J Korean Med Assoc.  2017 May;60(5):377-383. 10.5124/jkma.2017.60.5.377.

Regional anesthetic management of elderly patients

• Kwak KH
• Park SS

• KMID: 2378969
• DOI: http://doi.org/10.5124/jkma.2017.60.5.377

Abstract

In general, elderly patients are less able to respond to perioperative stress and are more likely to suffer from postoperative complications and even death because of the decline in their functional organ reserve. Although no definitive evidence indicates that regional anesthesia is superior to general anesthesia in terms of the long-term prognosis in the elderly, regional anesthesia appears to be beneficial in many ways because it reduces bleeding during surgery, the stress response, and the incidence of thromboembolic complications, as well as facilitating excellent postoperative pain control. However, some issues specific to the elderly should also be considered. Age-related anatomical changes in elderly patients may make it difficult to perform epidural and spinal anesthesia, and physiologic and pharmacodynamic responses to local anesthetics may change with age. Elderly patients also show a greater extent of sensory and motor block, and are at a greater risk of hypotension after epidural and spinal block. In order to provide optimal anesthetic care and to facilitate a rapid recovery and improved outcomes in elderly patients, clinicians must have a better understanding of age-related changes when regional anesthesia is administered. Additionally, tailored anesthetic techniques should be used, as well as good perioperative care, in accordance with the type of surgery and the individual physical status of elderly patients.

Keyword

Aged; Anesthesia, conduction; Anesthetics, local

MeSH Terms

Aged*
Anesthesia, Conduction
Anesthesia, General
Anesthesia, Spinal
Anesthetics, Local
Hemorrhage
Humans
Hypotension
Incidence
Pain, Postoperative
Perioperative Care
Postoperative Complications
Prognosis
Anesthetics, Local

Reference

1. Yoo HJ. Clinical implications of geriatric syndromes. J Korean Med Assoc. 2014; 57:738–742.

2. Leung JM, Dzankic S. Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients. J Am Geriatr Soc. 2001; 49:1080–1085.

3. Luger TJ, Kammerlander C, Gosch M, Luger MF, Kammer-lander-Knauer U, Roth T, Kreutziger J. Neuroaxial versus general anaesthesia in geriatric patients for hip fracture surgery: does it matter? Osteoporos Int. 2010; 21:Suppl 4. S555–S572.

4. Tsui BC, Wagner A, Finucane B. Regional anaesthesia in the elderly: a clinical guide. Drugs Aging. 2004; 21:895–910.

5. Rabinowitz A, Bourdet B, Minville V, Chassery C, Pianezza A, Colombani A, Eychenne B, Samii K, Fourcade O. The paramedian technique: a superior initial approach to continuous spinal anesthesia in the elderly. Anesth Analg. 2007; 105:1855–1857.

6. Ryu CG, Ryu HG, Lee CJ, Bahk JH. The effect of angle on the position of the catheter tip in paramedian approach of thoracic epidural catheterization. Anesth Pain Med. 2007; 2:262–265.

7. Simon MJ, Veering BT. Factors affecting the pharmacokinetics and neural block characteristics after epidural administration of local anaesthetics. Eur J Pain Suppl. 2010; 4:209–218.

8. Simon MJ, Veering BT, Stienstra R, van Kleef JW, Burm AG. Effect of age on the clinical profile and systemic absorption and disposition of levobupivacaine after epidural administration. Br J Anaesth. 2004; 93:512–520.

9. Simon MJ, Veering BT, Stienstra R, van Kleef JW, Burm AG. The effects of age on neural blockade and hemodynamic changes after epidural anesthesia with ropivacaine. Anesth Analg. 2002; 94:1325–1330.

10. Veering BT, Burm AG, Feyen HM, Olieman W, M Souverijn JH, Van Kleef JW. Pharmacokinetics of bupivacaine during postoperative epidural infusion: enantioselectivity and role of protein binding. Anesthesiology. 2002; 96:1062–1069.

11. Scott JC, Stanski DR. Decreased fentanyl and alfentanil dose requirements with age: a simultaneous pharmacokinetic and pharmacodynamic evaluation. J Pharmacol Exp Ther. 1987; 240:159–166.

12. Pitkanen M, Haapaniemi L, Tuominen M, Rosenberg PH. Influence of age on spinal anaesthesia with isobaric 0.5% bupivacaine. Br J Anaesth. 1984; 56:279–284.

13. Veering BT, Burm AG, Spierdijk J. Spinal anaesthesia with hyperbaric bupivacaine: effects of age on neural blockade and pharmacokinetics. Br J Anaesth. 1988; 60:187–194.

14. Paqueron X, Boccara G, Bendahou M, Coriat P, Riou B. Brachial plexus nerve block exhibits prolonged duration in the elderly. Anesthesiology. 2002; 97:1245–1249.

15. Hanks RK, Pietrobon R, Nielsen KC, Steele SM, Tucker M, Warner DS, King KP, Klein SM. The effect of age on sciatic nerve block duration. Anesth Analg. 2006; 102:588–592.

16. Dorfman LJ, Bosley TM. Age-related changes in peripheral and central nerve conduction in man. Neurology. 1979; 29:38–44.

17. Wadud R, Laiq N, Qureshi FA, Jan AS. The frequency of postdural puncture headache in different age groups. J Coll Physicians Surg Pak. 2006; 16:389–392.

18. Nakasuji M, Suh SH, Nomura M, Nakamura M, Imanaka N, Tanaka M, Nakasuji K. Hypotension from spinal anesthesia in patients aged greater than 80 years is due to a decrease in systemic vascular resistance. J Clin Anesth. 2012; 24:201–206.

19. Kyokong O, Charuluxananan S, Sriprajittichai P, Poomseetong T, Naksin P. The incidence and risk factors of hypotension and bradycardia associated with spinal anesthesia. J Med Assoc Thai. 2006; 89:Suppl 3. S58–S64.

20. Critchley LA. Hypotension, subarachnoid block and the elderly patient. Anaesthesia. 1996; 51:1139–1143.

21. Sumi M, Sakura S, Koshizaki M, Saito Y, Kosaka Y. The advantages of the lateral decubitus position after spinal anes-thesia with hyperbaric tetracaine. Anesth Analg. 1998; 87:879–884.

22. Khan F, Spence VA, Belch JJ. Cutaneous vascular responses and thermoregulation in relation to age. Clin Sci (Lond). 1992; 82:521–528.

23. Vassilieff N, Rosencher N, Sessler DI, Conseiller C. Shivering threshold during spinal anesthesia is reduced in elderly patients. Anesthesiology. 1995; 83:1162–1166.

24. Frank SM, Fleisher LA, Breslow MJ, Higgins MS, Olson KF, Kelly S, Beattie C. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events: a randomized clinical trial. JAMA. 1997; 277:1127–1134.

25. Rajagopalan S, Mascha E, Na J, Sessler DI. The effects of mild perioperative hypothermia on blood loss and transfusion requirement. Anesthesiology. 2008; 108:71–77.

26. Sessler DI. Non-pharmacologic prevention of surgical wound infection. Anesthesiol Clin. 2006; 24:279–297.

27. Lim SM, Kim MW. Evaluation of minimal dose of midazolam for sedation in geriatric spinal anesthesia. Korean J Anesthesiol. 2006; 51:65–69.

28. Shinozaki M, Usui Y, Yamaguchi S, Okuda Y, Kitajima T. Recovery of psychomotor function after propofol sedation is prolonged in the elderly. Can J Anaesth. 2002; 49:927–931.

29. Kim J, Kim WO, Kim HB, Kil HK. Adequate sedation with single-dose dexmedetomidine in patients undergoing transurethral resection of the prostate with spinal anaesthesia: a dose-response study by age group. BMC Anesthesiol. 2015; 15:17.

30. Sieber FE, Zakriya KJ, Gottschalk A, Blute MR, Lee HB, Rosenberg PB, Mears SC. Sedation depth during spinal anesthesia and the development of postoperative delirium in elderly patients undergoing hip fracture repair. Mayo Clin Proc. 2010; 85:18–26.

31. Ilfeld BM, Vandenborne K, Duncan PW, Sessler DI, Enneking FK, Shuster JJ, Theriaque DW, Chmielewski TL, Spadoni EH, Wright TW. Ambulatory continuous interscalene nerve blocks decrease the time to discharge readiness after total shoulder arthroplasty: a randomized, triple-masked, placebo-controlled study. Anesthesiology. 2006; 105:999–1007.

32. van Lier F, van der Geest PJ, Hoeks SE, van Gestel YR, Hol JW, Sin DD, Stolker RJ, Poldermans D. Epidural analgesia is associated with improved health outcomes of surgical patients with chronic obstructive pulmonary disease. Anesthesiology. 2011; 115:315–321.

33. Matot I, Oppenheim-Eden A, Ratrot R, Baranova J, Davidson E, Eylon S, Peyser A, Liebergall M. Preoperative cardiac events in elderly patients with hip fracture randomized to epidural or conventional analgesia. Anesthesiology. 2003; 98:156–163.

34. Beattie WS, Badner NH, Choi P. Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis. Anesth Analg. 2001; 93:853–858.

35. Steinbrook RA. Epidural anesthesia and gastrointestinal motility. Anesth Analg. 1998; 86:837–844.

36. Urwin SC, Parker MJ, Griffiths R. General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomized trials. Br J Anaesth. 2000; 84:450–455.

37. Guay J, Parker MJ, Gajendragadkar PR, Kopp S. Anaesthesia for hip fracture surgery in adults. Cochrane Database Syst Rev. 2016; 2:CD000521.