Older Patients May Be Getting Too Much Anesthesia

PRESSURE'S ON Older patients are more susceptible to hypotension after induction.

When it comes to determining appropriate anesthetic doses, your anesthesia providers may be paying more attention to patient ASA ratings than they are to patient age. That's a concern, since older patients tend to be more susceptible to hypotension after induction, and to the resultant potential for complications.

When researchers at the Yale School of Medicine examined the records of 799 patients 65 years or older who'd had gastrointestinal surgeries, gynecologic-oncology procedures or thoracic procedures, they found that older patients with ASA ratings of 3 or 4 were given less propofol than younger patients, but that those with ratings of 1 or 2 were given the same doses as their younger counterparts. What's more, the doses were typically at the upper limit of recommended dosing for propofol, despite the fact that elderly patients were significantly more likely than younger patients to experience a significant drop in mean arterial pressure after induction. Additionally, average fentanyl doses given to older patients were significantly above the guideline-recommended dosing range.

The researchers, who presented their findings (tinyurl.com/mn2ggwn) at last fall's annual meeting of the American Society of Anesthesiologists, concluded that objective assessment and additional dose adjustments are needed to yield "stable hemodynamics" in elderly patients.

NOT FOOLPROOF Complications are not rare with take-home pain catheters.

Pain Pump Results May Vary
Continuous peripheral nerve catheters with pain pumps have a growing number of advocates, but 2 University of Chicago physicians are cautioning practitioners that "success and intervention rates may not match (those cited in) published studies." They point out that an oft-cited study (tinyurl.com/onndfbp) of 620 patients (in which only 4.2% required post-operative interventions) excluded patients with obstructive sleep apnea, cardiopulmonary issues, morbid obesity and chronic opioid use.

To evaluate the efficacy of their facility's catheter program, Tariq M. Malik, MD, and Sehar S. Gafoor, MD, conducted a 2-year retrospective analysis (tinyurl.com/ljvx95h) that turned out to be less encouraging. Of 334 patients, 314 were satisfied with the pain control the technique provided, but a total of 70 complications were reported, with 17 cases of premature removal of the catheter leading the way, followed by leakage (11), poor control (8) and primary failure (6). Additionally, 100 patients had questions that weren't answered by (or seen on) their written instructions, and 15 called the facility after hours.

There were also 4 cases of stuck catheters, 2 of which required skin exploration around the insertion site, and one reported hematoma. The take home: "Continuous peripheral nerve catheters provide a superior mode of analgesia," they say, "(but) our own experience shows that managing a patient with CPNC at home requires much attention and care."

Patients Prefer Phone Calls
If you assume patients would prefer to take care of their pre-anesthesia evaluations (PAEs) over the phone, rather than in person, you're right, and now there's data (tinyurl.com/jwem7lj) to back up that assumption. The University of Texas Medical Branch used to ask patients to come in for their PAEs. Then, came Hurricane Ike, in 2008, and, in its wake, devastation that required the facility to temporarily switch to phone-based information gathering. Not surprisingly, the question arose: Which did patients prefer?

The answer: An overwhelming majority (97%) of 75 surveyed patients said they preferred the ease and convenience of taking care of the assessment over the phone, regardless of how far they lived from the facility. The expressed preference was across the board, regardless of gender, age, type of surgery, type of anesthetic, admission status or education level. Folks simply preferred the phone, even those few who were ultimately dissatisfied with their anesthetic (primarily because of PONV).

Phone calls were also just as efficacious, say the researchers. None of the surveyed patients had surgical delays or cancellations.