Minimizing perioperative adverse events in the elderly
2001; Elsevier BV; Volume: 87; Issue: 4 Linguagem: Inglês
10.1093/bja/87.4.608
ISSN1471-6771
Autores Tópico(s)Enhanced Recovery After Surgery
ResumoElderly patients still have the highest postoperative mortality and morbidity rate in the adult surgical population. Preoperative clinical assessment to detect patients at high risk of postoperative events, and specific intraoperative and postoperative anaesthesia management are important to minimize postoperative adverse events in the elderly. Elderly patients still have the highest postoperative mortality and morbidity rate in the adult surgical population. Preoperative clinical assessment to detect patients at high risk of postoperative events, and specific intraoperative and postoperative anaesthesia management are important to minimize postoperative adverse events in the elderly. Among the steadily increasing population of surgical patients aged 65 yr and older, the fastest growing sector is individuals of 85 yr or older. 149Weintraub HD Kekoler LJ. Demographics of aging.in: McLeskey CH Geriatric Anesthesiology. Williams & Wilkins, 1997: 3-12Google Scholar As a result, greater numbers of patients are presenting for surgery with ageing‐related, pre‐existing conditions that place them at greater risk of an adverse outcome, such as cardiac or pulmonary disease or diabetes mellitus. 122Roy RC. Anesthetic implications of the rectangular survival curve.in: McLeskey CH Geriatric Anesthesiology. Williams & Wilkins, 1997: 13-28.Google Scholar It is, therefore, not surprising that the elderly have the highest mortality rate in the adult surgical population. 108Pedersen T Eliasen K Henriksen E. A prospective study of mortality associated with anaesthesia and surgery: risk indicators of mortality in hospital.Acta Anaesthesiol Scand. 1990; 34: 176-182Crossref PubMed Google Scholar Postoperative adverse effects on the cardiac, pulmonary, cerebral systems, and on cognitive function are the main concerns for elderly surgical patients who are at high risk. Recently some studies have focused on elderly surgical patients regarding the incidence of postoperative complications, predictors for developing postoperative complications, preoperative assessment and screening for elderly patients at high risk, and perioperative management. In this review, we document the incidence of postoperative adverse outcomes and discuss ways of improving perioperative anaesthesia care for this vulnerable surgical population. Mortality associated with anaesthesia and surgery is defined as the death rate within 30 days of operation. Advances in anaesthetic/surgical technique and perioperative care have substantially reduced related mortality. 43Djokovic JL Hedley‐Whyte J. Prediction of outcome of surgery and anesthesia in patients over 80.JAMA. 1979; 242: 2301-2306Crossref PubMed Scopus (192) Google Scholar, 108Pedersen T Eliasen K Henriksen E. A prospective study of mortality associated with anaesthesia and surgery: risk indicators of mortality in hospital.Acta Anaesthesiol Scand. 1990; 34: 176-182Crossref PubMed Google Scholar However, overall mortality in the general population remains at 1.2%, 108Pedersen T Eliasen K Henriksen E. A prospective study of mortality associated with anaesthesia and surgery: risk indicators of mortality in hospital.Acta Anaesthesiol Scand. 1990; 34: 176-182Crossref PubMed Google Scholar compared with 2.2% in patients aged 60–69 yr, 108Pedersen T Eliasen K Henriksen E. A prospective study of mortality associated with anaesthesia and surgery: risk indicators of mortality in hospital.Acta Anaesthesiol Scand. 1990; 34: 176-182Crossref PubMed Google Scholar 2.9% in those 70–79 yr, 108Pedersen T Eliasen K Henriksen E. A prospective study of mortality associated with anaesthesia and surgery: risk indicators of mortality in hospital.Acta Anaesthesiol Scand. 1990; 34: 176-182Crossref PubMed Google Scholar 5.8–6.2% in patients over 80 yr, 43Djokovic JL Hedley‐Whyte J. Prediction of outcome of surgery and anesthesia in patients over 80.JAMA. 1979; 242: 2301-2306Crossref PubMed Scopus (192) Google Scholar and 8.4% in those over 90 yr. 69Hosking MP Lobdell CM Warner MA Offord KP Melton 3rd., LJ Anaesthesia for patients over 90 years of age. Outcomes after regional and general anaesthetic techniques for two common surgical procedures.Anaesthesia. 1989; 44: 142-147Crossref PubMed Scopus (0) Google Scholar Major surgery further increases elderly mortality; for example, emergency abdominal surgery results in a 9.7% mortality for patients over 80 yr, 79Kettunen J Paajanen H Kostiainen S. Emergency abdominal surgery in the elderly.Hepato‐Gastroenterology. 1995; 42: 106-108PubMed Google Scholar thoracotomy in a 17% mortality for those over 70 yr, 20Breyer RH Zippe C Pharr WF Jensik RJ Kittle CF Faber LP. Thoracotomy in patients over age seventy years: ten‐year experience.J Thorac Cardiovasc Surg. 1981; 81: 187-193PubMed Google Scholar and any major surgical procedure a 19.8% mortality in those over 90 yr. 2Ackermann RJ Vogel RL Johnson LA Ashley DW Solis MM. Surgery in nonagenarians: morbidity, mortality, and functional outcome.J Fam Pract. 1995; 40: 129-135PubMed Google Scholar The function capacity of organs reduces with ageing, resulting in decreased reserve and ability to endure stress. 75Jones AG Hunter JM. Anaesthesia in the elderly. Special considerations.Drugs Aging. 1996; 9: 319-331Crossref PubMed Google Scholar, 114Priebe HJ. The aged cardiovascular risk patient.Br J Anaesth. 2000; 85: 763-778Crossref PubMed Google Scholar Advanced age is, therefore, a significant risk factor for increased mortality. 43Djokovic JL Hedley‐Whyte J. Prediction of outcome of surgery and anesthesia in patients over 80.JAMA. 1979; 242: 2301-2306Crossref PubMed Scopus (192) Google Scholar, 108Pedersen T Eliasen K Henriksen E. A prospective study of mortality associated with anaesthesia and surgery: risk indicators of mortality in hospital.Acta Anaesthesiol Scand. 1990; 34: 176-182Crossref PubMed Google Scholar, 114Priebe HJ. The aged cardiovascular risk patient.Br J Anaesth. 2000; 85: 763-778Crossref PubMed Google Scholar Co‐existing disease further depresses organ function and/or reserve, exacerbating risk. 75Jones AG Hunter JM. Anaesthesia in the elderly. Special considerations.Drugs Aging. 1996; 9: 319-331Crossref PubMed Google Scholar, 108Pedersen T Eliasen K Henriksen E. A prospective study of mortality associated with anaesthesia and surgery: risk indicators of mortality in hospital.Acta Anaesthesiol Scand. 1990; 34: 176-182Crossref PubMed Google Scholar For example, pre‐existing hypertension, diabetes mellitus, or renal failure contributes to a higher incidence of perioperative myocardial infarction (MI) (5.1%), cardiac death (5.7%) 68Hood DB Weaver FA Papanicolaou G Wadhwani A Yellin AE. Cardiac evaluation of the diabetic patient prior to peripheral vascular surgery.Ann Vasc Surg. 1996; 10: 330-335Abstract Full Text PDF PubMed Google Scholar or ischaemia (12–17.7%). 30Charlson ME MacKenzie CR Gold JP et al.The preoperative and intraoperative hemodynamic predictors of postoperative myocardial infarction or ischemia in patients undergoing noncardiac surgery.Ann Surg. 1989; 210: 637-648Crossref PubMed Google Scholar Additional risk factors in the elderly 2Ackermann RJ Vogel RL Johnson LA Ashley DW Solis MM. Surgery in nonagenarians: morbidity, mortality, and functional outcome.J Fam Pract. 1995; 40: 129-135PubMed Google Scholar, 43Djokovic JL Hedley‐Whyte J. Prediction of outcome of surgery and anesthesia in patients over 80.JAMA. 1979; 242: 2301-2306Crossref PubMed Scopus (192) Google Scholar, 69Hosking MP Lobdell CM Warner MA Offord KP Melton 3rd., LJ Anaesthesia for patients over 90 years of age. Outcomes after regional and general anaesthetic techniques for two common surgical procedures.Anaesthesia. 1989; 44: 142-147Crossref PubMed Scopus (0) Google Scholar, 108Pedersen T Eliasen K Henriksen E. A prospective study of mortality associated with anaesthesia and surgery: risk indicators of mortality in hospital.Acta Anaesthesiol Scand. 1990; 34: 176-182Crossref PubMed Google Scholar (Table 1) include the need for emergency surgery, 2Ackermann RJ Vogel RL Johnson LA Ashley DW Solis MM. Surgery in nonagenarians: morbidity, mortality, and functional outcome.J Fam Pract. 1995; 40: 129-135PubMed Google Scholar, 69Hosking MP Lobdell CM Warner MA Offord KP Melton 3rd., LJ Anaesthesia for patients over 90 years of age. Outcomes after regional and general anaesthetic techniques for two common surgical procedures.Anaesthesia. 1989; 44: 142-147Crossref PubMed Scopus (0) Google Scholar major surgical procedures, ASA physical status III or IV, and poor nutritional status.Table 1Risk factors for postoperative mortality in elderly surgical patients. *MET indicates metabolic equivalentASA physical statusIII and IVSurgical proceduresMajor and/or emergency proceduresCo‐existing diseaseCardiac, pulmonary disease, diabetes mellitus, liver, and renal impairmentFunctional status<1–4 MET*Nutritional statusPoor, albumin <35%, anaemiaPlace of residenceNot living with familyAmbulatory statusBedridden Open table in a new tab One study of 80‐yr‐old patients concluded that MI was the leading cause of postoperative death. 43Djokovic JL Hedley‐Whyte J. Prediction of outcome of surgery and anesthesia in patients over 80.JAMA. 1979; 242: 2301-2306Crossref PubMed Scopus (192) Google Scholar Pre‐existing cardiac disease predisposes substantial perioperative risk. 10Badner NH Knill RL Brown JE Novick TV Gelb AW. Myocardial infarction after noncardiac surgery.Anesthesiology. 1998; 88: 572-578Crossref PubMed Scopus (319) Google Scholar, 30Charlson ME MacKenzie CR Gold JP et al.The preoperative and intraoperative hemodynamic predictors of postoperative myocardial infarction or ischemia in patients undergoing noncardiac surgery.Ann Surg. 1989; 210: 637-648Crossref PubMed Google Scholar, 71Howell SJ Sear JW Sear YM Yeates D Goldacre M Foex P. Risk factors for cardiovascular death within 30 days after anaesthesia and urgent or emergency surgery: a nested case‐control study.Br J Anaesth. 1999; 82: 679-684Crossref PubMed Google Scholar, 86Landesberg G Einav S Christopherson R et al.Perioperative ischemia and cardiac complications in major vascular surgery: importance of the preoperative twelve‐lead electrocardiogram.J Vasc Surg. 1997; 26: 570-578Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 109Plumlee JE Boettner RB. Myocardial infarction during and following anesthesia and operation.South Med J. 1972; 65: 886-889Crossref PubMed Google Scholar Patients with coronary artery disease have a 4.1% incidence of perioperative MI, 7Ashton CM. Perioperative myocardial infarction with noncardiac surgery.Am J Med Sci. 1994; 308: 41-48Crossref PubMed Google Scholar and a 5.5% rate of reinfarction if older than 65 yr (compared with 3.5–4.2% rate of reinfarction in the general population). 129Shah KB Kleinman BS Sami H Patel J Rao TL. Reevaluation of perioperative myocardial infarction in patients with prior myocardial infarction undergoing noncardiac operations.Anesth Analg. 1990; 71: 231-235Crossref PubMed Google Scholar Ischaemic episodes reportedly occur in 24–41% of patients with coronary artery disease during the first week after major non‐cardiac surgery. 30Charlson ME MacKenzie CR Gold JP et al.The preoperative and intraoperative hemodynamic predictors of postoperative myocardial infarction or ischemia in patients undergoing noncardiac surgery.Ann Surg. 1989; 210: 637-648Crossref PubMed Google Scholar, 95Mangano DT Browner WS Hollenberg M London MJ Tubau JF Tateo IM. Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. The Study of Perioperative Ischemia Research Group.N Engl J Med. 1990; 323: 1781-1788Crossref PubMed Google Scholar, 96Mangano DT Wong MG London MJ Tubau JF Rapp JA The Study of Perioperative Ischemia (SPI) Research Group Perioperative myocardial ischemia in patients undergoing noncardiac surgery–II: Incidence and severity during the 1st week after surgery.J Am Coll Cardiol. 1991; 17: 851-857Crossref PubMed Scopus (0) Google Scholar Ischaemic heart disease combined with previous MI produces a higher incidence of postoperative MI in elderly patients than in younger patients with the same conditions. 10Badner NH Knill RL Brown JE Novick TV Gelb AW. Myocardial infarction after noncardiac surgery.Anesthesiology. 1998; 88: 572-578Crossref PubMed Scopus (319) Google Scholar, 129Shah KB Kleinman BS Sami H Patel J Rao TL. Reevaluation of perioperative myocardial infarction in patients with prior myocardial infarction undergoing noncardiac operations.Anesth Analg. 1990; 71: 231-235Crossref PubMed Google Scholar In the general elderly population over 60 yr, the incidence of MI after non‐cardiac surgery is reported to be 0.1–0.15%, 108Pedersen T Eliasen K Henriksen E. A prospective study of mortality associated with anaesthesia and surgery: risk indicators of mortality in hospital.Acta Anaesthesiol Scand. 1990; 34: 176-182Crossref PubMed Google Scholar, 109Plumlee JE Boettner RB. Myocardial infarction during and following anesthesia and operation.South Med J. 1972; 65: 886-889Crossref PubMed Google Scholar with mortality as high as 50–83%. 109Plumlee JE Boettner RB. Myocardial infarction during and following anesthesia and operation.South Med J. 1972; 65: 886-889Crossref PubMed Google Scholar Tables 2 and 3 list the clinical predictors of increased perioperative cardiovascular risk 47Eagle KA Brundage BH Chaitman BR et al.Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery.Circulation. 1996; 93: 1278-1317PubMed Google Scholar and the cardiac risk stratification index for non‐cardiac surgical procedures, 47Eagle KA Brundage BH Chaitman BR et al.Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery.Circulation. 1996; 93: 1278-1317PubMed Google Scholar respectively, for the general population.Table 2Clinical predictors of increased perioperative cardiovascular risk. ECG indicates electrocardiogram. *The American College of Cardiology National Database Library defines recent MI as greater that 7 days but less than or equal to 1 month (30 days). †May include 'stable' angina in patients who are unusually sedentary. ‡From reference 25Campeau L. Letter: Grading of angina pectoris.Circulation. 1976; 54: 522-523Crossref PubMed Google Scholar reproduced with permission. From reference 47Eagle KA Brundage BH Chaitman BR et al.Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery.Circulation. 1996; 93: 1278-1317PubMed Google Scholar reproduced with permissionMajorUnstable coronary syndromes•Recent myocardial infarction* with evidence of important ischaemic risk by clinical symptoms or non‐invasive study•Unstable or severe angina† (Canadian Class III or IV)‡Decompensated congestive heart failureSignificant arrhythmias•High‐grade atrioventricular block•Symptomatic ventricular arrhythmias in the presence of underlying heart disease•Supraventricular arrhythmias with uncontrolled ventricular rateSevere valvular deseaseIntermediateMild angina pectoris (Canadian Class I or II)Prior myocardial infarction by history or pathological Q wavesCompensated or prior congestive heart failureDiabetes mellitusMinorAdvanced ageAbnormal ECG (left ventricular hypertrophy, left bundle branch block, ST–T abnormalities)Rhythm other than sinus (e.g. atrial fibrillation)Low functional capacity (e.g. inability to climb one flight of stairs with bag of groceries)History of strokeUncontrolled systemic hypertension Open table in a new tab Table 3Cardiac risk stratification for non‐cardiac surgical procedures. Risk=combined incidence of cardiac death and non‐fatal myocardial infarction. †Patients in this group do not generally require further preoperative cardiac testing. From reference 47Eagle KA Brundage BH Chaitman BR et al.Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery.Circulation. 1996; 93: 1278-1317PubMed Google Scholar reproduced with permissionHigh risk (reported cardiac risk often more that 5%)Emergency major operations, particularly in the elderlyAortic and other major vascular surgeryPeripheral vascular surgeryAnticipated prolonged surgical procedures associated with large fluid shifts orblood lossIntermediate risk (reported cardiac risk generally less than 5%)Carotid endarterectomyHead and neck surgeryIntraperitoneal and intrathoracic surgeryOrthopaedic surgeryProstate surgeryLow risk (reported cardiac risk often more that 1%)†Endoscopic procedureSuperfical procedureCataract removalBreast surgery Open table in a new tab The respiratory mortality ranged from 0–0.6% depending on the surgical sites and the presence of pulmonary risk factors. 18Bluman LG Mosca L Newman N Simon DG. Preoperative smoking habits and postoperative pulmonary complications.Chest. 1998; 113: 883-889Abstract Full Text Full Text PDF PubMed Google Scholar, 105Olsson GL Hallen B Hambraeus‐Jonzon K. Aspiration during anaesthesia: a computer‐aided study of 185,358 anaesthetics.Acta Anaesthesiol Scand. 1986; 30: 84-92Crossref PubMed Google Scholar, 134Szekely LA Oelberg DA Wright C et al.Preoperative predictors of operative morbidity and mortality in COPD patients undergoing bilateral lung volume reduction surgery.Chest. 1997; 111: 550-558Abstract Full Text Full Text PDF PubMed Google Scholar Aspiration during anaesthesia had a high mortality of 5%. 105Olsson GL Hallen B Hambraeus‐Jonzon K. Aspiration during anaesthesia: a computer‐aided study of 185,358 anaesthetics.Acta Anaesthesiol Scand. 1986; 30: 84-92Crossref PubMed Google Scholar The mortality of pulmonary embolism was reported from 0.03–0.64% in elderly patients who underwent incontinence surgery and total hip replacement surgery respectively. 5Anonymous Collaborative overview of randomised trials of antiplatelet therapy—III: reduction in venous thrombosis and pulmonay embolism by antiplatelet prophylaxis among surgical and medical patients.BMJ. 1994; 308: 235-246Crossref PubMed Google Scholar, 133Sultana CJ Campbell JW Pisanelli WS Sivinski L Rimm AA. Morbidity and mortality of incontinence surgery in elderly women: an analysis of Medicare data.Am J Obstet Gynecol. 1997; 176: 344-348Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Risk factors for developing pulmonary embolism include age, malignancy, obesity, and the type of surgery performed. 5Anonymous Collaborative overview of randomised trials of antiplatelet therapy—III: reduction in venous thrombosis and pulmonay embolism by antiplatelet prophylaxis among surgical and medical patients.BMJ. 1994; 308: 235-246Crossref PubMed Google Scholar, 6Anonymous Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: pulmonary embolism prevention (PEP) trial.Lancet. 2000; 355: 1295-1302Abstract Full Text Full Text PDF PubMed Google Scholar, 127Sha M Ikeda M Tanifuji Y. Perioperative pulmonary embolism: a nationwide survey in Japan.Masui Jap J Anesthesiol. 1999; 48: 1144-1149PubMed Google Scholar, 133Sultana CJ Campbell JW Pisanelli WS Sivinski L Rimm AA. Morbidity and mortality of incontinence surgery in elderly women: an analysis of Medicare data.Am J Obstet Gynecol. 1997; 176: 344-348Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Recent studies demonstrated that prophylactic low dose aspirin or low dose low molecular weight heparin in high risk elderly surgical patients are effective and safe to prevent or decrease the morbidity or mortality of deep venous thrombosis (DVT) and pulmonary embolism. 5Anonymous Collaborative overview of randomised trials of antiplatelet therapy—III: reduction in venous thrombosis and pulmonay embolism by antiplatelet prophylaxis among surgical and medical patients.BMJ. 1994; 308: 235-246Crossref PubMed Google Scholar, 6Anonymous Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: pulmonary embolism prevention (PEP) trial.Lancet. 2000; 355: 1295-1302Abstract Full Text Full Text PDF PubMed Google Scholar, 127Sha M Ikeda M Tanifuji Y. Perioperative pulmonary embolism: a nationwide survey in Japan.Masui Jap J Anesthesiol. 1999; 48: 1144-1149PubMed Google Scholar Neuraxial block can reduce the odds of pulmonary embolism by 55% and deep vein thrombosis by 44%. 120Rodgers A Walker N Schug S et al.Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials.BMJ. 2000; 321: 1493www.bmj.orgCrossref PubMed Google Scholar The Pulmonary Embolism Prevention Trial Collaborative Group recently reported that aspirin reduced the morbidity and mortality of DVT and pulmonary embolism by 30% with a slight increase in gastrointestinal bleeding of lesser severity in elderly patients undergoing surgery for hip fracture. 5Anonymous Collaborative overview of randomised trials of antiplatelet therapy—III: reduction in venous thrombosis and pulmonay embolism by antiplatelet prophylaxis among surgical and medical patients.BMJ. 1994; 308: 235-246Crossref PubMed Google Scholar The cerebrovascular mortality was 0.05% in elderly patients who underwent incontinence surgery. Peri operatively, the period of greatest risk appears to be the postoperative period. 108Pedersen T Eliasen K Henriksen E. A prospective study of mortality associated with anaesthesia and surgery: risk indicators of mortality in hospital.Acta Anaesthesiol Scand. 1990; 34: 176-182Crossref PubMed Google Scholar It is the most physiologically stressful, with major changes in adrenergic activity, body temperature, pulmonary function, fluid balance, and perception of pain. 95Mangano DT Browner WS Hollenberg M London MJ Tubau JF Tateo IM. Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. The Study of Perioperative Ischemia Research Group.N Engl J Med. 1990; 323: 1781-1788Crossref PubMed Google Scholar These changes cause tachycardia and hypertension, increase imbalance in oxygen supply and demand, and incur cardiac ischaemia. 96Mangano DT Wong MG London MJ Tubau JF Rapp JA The Study of Perioperative Ischemia (SPI) Research Group Perioperative myocardial ischemia in patients undergoing noncardiac surgery–II: Incidence and severity during the 1st week after surgery.J Am Coll Cardiol. 1991; 17: 851-857Crossref PubMed Scopus (0) Google Scholar, 109Plumlee JE Boettner RB. Myocardial infarction during and following anesthesia and operation.South Med J. 1972; 65: 886-889Crossref PubMed Google Scholar Most of the pulmonary emboli occurred during the surgical procedure or within 7 days of surgery. 127Sha M Ikeda M Tanifuji Y. Perioperative pulmonary embolism: a nationwide survey in Japan.Masui Jap J Anesthesiol. 1999; 48: 1144-1149PubMed Google Scholar Accordingly, to decrease perioperative risk in the elderly population requires rigorous preoperative assessment of organ function and reserve, good intraoperative control of concomitant disorders such as coronary artery disease, ischaemic heart disease, hypertension, chronic obstructive pulmonary disease (COPD) or diabetes mellitus, and vigilant postoperative monitoring and pain management. For example, patient‐controlled analgesia/epidural analgesia (PCA/PCEA) can decrease postoperative myocardial ischaemia. 15Bartels C Bechtel JF Hossmann V Horsch S. Cardiac risk stratification for high‐risk vascular surgery.Circulation. 1997; 95: 2473-2475Crossref PubMed Google Scholar, 124Scheini H Virtanen T Kentala E et al.Epidural infusion of bupivacaine and fentanyl reduces perioperative myocardial ischaemia in elderly patients with hip fracture–a randomized controlled trial.Acta Anaesthesiol Scand. 2000; 44: 1061-1070Crossref PubMed Scopus (0) Google Scholar Ageing affects cardiac function in many ways. Stiffening of large arteries increases afterload on the heart, while myocardial stiffening impairs early diastolic filling. 53Fleg JL. Alterations in cardiovascular structure and function with advancing age.Am J Cardiol. 1986; 57: 33-44Abstract Full Text PDF PubMed Google Scholar, 114Priebe HJ. The aged cardiovascular risk patient.Br J Anaesth. 2000; 85: 763-778Crossref PubMed Google Scholar The beta‐adrenergic responsiveness of the heart decreases. Contractility does not change (despite prolongation in duration 26Capasso JM Malhotra A Remily RM Scheuer J Sonnenblick EH. Effects of age on mechanical and electrical performance of rat myocardium.Am J Physiol. 1983; 245: H72-H81PubMed Google Scholar), but the resulting increase in end‐diastolic volume plays an important role in preserving maximal cardiac output during exercise. Conduction abnormalities and bradyarrhythmias are more prevalent in the elderly and hypertension is common, potentially contributing to ischaemic heart disease and sudden cardiac death. Antihypertensive treatment appears to reduce cardiovascular mortality and heart failure. 148Weijenberg MP Feskens EJ Kromhout D. Blood pressure and isolated systolic hypertension and the risk of coronary heart disease and mortality in elderly men (the Zutphen Elderly Study).J Hypertens. 1996; 14: 1159-1166Crossref PubMed Scopus (0) Google Scholar Silent ischaemia and unrecognized MI also occur. 70Howell SJ Hemming AE Allman KG Glover L Sear JW Foex P. Predictors of postoperative myocardial ischaemia. The role of intercurrent arterial hypertension and other cardiovascular risk factors.Anaesthesia. 1997; 52: 107-111Crossref PubMed Google Scholar, 153Windsor A French GW Sear JW Foex P Millett SV Howell SJ. Silent myocardial ischaemia in patients undergoing transurethral prostatectomy. A study to evaluate risk scoring and anaesthetic technique with outcome.Anaesthesia. 1996; 51: 728-732Crossref PubMed Google Scholar Elderly patients at high risk for these conditions can be identified preoperatively by ambulatory electrocardiography and/or exercise or pharmacological stress testing. 70Howell SJ Hemming AE Allman KG Glover L Sear JW Foex P. Predictors of postoperative myocardial ischaemia. The role of intercurrent arterial hypertension and other cardiovascular risk factors.Anaesthesia. 1997; 52: 107-111Crossref PubMed Google Scholar, 110Poldermans D Arnese M Fioretti PM et al.Improved cardiac risk stratification in major vascular surgery with dobutamine‐atropine stress echocardiography.J Am Coll Cardiol. 1995; 26: 648-653Crossref PubMed Scopus (0) Google Scholar, 153Windsor A French GW Sear JW Foex P Millett SV Howell SJ. Silent myocardial ischaemia in patients undergoing transurethral prostatectomy. A study to evaluate risk scoring and anaesthetic technique with outcome.Anaesthesia. 1996; 51: 728-732Crossref PubMed Google Scholar The most common cardiac complications associated with surgery in elderly patients are MI and myocardial ischaemia. Infarction usually occurs during the first 3 days after surgery, particularly on the first postoperative day. Most postoperative MIs are silent and have non‐Q wave characteristics. 109Plumlee JE Boettner RB. Myocardial infarction during and following anesthesia and operation.South Med J. 1972; 65: 886-889Crossref PubMed Google Scholar, 129Shah KB Kleinman BS Sami H Patel J Rao TL. Reevaluation of perioperative myocardial infarction in patients with prior myocardial infarction undergoing noncardiac operations.Anesth Analg. 1990; 71: 231-235Crossref PubMed Google Scholar Postoperative pain control combined with residual anaesthetic effects is responsible for the silent nature of an MI, making them difficult to detect and their precise onset difficult to determine. 7Ashton CM. Perioperative myocardial infarction with noncardiac surgery.Am J Med Sci. 1994; 308: 41-48Crossref PubMed Google Scholar, 10Badner NH Knill RL Brown JE Novick TV Gelb AW. Myocardial infarction after noncardiac surgery.Anesthesiology. 1998; 88: 572-578Crossref PubMed Scopus (319) Google Scholar, 86Landesberg G Einav S Christopherson R et al.Perioperative ischemia and cardiac complications in major vascular surgery: importance of the preoperative twelve‐lead electrocardiogram.J Vasc Surg. 1997; 26: 570-578Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 109Plumlee JE Boettner RB. Myocardial infarction during and following anesthesia and operation.South Med J. 1972; 65: 886-889Crossref PubMed Google Scholar, 129Shah KB Kleinman BS Sami H Patel J Rao TL. Reevaluation of perioperative myocardial infarction in patients with prior myocardial infarction undergoing noncardiac operations.Anesth Analg. 1990; 71: 231-235Crossref PubMed Google Scholar Monitoring for specific ECG changes (S–T elevation and Q wave) accompanied by elevated CK, CK‐MB isoenzyme and troponin T and I levels enables diagnosis. These data also permit identification of an MI as definite, probable or possible. 10Badner NH Knill RL Brown JE Novick TV Gelb AW. Myocardial infarction after noncardiac surgery.Anesthesiology. 1998; 88: 572-578Crossref PubMed Scopus (319) Google Scholar, 30Charlson ME MacKenzie CR Gold JP et al.The preo
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