Anaesthesia in centenarians undergoing orthopedic surgery:
a retrospective study
Lars Hove, Thomas Rohde*, Henning Bay Nielsen
Departments of Anaesthesia and Orthopedic Surgery*, Gentofte Hospital, University
of Copenhagen, Denmark
The elderly patient is vulnerable to anaesthesia may be due to that dehydration aggravate preoperative fasting. Over six months, we evaluated retrospectively the development of marked hypotension (systolic pressure < 80 mmHg) in patients (age ≥ 80 yr) undergoing surgery for a fracture of the proximal femur. Nine-two patients (age 87 (80-101) yr; median with range) were identified and 68 patients received general anaesthesia (GA; a combination either of recofol and fentanyl/remifetanil, or sevofluran and fentanyl), while 24 patients had spinal anaesthesia (SPI) with bupivacain. For 49 patients (53%) there was at least one episode of marked hypotension and the incidence was higher in GA patients than in SPI patients (62% vs. 29%; P<0.05). Intravenous administration of ephedrine was used in more GA than in SPI patients (76% vs. 42%; P<0.05) although the perioperative blood loss (200 (50-1200 ml) and total fluid administration (2.0 (1.0-3.6) L) were similar. Independent of anaesthetic methods used and development of hypotension the length of postoperative in-hospital stay was 13 (1-150) days. The hypotensive incidence did not correlate to preoperative haemoglobin, perioperative blood loss, or fluid administration and the one-year mortality rate was 29% in SPI and GA patients. As more patients in general anaesthesia appear to require intravenous administration of ephedrine, we conclude that spinal anaesthesia is desirable for femoral surgery in the elderly but hypotension should be avoided.
General or spinal anaesthesia may be offered to patients undergoing orthopedic surgery and on an average the postoperative mortality is low but in the elderly the in-hospital and 4-month mortality rates are 11% and 50%, respectively (Oliver et al. 2004). Several factors influence mortality and in the elderly cardiovascular diseases are often subclinical (Chaves et al. 2004). In addition, already at admission the elderly patient is dehydrated which is accentuated by the fasting rules ahead of surgery. Anaesthesia causes a drop in blood pressure (Chiu et al. 2001) and depletion of intravascular volume increases the risk for marked hypotension. A marked reduction in blood pressure challenges regional tissue oxygenation (van Lieshout et al. 2003) and perioperative hypotension may affect postoperative recovery. Retrospectively we assessed the incidence of marked hypotension as defined by a systolic blood pressure below 80 mmHg (Pelosi et al. 2003, Schuttler et al. 1997) corresponding to the lower part of cerebral autoregulation (Lassen 1971). We hypothesised that the preoperative haemoglobin concentration correlates to development of perioperative hypotension, which may be influenced by fluid administration and blood loss. In addition, the choice of anaestheisa may be of importance and we investigated the 1-year postoperative mortality rate by use of the Danish Central Register.
In the hospital files we performed a search for patients (age ≥ 80 yr) who had been in anaesthesia for orthopedic surgery in a 12-month period (2002-2003). Inclusion criteria was patients who had been in anesthesia for orthopedic surgery and we located ninety-two patients in whom surgery was performed for hip athroplasty (n=31) or osteosynthesis of a fracture of proximal femur (x=61). The patients age and weight were 87 (80-101) yr and 60 (40-102) kg (median with range), respectively, and 76 patients were females and 16 patients males. The majority of patients were living in their own home and the remaining patients were in a nursing home and several patients were diagnosed with dementia (Table 1).
Legends to table
F, female; m, male. *, different value from SPI, P < 0.05.
According to age and co-morbidity most patients were in class ASA II or III. In 68 patients general anaesthesia was induced by thiopentone and suxamethonium facilitated oral intubation. Thereafter, according to weight, anaesthesia was maintained with recofol and remifentanil (n=42), recofol and fentanyl (n=2), sevoflurane and fentanyl (n=18) or sevoflurane and remifentanil (n=6). In 24 patients spinal anaesthesia was with bupivacain (5 mg/ml). Blood pressure was noted every fifth minute until extubation, and we defined marked hypotension as a drop in systolic pressure to below 80 mmHg following induction. Blood loss and administration of isotonic saline and colloids given intravenously were noted as well as duration of surgery and the total dose of ephedrine. Through the hospital system we tracked when the patients were admitted to hospital and when they were discharged.
Data are presented as medians with range and evaluated by a Friedmans test of variance and a Kruskal-Wallis test for unpaired non-parametric data. A P-value below 0.05 was considered statistically significant.
Preoperative values for the concentrations of haemoglobin, potassium, sodium and creatinin were 7.6 (5.2-9.6) mmol·L-l, 4.0 (2.6-4.7) mmol·L-l, 137 (122-142) mmol·L-l and 72 (43-164) mmol·L-l, respectively. Mean arterial pressure was 105 (70-177) mmHg and as the patients appeared in the operating room the first recordings of heart rate and arterial O2 saturation were 90 (60-135) b·min-1 and 95 (82-100) %, respectively. Perioperative fluid administration was isotonic saline (1500 (1000-3000) ml) and colloids (500 (500-1500) ml). Including perioperative blood transfusions the total fluid infusion was 2000 (1000-3600) ml or 36 (14-78) ml·kg-l and perioperative blood loss was 200 (50-1200) ml.
For 49 patients (53%) there was at least one episode of marked hypotension and the incidence was higher in GA patients than in SPI patients (62% vs. 29%; P<0.05). In patients with recofol-remifentanil anaesthesia the incidence of marked hypotension was 64% as compared to 55% in patients with sevoflurane-fentanyl anaesthesia. Intravenous administration of ephedrine was used in 47 patients and the drug was injected in more GA patients than in SPI patients (75% vs. 42%, P<0.05) at a similar dose.
The preoperative concentration of haemoglobin was similar in patients who developed hypotension and in patients who maintained higher blood pressure. This was also the case for fluid administration and blood loss. There was no correlation between any preoperative data and development of marked hypotension during anaesthesia. Independent of preoperative hemoglobin, anaesthetic methods and hypotension, postoperative recovery was 13 (1-150) days. Within 1 year after surgery 27 patients were registered as dead and in SPI and GA patients the number of deaths were 7 and 20 patients, respectively, corresponding to a one-year mortality rate of 29% in both groups.
In this retrospective material, transient marked hypotension appeared in about half of elderly patients who underwent orthopedic surgery. The incidence of hypotension was higher in patients in general anaesthesia than in spinal anaesthesia and hypotension was not correlated to preoperative haemoglobin, fluid administration or postoperative recovery. Ephedrin was administered to more patients in general anaesthesia than to patients in spinal anaesthesia.
The growing population of patients in the age of 80 yr and older involves an increased need for orthopedic surgery and in turn careful selection of anaesthesia as in elderly patients cardiovascular disease often is subclinical (Chaves et al. 2004). During anaesthesia circulation should be stable, whereby regional blood supply is ensured. Normally wide variations in blood pressure are well-tolerated (Lasen 1971), but the individual lower blood pressure that decreases flow is not known. In the present retrospective study of elderly patients, marked hypotension appears to be a general complication, probably related to that more patients underwent general anaesthesia, Following induction of anaesthesia hypotension is commonly reported (Chiu et al. 2001) and in elderly patients blood pressure may increase after intubation (Habib et al. 2002). It is important to note, though, that perioperative hypotension does not predict recovery as previous reported in elderly patients undergoing elective ophthalmic surgery (Luntz et al. 2004). In addition even 30-day mortality is significant as reported in a Danish population (Palm et al. 2006) and in the present study about one-third of the population was dead one year after the surgery. Other reports that functional recovery is limited to 50% of those who fracture being a significant economic burden on the health care system (Wehren and Magaziner 2003).
In several patients recofol-remifentanil anaesthesia was used and although the incidence of marked hypotension tended to be higher than in patients with sevoflurane-fentanyl anaesthesia, it did not reach statistical significance. This should be compared to that in a multicentre, double-blind randomised study of recofol-remifentanil or recofol-alfentanil anaesthesia hypotension may appear in up to 53% of patients undergoing surgery for major abdominal surgery (Schuttler et al. 1997) and recofol and sevoflurane-based maintenance of anaesthesia induces similar patient discomfort and recovery in the elderly (Luntz et al. 2004). However, anaesthesia with remifentanil provokes more episodes with hypotension than fentanyl (Joshi et al. 2002) or alfentanil (Schuttler et al. 1997, Nilsson et al. 2002) anaesthesia although hypotesion may be easily corrected by remifentanil dose reduction.
This may explain why ephedrin appeared to be used more frequent in GA patients. In elderly patients the use of vasoactive drugs may have detrimental effects on myocardium as the incidence of cardiovascular disease increases with age (Chaves et al. 2004). It should also be considered that spinal anasthesia offers post-operative pain relief as well as development of nausea due to morfin is limited.
In elderly patients and in cases when marked hypotension can be expected during surgery in general anesthesia, monitoring of the patients should be supplemented by equipment that easily determines changes in central and peripheral hemodynamic. Near-infrared spectrophotometry is a technique that based on the light absorbing properties of haemoglobin measures changes in tissue oxygenation, which reflect the metabolic rate and the balance between local O2 delivery and utilization (Boushel et al. 1998, Madsen and Secher 1999). During anaesthesia, the use of such non-invasive methods would guide when a low blood pressure is too low for a steady O2 balance and in particularly cerebral oxygenation of elderly patients as the cerebral autoregulation may be shifted to the right due to atherosclerosis.
In response to orthopedic surgery up to about half of elderly patients may develop transient marked hypotension. Spinal anaesthesia is recommended to elderly patients.
1. Boushel R, Pott F, Madsen P, Radegran G, Nowak M, Quistorff B, Secher N. Muscle metabolism from near infrared spectroscopy during rhythmic handgrip in humans. Eur J Appl Physiol 1998; 79: 41-8.
2. Chaves PH, Kuller LH, O´Leary DH, Manolio TA, Newman AB. Subclinical cardiovascular disease in older adults: insigths from the cardiovascular health study. Am J Geriatr Cardiol 2004; 13: 137-51.
3. Chiu CL, Tew GP, Wang CY. The effect of prophylactic metaraminol on systemic hypotension caused by induction of anaesthesia with propofol in patients over 55 years old. Anaesthesia 2001; 56: 893-7.
4. Habib AS, Parker, JL, Maguire AM, Rowbotham DJ, Thompson JP. Effects of remifentanil and alfentanil on the cardiovascular responses to induction of anaesthesia and tracheal intubation in the elderly. Br J Anaesth 2002; 88: 430-3.
5. Joshi GP, Warner DS, Twersky RS, Fleisher LA. A comparison of the remifentanil and fentanyl adverse effect profile in a multicenter phase IV study. J Clin Anesth 2002; 14: 494-9.
6. Lassen, NA. Regulation of cerebral circulation. Acta Anaesthesiol Scand 1971; 45: 78-80.
7. Luntz SP, Janitz E, Motsch J, Bach A, Martin E, Bottiger BW. Cost-effectivenes and high patient satisfaction in the elderly: sevoflurane versus propofol anaesthesia. Eur J Anaesthesiol 2004; 21: 115-22.
8. Madsen PL, Secher NH. Near-infrared oximetry of the brain. Prog Neurobiol. 1999; 58: 541-60.
9. Nilsson LB, Viby-Mogensen J, Moller J, Fonsmark I, Ostergaard. Remifentanil vs. alfentanil for direct laryngoscope: a randomized study comparing two intravenous anaesthesia techniques. TIVA for direct laryngoscope. Acta Anaesthesiol Belg 2002; 53: 213-9.
10. Oliver CW, Burke C. Hip fractures in centenarians. Injury 2004; 35: 1025-30.
11. Palm H, Krasheninnikoff M, Jacobsen S. Surgical treatment of proximal femoral fractures. Ugeskr Laeger 168: 2891-6, 2006.
12. Pelosi G, Gratarola A, Mendola C, Bellomo G. Total intravenous anesthesia with propofol and remifentanil for elective non-cardiac surgery. Minerva Anestesiol 1999; 65: 791-8.
13. Schuttler J, Albrecht S, Breivik H et al A comparison of remifentanil and alfentanil in patients undergoing major abdominal surgery. Anaesthesia 1997; 52: 307-17.
14. van Lieshout JJ, Wieling W, Karemaker JM, Secher NH. Syncope, cerebral perfusion, and oxygenation. J Appl Physiol 2003; 94: 833-48.
15. Wehren LE, Magaziner J. Hip fracture: risk factors and outcomes. Curr Osteoporos Rep 2003; 2: 78-85.
Address for correspondence
Henning Bay Nielsen. MD DMSci
Department of Anaesthesia
Niels Andersens Vej 65
Copyright Priory Lodge Education Limited 2007
First Published August 2007