1 GERİATRİK HASTALARDA ANESTEZİ Prof.Dr.Tayfun GülerÇ.Ü. Tıp FakültesiAnesteziyoloji Anabilim Dalı
2 GERİATRİK HASTALARDA CERRAHİ Hasta > 65 yaşToplumun %11.3Sağlık giderlerinin %33’üHastane yatağı işgali %38Cerrahi girişimlerin %21Ölmeden önce yaklaşık %50’si cerrahi girişim görecekGeriatrik hasta kategorisine giren hasta sayısı giderek arttığından anestezistler, geriatrik anestezi konusunda da uzmanlık kazanmak durumunda kalmaktadırlar. Günümüzde artık ileri yaş operasyonlar ve anestezi uygulamaları için bir kontrendikasyon teşkil etmemekle birlikte anesteziye bağlı morbidite ve mortalite, genç hastalara kıyasla geriatrik hastalarda hala yüksek olma eğilimini sürdürmektedir.Barash, Cullen: Clinical anesthesia
4 GERİATRİK OFTALMİK OPERASYONLAR STRATEJİ:Preoperatif medikal durumun stabilizasyonu ve optimizasyonuUygun intraoperatif anestezi tekniğinin seçilmesi ve uygun yönetimiErken postoperatif durumun stabilizasyonuPostoperatif ağrı tedavisi
5 GERİATRİK OFTALMİK OPERASYONLAR STRATEJİ:Preoperatif medikal durumun stabilizasyonu ve optimizasyonuUygun intraoperatif anestezi tekniğinin seçilmesi ve uygun yönetimiErken postoperatif durumun stabilizasyonuPostoperatif ağrı tedavisi5
6 PREOPERATİF DÖNEM Fonksiyonel durum Laboratuar testleri Premedikasyon Kardiyovasküler sistemSolunum sistemiSantral sinir sistemiDiğer organ sistemleriLaboratuar testleriPremedikasyonYaşın ilerlemesine bağlı olarak ortaya çıkan organ sistem fonksiyonel kapasitesindeki erozyon ve eşlik eden sistem hastalıkları, yaşlı hastalarda perioperatif komplikasyonların artmasından sorumlu olan başlıca değişikliklerdir.Preoperatif mental ve fiziksel durumun iyi olması ve operasyondan önceki yaşam kalitesinin yüksek olması cerrahi sonrasındaki sonucun iyi olmasına katkıda bulunmaktadır. Bu nedenle yaşlı hastalarda ayrıntılı bir preoperatif değerlendirme çok önemlidir ve hastanın özellikle kardiyovasküler fonksiyonel rezervi ile tüm metabolik ve nütrisyonel durumu üzerine odaklanmalıdır.
7 KARDİYOVASKÜLER SİSTEM Kardiyak output depresyonuKoroner arter hastalığıHipertansiyonDiyastolik fonksiyon bozukluğuKardiyak ritm bozukluklarıYaşlı hastalarda yaşın ilerlemesi ile birlikte giderek artan bir kardiyak output azalması mutadtır. Bunun klinikteki anlamı, yaşlı kalbin stres altında kardiyak outputu geç hastalarda olduğu gibi arttıramayacak olması ve kolaylıkla hipotansiyon gelişebileceğidir.Bu yaş grubunda koroner arter hastalığı olasılığı yüksektir.
8 İLERİ TETKİK GEREKSİNİMİ Koroner arter hastalığıAtriyal fibrilasyonSemptomatik bradikardiKalp bloğuYüksek dereceli bloklarSol dal bloğuCiddi aort stenozu
9 SOLUNUM SİSTEMİ Yapısal değişiklikler: Akciğer parenkiminde fiziksel değişikliklerGaz değişiminin etkinliğinde azalmaAnatomik ve ölü boşluk miktarında artışSık görülen akciğer hastalıklarıKronik obstrüktif akciğer hastalıklarıPerioperatif oksijen uygulaması zorunluluğuYaş > 70
10 SİNİR SİSTEMİ Santral sinir sistemi Periferik sinir sistemi Beyin kitlesinde azalmaSenil nörolojik disfonksiyonPeriferik sinir sistemiGörme, işitme, koku, pozisyon algılama, periferik ağrı ve sıcaklık algılama eşiğinde yükselmeOtonom sinir sistemiOtonomik refleks yanıtta bozulmaThe complex integrated autonomic reflex responses that maintain cardiovascular and metabolic homeostasis precisely in young adults are nevertheless progressively impaired in elderly individuals.66 This may explain the increased incidence and severity of arterial hypotension seen in older patients following anesthetic induction.67 Baroreflex responsiveness, the vasoconstrictor response to cold stress, and beat-to-beat heart rate responses following postural change in elderly subjects become progressively less rapid in onset, smaller in magnitude, and less effective in stabilizing blood pressure under a variety of circumstances.68 The autonomic nervous system in the elderly patient is “underdamped,” permitting wider variation from homeostatic set points and delayed restabilization during hemodynamic stress.69 Therefore, anesthetic agents that disrupt end-organ function or reduce plasma catecholamines, or techniques associated with a pharmacologic sympathectomy such as spinal or epidural anesthesia produce arterial hypotension that is more severe in elderly than in young patients.70
11 HEPATORENAL SİSTEM Karaciğer Böbrekler Karaciğer kitlesinde azalma Splanknik kan akımında azalmaKaraciğer fonksiyon testleri normalBöbreklerBöbrek kitlesinde azalmaBöbrek kan akımında azalma
12 METABOLİZMA - ENDOKRİN Obezite:Hipertansiyon, inme, diyabet için risk faktörüPreoperatif değerlendirme:Yandaş hastalıkların aranmasıDiyabetKoroner arter hastalığı riskiKalp yetersizliği riskiKardiyovasküler, renal, nörolojikObesityIt is estimated that 64% of adults in the United States are overweight or obese and 4.7% are extremely obese. Obesity is an independent risk factor for heart disease. Hypertension, stroke, hyperlipidemia, diabetes mellitus, and OSA are more common in obese people. Morbidly obese patients require special operating room tables and gurneys to support excessive weight. Venous access and invasive and noninvasive monitoring may be difficult, and airways may require specialized equipment, techniques, and personnel.Preoperative identification and planningfor these contingencies will avoid delays on the day of surgery. Preoperative evaluation should be directed toward identifying significant co-existing diseases such as OSA, pulmonary hypertension, and heart failure. Many of these patients will not be able to lie flat and will require general anesthesia.
13 PREOPERATİF LABORATUAR TESTLERİ Rutin preoperatif testlerHemoglobin – hematokritSerum glukoz konsantrasyonuRenal fonksiyonElektrokardiyografiGöğüs grafisiPreoperative Laboratory TestingTo optimize a patient’s medical condition for surgery and anesthesia, laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years old) should be routinely tested for hemoglobin– hematocrit, glucose, renal function, and 12-lead electrocardiograph and chest radiograph abnormalities. The usefulness of routine laboratory testing as a part of preoperative assessment, however, has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is costly, especially because evidence is lacking that such testing may predict or improve perioperative outcomesEven though ECG abnormalities are increasingly more common with advanced age, abnormalities alone have not been shown to predict postoperative cardiac complications in the elderly [13,15]. Although abnormal ECG findings are common in the elderly, significant abnormalities that impact care are low in the absence of a history or symptoms of cardiac disease . Centers for Medicare and Medicaid Services will not provide coverage for age-based ECGs or ECGs performed simply as a preoperative test. A practitioner must provide a supporting diagnosiswith an acceptable ICD-9 code . ECGs are acceptable if performed within 6 months and the patient has had no change in symptoms.
14 PREOPERATİF LABORATUAR TESTLERİ Yaşlılarda sık görülen farklılıklar:Anemi: % 10Yüksek kreatinin düzeyi: % 12Hiperglisemi : % 7Rutin testlerin endikasyonları:Cerrahinin tipiEşlik eden hastalıklarPerioperatif yönetime olan etkisiIn a recent prospective cohort study of 544 consecutive geriatric patients undergoing noncardiac surgery,4 we found that the prevalence of abnormal preoperative electrolyte values and thrombocytopenia in elderly surgical patients was low (0.5% to5%). The prevalence of anemia, high creatinine values, and hyperglycemia was higher (10%, 12%, and 7%, respectively). However, none of the abnormal preoperative tests were associated with postoperative adverse outcomes by multivariate analysis whenpatients’ medical conditions and types of surgery were included. Our results, along with those from Schein et al.3 would suggest that the recommendations to eliminate routine preoperative laboratory testing may be extended to geriatric surgical patients with few comorbid conditions (e.g., American Society of Anesthesiologists physical status ≤ II). Our results also suggest that the present guidelines for routine preoperative laboratory testing in elderly patients should be reevaluated. Specifically, routinepreoperative laboratory testing for hemoglobin, creatinine, glucose, platelet, and electrolytes based on age alone may not be indicated. Rather, the performance of these tests should be based on the type of surgery, a patient’s comorbidities, and the likelihoodthat the results of these tests will change perioperative care.Healthy patients of any age who undergo low or intermediate risk procedures (without expected significant blood loss) are unlikely to benefit from any tests. Patients who have stable, well-controlled, mild to moderate severity co-existing diseases, and who follow up regularly with primary care or specialist physicians are unlikely to benefit from additional diagnostic testing before surgery. In general,tests are only recommended if they will result inA change, cancellation, or postponement of the surgical procedureA change in anesthesia and medical managementA change in monitoring or guidance of intra- or post-operative careConfirmation of a suspected abnormality based on the patient’s history and physical examinationA recent study by Schein et al.3 which included more than 19,000 elderly patientsrandomized to undergo cataract surgery with or without a standard battery of laboratorytests, showed that perioperative morbidity and mortality rates were similar in bothgroups. The investigators recommended that preoperative testing in geriatric patientsundergoing cataract surgery or procedures with similar surgical risk should be performedonly when clinically indicated by history or physical examination. The surgicalrisk associated with cataract surgery is small, and therefore the results of this studymay not be directly generalized to all geriatric surgical patients.Dzankic S, Pastor D, Gonzalez C, et al: Prevalence and prognostic value of abnormal laboratory tests in elderly surgical patients. Anesth Analg 2000; 90:S166.
19 ANESTEZİ YÖNTEMİNİN SEÇİLMESİ Topikal anesteziKolay, ucuzSedasyon / analjezi gereksinimiRejyonel anesteziAnaljezi, anestezi, akineziGenel anesteziEkipman, ekip, risk, maliyetOftalmolojik cerrahide operatör, operasyon süresince tamamen gevşemiş, kıpırdamayan, ağrı duymayan intraoküler cerrahi uygulanan hastalarda da ek olarak azalmış bir intraoküler basınç ister. Bu taleplerin, yapılacak ameliyatın tipi, hastanın genel durumu ve cerrahın seçimine göre farklı anestezi teknikleri ile yerine getirilmesi mümkün olur.
20 OFTALMİK CERRAHİDE ANESTEZİDEN BEKLENTİLER Hasta güvenliğiHareketsizlikAnaljeziMinimal kanamaOkülokardiyak refleksin önlenmesiİntraoküler basıncın kontrolüOftalmik cerrahide anestezi uygulamasından beklenenlerin yerine getirilmesine yönelik çabalar, yaşlı hastalarda çok daha abartılı, çok daha riskli ve kötü sonuçlanabilecek yanıtlarla birlikte olabilir. Bu nedenle yaşlı olguların oftalmik cerrahisinde hastaların perioperatif morbidite ve mortalitesinin azaltılmasına yönelik tedbirlerin alınmasından hem operatör, hem de anestezist birlikte sorumludur.Whereas the list of ocular surgical interventions is lengthy, these procedures may, in general, be classified as extraocular or intraocular. This distinction is critical because anesthetic considerations are different for these two major surgical categories. For example, with intraocular procedures, profound akinesia (relaxation of recti muscles) and meticulous control of intraocular pressure (IOP) are requisite. However, with extraocular surgery, the significance of IOP fades, whereas concern about elicitation of the oculocardiac reflex assumes prominence.
22 İNTRAOKÜLER BASINCIN KONTROLÜ İnhalasyon anestezikleriBarbitüratlarNöroleptiklerOpioidlerTranklizanlarHipnotiklerPropofol, etomidatCentral Nervous System DepressantsInhalation anesthetics purportedly cause dose-related decreases in IOP.11 The exact mechanisms are unknown, but postulated etiologies include depression of a central nervous system (CNS) control center in the diencephalon,4 reduction of aqueous humor production, enhancement of aqueous outflow, or relaxation of the extraocular muscles.7 Moreover, virtually all CNS depressants, including barbiturates,12 neuroleptics,13 opioids, tranquilizers,7 and hypnotics, such as etomidate,14 and propofol,15 lower IOP in both normal and glaucomatous eyes. It is interesting that etomidate, despite its proclivity to produce pain on intravenous (iv) injection and skeletal muscle movement, is associated with a significant reduction in IOP.16 However, etomidate-induced myoclonus may be hazardous in the setting of a ruptured globe.
24 TOPİKAL/REJYONEL ANESTEZİ Preoperatif sedasyon:Enjeksiyon konforuHareketsizlikAnksiyetenin giderilmesiAmneziİntraoperatif sedasyon:The majority of ophthalmologic surgeries are performed with regional nerve block anesthesia. Preoperatively, sedation may be required during the placement of the nerve block to decrease the discomfort of the injection, limit patient motion, relieveanxiety, and produce amnesia about the procedure. Intraoperatively, sedatives may also be administered to relieve anxiety and prevent uncontrolled and unexpected movement.24
25 PERİOPERATİF SEDASYON Amaç:Sakin, uyumlu ve uyanık hastaReflekslerin baskılanmamasıHavayolu açıklığının korunmasıSedasyon düzeyleri *Minimal sedasyon (anksiyoliz)Orta düzey sedasyon/analjezi (bilinçli sedasyon)Derin sedasyon ve analjeziHowever, it is also importantduring surgery for the patient be calm, cooperative,and aware; reflexes should not be obtunded; and theairway should not be obstructed. Ideal sedation levelscan be achieved by careful intravenous titration ofsuitable agents while monitoring the effect of thesedative and analgesic agents.* American Society of Anesthesiologists
26 SEDASYON DÜZEYLERİ OPİOİD MİNİMAL BİLİNÇLİ DERİN Bilinç Açık Kapalı Uyarıya yanıt+-HavayoluTehlikedeVentilasyonNormalKardiyovaskülerBİLİNÇLİ SEDASYONBilinç kaybıVerbal / taktil uyarılara yanıtHavayolu açıkSpontan solunum yeterliKardiyovasküler fonksiyon yeterliDERİN SEDASYONBilinç kapalıZorlukla ya da ağrılı uyaranlarla uyandırmaVentilatuar fonksiyon bozulabilirHavayolu açıklığı bozulabilirVentilasyon desteği gerekebilir
27 UYGULAMA YOLLARI Tercih edilen uygulamalar İntravenözOralİnhalasyonTercih edilmeyen uygulamalarEnteralSubkütanİntramuskülerRoute of administrationThe intravenous route is the preferred method of administration, however in some very young children, oral and inhalation agents may be necessary. The enteral, subcutaneous, or intramuscular routes are best avoided whenever possible because of unpredictabilityof absorption and distribution of the drugs.
28 İLAÇ SEÇİMİ İki ana grup Kombinasyonda sinerjistik etki SedatiflerAnaljeziklerKombinasyonda sinerjistik etkiDoz titrasyonuna dikkatGereksinim olup olmadığına dikkat:Hastanın hareketlenmesinin nedeni?Yetersiz blok, ağrıAnksiyeteChoice of drugsThe drugs commonly used fall into two main categories, namely sedatives and analgesics. When used in combination these drugs have a synergistic effect and need to be titrated carefully [32–34]. Additionally, it is important to differentiate between patient movement as a result of anxiety and that as a result of pain. Administration of additional sedatives in the presence of pain resulting from inadequate regional block will only worsen the situation and result in a deeply sedated, uncooperative patient with uncontrolled movement.
30 BENZODİAZEPİNLER SSS üzerine etkileri: Göz içi basıncında azalma HipnotikAnksiyolitikAmnestikGöz içi basıncında azalmaKardiyovasküler sisteme etkileri minimalAşırı dozlarda solunum depresyonu olasıBenzodiazepinesBenzodiazepines are the most commonly used drugs for peri-operative sedation. They act by binding to the g-aminobutyric acid (GABA) complex and inhibit neuronal transmission. These drugs exhibit hypnotic, anxiolytic, and amnestic properties and lower intraocular pressure. Cardiovascular and respiratory depression is seen with excessive doses.Diazepam has a long half-life, which is further prolonged in the elderly. Its original formulation (Valium; Roche Laboratories, Nutley, NJ), which contained propylene glycol, was associated with venous irritation and phlebitis . The newer lipid-based formulation (Dizac;Ohmeda, Liberty Corner, NJ) is less irritating .. Respiratory depression and apnea occurs with all benzodiazepines and is more likely to occur in the presence of opioids, old age, and debilitating disease.
31 BENZODİAZEPİNLER Diazepam Midazolam Lorazepam Yarılanma ömrü:20-50 saatDoz: 0.01 – 0.1 mg/kg, ivMidazolamYarılanma ömrü: saatLorazepamEtkisi yavaş başlar, uzun sürerSedatif etkisi fazla
32 PROPOFOL Nonbarbitürat sedatif – hipnotik Ciddi solunum depresyonu riskiAnaljezik etkisi yokİntraoküler basınçta azalmaSürekli iv infüzyon(1)Hasta kontrollü sedasyon(2)(1)J Cataract Refract Surg 2001;27:1372– 9.(2) Can J Anaesth 1996;43:1014–8.Propofol in small incremental intravenous doses (20 mg) has been used to achieve amnesia for regional eye blocks ; however, propofol provides no analgesia for insertion of the block needle and therefore semiconscious patients may have a startle response to needle insertion. A single dose of propofol (0.98 mg/kg) has been shown to reduce intraocular pressure (IOP) by 17% to 27%, which is also beneficial during ophthalmologic surgery . This change occurs immediately following injection and may be related to relaxation of the extraocular muscles. Continuous infusion of propofol (1.5 mg/kg/hour) has been found to be effective during cataract surgery under topical anesthesia but does require close monitoring for signs of respiratory depression . Patient-controlled sedation using propofol (0.3 mg/kg, lockout interval of 3 minutes) in 55 elderly patients undergoing cataract surgery has been reported . Patients used less than 1 mg/kg and reported a high degree of satisfaction. One patient developed excessive sedation and transient respiratory depression, which responded to patient stimulation.
34 DEKSMEDETOMİDİN Alfa-2 adrenerjik agonist Sedatif-hipnotik-analjezik Kardiyovasküler etkileri:Kalp hızında azalmaSistemik vasküler dirençte azalmaSistemik kan basıncında azalmaDexmedetomidineDexmedetomidine is an a2-adrenergic agonist and produces a sedative-hypnotic effect by an action on a2-receptors in the locus ceruleus and an analgesic effect by its action on a2-receptors within the locus ceruleus and the spinal cord . In volunteers, dexmedetomidine sedation reduced minute ventilation but did not alter the slope of the ventilatory response to increasing CO2 . The effects on the cardiovascular system are a decreased heart rate; decreased systemic vascular resistance; and indirectly decreased myocardial contractility, cardiac output, and systemic blood pressure . Used as a premedicant at intravenous doses of 0.33 to 0.67 mg/kg given 15 minutes before surgery, dexmedetomidine appears to be efficacious with minimal cardiovascular side effects . When used for intraoperative sedation, dexmedetomidine (0.7 mg/kg/hr) had a slower onset than propofol but had similar cardiorespiratory effects. With continuous infusion sedation after termination of the infusion was more prolonged, as was recovery of blood pressure; however, lower doses of opioid were needed in the first hour postoperatively . A double-blind placebo-controlled comparative study of intramuscular dexmedetomidine (1 mg/kg) and midazolam (20 mg/kg) before peribulbar block for cataract surgery revealed comparable sedation in both groups, but dexmedetomidine was more effective at lowering IOP .
35 OPİOİD ANALJEZİKLER Analjezik gereksinimi: Opioid analjezikler Lokal anestezik enjeksiyonunda ağrıİntraoperatif ağrıİris manüplasyonuİrigasyon – aspirasyonİntraoküler lens manüplasyonuOpioid analjeziklerFentanilAlfentanilRemifentanilOpioid Analgesic AgentsAnalgesic agents may be administered before performing regional nerve block to decrease the pain associated with the injection. Additionally, pain may occur intraoperatively as a result of the light from the operating microscope, iris manipulation, irrigationaspiration, and intraocular lens manipulation [78,79] necessitating intraoperative analgesics.
38 SEDASYON İÇİN UYGUN OLMAYAN HASTALAR Kronik spontan öksürükDüz yatarken nefes darlığıParkinson tipi titremeAlzheimer hastalarıKlostrofobik hastalar38
39 ANESTEZİ YÖNETİMİ Genel anestezi Yandaş hastalıkların getirdiği ilave riskKoroner arter hastalığı, hipertansiyonKronik obstrüktif akciğer hastalıklarıİlaçlara abartılı yanıtKardiyovasküler sistemRespiratuar sistemSantral sinir sistemi
41 İNTRAOPERATİF YÖNETİM Genel anestezi:CiltEklemler – basınç noktalarıHavayoluİlaçların etki süresiHipotermiİntraoküler basınç
42 CİLT Bağ dokusu kaybı Çabuk hasarlanma Flaster ve EKG elektrodları Turnikeler ve kan basıncı manşonuIsıtıcı blanketler yanık oluşturabilir
43 EKLEMLER VE BASINÇ NOKTALARI Sinir gerilmesine bağlı hasarBrakiyal pleksus yaralanmasıUlnar sinir yaralanmasıBoyun yaralanmasıGöz yaralanması
44 GÜÇ HAVAYOLU Sert boyun ve çene Kötü dişler Maskenin yüze oturtulmasında güçlükAspirasyon riski
45 İLAÇLARIN DOZ VE ETKİ SÜRESİ Vücut kompozisyonunda değişiklikKan volümünde azalmaKas kitlesinde azalmaPlazma proteinlerinde azalmaDolaşım zamanında azalmaMetabolizma ve klirenste azalma
46 HİPOTERMİ Bazal metabolizma hızında azalma Isı oluşturma kapasitesinde azalmaÇıplak hastaSoğuk bekleme ve operasyon odasıSoğuk sıvılar ile yıkamaVazodilatasyon
47 HİPOTERMİ ZARARLI MI? Titreme enerji gerektirir Oksijen tüketimiMiyokard iskemisiİlaç metabolizmasında yavaşlamaYaşlı hastalarda hipotermi bekleyin ve ısıtmayı planlayın
48 GERİATRİK OLGULARDA TOPİKAL MEDİKASYONLAR Midriyatik ilaçlarFenilefrin (sempatik agonist)Hipertansiyon & Refleks bradikardiEpinefrin (sempatik agonist)Hipertansiyon & TaşikardiSiklopentolat (antikolinerjik)SSS toksisitesiAtropin, skopolamin (antikolinerjik)Santral antikolinerjik sendromANESTHETIC RAMIFICATIONS OF OPHTHALMIC DRUGSTopikal oftalmik ilaçların bazıları geriatrik olgularda sorun yaratabilir. Bu ilaçların konjunktiva veya nazolakrimal kanaldan drenajı sonrasında nazal mukozadan sistemik absorbsiyonu mümkün olabilir. Bu ilaçların uygulanmasından sonraki birkaç dakika, gözün iç kantusuna uygulanan manuel bası ile bu emilim önemli ölçüde azaltılabilir.CyclopentolateDespite the popularity of cyclopentolate as a mydriatic, it is not without side-effects, which include CNS toxicity. Manifestations include dysarthria, disorientation, and frank psychotic reactions. Purportedly, CNS dysfunction is more likely to follow use of the 2% solution, as opposed to the 1% solution.69 Furthermore, cases of convulsions in children after ocular instillation of cyclopentolate have been reported.70 Hence, for pediatric usage, 0.5–1.0% solutions are recommended. Cyclopentolate, at higher concentrations, also causes cycloplegia.48
49 GERİATRİK OLGULARDA TOPİKAL MEDİKASYONLAR Miyotik ilaçlarPilokarpin (kolinerjik agonist)Bradikardi, terlemeAsetilkolin (kolinerjik agonist)Bronkospazm, Hipotansiyon & BradikardiEkotiyofat (kolinesteraz inhibitörü)Süksinilkolinin etkisinde uzamaAcetylcholineAcetylcholine is commonly used intraocularly after lens extraction to produce miosis. The local use of this drug may occasionally result in such systemic effects as bradycardia, increased salivation, and bronchial secretions, as well as bronchospasm. The side-effects, including hypotension and bradycardia,57 that may develop in patients given acetylcholine after cataract extraction may be rapidly reversed with iv atropine. Furthermore, one might anticipate that vagotonic anesthetic agents such as halothane could accentuate the effects of acetylcholine.Echothiophate is a long-acting anticholinesterase miotic that lowers IOP by decreasing resistance to the outflow of aqueous humor. Useful in the treatment of glaucoma, echothiophate is absorbed into the systemic circulation after instillation in the conjunctival sac. Any of the long-acting anticholinesterases may prolong the action of succinylcholine,58 because, after a month or more of therapy, plasma pseudocholinesterase activity may be less than 5% of normal.59 It is said, moreover, that normal enzyme activity does not return until 4–6 weeks after discontinuance of the drug.60 Hence, the anesthesiologist should anticipate prolonged apnea if these patients are given a usual dose of succinylcholine. In addition, a delay in metabolism of ester local anesthetics should be expected.49
50 GERİATRİK OLGULARDA TOPİKAL MEDİKASYONLAR Intraoküler basıncı azaltan ilaçlarTimolol, betaksolol (beta adrenerjik antagonist)Bradikardi,Hipotansiyon,Konjestif kalp yetersizliği,BronkospazmMidriyatik olarak kullanılan yukarıdaki ilaçların sistemik toksisite potansiyelleri50
51 İLAÇ ETKİLEŞİMİ Topikal oküler ilaçlar: Asetilkolin Antikolinesteraz KokainEpinefrinFenilefrinTimololSome of the potentially worrisome topical ocular drugs include acetylcholine, anticholinesterases, cocaine, cyclopentolate, epinephrine, phenylephrine, and timolol. In addition, intraocular sulfur hexafluoride and other intraocular gases have important anesthetic ramifications. Furthermore, certain ophthalmic drugs given systemically may produce untoward sequelae germane to anesthetic management. Drugs in this category include glycerol, mannitol, and acetazolamide.Anticholinesterase AgentsCocaineCocaine, introduced to ophthalmology in 1884 by Koller, has limited topical ocular use, because it can cause corneal pits and erosion. However, as the only local anesthetic that inherently produces vasoconstriction and shrinkage of mucous membranes, cocaine is commonly used in a nasal pack during dacryocystorhinostomy. The drug is so well absorbed from mucosal surfaces that plasma concentrations comparable to those after direct iv injection are achieved.61 Because cocaine interferes with catecholamine uptake, it has a sympathetic nervous system potentiating effect.61Historically, epinephrine had often been mixed with cocaine in hopes of augmenting the degree of vasoconstriction produced. This practice is both superfluous and deleterious because cocaine is a potent vasoconstrictor in its own right, and the combination of epinephrine with cocaine may trigger dangerous cardiac dysrhythmias. It has been shown that cocaine used alone, without topical epinephrine, to shrink the nasal mucosa in conjunction with halothane or enflurane does not sensitize the heart to endogenous epinephrine during halothane or enflurane anesthesia.62 However, animal studies have shown that after pretreatment with exogenous epinephrine, cocaine facilitates the development of epinephrine-induced cardiac dysrhythmias during halothane anesthesia.63The usual maximal dose of cocaine used in clinical practice is 200 mg for a 70-kg adult, or 3 mg•kg-1. However, 1.5 mg•kg-1 is preferable, because this lower dose has been shown not to exert any clinically significant sympathomimetic effect in combination with halothane.64 Although 1 g is considered to be the usual lethal dose for an adult, considerable variation occurs. Furthermore, systemic reactions may appear with as little as 20 mg.Meyers65 described two cases of cocaine toxicity during dacryocystorhinostomy, underscoring that cocaine is contraindicated in hypertensive patients or in patients receiving drugs such as tricyclic antidepressants or monoamine oxidase inhibitors. In addition, sympathomimetics such as epinephrine or phenylephrine should not be given with cocaine.Obviously, before administering cocaine or another potent vasoconstrictor for dacryocystorhinostomy, the physician should carefully search out possible contraindications. To avoid toxic levels, doses of dilute solutions should be meticulously calculated and carefully administered. If serious cardiovascular effects occur, labetalol should be used to counteract them.66 In the past, propranolol was widely used to control cocaine-induced hypertension,67 but a lethal hypertensive exacerbation has been ascribed to unopposed a stimulation.68 Labetalol offers the advantage of combined a and b blockade.EpinephrineAlthough topical epinephrine has proved useful in some patients with open-angle glaucoma, the 2% solution has been associated with such systemic effects as nervousness, hypertension, angina pectoris, tachycardia, and other dysrhythmias.71Some anesthesiologists have maintained that it is unwise to use epinephrine in patients being anesthetized with a halogenated hydrocarbon. However, Smith and colleagues72 reported on the administration of epinephrine into the anterior chamber of patients undergoing cataract surgery by phacoemulsification and aspiration. They concluded it is safe to administer epinephrine into the anterior chamber in doses up to 68 mg•kg-1 under these circumstances. It was postulated that the iris, with its rich supply of adrenergic receptors, may be able to capture with extreme rapidity the epinephrine given into the eye. Apparently, there is not much systemic absorption from the globe.PhenylephrinePupillary dilation and capillary decongestion are reliably produced by topical phenylephrine. Although systemic effects secondary to topical application of prudent doses are rare,73 severe hypertension, headache, tachycardia, and tremulousness have been reported.71In patients with coronary artery disease, severe myocardial ischemia, cardiac dysrhythmias, and even myocardial infarction may develop after topical 10% eyedrops. Those with cerebral aneurysms may be susceptible to cerebral hemorrhage after phenylephrine in this concentration. In general, a safe systemic level follows absorption from either the conjunctiva or the nasal mucosa after drainage by the tear ducts. However, phenylephrine should not be given in the eye after surgery has begun and venous channels are patent.Children are especially vulnerable to overdose and may respond in a dramatic and adverse fashion to phenylephrine drops. Hence, the use of only 2.5%, rather than 10%, phenylephrine is recommended in infants and the elderly, and the frequency of application should be strictly limited in these patient populations.Timolol and BetaxololTimolol, a nonselective b-adrenergic blocking drug, is a popular antiglaucoma drug. Because significant conjunctival absorption may occur, timolol should be administered with caution to patients with known obstructive airway disease, congestive heart failure, or greater than first-degree heart block. Life-threatening asthmatic crises have been reported after the administration of timolol drops to some patients with chronic, stable asthma.74 Not unexpectedly, the development of severe sinus bradycardia in a patient with cardiac conduction defects (left anterior hemiblock, first-degree atrioventricular block, and incomplete right bundle-branch block) has been reported after timolol.75 Moreover, timolol has been implicated in the exacerbation of myasthenia gravis76 and in the production of postoperative apnea in neonates and young infants.77,78In contrast to timolol, an even newer antiglaucoma drug, betaxolol, a b1 blocker, is said to be more oculospecific and have minimal systemic effects. However, patients receiving an oral b blocker and betaxolol should be observed for potential additive effect on known systemic effects of b blockade. Caution should be exercised in patients receiving catecholamine-depleting drugs. Although betaxolol has produced only minimal effects in patients with obstructive airways disease, caution should be exercised in the treatment of patients with excessive restriction of pulmonary function. Moreover, betaxolol is contraindicated in patients with sinus bradycardia, congestive heart failure, greater than first-degree heart block, cardiogenic shock, and overt myocardial failure.Intraocular Sulfur HexafluorideFor a patient with a retinal detachment, intraocular sulfur hexafluoride79 or other gases such as certain perfluorocarbons may be injected into the vitreous to mechanically facilitate reattachment. These recommendations do not apply to open-eye procedures during which volume and pressure changes are readily compensated for by fluid and gas leak.Stinson and Donlon80 suggest terminating nitrous oxide 15 minutes before gas injection to prevent significant changes in the size of the intravitreous gas bubble. The patient is then given virtually 100% oxygen (admixed with a small percentage of volatile agent) for the balance of the operation without adversely affecting intravitreous gas dynamics. Furthermore, if a patient requires reoperation and general anesthesia after intravitreous gas injection, nitrous oxide should be avoided for 5 days subsequent to air injection and for 10 days after sulfur hexafluoride injection (Table 34-3).81Table 34-3. DIFFERENTIAL SOLUBILITIES OF GASESBlood: Gas PartitionCoefficientsSulfur hexafluoride 0.004Nitrogen 0.015Nitrous oxide 0.468Perfluoropropane and octafluorocyclobutane may also be used in vitreoretinal surgery to support the retina. Like sulfur hexafluoride, these gases are relatively insoluble and require discontinuance of nitrous oxide at least 15 minutes before injection. Should the patient require reoperation, it must be remembered that perfluoropropane lingers in the eye for longer than 30 days.82Systemic Ophthalmic DrugsIn addition to topical therapies, various ophthalmic drugs given systemically may result in complications of concern to the anesthesiologist. These systemic drugs include glycerol, mannitol, and acetazolamide. For example, oral glycerol may be associated with nausea, vomiting, and risk of aspiration. Hyperglycemia or glycosuria, disorientation, and seizure activity may occur after oral glycerol.The recommended iv dose of mannitol is 1.5–2 g•kg-1 given over a 30- to 60-minute interval. However, serious systemic problems may result from rapid infusion of large doses of mannitol. These complications include renal failure, congestive heart failure, pulmonary congestion, electrolyte imbalance, hypotension or hypertension, myocardial ischemia, and, rarely, allergic reactions. Clearly, the patient’s renal and cardiovascular status must be thoroughly evaluated before mannitol therapy.Acetazolamide, a carbonic anhydrase inhibitor with renal tubular effects, should be considered contraindicated in patients with marked hepatic or renal dysfunction or in those with low sodium levels or abnormal potassium values. As is well known, severe electrolyte imbalances can trigger serious cardiac dysrhythmias during general anesthesia. Furthermore, people with chronic lung disease may be vulnerable to the development of severe acidosis with long-term acetazolamide therapy. Topically active carbonic anhydrase inhibitors have been developed83 and are now commercially available. Such topical agents might well be expected to be relatively free of clinically significant systemic effects.
53 SIK GÖRÜLEN POSTOPERATİF KOMPLİKASYONLAR Derlenme OdasıSIK GÖRÜLEN POSTOPERATİF KOMPLİKASYONLARAğrıBulantı- kusmaSolunumsal sorunlarKardiyovasküler dengesizlikSıcaklık değişiklikleriSıvı ve elektrolit dengesizlikleriSerebral fonksiyon bozukluğu
54 POSTOPERATİF AĞRI KONTROLÜ Postoperatif ağrı mutad değilAğrılı girişimlerSkleral bucklingEnükleasyonRüptüre glob onarımıPostoperatif ağrının diğer nedenleri:İntraoküler hipertansiyonKorneal abrazyonDiğer komplikasyonlar54
55 GERİATRİK HASTALARDA AĞRI KONTROLÜ Lokal anestezik infiltrasyonuOpioidlerMorfinMeperidinNon-Steroidal anti-inflamatuar ilaçlarDiklofenak sodyum, iv, imParasetamol, ivSteroidlerDeksametazon, iv
56 AĞRI TEDAVİSİNİN KOMPLİKASYONLARI Aşırı sedasyonSolunum depresyonuAjitasyonÜriner retansiyonBulantı ve kusma
57 BULANTI VE KUSMA Başlıca nedenler: Cerrahi işlemin tipi Anestezik ilaçlarErken oral sıvı alımıHareketAğrı
59 SOLUNUMSAL KOMPLİKASYONLAR HipoksemiSaO2 < %90PaO2 < 55 mmHgÖnemli bir kısmı (%95) tanınmayabilirYaşlı hastaların PaO2 düzeyleri daha düşüktürAlthough pulmonary complications are more frequent in the elderly after anesthesiaand surgery, old age independently is not considered to be a risk factor for perioperativepulmonary dysfunction.45 More significant risk factors are a history of smoking,obesity, and preexisting pulmonary disease. Preventive and treatment options inthe perioperative period relating to the respiratory system are discussed in the followingsection.
60 HİPOKSEMİ İÇİN RİSK FAKTÖRLERİ Anestezi süresiCerrahinin yeriHastanın yaşıSigara öyküsüAnestezi tipiPostoperative PeriodPulmonary complications are frequently observed in elderly surgical patients. In1987, a prospective study of 7,306 consecutive patients undergoing noncardiacsurgery reported a pulmonary complication rate of 10.2% in octogenarians.55 A recentstudy by our group also reported a complication rate of 7% related to the pulmonarysystem.9 Most pulmonary complications were caused by pneumonia or adult respiratorydistress syndrome.
62 KARDİYOVASKÜLER SORUNLAR HipotansiyonAnesteziklerin artık etkisiStimülasyon olmayışıSıvı dengesinde bozulmaHipovolemiHipervolemiMiyokard iskemisiCardiovascular ComplicationsCardiovascular complications are one of the most common adverse postoperative outcomes in geriatric surgical patients, and congestive heart failure is the most common cardiac complication that occurs after operation. 9 In a previous study, we found that a history of congestive heart failure was associated with adverse postoperative cardiac outcomes and in-hospital death. 9 In nonsurgical patients, the mortality risk for patients with congestive heart failure has been reported to be as high as 50% 2 years after diagnosis. 23 It is a common belief that systolic function decreases with age, but, in fact, in the absence of coexistent cardiovascular disease, resting systolic cardiac function is well preserved even at advanced age. 24 Despite the preservation of left ventricular systolic function, heart failure also can result from left ventricular diastolic dysfunction, which is frequently not measured in routine preoperative testing.Clinical diagnosis of heart failure in older patients is particularly difficult because of the lack of typical symptoms and physical findings. 25 In patients with a history of congestive heart failure, one third may have normal systolic function. 26 The assessment of diastolic filling in these patients may be particularly important. As such, there is a need to reappraise how left ventricular function is evaluated in the preoperative period to allow appropriate perioperative monitoring and therapy in this elderly surgical cohort.
65 MENTAL DURUM DEĞİŞİKLİKLERİ Uyanmada gecikmePostoperatif deliryumEtyolojik nedenlerİlaç etkileşimi ve yan etkisiDepresyonSerebral vasküler yetersizlikMetabolik dengesizlikÖnlemlerPolifarmasiden kaçımaOksijenasyonGeriatrik hastaların genel anesteziden çıkışları gecikebilir. Postoperatif dönemde yeniden bilinçleri kapanabilir. Yakın takip zorunludur.Günübirlik cerrahi girişimler sonrasında bile postopertif deliryum yaşlı hastalarda, kognitif fonksiyonun preoperatif düzeyine dönmesini geciktirmektedir.Cognitive DysfunctionDelirium, an acute disorder of attention and cognition, is common and a serious problem for hospitalized geriatric patients. In general, delirium is the manifestation or symptom of an underlying medical illness for which multiple causes exist. Delirium can be superimposed on dementia or other neurologic disorders associated with global cognitive impairment. As a result, the course of delirium can vary considerably and depends on the resolution of the causative factors. Delirium has been reported to occur in 14% to 50% of hospitalized medical patients, with an associated mortality rate ranging from 10% to 65%. 5,6 Factors that predispose the elderly to delirium include aging processes in the brain, structural brain disease, a reduced capacity for homeostatic regulation, visual and hearing impairment, a high prevalence of chronic disease that may result in a reduced resistance to acute diseases, and age-related changes in the pharmacokinetics and pharmacodynamics of drugs. 5,7 Sleeping disorder, sensory deprivation or overload, and psychologic stress resulting from bereavement or relocation to an unfamiliar environment are common precipitants of delirium. 8DrugsAlthough previous studies have shown that certain drugs may be associated with postoperative delirium, 16 no prospective randomized clinical trials have determined whether the elimination of certain drugs used in the perioperative period will actually decrease the incidence of postoperative cognitive dysfunction. As a result, no definitive guidelines can be provided at present regarding avoiding certain drugs in the perioperative period. However, a sensible guideline is that “polypharmacy” is best avoided in elderly patients, because delirium has been shown to be related to the number of medications prescribed.
66 SONUÇAs anesthesiologists and perioperative physicians, our role will likely be focused onstabilization and optimization of preoperative medical conditions, selection of appropriateintraoperative anesthetic techniques and management, stabilization of otherimmediate postoperative conditions, and management of postoperative pain. The goalof this chapter is to review several important and controversial areas to provide clinicianswith current available evidence guiding the perioperative treatment of geriatricpatients having surgery.
67 DİYABETİK HASTALARPreoperatif kan glukoz düzeyinin kontrol altına alınmasıİnsüline bağımlı diyabetiklerin sabah ameliyata alınmasıİntraoperatif glisemi kontrolü (saatlik)Glisemi < 100 mg/dl Dekstroz, ivGlisemi > 200 mg/dl İnsülin,0.1 U/kg, ivPostoperatif aç kalma süresinin kısaltılması
68 SONUÇ Sedasyon/analjezi Strateji seçimi: Başarının anahtarı Güvenli ve etkin yöntemStrateji seçimi:Hastanın öncelikleriYan etki olasılığının değerlendirilmesiBaşarının anahtarıPreoperatif değerlendirmeHastanın hazırlanmasıSummarySedation/analgesia for ophthalmologic surgery is safe and effective . The choice of sedation/analgesia strategy should be based on patient preference and the assessment of risk for adverse events. Preoperative screening and preparation of the patient is most important in obtaining cooperation and patient acceptance.Despite the obvious effectiveness of the various strategies, there is a small group of patients who are not suitable for regional anesthesia with sedation. Patients with chronic spontaneous cough, shortness of breath while lying flat, parkinsonian head tremor, Alzheimer’s disease, or claustrophobia may be very difficult to manage with regional anesthesia and light sedation. These patients may best be managed with a general anesthetic.