Geriatric pain management, pharmacological and nonpharmacological considerations

Persistent pain is prevalent in the elderly population, although it is not an inevitable part of aging. It is important to understand how to manage pain effectively in old age, particularly because an increasing number of individuals are becoming older, or living longer. Several problems, less common in younger adults, may complicate the treatment of pain. An accurate pain assessment is required for the most efficient strategy of pain treatment. Challenges to an effective pain assessment include: pain underreporting by patients, atypical manifestations of pain in elderly, age-associated pharmacodynamic and pharmacokinetic changes to specific drugs, other general age-related changes, and misconceptions about tolerance or addiction to opioids. However, physicians are able to provide geriatric patients with appropriate analgesia by using comprehensive assessment involving a multidisciplinary approach, and the appropriate use of various treatment modalities.

Geriatric pain management, pharmacological and nonpharmacological considerations

Persistent pain is prevalent in the elderly population, although it is not an inevitable part of aging. It is important to understand how to manage pain effectively in old age, particularly because an increasing number of individuals are becoming older, or living longer. Several problems, less common in younger adults, may complicate the treatment of pain. An accurate pain assessment is required for the most efficient strategy of pain treatment. Challenges to an effective pain assessment include: pain underreporting by patients, atypical manifestations of pain in elderly, age-associated pharmacodynamic and pharmacokinetic changes to specific drugs, other general age-related changes, and misconceptions about tolerance or addiction to opioids. However, physicians are able to provide geriatric patients with appropriate analgesia by using comprehensive assessment involving a multidisciplinary approach, and the appropriate use of various treatment modalities.(AU)

Postoperative apnea, respiratory strategies, and pathogenesis mechanisms: a review.

Recovery from anesthesia is ideally routine and uneventful. After extubation, the recovering postoperative patient ought to breathe without supportive care or additional oxygenation. It has been demonstrated in previous studies that postoperative pulmonary complications are clinically relevant in terms of mortality, morbidity, and length of hospital stay. Compromised postoperative ventilation can be described as the condition in which the postoperative patient does not have satisfactory spontaneous ventilation support and adequate oxygenation. Causes of impaired ventilation, oxygenation, and airway maintenance can be mechanical, hemodynamic, and pharmacologic. This review describes prevalence and differential diagnosis, including co-morbidities of postoperative apnea. The physiological mechanisms of breathing and prolonged postoperative apnea are also reviewed; these mechanisms include influences from the brainstem, the cerebral cortex, and chemoreceptors in the carotid and aortic body. Causes of prolonged postoperative apnea and management are also discussed.

Preanesthetic Assessment of the Jehovah's Witness Patient.

The Jehovah's Witnesses, a religious group of 7 million people in more than 200 countries, teaches its followers to not accept blood, resulting in potentially challenging and ethical dilemmas for anesthesiologists. In recent years, Jehovah's Witnesses changed certain elements of their approach to blood transfusion practice, including accepting autologous transfusions in certain circumstances. We examine mechanisms to resolve ethical conflicts, such as additional medical consultations with other involved physicians, surgeons, and anesthesiologists; short-term counseling or psychiatric consultation for patient and family; case management conferences; consultation with individuals trained in clinical ethics or a hospital-based ethics committee; and discussions with hospital administration. We also discuss treatment options, including certain blood products, anesthetic techniques, and pharmacological interventions.

Left-to-right cardiac shunt: perioperative anesthetic considerations.

Congenital heart disease (CHD) affects roughly 8/1000 live births. Improvements in medical and surgical management in recent decades have resulted in significantly more children with left-to-right cardiac shunts surviving into adulthood. Surgical care of these patients for their original cardiac defect(s) or other non-cardiac medical conditions requires thorough understanding of cardiopulmonary changes and mastery of treatment options. Commonly encountered CHD with left-to-right shunt include atrial septal defect (ASD), ventricular septal defect (VSD), endocardial cushion defect (ECD) and patent ductus arteriosus (PDA). The key pathological change is increased pulmonary vascular resistance (PVR) and pressure secondary to increased blood flow from the left-to-right shunt. Increasing PVR and pulmonary arterial hypertension (PAH) will lead to reversed direction of blood flow through the cardiac defect (Eisenmenger Syndrome) and heart failure. Cardiac defects with left-to-right shunt generally require surgical or trans-catheter repair at an early age. We review the current concepts and general principles of perioperative anesthetic management of CHD, including neuraxial anesthesia. Current techniques and unique pharmacodynamic and pharmacokinetic effects of some commonly used anesthetic agents in patients with left-to-right shunt are also reviewed.

Endotracheal tube cuff leak with mysterious laryngotracheal pathology.

A 63 year-old obese man with gastroesophageal reflux disease, hiatal hernia, and no known history of airway pathology was to undergo a total knee arthroplasty. After intubation, however, repeated cuff leaks, decreasing tidal volumes, and desaturations prompted five additional endotracheal tube placements. Findings on radiography, computed tomography, and fiberoptic laryngoscopy and tracheoscopy were equivocal. Factors contributing to this challenge of persistent and repeated cuff leaks in the absence of known airway pathology could include various laryngotracheal abnormalities.

Mucopolysaccharidoses: anesthetic considerations and clinical manifestations.

Mucopolysaccharidosis (MPS) is a group of genetic disorders that presents challenges during anesthetic care and in particular difficulty with airway management. Patients should be managed by experienced anesthesiologists at centers that are familiar with these types of conditions. Rarely encountered disease states have been identified as important topics in the continuing education of clinical anesthesiologists. This review will define MPS, describe the pathophysiology of MPS, describe how patients with this rare lysosomal storage disorders have dysfunction of tissues, cite the incidence of MPS, list the clinical manifestations and specific problems associated with the administration of anesthesia to patients with MPS, present treatment options for patients with MPS, define appropriate preoperative evaluation and perioperative management of these patients, including, to anticipate potential postoperative airway problems.

Update on neonatal resuscitation.

Although only 10% of neonates born in the United States require resuscitation, availability of well trained personnel skilled in neonatal resuscitation can result in a significant decline in neonatal morbidity and mortality. One important aspect of performing a successful resuscitation is having a good understanding of the complex dynamics of fetal/neonatal physiology and the adaptations that must be made to transition to extrauterine life. This knowledge will allow one to better serve the resuscitative needs of the neonate. Performing a risk assessment by evaluating maternal and fetal risk factors is important. Review of medical history including medications, may reveal other medical conditions (e.g. gestational diabetes, preeclampsia, etc.). Once the need for resuscitation is recognized, easy access to equipment, medication and supplies can result in a successful resuscitative effort.

Wegener's granulomatosis.

The immunopathologic disease, Wegener's granulomatosis, presents a challenge to the anesthesiologist due to multisystem involvement resulting in potential abnormalities of the airway, respiratory, circulatory, renal, and central/peripheral nervous systems. It is a systemic vasculitis of small, medium and occasional large arterial involvement. A familiarity with the proper approach to perioperative management is essential. Additional considerations must be made as problems arise from immunosuppressant and corticosteroid treatment.

Malignant hyperthermia associated with diabetic hyperosmolar hyperglycemic nonketotic state in a young man.

Malignant hyperthermia (MH) is a rare complication that often leads to adverse outcomes, catastrophic events, or death. Although various risk factors and underlying diseases are associated with this condition, unusual presentations may be missed. Malignant hyperthermia is an uncommon complication encountered during the treatment of patients with diabetic ketoacidosis. We present a case of an MH-like syndrome in a young Hispanic man who was diagnosed with new-onset diabetes mellitus and hyperglycemic hyperosmolar nonketotic state. The patient had no obvious risk or precipitating factors for MH.

Rheumatoid arthritis: current pharmacologic treatment and anesthetic considerations.

A diagnosis of rheumatoid arthritis carries with it a lifelong progressive disease; however twenty percent of patients enjoy periods of partial to total remission. After remission, the disease will frequently plague previously unaffected joints. Life expectancy is reduced by an average of three to seven years. Complications of RA include vasculitis and amyloidosis affecting any vessel, including the aorta. Additionally, complications of therapy such as chronic NSAID use leading to GI bleeding and infections associated with long term steroid use, can add to the difficulties of the disease. The recent discovery and use of anticytokines and DMARDs has lead to greatly reduced symptomology associated with RA and greater patient comfort. Side effects of drugs should be well understood including the risk of bleeding from NSAIDs. Management and surgical intervention of problems that arise from this disease vary dramatically. The anesthesiologist must be aware of airway pathologies, pain management techniques, and available pharmacology parameters.

Chronic pain and ultrarapid opioid detoxification.

Availability of opiate substances through physicians and on the street has led to a rise in dependence and in addiction resulting in countless numbers of people hooked on these drugs. Long-term use of these agents results in reduction of endogenous supply of opiate replaced by these exogenous compounds. A technique known as Ultrarapid Detoxification (UROD) has been developed and appears more promising than conventional modalities. UROD has been modified over 3 decades resulting in a safe and an effective general anesthetic that results in hemodynamically stable withdrawal without manifestation of central nervous system hyperarousal. A cornerstone of this technique involves clonidine, which stimulates reuptake of catecholamines and allows for large doses of opioid antagonist to be delivered without significant changes in heart rate or blood pressure, displacing the opiate. Though techniques vary from center to center, safety should be paramount with the technique performed in an intensive care unit with trained professional anesthesiologists. Psychosocial issues should be evaluated by a trained addictionalist and most people will succeed from the UROD procedure without experiencing the horrible withdrawal syndrome. Patients must have realistic goals and be prepared to deal with psychosocial issues post-procedure.

A contemporary review of multiple organ failure.

MOF or MOSF is a serious condition that represents a leading cause of death in critically ill or injured patients. It commonly begins as a result of injury, widespread inflammation, infection, shock or a combination of the above. Progression from SIRS to MOSD and on to MOF can occur within days. Therefore, careful systemic monitoring of respiratory, cardiovascular central nervous, renal, hepatic, gastrointestinal and hematologic function is vital. Although certain mechanisms such as decreased O2 supply to cells, neutrophil priming, increased TNF-alpha, interleukins, and NO have been implicated, an effective treatment for this condition remains elusive. The anesthesiologist and critical care professionals must work together to effectively evaluate and treat the MOF patient.