Cardiac surgery in geriatric patients.

From June, 1960, to January, 1976, 157 patients 65 years or older had elective operations with cardiopulmonary bypass. Ninety-three patients had one or two valves replaced, 47 had coronary artery surgery, and 17 had both. The operative mortality rate was 22.6 percent (21 of 93), 19.1 percent (nine of 47), and 5.8 percent (one of 17), respectively. The over-all mortality rate was 19.7 percent (31 of 157). The mortality rate of patients of 65 to 69 years of age was 20 percent (22 of 110) and 19 percent (9 of 47) in patients 70 years or more. Ninety-four of these operations were performed within the last 3 years, with a reduction in patients' mortality rate to 9.6 percent (nine of 94). A retrospective study revealed a significant correlation between operative mortality rate and preoperative heart size. We could find no correlation between operative mortality rate and diabetes, smoking history, or hyperlipidemia. The major causes of death were myocardial infarction (68 percent-21 of 31), pulmonary complications (35 percent-11 of 31), infections (29 percent-nine of 31), and renal failure (29 percent-nine of 31) or combinations thereof. The patients who died had 2.5 times the number of complications of the survivors. Ninety percent of our patients in the past 3 years have survived their operation. Therefore, elective cardiac operations can be performed with an acceptable mortality rate in patients over the age of 65 years.     

Medical considerations and perioperative care for rheumatoid surgery

Surgery on patients with RA should be undertaken after careful consideration of a number of issues. These include an overall assessment of the status of the patient's arthritis, general health and preparedness for the procedure and the rehabilitation which follows. Special attention must be given to organs that may be affected by the systemic involvement which occurs with rheumatoid disease. Sites requiring specific review include the cervical spine, lungs, airway, bone, and bone marrow. Intraoperatively and postoperatively rheumatoid patients may require supplementary corticosteroids and an adjustment of the dose of their antirheumatic medications. Various systemic rheumatic diseases can have predominantly hand signs and symptoms at their onset. It is valuable to be familiar with the clinical features of gout with tophaceous inflammation, psoriatic arthritis, Raynaud's disease, and amyloidosis.     

术前输注支链氨基酸对老年人开腹手术围术期体温的影响

目的 观察老年人术前给予支链氨基酸对围术期体温的影响.方法 选择60例ASAⅠ或Ⅱ级,年龄60～84岁行择期腹部手术的患者,随机均分为两组.观察组术前1 h给予支链氨基酸3.5 ml/kg;对照组给予羟乙基淀粉溶液3.5 ml/kg.记录入室时(T1)、诱导时(T2)、切皮时(T3)、诱导后1 h(T4)、诱导后2 h(T5)、术后2 h(T6)的中心温度(食管温度),同时记录围术期寒战的发生率.结果 观察组术中、术后体温无明显变化;对照组术中、术后体温较术前明显下降,明显低于观察组.围术期寒战的发生率显著高于观察组(P<0.05).结论 术前输注支链氨基酸有助于维护老年腹部外科患者的体温,并降低术后寒战的发生率.     

Dermatologic surgery and the pregnant patient.

BACKGROUND: Because of concerns about potential harm to the mother or fetus, dermatologic surgeons are frequently hesitant to perform cutaneous surgery on pregnant patients. OBJECTIVE: To review the relevant physiologic changes during pregnancy, appropriate preparation for and timing of procedures, and drug safety. METHODS: A literature review was performed of dermatologic and nondermatologic journals discussing physiology, surgery, and drug safety in the pregnant patient. RESULTS: Special positioning is required for the pregnant patient during surgery. Low doses of most local anesthetics with epinephrine as well as nitrous oxide less than 50% are safe to use during pregnancy. Sedatives and opioids are potential teratogens and should be avoided. Safe antibiotics to use during skin surgery in pregnancy include penicillins, cephalosporins, and nonestolate erythromycin. If necessary, lymph node dissections under general anesthesia in the pregnant melanoma patient should occur during the second trimester. CONCLUSION: With appropriate preparation, safe and successful cutaneous surgery can be performed on the pregnant patient.     

Cardiac anesthesia and surgery in geriatric patients

The average age of US population is steadily increasing, with more than 15 million people aged 80 and older. Coronary artery disease and degenerative cardiovascular diseases are particularly prevalent in this population. Consequently, an increasing number of elderly patients are referred for surgical intervention. Advanced age is associated with decreased physiologic reserve and significant comorbidity. Thorough preoperative assessment, identification of the risk factors for perioperative morbidity and mortality, and optimal preparation are critical in these patients. Age-related changes in comorbidities and altered pharmacokinetics and pharmacodynamics impacts anesthetic management, perioperative monitoring, postoperative care, and outcome. This article updates the age-related changes in organ subsystems relevant to cardiac anesthesia, perioperative issues, and intraoperative management. Early and late operative outcome in octogenarians undergoing cardiac surgery are reviewed. The data clearly indicate that no patient group is "too old" for cardiac surgery and that excellent outcomes can be achieved in selected group of elderly patients.     

Thyroid surgery in geriatric patients: a literature review

Background

Thyroid disease is common in the elderly population. The incidence of hypothyroidism and multinodular goitre gradually increases with age. In view of a growth of aging population, we performed a literature review about the feasibility of thyroid surgery in the elderly.

Methods

We conducted a literature search in the PubMed database in September 2012 and all English-language publications on thyroidectomy in geriatric patients since 2002 were retrieved. The potential original articles mainly focusing on thyroidectomy in elderly patients were all identified and full texts were obtained and reviewed for further hand data retrieving.

Results

We retrieved five papers based on different primary end-point. Four were retrospective non randomized studies and one was prospective non randomized study. At last 65, 70, 75 and 80 years were used as an age cut-off. All studies evaluate the indications of thyroidectomy in geriatric patients, postoperative morbility and mortality. Only one study specifically assesses the rate of the rehospitalization after thyroidectomy among the elderly.

Conclusions

Thyroid nodules are particularly important in elderly patients, as the incidence of malignancy increases and they are usually more aggressive tumors. An age of at least 70 years is an independent risk factor for complications after general surgery procedures. Thyroid surgery in patients aged 70 years or older is safe and the relatively high rate of thyroid carcinoma and toxic goiter may justify an aggressive approach. A programmed operation with a careful pre-operative evaluation and a risk stratification should make the surgical procedures less hazardous, specially in 80 years old patients with an high ASA score.

     

Lowe's syndrome with Fanconi syndrome for ocular surgery: perioperative anesthetic considerations

Lowe's syndrome is a rare inherited metabolic disorder characterized by mental retardation, kidney malfunction, and abnormalities of the eyes and bones. A 4 month-old child with Lowe's and Fanconi's syndrome, undergoing bilateral congenital cataract surgery, is presented. Preoperative electrolyte imbalance was corrected by potassium, calcium, magnesium, phosphate, and bicarbonate supplementation. Anesthesia was administered uneventfully using appropriate anesthetic agents and monitoring. Adequate preoperative evaluation and optimization, along with selection of anesthetic agents and fluid and electrolyte management with appropriate perioperative monitoring, is key to a successful outcome.     

Abdominal emergency surgery in the geriatric patients. Our experience

The ageing process of general population implies new socio-sanitary problems. Indications for surgical intervention have been modified and enhanced. As far as elective surgery is concerned, the results in elderly subjects do not seem alarming, whereas less satisfactory results have been registered in the patients who underwent an emergency surgical intervention, where nowadays morbidity and mortality still turn out to be high. The Authors have reported their experience of emergency surgery in the geriatric patient. From 1982 to 2002, 718 pts (361 males, 50.3% and 357 females, 49.7%; average age 50 yrs, range 5-92) underwent emergency surgical interventions for abdominal lesions. The pts were subdivided in two groups: group A (> 65 years; 190 pts, 87 males and 103 females; average age 72 yrs, range 66-92); control group B (<65 years; 528 pts, 274 males and 254 females; average age 43 yrs, range 5-65). The results were assessed in terms of morbidity and of the operative and post-operative mortality. Postoperative morbidity proved to be equal to 25.7% (36.3% in the group A, 21.9% in the group B), while intraoperative mortality equal to 0.27%. Postoperative mortality resulted equal to 12.1% (significantly higher in group A pts -- 16.8%- than in group B pts --10.4%). The mortality of the 190 pts belonging to group A was higher in the pts which were presenting respectively 1, 2, 3 or more concomitant diseases. The progressive percentage increase in the number of interventions on elderly pts not only can be due to the demographic increase of old people, but it can also be linked to a change in the surgeon's attitude. At the present time, while elective geriatric surgery implies an acceptable mortality rate (5-8 %), emergency geriatric surgery has not notably modified the prognosis in the last decades and mortality has turned out to be still high (20-30%). We think that it will be possible to obtain better results through geriatric surgery only by reducing emergency interventions as much as possible. In order to do so, it will be important to insist on intervening before the illness, during its natural evolution, requires actions which cannot be postponed. This would lead to positive results not only in terms of mortality and morbidity, which are still considered as the main targets, but also as far as the period of the stay in hospital and costs are concerned.     

Intravenous sedation in 200 geriatric patients undergoing office oral surgery.

Two hundred geriatric patients ranging from age 65 to 92 yr (mean age 72 yr) were evaluated for office oral surgery and intravenous sedation. Surgical time ranged from 6 to 129 min. Monitored anesthesia care was utilized for the administration of fentanyl, midazolam or diazepam, and methohexital. No serious complications were seen and no patients were hospitalized.     

Optimizing perioperative management of geriatric patients with head and neck cancer

Given emerging demographic trends, many more elderly patients are being diagnosed with head and neck cancers. The surgical care paradigm for this cohort of patients must take into account specific challenges inherent to geriatric perioperative management. This article attempts to summarize the existing body of literature relevant to the geriatric head and neck cancer population, and to extrapolate relevant data from geriatric perioperative medicine in order to better understand and guide management decisions. The involvement of geriatricians and of patients' primary care providers may be invaluable in assisting in complex perioperative decision‐making and in participating in longitudinal management. Preoperative risk stratification and assessment of medical, social, and functional variables are critical for appropriate decision‐making in this challenging patient population. © 2013 Wiley Periodicals, Inc. Head Neck 36 : 743–749, 2014     

Causes of perioperative stroke after carotid endarterectomy: Special considerations in symptomatic patients

In order to maximize the efficacy of carotid endarterectomy (CEA), the rate of perioperative stroke must be kept to a minimum. A recent analysis of carotid surgery at our institution found that most perioperative strokes were due to technical errors resulting in thrombosis or embolization. From 1992 through 1997 we have performed nearly 1200 additional CEAs; the purpose of this study was to examine recent trends in the causes of perioperative stroke, with specific attention to differences in symptomatic and asymptomatic patients. The records of 1041 patients undergoing 1165 CEAs were reviewed from a prospectively compiled database. Analysis of these data showed that a history of preoperative stroke appears to increase the risk of perioperative stroke after CEA. Surgical factors associated with perioperative stroke include an inability to tolerate clamping, use of an intraarterial shunt, and having surgery performed under general anesthesia; these factors are clearly interrelated and only the use of intraarterial shunting remains a risk factor by multivariate analysis. Over half of all perioperative strokes (54%) appear to be caused by intraoperative or postoperative thrombosis and embolization. The patient requiring use of intraarterial shunting and/or with a preoperative stroke most likely has a significant watershed area of brain at increased risk of infarction. However, technical errors are still the most common cause of perioperative stroke in these high-risk patients. Such high-risk patients may manifest clinical stroke from small emboli that may be tolerated by asymptomatic clamptolerant patients. Technical precision and appropriate cerebral protection are particularly critical for successful outcomes in high-risk patients. Presented at the Twenty-fifth Annual Meeting of the Peripheral Vascular Surgery Society, Toronto, Ontario, Canada, June 10, 2000.