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This chapter addresses the following Geriatric Fellowship Curriculum Milestone: #44

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LEARNING OBJECTIVES

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Learning Objectives

  • Utlitize national guidelines such as the American Heart Association/American College of Cardiology guidelines to risk stratify older adults prior to surgery

  • Discuss anesthetic options for different types of surgery

  • Understand the difference between general anesthesia, regional anesthesia, and peripheral nerve blocks

  • Discuss common postoperative complications experienced by older adults after surgery

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Key Clinical Points

  1. The American Society of Anesthesiologists physical score is not a risk calculator but rather a clinician’s tool, used to describe a patient’s medical comorbidity in light of how it affects function.

  2. Effective preanesthetic evaluation is best accomplished through good communication between primary and specialist physicians, the surgeon, the anesthesiologist, and the patient.

  3. The main types of anesthesia are general anesthesia, monitored anesthesia care (sedation), regional anesthesia, and peripheral nerve blocks. A single surgery may require one or several of these techniques.

  4. Normal physiology of aging and pathophysiology of aging combine to predispose older adults to postoperative complications.

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Perioperative management of the older adult is complex. Anesthetic care itself is challenging, and both preoperative preparation and postoperative care for older adults assume greater importance than for young, healthy adults. Ideally, care is based on a comprehensive plan that integrates the roles of the anesthesiologist, surgeon, geriatrician, primary caregivers, and medical specialists. This chapter provides an overview of the role of the anesthesiologist and anesthesia techniques in pre-, peri-, and postoperative care of the older adult, in order to improve communication with other professionals who provide care to this vulnerable population.

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ANESTHESIA AND THE ANESTHESIOLOGIST

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Anesthesia is the art and science of controlling physiologic processes in order to permit interventions on the body that would be intolerable owing to normal compensatory mechanisms. Surgery, which involves a direct assault on body tissues, is the standard paradigm for understanding anesthesia. Anesthesiologists perform other valuable services, including sedation for less invasive procedures, management of pain syndromes, and the provision of critical care. European anesthesiologists are also actively involved in emergency care. Anesthesia is based on an understanding of homeostatic mechanisms and their manipulation. Homeostenosis, the restricted range and capacity of homeostatic mechanisms associated with aging, provides a challenge to the anesthesiologist. In order to tailor appropriate anesthesia care for an older adult, the anesthesia team must be familiar with the effects of aging on multiple organ systems, particularly the heart, lungs, and brain, and must be familiar with physiologic changes of age, such as changes in drug sensitivity, increase in body fat, decreased glomerular filtration, and reduced hepatic blood flow, which affect anesthetic drug action and duration.

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PREOPERATIVE CARE OF THE OLDER SURGICAL PATIENT

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Preoperative care can take place in multiple settings and can occur briefly or over a period of time. The most important goal of preoperative assessment is not the risk assessment, but the ...

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