Midazolam Effects on Preoperative Anxiety and Hemodynamic Changes for Hypertensive and Normotensive Elderly Patients / 대한마취과학회지

BACKGROUND: Midazolam, a water soluble benzodiazepine, is a good sedative, hypnotic, anxiolytic, and anticonvulsant drug. During stressful condition such as an operation, sympathetic tone increases and cardiovascular variables are unstable. This study evaluated the effects of midazolam for cardiovascular stability in elderly patients during anxiety and stress conditions. Method: Thirty patients (aged 61-93 yrs and in ASA 1, 2, and 3), who were scheduled for lower extremity surgery and showed elevated blood pressure before anesthesia, were divided into two groups. Group 1 (n = 15) has taken antihypertensive medication and group 2 (n = 15) had no hypertension history. Blood pressure and pulse of all patients were checked at 8 AM on operation day, arrival in operation room, 5, 10, 15 min. before anesthesia and every 5 min after anesthesia. Patients were given intravenous midazolam 0.01 mg/kg every 5 min until blood pressure lowered to 140/90 mmHg or spontaneous eye closing. RESULTS: The midazolam doses were 1.7 mg in group 1, 1.2 mg in group 2, and the total dose of midazolam for elderly patient was 1.5 mg (0.03 mg/kg). The sedation level was between the Ramsey scale 3-4. Age is a major determinant in deciding the dose of the drug. Blood pressure at arrival in the operation room was significantly elevated, but, 15 min after the midazolam injection, blood pressure was decreased to blood pressure level at 8 AM of the operation day. Conclusion: The total dose of midazolam for the elderly is nearly 1/3-1/4 of the recommened dose for healthy young adults. Small doses of midazolam in elderly patients were good for anxiolysis and cardiovascular stability.

Analysis of Preoperative Echocardiography in 381 Geriatric Patients / 대한마취과학회지

BACKGROUND: In geriatric patients, cardiovascular disease is common and a main cause of perioperative morbidity and mortality. Therefore preoperative evaluation of cardiac function is important. The purpose of this study is to evaluate preoperative echocardiography in geriatric patients for understanding aging heart changes and proper selection of patients. METHODS: In the 381 geriatric patients, authors evaluated chamber size, wall thickness, wall motion, valve abnormalities and ejection fraction. In addition, in patients who had left ventricular dysfunction (ejection fraction < OR = 55%), authors evaluated past medical histories and electrocardiographic (ECG) findings. RESULTS: Left atrial enlargement was present in 16%, left ventricular enlargement in 3%, right ventricular enlargement in 6%, ascending aorta dilatation in 13% and left ventricular hypertrophy (LVH) in 28%. Aortic regurgitation (AR) was present in 44%, mitral regurgitation (MR) in 42%, aortic valve calcification in 21% and hypokinesia of the left ventricular wall in 4%. Left ventricular dysfunction was present in 18 patients and their past medical histories showed hypertension in 39%, myocardial ischemia in 33%, congestive heart failure in 28% and diabetus mellitus in 28%. Also their ECG findings showed LVH in 45%, atrial fibrillation in 30% and ventricular premature contraction in 15%. Among the 18 patients with left ventricular dysfunction, 16 patients (89%) had dyspnea or heart disease histories such as myocardial ischemia, myocardial infarction, congestive heart failure, premature ventricular contraction and atrial fibrillation. CONCLUSIONS: 16% of the patients showed a normal echocardiograpy. Abnormal findings of the echocardiography were, in order of frequency, AR (44%), MR (42%) and LVH (28%). Dyspnea or cardiac disease histories were present in 89% of the left ventricular dysfunction patients.

Analgesic Effect and Postoperative Cognitive Impairment of Patient Controlled Analgesia in Postoperative Elderly / 대한마취과학회지

BACKGROUND: Since postoperative cognitive impairement is common in elderly patients and normal cognitive function is important for proper use of patient controlled analgesia (PCA), we compared the efficacy, adverse effect and postoperative cognitive impairment among postoperative elderly patients given the PCA morphine, fentanyl and meperidine. METHODS: Forty-five elderly patients were randomly allocated to receive patient-controlled analgesia with either morphine, fentanyl or meperidine following upper abdominal surgery. Patients were evaluated for used doses, adverse effects, visual analogue scale, the satisfaction for analgesia during postoperative 2 days and the Mini Mental Status Examination (MMSE) and the Short Portable Mental Status Questionnaire (SPMSQ) at posoperative 1 day. RESULTS: Patients receiving the PCA fentanyl used more opioid based on a dose expressed as morphine equivalents using the putative potency ratios of 1:10:0.01 (morphine/meperidine/fentanyl). But adverse effects, visual analogue scale, and the satisfaction for analgesia were not statistically different between groups. The decrease in MMSE in the PCA-meperidine group was significantly greater than that seen in the PCA-fentanyl group and the PCA-morphine group. SPMSQ were not statistically different between groups. CONCLUSION: The present result suggest that PCA is effective method in posterative elderly without serious complications. But PCA meperidine may be avoided in the elderly because it can contribute to decrease postoperative cognitive function.

Analgesic Effect and Postoperative Cognitive Impairment of Patient Controlled Analgesia in Postoperative Elderly / 대한마취과학회지

BACKGROUND: Since postoperative cognitive impairement is common in elderly patients and normal cognitive function is important for proper use of patient controlled analgesia (PCA), we compared the efficacy, adverse effect and postoperative cognitive impairment among postoperative elderly patients given the PCA morphine, fentanyl and meperidine. METHODS: Forty-five elderly patients were randomly allocated to receive patient-controlled analgesia with either morphine, fentanyl or meperidine following upper abdominal surgery. Patients were evaluated for used doses, adverse effects, visual analogue scale, the satisfaction for analgesia during postoperative 2 days and the Mini Mental Status Examination (MMSE) and the Short Portable Mental Status Questionnaire (SPMSQ) at posoperative 1 day. RESULTS: Patients receiving the PCA fentanyl used more opioid based on a dose expressed as morphine equivalents using the putative potency ratios of 1:10:0.01 (morphine/meperidine/fentanyl). But adverse effects, visual analogue scale, and the satisfaction for analgesia were not statistically different between groups. The decrease in MMSE in the PCA-meperidine group was significantly greater than that seen in the PCA-fentanyl group and the PCA-morphine group. SPMSQ were not statistically different between groups. CONCLUSION: The present result suggest that PCA is effective method in posterative elderly without serious complications. But PCA meperidine may be avoided in the elderly because it can contribute to decrease postoperative cognitive function.

Changes in Cardiopulmonary Variables during Cemented Hip Arthroplasty in the Elderly Patients / 대한마취과학회지

BACKGROUND: Bone cement implantation syndrome is characterized by hypotension, hypoxemia, cardiac arrhythmia, cardiac arrest, or any combination of these complications. The purpose of this study was to examine the effects of methylmethacrylate bone cement on cardiopulmonary variables during cemented hip arthroplasty in the elderly patients. METHODS: Twenty patients, aged over 65, undergoing cemented hip arthroplasty under general anesthesia were evaluated. Various cardiopulmonary variables with pulmonary and radial artery catheter, analysis of arterial blood gases, and capnography were measured at pre- and post-prosthetic insertion. RESULTS: The application of methylmethacrylate bone cement and femoral prosthesis resulted in an increase in pulmonary artery pressure and pulmonary vascular resistance, but there were no significant changes in blood pressure, heart rate, cardiac output, and systemic vascular resistance. Cemented hip arthroplasty was also associated with increased PaCO2 and dead space ventilation. Decreased PaO2 (1 atient) and hypotension (2 patients) were noted just after implatation of bone cement and prosthesis. CONCLUSIONS: In conclusion, hip arthroplasty with methylmethacrylate bone cement is associated with substantial risk in the elderly patients. We make recommendations of measures for the prevention and the management against hypotension and hypoxemia during cemented hip arthroplasty in the elderly patients.

Hyperkalemia Following Succinylcholine Administration in Elderly Patient with Chronic Hypokalemia: A case report / 대한마취과학회지

Acute hyperkalemia may result from excessive load, transcellular shift, decreased renal excretion and so on. Potassium release following succinylcholine administration is sufficient to cause ventricular dysrrhythmia and cardiac arrest in some conditions such as severe burn, massive trauma, spinal cord injury, some neuromuscular disease, and cerebral damage. We experienced a case of acute hyperkalemia associated with cardiac arrythmia immediately after administration of succinylcholine in a 80 year-old male patient who was diagnosed as spondylitis tuberculosa and psoas abscess. The hyperkalemia was attenuated by calcium chloride and sodium bicarbonate and cardiovascular instability was treated by vasoactive drugs symptomatically. Though the eldery patient with diabetes mellitus had been shown chronic hypokalemia, we should be aware of occurrence of sudden hyperkalemia after administration of succinylcholine.

Three Cases of Taylor's Approach in Geriatric Patients / 대한마취과학회지

The Taylor's approach is a special paramedian approach to enter the L5-S1 interspace. The L5-S1 interspace is the largest in vertebral column. This approach is particularly useful when the interspace has been narrowed by pathologic bone destruction such as rheumatoid arthritis or osteoarthritis. Surgery in geriatric patients is associated with a markedly higher incidence of perioperative complication or mortality rate. Optimal anesthetic management of geriatric patients depends on understanding of the normal anatomy and physiologic changes in response to drug in aging. We studied of 3-geriatric patients with Taylor's approach. These patients had problems with respiratory dysfunction and anatomic constraints, which make other approaches unfeasible.

Action Duration of Atracurium in the Elderly Patients / 대한마취과학회지

BACKGROUND: The effects of a muscle relaxant may differ in elderly compared with young adult patients for a variety of the pharmacokinetic and pharmacodynamic reasons. Atracurium is eliminated by nonorgan dependent pathway, Hofmann elimination and ester hydrolysis. So there are some arguments for age-related differences. The purpose of this study was to compare the differences of the onset and duration of atracurium in young and elderly. METHODS: Eighteen young adults (21-54 yr) and 18 elderly (>65 yr) patients anesthetized with nitrous oxide and enflurane. Atracurium (0.5 mg/kg) was given and then intubation was performed after T1 response was blocked more than 80%. Neuromuscular relaxation was measured by the first twitch of train-of-four (T1) response at the adductor pollicis after supramaximal stimulation of ulnar nerve at 2Hz every 12 sec. The onset (disappearance of T1) and duration of 5, 25, 50, 75% recovery time of T1 and recovery index (time for 25-75% recovery of T1) were recorded. RESULTS: Onset of block was not significantly different between the young and elderly. Recovery time of 5, 25, 50, 75% and recovery index were not prolonged in elderly compared with young adults. CONCLUSIONS: There were no significant differences between young and elderly adults in onest time, recovery time of 5, 25, 50, 75% and recovery index when atracurium is used in a single bolus dose. The results suggest that atracurium in elderly patients has similar onset and action duration compared with younger patients.