Applied Geriatric Anesthesia Ved Prakash Kumra
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1Applied Geriatric Anesthesia
2Applied Geriatric Anesthesia
Ved Prakash Kumra MD, DA, Dac, MAcFI Emeritus Consultant Deptt. of Anesthesiology Pain and Perioperative Medicine Sir Ganga Ram Hospital, New Delhi Formerly, Vice President ISA (National)-2000
3Published by
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Applied Geriatric Anesthesia
© 2008, Jaypee Brothers Medical Publishers
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First Edition: 2008
9788184482706
Typeset at JPBMP typesetting unit
Printed at Gopsons
4
To My mother
Mrs Saraswati Devi Kumra
01.01.1916 – 01.01.2006
5Contributors
Foreword
In India geriatric population is raising consequent on the increase in average life expectancy. Geriatric surgical problems relate to all the organ systems. Many surgical options are available to them and the concern is about the safety of surgery in the elderly age group. Dr VP Kumra an expert anesthesiologist has felt the dire needs of the profession to highlight specific issues and he has edited the book ‘Applied Geriatric Anesthesia’ with contribution from several experts.
The chapters contain Basic sciences, Pathophysiology to include every aspect of geriatric surgery with special reference to anesthetic services. I am delighted to know that this book could fill in the large gaps in our knowledge, particularly for the trainees in anesthesia and postgraduates. The book reflects Dr Kumra's ambition to share his lifetime experiences with all the anesthesiologists, particularly the trainees who have chosen this speciality.
I am sure the book will be useful addition to the existing anesthesiology literature. Dr Kumra and all the contributors deserve our heartiest congratulations.
(Prof A Rajasekaran)
ADDRESS FOR COMMUNICATION
At Delhi:
At Chennai
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New Delhi-110 029
Tel.: 011-26589090 (Per)
E-mail: drrajasekaran@vsnl.net
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Tel. Off.: 044-28284647 (Res) 044-24421032
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Message
The population of the elderly, during the post independent years, has unmistakenly gone up, be it the metros or the far-flung remote villages of India. The trend will continue though this speaks well of a caring society, it does burden the medical fraternity with an unenvious responsibility of looking after the needs of a segment, which is mentally and physically frail. Aging is accompanied by changes in organ functions and their response to drugs. The margin of various functional reserves drops down causing a severe fall in their capacity to adapt to various stresses. Though adequate to deal with their day-to-day sedentary life, the serious shortcoming comes to the fore in the presence of surgery, infections, anaemia and preoperative psychological tensions.
Seeing a morbid centurion on to operating table an anesthesiologist feels more than challenging. While dealing with the elderly we should appreciate that there is not always a correlation between the biological and the chronological age. It makes the anesthesiologist's task more difficult. A septuagenarian, thus, could physiologically be more decompensated than an octogenarian.
It is heartening to observe the concern of Dr VP Kumra and other contributors. Forewarned is, indeed, forearmed. Their endeavour to educate will go a long distance to arm the anesthesiologist on various fronts and suitably equip him. Compromised as these elderly are, it becomes difficult to retrieve an undesirous anesthetic move. With detailed information on almost all the aspects, the book will be a ready source of reference under such situations. I do expect the book will adequately address the needs of the knowledge seeking students, practitioners and consultants. The practitioners of Gerontology should 9also find the book useful. However, the one to benefit the maximum is the remotely placed anesthesiologist starved of contemporary knowledge.
Well conceived and timely written by Indian authors the book will also serve the growing needs of a growing population.
Dr Kumra and his team need to be congratulated for their brilliant effort.
(RS Saxena)
10Preface
The need of subspeciality with specific deliberations in relation to geriatric surgical patient population was long overdue. With heightened awareness about the essential role of anesthesiologists that is critical to optimal perioperative anesthesia care to this valuable patient population, geriatrics anesthesia's existence is increasingly becoming a reality, especially because of a steep global rise in elderly population above the age of 65 years who are chronically on multiple drug therapy and undergo at least 2–3 surgeries in a life time.
This inaugural textbook will not only appease physicians closely involved in anesthesia care of the elderly, but also complement the purported special status of the elderly patient across various specialities of medical science.
The book is a compilation of various reviews on the topic concerned and personal experiences of majority of the contributors who are well known at national and international levels in the field of Anesthesiology, Pain and Perioperative care.
It would be particularly useful to postgraduate trainees in anesthesia. Most importantly, it will help improving clinical practice of anesthesia involving aged patients.
Ved Prakash Kumra
11Introduction
Population explosion over the age of 65 years, represents the fastest growing segment globally, especially in the developing countries. In India, according to the Census, Registrar General of India, 2001, the life expectancy has increased from 32 years in 1947 to 65 years in 2001 raising the quantum of elderly population from approx. 19.00 millions in 1950 to 75.9 millions in 2001 and is expected to be more than 140 millions by 2020. Aging of the baby-boom population and the decrease in adult mortality rate seen in the recent few decades has also predicted a dramatic increase in global elderly population between 2010 and 2030. Population over 65 years is expected to grow by 75%, and the cumulative growth of the population above 85 years, between 1995-2050 is expected to rise by 400%.
The implications of aging population for the practice of medical speciality especially anesthesiology, are profound as age-related changes in physiology and pharmacology can adversely influence every aspect of perioperative care. In addition, associated age-related co-medications in over 50% of these elderly make their management more complex and complicated. They are also prone to require at least one or two surgeries in lifetime.
The associated diseases like hypertension, ischaemic heart disease, diabetes mellitus and hepatorenal dysfunction essentially warrant thorough assessment and planning of a clear-cut anesthetic protocol in this age group. This has projected the need for another subspeciality, geriatric anesthesia, to provide holistic and efficient care for this growing population.
During the past few years, number of lecture series, reviews and guidelines are being issued from time to time in the western literature to streamline various issues for the management of geriatric surgical population. With these sensitive issues in mind, I have ventured to consult contemporary eminent anesthesiologists, proficient in their respective fields and requested them to contribute their experience in the prevailing Indian conditions. We hope it will initiate the process of preparing the guidelines for perioperative care of the elderly and enable us to comprehensively look after this heterogenous population adequately and provide them healthy lifespan.
We hope the information regarding pathophysiological alteration in aging and its implications, pharmacology of aging, age related diseases and perioperative care shall be very useful for the geriatric 12surgical patient and will stimulate the anesthesiologists to take interest to further this noble cause.
In this upcoming new subspeciality of great importance, each chapter provides detailed background of pathophysiology and its anesthetic implications. It may obviously result in few repetitions or overlap. Nevertheless, it will provide additional stress on the vital steps in patient management in this age group.
I dedicate this book to my most respected teacher, mentor and guide, Late Dr Faqir Chand Khandpure for providing vision and encouragement to be thoroughly involved in the speciality of anesthesia. It in his inspiration that stimulated me to write this book on very vital subject for the care of elderly patients.
I am grateful to Dr BK Rao, Chairman, Board of Management, Sir Ganga Ram Hospital for his continuous support and encouragement.
I also owe my heartfelt thank and gratitude to Dr Jayashree Sood for her support and providing the most useful, experts secretarial services, without whom the work would not have completed in time.
My special thanks go to Dr Raminder Sehgal and Dr Amitabh Dutta for their uninterrupted help during the completion of this book.
I take this opportunity to thank all the contributors for various chapters, who realizing the importance and the need for such a book, spared their most precious time out of their very busy schedule to write chapters and justified the output.
In the end I thank Mr Mukesh Suryavanshi, Mrs Silvi Philip and Mr Prakash Bisht for their secretarial help.
Finally, I have no words to express my gratitude and sincerest thanks to my wife Poonam, without whose support I could never have succeeded in the completion of this herculean task and my children Shruti-Pankaj, Shaloo-Pardeep and Bhavna-Vivek, who always inspired me throughout my effort.
Ved Prakash Kumra