Elderly - Renal/Hepatic/Pharm Flashcards
Elyte Changes:
•Impaired ability to _____ and ____ urine
•Responsiveness to ADH •Conservation of sodium
•Aldosterone •Potassium level
- concentrate and dilute
Note: elderly have decrease ability to absorb Na and H2O - DECREASED response to aldosterone
Hepatic System
•Liver size-mass ____ by ____ by age of 80
•Hepatic blood flow-proportionally ____
-loss of perfused hepatic mass largely explains the decreased rates of _________ and prolonged clinical effects of ______
- decreases by 40%
- reduced
- plasma clearance
- narcotics
Hepatic System
•Liver function
–Plasma cholinesterase-more decrease in ___ than ____
–Age related difference in binding of drugs to protein do not alter _______ significantly
- men THAN women (consider sux)
* pharmacokinetics
Hematologic System
•Immune system response decreased ______ activity
•decreased _______
•decreased response to allergens and impaired _______
•_____ is 2nd only to respiratory failure as cause of M/M in elderly trauma patients
- decrease B and T lymphocyte
- immunoglobin E
- impaired hypersensitivity
- sepsis
Endocrine System
•Diabetes
–Increased incidence of _____
•Thyroid function (impaired esp in _____)
- insulin resistance
* women
GI System
•Gastric emptying- _______ gastric emptying time
•______ in gastric pH
•Prone for aspiration due to decrease in ______
- prolonged
- increased
- laryngeal reflexes
Perioperative Risk
•Major M/M
•Major risk factors for increased _______
•Concomitant diseases such as ____, ___, ___, osteoarthritis
- mortality rate
* DM, HTN, RA
Pharmacology
•Factors: Plasma binding
•Albumin and α1- acid glycoprotein
•_____ production of albumin which binds _____ drugs (i.e. _____, benzo, ____)
•A1 glycoprotein actually ________ with age (binding of ____ drugs i.e. ____)
- Decreased, acidic drugs, (barbs, opioids)
* Increases, basic drugs (LAs)
Pharmacology
•Body content- ____ therefore increased Vd of ___ soluble drugs
•Decreased Vd of _______ drugs
•Will need to _____ dosing of barbs, opiods, benzo
- increased body fat, lipid soluble
- water soluble
- decrease
Pharmacology
•Drug metabolism-remember decreased _____ and _____
•UNCHANGED in elderly- ____, _____, red cell mass, and response to _______
- renal and hepatic flow
* ECF, plasma volume, muscle relaxants
Pharmacologic agents
•Induction agents
•Thiopental- typically require less than _____ versus 20 y.o most likely due to slower _____, - prolonged _______
- 1/2 dose
- redistribution
- plasma concentration
Pharmacologic agents
•Induction agents
•Etomidate-decrease dose due to decreased ______ and initial ________- remember if pt is severely compromised (I.e. hypovolemic) probably will still see ______ after induction
- clearance, volume of distribution
* unstable hemodynamics
Pharmacologic agents
•Induction agents
•Propofol- go slow typically requires less than _____ dose – increased ______ and decreased ____
- 1/2 normal induction
- increased brain senstivity
- decreased clearance
Pharmacologic Agents
•Opiods-pharmacokinetics smaller initial ______ /delayed intercompartmental ______.
•_____ elimination 1/2 life
•Pharmacodynamics-increased ______
- Vd
- transfer of drug
- prolonged
- brain sensitivity
Benzodiazepines
______ - not a good choice, accumulation in _____,volume of distribution is ____, elimination slowed 1/2 life is more than ___ hrs can be confused for days.
- Diazepam
- fat stores
- larger
- 36
Benzodiazepines
Midazolam-b/c lipid soluble at ________, undergoes similar pharmacokinetic changes
- ______ increases pharmacodynamic sensitivity to midazolam independent of pharmacokinetics.
- physiologic pH
* aging
Benzodiazepines
Lorazepam- less ____ , elimination 1/2 life remains relatively ____
- lipid soluble
* unchanged
Neuromuscular blockers
Effective doses of sux and NDMR virtually _____
•_____ = 2 fold prolongation in onset of neuromuscular blockade
•recovery from NDMR-dependent on ____ is _____
•decreased hepatic flow d/t decreased mass- _____ clearance of ____ and ____
•elderly ___ may have prolonged effect for sux due to decreased ___
- unchanged
- decreased CO
- renal, prolonged
- decreased, roc and vec
- men, plasma cholinesterases
Inhalational Agents
•____ MAC requirements ( __% per decade after age of 40)
• ______ effect more pronounced and attenuated tachycardia for _____ and isoflurane
•Isoflurane ______ in elderly more than younger population
- decreased, 6%
- myocardial depression, desflurane
- decrease CO
Local Anesthetics
•Aging - _____ for all sensory modalities (touch, temp, proprioception, hearing, vision, pain)
•Be careful-regional has a more extensive ____, time of onset is ____
•Typically need to ____ LA doses in this population
•Increased ____ d/t decreased _____ of local anesthetics-esp. important if using an infusion technique or top off doses
- increased threshold
- cephalad spread, decreased
- decrease
- DOA, clearance
ANESTHETIC MANAGEMENT
•Consider effect of age on anesthetic requirement
–Sensitivity to ____, _____, _____
–IV induction and opioid doses
–Which opioid and NMBA best for prompt recovery
–Dosing of epidural –Muscle relaxant dose –Relaxant reversal dose
- fentanyl, alfentanil, midazolam
ANESTHETIC MANAGEMENT •Peripheral ischemic injury •Airway reflexes - decreasd •Body temperature - poor regulation •Supplemental \_\_\_\_\_\_
- oxygen
Note: be careful with positioning of elderly, careful with skin and bony prominences
POSTOPERATIVE CARE •\_\_\_\_\_ implications •Prolonged anesthetic effects on \_\_\_\_ •Hospitalization •\_\_\_ management
- pulmonary
- mentation
- pain
PSYCHOSOCIAL ISSUES •Consider \_\_\_\_ –Increase risk of postop \_\_\_\_ •Emotional and psychological abnormalities more common •DNR status and modifications
- depression
* M&M
SUMMARY
•____ at greater risk of M&M
•Adequate diagnosis and treatment of disease and meticulous attention to detail
•Adequate pre-op prep, positioning and monitoring VITAL
•Stay out of harm’s way!
- elderly
Elderly Population - Renal Status
•_____ renal blood flow and decreased _____
•Pre-existing renal function- renal fx decline with age; decrease capacity to respond to changes in ____/____ balance
•Predisposed to hypo/_______
- decreased; renal mass
- water/electrolyte
- hyperkalemia
