower SES
  4. 2nd surgery
  5. post op infection
  6. resp. complications
46
Q

What are 7 anesthetic implications we can do for the elderly?

A
  1. neuraxial/regional anesthesia
  2. avoid long-acting NMBD & reverse adequately
  3. opioid sparing strategies
  4. Neutralize stomach acid w/ non-particulates (Bicitra)
  5. EEG based titration
  6. avoid HoTN - can’t compensate
  7. pad skin & nerves
47
Q

Drug Challenges

What are the drug challenges r/t decreased CO?

A
  • slower distribution to site of action
  • slower redistribution
  • slower distribution to metabolic organs

slower onset & clearance

less redose of meds needed

48
Q

Drug Challenges

What are the 4 drug challenges r/t the NMJ?

A
  1. increased distance b/w axon & motor end plate
  2. decreased concentration of Ach
  3. decreased amount of Ach in presynaptic vesicle
  4. decreased release of Ach

less efficient NMJ - less NMBD required

49
Q

Drug Challenges

What happens to drugs that depend on kidney/liver metabolism?

A
  • prolonged effect & DOA
  • decreased re-dose needed in maintenance
  • delayed recovery for non-depolarizers
50
Q

What is the pre-op assessment for thoracic non-cardiac surgery?

A
  1. TTE - r/o pulm. HTN
  2. poor exercise tolerance, DM, CAD, or CHF
  3. perfusion imaging w/ dobutamine stress test or persantine thallium scan
  4. coronary angio
  5. surgical revascularization
  6. case by case management

if no to any of the above = candidate for lung resection surgery

51
Q

What is the formula for ppoFEV1?

A

ppoFEV1 = pre-op FEV1% x (1- % lung tissue removed/100)

52
Q

What do we want a ppoFEV1 to be before we extubate our pts?

A

at least 40%

53
Q

What 3 things are a part of the “three-legged” stool of pre-thoracotomy resp. assessment?

A
  1. Respiratory mechanics
  2. cardiopulmonary reserve
  3. lung parenchymal function
54
Q

Pre-thoracotomy resp. assessment

How do we assess Resp. Mechanics?

A
  1. FEV1 ppo >40%
  2. MVV
  3. RV/TLC
  4. FVC
55
Q

Pre-thoracotomy resp. assessment

How do we assess cardiopulm. reserve?

A
  1. VO2 max (>15mL/kg/min)
  2. stair climb > 2 flights
  3. 6 min walk
  4. exercise SpO2 <4%
56
Q

pre-thoracotomy resp. assessment

How do we assess lung parenchymal function?

A
  1. DLCO (ppo > 40%)
  2. PaO2 > 60
  3. PaCO2 < 45
57
Q

Post-thoracotomy anesthetic management

What do we do if ppoFEV1 is > 40%?

A

extubate in operating room if:
* pt is AWaC
* (alert, warm, and comfortable)

58
Q

Post-thoracotomy anesthetic managment

What do we do if the ppoFEV1 is 30-40%?

A

consider extubation based on:
* exercise tolerance
* DLCO >40%
* V/Q scan
* associated diseases

59
Q

Post-thoracotomy anesthetic management

What do we do when the ppoFEV1 is < 30%?

A
  • Staged weaning from mechanical ventilation
  • consider extubation if > 20% plus: thoracic epidural analgesia
60
Q

How many subsegments are in the R lung?

A

RUL: 6
RML: 4
RLL: 12

61
Q

How many subsegments are in the L lung?

A

LUL: 10
LLL: 10

Principles of Anesthesia II - Fall 2024 (10 decks)

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