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Mar: Sem 4 - Principles II > Exam 2: Old peeps > Flashcards

Exam 2: Old peeps Flashcards

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1
Q

What is Aging?

A

Universal and progressive physiologic process
* Decreasing end-organ reserve
* Decreased functional capacity
* Increased homeostatic imbalance
* Increasing incidence of pathophysiologic processes

S3

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2
Q

Nervous system and aging

Memory decline is related to inability to complete ____.

A

ADL’s
*40% of people > 60 y/o
Not inevitable

S5

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3
Q

Nervous system and aging

Changes in the nervous system associated with aging include what three things?

A
  • Cerebral Atrophy
  • ↓ Gray matter (neuronal shrinkage - there’s only a small amount of loss)
  • ↓ White matter (increase in ventricular size on kahoot, and progressive loss of memory, balance and mobility)

S6

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4
Q

Brain ventricle size will ____ with age.

A

increase

S6

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5
Q

Nervous system and aging

Which of the following neurotransmitters show a decrease associated with aging?

Dopamine
ACh
NE
Serotonin
Glutamate

A

Dopamine
ACh
NE
Serotonin
Glutamate is unchanged

S7

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6
Q

Coupling of CMRO₂, CBF, and EEG is increased or decreased due to aging?

A

Trick question. CMRO₂ and CBF, decrease in a parallel fashion therefore the EEG remains unchanged secondary to aging.

S7

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7
Q

Neuraxial changes

Is epidural space increased or decreased due to aging?

A

Decreased

S8

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8
Q

Neuraxial changes

What occurs with dura permeability secondary to aging?

A

Dura permeability increases. therefore less of a dose to get to therapeutic level

S8

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9
Q

Neuraxial changes

What occurs with CSF volume secondary to aging?

A

Volume of CSF decreases. less dilution of agent

S8

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10
Q

neuraxial changes

What two changes are seen in myelinated fibers of dorsal and ventral nerve roots secondary to aging?

A

↓ diameter of roots
↓ number of roots
this increases susceptibility of block

S8

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11
Q

Elderly patients are more/less sensitive to neuraxial and peripheral nerve blocks?

A

more sensitive

S9

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12
Q

Peripheral

Decreases in what two characteristics of the peripheral nervous system are noted secondary to aging?

A
  • Inter-Schwann cell distance
  • Conduction velocity

S9

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13
Q

thump-thump

What cardiac changes are noted due to aging?

A
  • ↓ myocyte number
  • ↓ SA node cells (tachy or brady syndromes)
  • ↓ conduction velocity
  • Thickened LV & aortic valve
  • ↓ contractility
  • ↓ β-adrenergic sensitivity
  • ventricular stiffness which leads to higher filling pressures

S10-11

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14
Q

thump-thump

What happens to vasculature as we age? Why?

A

Vessels become more stiff

  • ↓ collagen & elastin
  • ↓ Nitric Oxide vasodilation
  • early wave deflection - increased afterload, diastolic dysfunction

s12

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15
Q

The tennis court

What two physiologic factors are decreased in the lungs as we age?

A
  • ↓ Elastic recoil
  • ↓ Surfactant

S13

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16
Q

Tennis court

What anatomic structures of the lungs become enlarged as we age? What is the result?

A

Bronchioles and alveolar ducts become enlarged leading to early collapse of small airways during exhalation.

  • ↑ anatomic dead space
  • ↑ closing capacity
  • impaired gas exchange

S13

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17
Q

tennis court

Loss of vertebral height and calcification of vertebrae lead to what three respiratory system consequences?

A
  • Barrel chest
  • Diaphragmatic flattening
  • Chest wall stiffening (increased WOB)

S14

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18
Q

tennis courts

Will the following see an increase or a decrease due to aging-related lung changes?

  • Vital Capacity
  • Closing Capacity
  • Residual Volume
  • Total Lung Capacity
A
  • ↓ VC
  • ↑ CC
  • ↑ RV
  • TLC about the same

S15

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19
Q

tennis courts

Decreased muscle mass and increased closing capacity will make FEV₁ decrease by ____% per decade.

A

6-8%

S16

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20
Q

tennis courts

What are the results of weaker pharyngeal muscles from aging-related changes?

A
  • ↓ secretion clearance
  • ↓ esophageal motility (aspiration risk)
  • ↓ protective upper airway reflexes
  • Inefficient coughing (suction aggressively)

S16

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21
Q

tennis courts

Whats the most important mechanism of action for aging-related A-a gradient changes? (V/Q)

A

FRC & CC mismatch increasing

Increasing shunt w/ decreasing arterial oxygenation.

S17

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22
Q

The beans

What renal consequences are there to aging?

A
  • ↓ GFR (comorbidities may exacerbate)
  • ↑ Urinary retention
  • ↑ UTI’s
  • Blunted response to aldosterone, vasopressin & renin (trouble adjusting to fluid and e-lytes)

S18

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23
Q

GFR drops about ____ per decade over 50 yo

A

10 mL/min

lecture Dr M

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24
Q

Butts and guts

Which phase of liver metabolism is more affected by aging?

A

Phase I more impaired: oxidation, reduction, hydroysis via CYP450)
Phase II ok: acetylation and conjugation

S19

I guess I remember these words

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25
Q

butts and guts

What are the components of Phase I liver metabolism?

A
  • Oxidation-Reduction
  • CYP450 Hydrolysis

meds that are metabolized through phase 1 have the most compromise anesthesia and narcotics will have a prolonged affect

S19

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26
Q

butts and guts

What is the mechanism for increased PONV in the elderly?

A

Trick question. Less PONV in the elderly.

Avoid Prochlorperazine, promethazine, & metoclopramide.
zofran is your BFF for the oldies

S19

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27
Q

dem bones

With aging, muscle mass and strength will ____ while subcutaneous fat will ____. With the msk system we also see ____ wound healing and ____ of dem bones

A
  • decrease
  • decrease (hard to thermoregulate)
  • impaired
  • osteoarthritis

S20

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28
Q

What is the vasoconstriction threshold?

A

Thermoregulation and the temp in which the body begins to vasoconstrict
* is it comparable in infants, children and adults
* 1 degree C less for adults over 60yo

S21

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29
Q

operative risk

FYI slide

A
  • US adults aging
    >65 increasing rapidly over next 3 decades
  • What is ”old age”
    • Denney/Denson….high mortality 90 y/o and up
    • Djokovi/Hedley-Whyte….ASA status predicted mortality
    • Del Guercio/Cohn…uncorrectable comorbidity in SICU; 100% mortality
    • Finlayson et al. high mortality from nursing home residents

S23

30
Q

What are 6 significant predictors of 6month & 1 year mortality for the elderly?

A
  • Impaired cognition
  • Recent fall
  • ↓ Albumin
  • Anemia
  • Functional dependence
  • Comorbidities

S24

31
Q

the vulnerable brain

How does neuroinflammation happen with the eldery in surgery?

A

S25

32
Q

Neurotoxicity factors

What four factors are thought to be involved in the pathogenesis of dementia?

A
  • Amyloid beta plaques
  • Tau
  • Ca⁺⁺
  • Neuroinflammation (TNF and IL)

S25-26

33
Q

Where do amyloid beta plaques accumulate intracellularly?

A

Trick question. Amyloid accumulates extracellulary.

S27

34
Q

What are amyloid plaques thought to do in the CNS?

A
  • Originally thought to be toxic (now not so much?)
  • May Disrupt cell membranes
  • they are a fragment of synaptic origin

Function actually unknown, synaptic origin.

S27

35
Q

What results were seen (regarding amyloid β) with mice who were administered volatile anesthetic?

A
  • Studied with halothane
  • Young mice had improved memory/learning after halothane exposure
  • Old mice had accelerated dementia

More study necessary - unclear translation to humans.

S28

36
Q

What medication class can cause a significant increase in amyloid plaques?

A

Volatiles Anesthetics

S28

37
Q

Tau

What is a neurofibrillary tangle?

A

Phosphorylated and aggregated τ (tau) proteins

S29

38
Q

Tau

What is destabilized by neurofibrillary tangles?

A

Microtubules

S29

39
Q

Tau

Decreases in temperature by ___ °C will increase the amount of τ protein.

A

2-3 °C

S29

40
Q

Tau

Repeated exposure to what drug class will cause an increase in phosphorylated τ protein?

A

volatile anesthetics (specifically halothane, isoflurane, & sevo)

increases phosphorylated tau

S29

41
Q

Flip card to see graph of Amyloid and Tau relations to symptoms.

A

S30

42
Q

Release of what ion is exaggerated due to anesthesia? What receptors are involved?

A

Release of Ca⁺⁺ from ryanodine and IP₃ receptors of endoplasmic reticulum.

S31

43
Q

Exaggerated Ca⁺⁺ release in the brain is thought to be linked to ______________.

A

neurotoxicity

S31

44
Q

Volatile anesthetics are known to cause malignant hyperthermia, how does this relate to Ca release and neurotoxicity?

A
  • Neurotoxicity d/t increased calcium is hypothesized to be a less dramatic release of Ca++
  • if we inhibit the Ca++ release, will this delay or decrease the neurotoxicity?
  • one school of thought is that the pt may have a genetic sensitivity that may have a RYR defect - but less dramatic than MH
    • dantrolene? as a Ca++ inhibitor prophylactcally?

S31

45
Q

Does dantrolene cross the blood brain barrier?

A

No

S31

46
Q

Neuroinflammation contributes to cognitive decline through the release of which three inflammatory factors?

A
  • Cytokines
  • IL-6
  • TNFα

S32

47
Q

What anesthetic drugs (mentioned in lecture) could be used to counteract inflammation?

Sus, because I checked and only one of these crosses the BBB.

A

Dexamethasone
Ketorolac
Lidocaine (actually can cross BBB)

S32

48
Q

General anesthesia (especially in older populations) is thought to contribute to ______.

A

POCD (Post-op cognitive dysfunction)
depends on the drug, duration of exposure and magnitude of exposure

S33

49
Q

What gas is thought to contribute the most to POCD?

A

Isoflurane > desflurane > propofol

S33

50
Q

What studies support the theory of anesthesia related to post-operative cognitive dysfunction?

A

Bedford 1955

“Adverse cerebral effects of anesthesia on old people”
1193 patients > 50 y/o
Received general anesthesia

Mental deterioration in 10% of these pts…long-term or permanent

S34-35

51
Q

Anesthesia is ____ for POCD, whilst surgery is likely ____.

A

Causative; additive

Dr M

52
Q

7 Anesthesia implications for the oldies

A
  1. Using neuraxial/regional anesthesia when possible
  2. Avoid long-acting NMBD and reverse adequately
  3. Opioid sparing strategies
  4. Neutralization of stomach acid with non-particulants
  5. Consider using EEG based titration
  6. Avoid hypotension
  7. Pad skin and nerves (pay special attention to body temp)

S37

53
Q

What occurs to drugs due to decreased cardiac output secondary to aging?

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

S38

54
Q

What neuromuscular junction changes contribute to drug challenges in an aging patient?

A
  • ↑ distance between axon and motor end plate
  • ↓ concentration of ACh receptors
  • ↓ ACh in presynaptic vesicle
  • ↓ ACh release

S39

55
Q

What drug changes are seen in an aging patient regarding kidney/liver dependent metabolism?

A
  • Prolonged drug effect
  • Decreased drug need during maintenance
  • Delayed recovery phase for non-depolarizing NMB’s

S40

56
Q

What drug changes do we see if the drug is not dependent on Kidney or liver metabolism?

A
  • No significant prolongation of effect
  • Essentially same requirements during maintenance
  • Essentially no delay in recovery phase

S40

57
Q

What do we see specifically with pulmonary resection and the elderly?

A
  • Mortality 80-92 y/o 3%
  • Respiratory complications 40% (2x more than younger population)
  • Cardiac complications 40% (3x more than younger population)
  • Lobectomy mortality is more acceptable (especially with newer techniques)
  • Pneumonectomy mortality excessive

S41

58
Q

What is the algorithm for preoperative assessment of Thoracic surgery patients?

A

S42

59
Q

How is predicted post-operative FEV₁ (ppo FEV₁) calculated?

A

(Preop FEV₁ %) x (1 - % of lung tissue removed/100)

S43

If: Preop FEV1 70% and RLL removed

ppoFEV1 = 70 x (1-29/100) = 50%

60
Q

How many lung segments are there?

A

42 total

S43

61
Q

How many lung segments are in the LUL?

A

10

S43

62
Q

How many lung segments are in the RLL?

A

12

S43

63
Q

How many lung segments are in the RUL?

A

6

S43

64
Q

How many lung segments are in the RML?

A

4

S43

65
Q

The right middle lobe and right lower lobe are resected in a critically ill patient. How much lung tissue was removed in this surgery?

A

16/42 = 38%

S43

66
Q

Predict the post-operative FEV₁ for a patient who had their right lower lobe removed. The patients preoperative FEV₁ is 70%.

A

(Preop FEV₁ %) x (1 - % of lung tissue removed/100)

PPO FEV₁ =70 x ( 1 - 28/100) = 50

S43

67
Q

What is the “triad” of preoperative thoracotomy assessment?

A

S44

68
Q

How would the CRNA manage extubation on a post-thoracotomy patient if the PPO FEV₁ is >40% ?

A

If > 40%, extubate in OR if awake, warm, & comfortable (AWaC)

S45

69
Q

How would the CRNA manage extubation on a post-thoracotomy patient if the PPO FEV₁ is 30 - 40% ?

A

Consider extubation based on:

  • Exercise tolerance
  • DLCO
  • V/Q
  • Comorbidities

S45

70
Q

How would the CRNA manage extubation on a post-thoracotomy patient if the PPO FEV₁ is <30% ?

A
  • Staged weaning from ventilator
  • Consider extubation if >20% plus thoracic epidural anesthesia in place.

S45

Mar: Sem 4 - Principles II (23 decks)

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