1. 老人急重症基礎核心課程 Geriatric Complications in ICU 2006 June 11 台大醫院麻醉部 葉育彰醫師

2. The field of geriatric critical care is still in its infancy.

3. Content 1. Anatomic and functional consequences of aging 2. Common geriatric complications 3. Minimizing complications

4. Copyright © 2000 by Churchill Livingstone

5. 1. Consequences of aging 1) Body composition 2) Respiratory system 3) Cardiovascular system 4) Nervous system 5) Renal/hepatic system 6) Blood and immune system

6. 1) Body composition Anatomic change Loss of skeletal muscle and other lean tissue components ↑ lipid fraction Functional change Prolonged drug effects ↓ metabolism and heat production ↓ resting cardiac output Copyright © 2000 by Churchill Livingstone

7. 2) Respiratory system Anatomic change ↑ thoracic stiffness ↓ lung recoil ↓alveolar surface area Functional change ↓Vital capacity / ↑FRC ↓FEV1 Impaired efficiency of gas exchange Copyright © 2000 by Churchill Livingstone

8. 2) Respiratory system ↓Ventilatory response Hypoxia Hypercapnia Functional change ↓T cell function ↓mucociliary clearnace ↓swallow function Copyright © 2000 by Churchill Livingstone

9. 3) Cardiovascular system Anatomic change ↓ elasticity ↓ β-adrenergic responsiveness Functional change ↓ cardiac and arterial compliance ↓ maximal heart rate ↓ cardiac output

10. 4) Nervous system Anatomic change Loss of neuronal tissue mass Deafferentation ↓ central neurotransmitter activity Functional change ↓ neural plasticity ↓ anesthetic requirement Impaired autonomic homeostasis

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12. 5) Renal / Hepatic system Anatomic change ↓ vascularity and perfusion Loss of tissue mass Functional change 80 y/o – GFR ↓45% ↓ drug clearance Inability to withstand salt or water loads

13. 6) Blood and Immune system Anatomic change Thymic involution Resorption of bone marrow Functional change Decreased immune competence Loss of hematopoietic reserve Copyright © 2006 University of Chicago Hospitals

14. 2. Common geriatric complications 1) Respiratory 2) Cardiovascular 3) Nervous system and Psychiatry 4) Others

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16. A) Respiratory system →Respiratory failure Pulmonary edema Pneumonia COPD Sleep apnea

17. Clin Geriatr Med 19 (2003) 205– 224

18. Pulmonary edema Heart failure Renal failure Fluid overload Transfusion ARDS Pneumonia

19. Community-acquired pneumonia Nosocomial pneumonia Prolonged mechanical ventilation Aspiration Inhalation Hematogenous spread

20. COPD – Acute exacerbation Inflammatory damage to small and large airways Destruction of lung parenchyma Limitation of expiratory airflow. ↑ risk of infection Chronic Acute exacerbation

21. Sleep apnea ↓ Slow-wave sleep ↓ REM sleep periods ↑ Pharyngeal resistance ↓ Pharyngeal area ↑ Drug effect Clin Geriatr Med 21 (2005) 701– 712

23. Sleep apnea Emergency Apnea Hypoxemia Long term side effects Hypertension Atrial fibrillation

24. B) Cardiovascular system Silent MI PAOD DVT Atrial fibrillation

25. Silent MI Silent or asymptomatic myocardial ischemia may affect 33 to 49% of older Americans with CAD J Gerontol a Biol Sci Med Sci 2002; 57(5):333-5

26. Silent MI Cognitive impairment Myocardial collateral circulation related to gradual progressive coronary artery narrowing A reduced sensitivity to pain because of aging changes such as systemic or localized autonomic dysfunction DM Geriatrics January 2003 Volume 58, Number 1

27. PAOD Prevalence of PAOD 20% of individuals over the age of 70 J Am Geriatr Soc. 1985;33:13-18 The risk of PAOD increased approximately twofold for every 10-year increase in age Circulation. 1995;91:1472- 1479

28. PAOD Leg ischemia Leg ulcer Infection Amputation ↑risk CAD Stroke

29. Deep Vein Thrombosis

30. Wells Score for DVT ( ≧ 3→75%) Active cancer 1 Paralysis, paresis, immobilization of the lower extremity 1 Recently bedridden > 3 days or major surgery within four weeks 1 Localized tenderness 1 Entire leg swollen 1 Calf swelling ≧ 3 cm when compared with the asymptomatic leg 1 Pitting edema (greater in the symptomatic leg) 1 Collateral superficial veins (nonvaricose) 1 Alternative diagnosis as likely or more possible than that of DVT -2

31. Wells score for PE (>6 → 78.4%) Clinical feature Points Clinical symptoms of DVT 3 Other diagnosis less likely than PE 3 Heart rate greater than 100 beats per minute 1.5 Immobilization or surgery within past 4 weeks 1.5 Previous DVT or PE 1.5 Hemoptysis 1 Malignancy 1

32. Atrial Fibrillation

33. Chronic Cardiac echo New onset Hypoxia Myocardial ischemia Electrolyte imbalances ↑Sympathetic nervous system activity

34. C) Nervous system and Psychiatry Delirium/Dementia Depression Acute weakness Stroke

35. Delirium Postoperative delirium incidence : 40% Arch Intern Med 1995;155(5):461– 5 80% in a university-based ICU JAMA 2001;286(21):2703– 10 Assessment:1+2+(3 or 4) 1-Acute change in mental status (Agitation) 2-Inattention 3-Disorganized thinking 4-Altered level of consciousness

36. Delirium Identify and Treat the causative factors Infection Electrolyte and metabolic abnormalities Major organ failure Medications

37. Delirium - outcome Prolonged hospital stay ↑ risk of developing a hospital-acquired complications such as a pressure sore Decline in functional status Readmission to the ICU Death Patients who recover from delirium are more likely to develop dementia over a 2-year period Intensive Care Med 2001;27(12):1892–900 J Gerontol 1993;48(5):M181– 6.

38. Dementia Chronic vs.New onset Causes 1/3: Vascular dementia 2/3: Alzheimer’s disease Incidence 75-79 → 6% 80-84 → 13% 85-89 → 22%

39. Dementia and Delirium Restraint use Goal: To prevent injury and to protect patients Guidelines Careful assessment Investigate and treat the cause Well-explanation Avoid pressure damage and abrasion to skin Remove periodically Reassess the need

40. Depression Low mood Sadness Inability to experience pleasure Changes in sleep appetite and energy In some geriatric patients, irritability and anxiety may be more prominent than sadness CNS Drugs 1998;9:17– 30

41. Depression Prevalence 10-14% major depression 40% depressive disorders J Am Geriatr Soc 1993;41(11): 1169– 76. Treatment Providing education and reassurance about medical procedures and prognosis If the prognosis is poor, support should beprovided early to help patient cope with issues around death and dying. Psychopharmacotherapy

42. Acute weakness Careful history D/D Central nervous system Peripheral nervous system Myopathy

43. Acute weakness Critical illness myopathy Causes Sepsis Neuromuscular blockade Corticosteroid use Prolonged recovery phase

44. Acute weakness Critical illness polyneuropathy Causes Old age Severely ill Sepsis Self-limited process Additional risk factors Duration of mechanical ventilator, hyperosmolality, parenteral nutrition, neuromuscular blockades,

45. Acute weakness Critical illness polyneuropathy S/S Motor and sensory system involvement Flaccid tetraparesis Muscle atrophy Reduced DTR Treatment Supportive care Treat the underlying conditions Prolong physical

46. Stroke Causes Cerebral ischemic Lacunar stroke Large artery occlusion Intracerebral hemorrhage Venous occlusion D/D Seizure Toxic-metabolic derangement

47. Stroke Restore adequate cerebral blood flow Prevent secondary brain injury Consultation and further management Daily interruption of continuous sedation Evaluate the neurological status Decreased the length of time patients spend on the ventilaor. (4.9 vs. 7.3 days)

48. D) Others Wound dehiscence and infection Stress ulcer Skin and mucosal breakdown Hypothermia Herpes Zoster Urine retention

49. Wound dehiscence and infection Risk factors Infection at the wound Weak tissue or muscle at the wound area Malnutrition Pressure on sutures (sutures too tight) Poor closure technique at the time of surgery Use of high dose or long-term corticosteroids Severe vitamin C deficiency (scurvy)

50. Stress ulcer 1-7% of ICU patients Mucosal hypoperfusion Increased gastric acidity Tx Prevention Esophagogastrodudenoscopy (EGD) Angiography Surgery

51. Skin and mucosal breakdown Pressure sore Feeding tube ET tube Tracheostomy tube Wound drainage or fistulas

52. Skin and mucosal breakdown Risk factors Immobility Decreased oxygen delivery Impaired nutritional status Extremes of age Obesity Edema DM Immunosuppression Infection Impaired sensation Vasopressors

53. Herpes Zoster Grouped vesicles or pustules in a dermatomal distribution Begin with pain and localized erythema Complications Postherpetic neuralgia Secondary infection Trigeminal nerve –corneal ulceration, blidness Deafness Meningoencephalitis Disseminated zoster

54. Urine retention BPH Drug Urethral calculus Pelvic mass Nerve injury UTI Acute genital herpes Neurogenic Complications Irritable Hypertension Tachycardia Bladder damage Renal failure

55. 3.Minimizing complication Assessment Planning Management

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57. Minimizing complications Predictable vs. Unpredictable Prevent predictable complications Prepare for unpredictable complications Standard of care Emergent management

58. Minimizing complications 1) Assessment of risk factors Patients Diseases Treatments (iatrogenic) 2) Planning for prevention Standard of care Monitoring Intervention 3) Management of complications ACLS Specific treatments

59. Silent MI 1) Assessment of risk factors Old age, heavy smoker Hypertension, CAD, DM Stop aspirin and Tapal for surgery 2) Planning for prevention 12-lead EKG and cardiac enzymes Reduce stress and adequate pain control Avoid anemia and hypothermia 3) Management of complications ACLS for ACS PCI or IABP with heparin

60. Thanks for your attention