|Year : 2017 | Volume
| Issue : 1 | Page : 58-60
The perioperative concerns of emergency neurosurgery in elderly patients: A series of three cases
Vidhu Bhatnagar1, SGS Datta2, Swayam Tara1
1 Department of Anesthesiology and Critical Care, Mumbai, Maharashtra, India
2 Department of Surgery, INHS Asvini, Mumbai, Maharashtra, India
|Date of Web Publication||17-Aug-2017|
Surg Cdr Vidhu Bhatnagar
Department of Anesthesiology and Critical Care, INHS Asvini, Near RC Church, Colaba, Mumbai - 400 005, Maharashtra
Source of Support: None, Conflict of Interest: None
Owing to many advances in anesthetic techniques, perioperative sophisticated monitoring as well as surgical techniques, there has been an exponential increase in the geriatric patients presenting for elective as well as emergency surgeries. Perioperative period in the elderly is more prone to adverse outcomes due to factors such as advanced age group, limited functional capacity, multiple comorbid conditions, impaired cognition as well as limited support at the home front. The severity of illness is a better predictor of outcomes if compared with the age. The perioperative risk of mortality and morbidity in elderly patients increases all the more if the surgery has to be performed in an emergency. We present a series of three cases, highlighting perioperative concerns and management of elderly patients undergoing emergency neurosurgeries at our institution.
Keywords: Cognition, coronary artery disease, drug-eluting stents, geriatrics, mitral valve stenosis, neurosurgical procedures, platelet aggregation inhibitors
|How to cite this article:|
Bhatnagar V, Datta S, Tara S. The perioperative concerns of emergency neurosurgery in elderly patients: A series of three cases. J Mar Med Soc 2017;19:58-60
| Introduction|| |
Aging is a physiological process, wherein, there is structural degeneration and graded loss of functional capacity of all organs and tissues. The number of elderly patients is increasing worldwide and there are no definite data regarding perioperative mortality and morbidity. There is a steep increase in morbidity beyond the age of 75 years, and the risk increases if the patients are taken up for emergency surgeries. The perioperative morbidity and mortality are compounded by prevalent diseases along with the biological aging. The objective for the care of the elderly perioperatively is to maintain hemodynamics, speed up recovery, and efforts to institute all measures to avoid any further decline in functional capacity. We present a series of three cases, highlighting perioperative concerns and management of elderly patients undergoing emergency neurosurgeries at our institution.
| Case Reports|| |
A 76-year-old female, with coronary artery disease (CAD) and hypertension, with two drug-eluting stents (DES) in the left anterior descending artery (LAD) and right coronary artery in situ, presented with low backache and weakness in both lower limbs (grade 4/5) and was diagnosed as a case of Pott's spine (D12). The patient was on antihypertensive medication and dual antiplatelet agents. Antitubercular therapy was initiated but power in both lower limbs, of the patient, decreased to 3/5 on the 5th day. The patient presented for emergency decompression surgery for Pott's spine at D12 level with pedicle screw fixation. Preanesthetic assessment (PA) revealed mild left ventricular dysfunction with ejection fraction (EF) 45% on an emergency two-dimensional echocardiography. The patient was accepted in American Society of Anesthesiologists grading (ASA)-III E) with high risk for cardiac events. Informed consent was taken. Induction was performed with fentanyl, etomidate, and vecuronium intravenously (IV) oral intubation. Anesthesia was maintained with 50% oxygen and air and sevoflurane in minimum alveolar concentration (MAC) of 0.5. Monitoring performed were pulse oximetry (SpO2), arterial blood pressure (ABP), heart rate (HR), electrocardiogram (ECG), end-tidal carbon dioxide, hourly urine output, and temperature. A noradrenaline infusion was required at 0.05 μg/kg/min to maintain hemodynamics intraoperatively. A volume of 2000 ml of crystalloids were infused intraoperatively. Total urine output was 700 ml. Maximum allowable blood loss (MABL) estimated was 800 ml keeping a target hemoglobin of 10 g%. Bleeding intraoperatively was 1000 ml. Random donor platelet (RDP) 8 units, fresh frozen plasma (FFP) 2 units, and packed red blood cell 1 unit were transfused intraoperatively, after completion of decompression and achieving hemostasis. The patient was extubated awake, and slowly, noradrenaline infusion was tapered. On assessment in the evening, patient's power in the lower limbs had improved to 4/5, and the volume in the drain was around 100 ml.
A 67-year-old male patient, with comorbidities of bronchial asthma and CAD, presented with low backache and foot drop for the past 10 days. The patient had DES to LAD in situ since 2003 and was on dual anticoagulants. PA revealed stable vital parameters, Glasgow coma scale (GCS) 15/15, power of 3/5 in the left lower limb with no sensory compromise, scattered wheeze in both mammary, and infra axillary regions on chest auscultation. There was listhesis of lumbar vertebra 5 along with severe thecal compression on magnetic resonance imaging. Emergency echocardiography demonstrated EF of 40% and septal akinesia. Pulmonary function tests had moderately obstructive lung disorder with hardly any improvement with beta agonist. The patient was accepted in ASA IIIE for emergency decompressive laminectomy and discectomy under general anesthesia with pedicle screw instrumentation. Informed consent was taken. The invasive monitoring for ABP and central venous pressure (CVP) monitoring were instituted before induction. Induction, maintenance of anesthesia, and monitoring were same as in the first case. A noradrenaline infusion was required at 0.03–0.05 μg/kg/min to maintain hemodynamics intraoperatively. A volume of 2000 ml of crystalloids were infused intraoperatively. Total urine output was 500 ml. Blood loss was 600 ml. Estimated MABL was 500 ml keeping a target hemoglobin of 10 g%. RDP 6 units were transfused intraoperatively after achievement of hemostasis because the patient was on dual anticoagulants. He was extubated awake; slowly, noradrenaline infusion was tapered. On assessment in the evening, patient's power in the lower limbs improved to 4/5 and improvement in foot drop was noticed and the volume in the drain was around 150 ml.
A 66-year-old female with rheumatic heart disease and a tight mitral stenosis in atrial fibrillation (AF) presented with left middle cerebral artery infarct and increased intracranial pressure with midline shift of 10 cm, GCS of E3V1M6 with intact gag reflex. She had undergone mitral valve repair in 1985, and she was on warfarin and ecosprin since then. The patient was taken up for emergency decompressive craniotomy. PA revealed HR 150/min, irregular, noninvasive blood pressure 98/52 mmHg, ECG high rate AF, echocardiography revealed mitral valve area of 0.68 m2 (tight mitral stenosis), moderate mitral regurgitation, atrial regurgitation, with moderate pulmonary artery hypertension. She was accepted in ASA grade IVE. Informed consent was taken. The invasive monitoring (ABP and CVP) was instituted under local anesthesia before induction. The basal vital parameters: HR 148/min, ABP 106/54 mm Hg, CVP 9 cm of water, ECG showed AF, and SpO2 on room air was 92%. Induction, maintenance of anesthesia, and monitoring were same as in the first case. An infusion of phenylephrine at the rate of 0.2–0.8 μg/kg/min was initiated just after induction for maintenance of hemodynamics. The hemodynamics and CVP were maintained within basal range with titration of IV fluids and vasopressor. Total fluid intake was 1500 ml normal saline; urine output was 400 ml; blood loss was 1000 ml. Estimated MABL was 700 ml keeping a target hemoglobin of 10 g%. Packed red blood cell (200 ml) and 4 pints of FFP were transfused. There was a brief period of hypotension despite adequate IV fluid management and phenylephrine infusion; thus, an infusion of noradrenaline at 0.08 μg/kg/min was added. The patient was extubated in Intensive Care Unit 2 h postsurgery on the improvement of GCS to E4V1M6 after tapering phenylephrine infusion. Post extubation, patient maintained hemodynamics with infusion noradrenaline, which was tapered after 24 h.
| Discussion|| |
As the geriatric population is increasing worldwide, the number of elderly patients presenting for elective as well as emergency surgeries is also increasing. Beyond the age of 30 years, the functional reserve of each organ system starts declining, and in the elderly population, there is structural degeneration as well as loss of functional capacity. The limited physiological reserve comes to forefront in times of crisis such as perioperative period., Forrest, in his study, showed that, following multivariate analysis, the risk of severe outcomes declines from 3% to 2% in the population aged 20–40 years but linearly increases in the population aged 40–80 years (2%–6%). Predictors of any severe outcome including death during perioperative period identified were ASA physical status of III or IV, age >50 years, history of cardiac failure or myocardial infarction ≤1 year, smoking, cardiovascular, thoracic, abdominal, or neurological surgery., Preoperative functional status of the patients also had an effect on outcomes which were worse in geriatric population. The anesthetic regimen has to be tailored according to the physiological reserve; the volatile and IV agents last longer due to increased volume of distribution; MAC requirement for volatiles also decreases in the elderly, though the onset may be delayed due to decreased cardiac output. Propofol produces an exaggerated fall in blood pressure, etomidate requirement beyond the age of 80 years may decrease by 50%, midazolam has increased duration and potency whereas Neuromuscular blocking agents are relatively unchanged. The effect of depth of anesthesia on outcomes is still a gray area.
A thorough PA for risk stratification of factors associated with severe outcomes and for recommendation of a management plan is an essential step. The multiple comorbid conditions limiting functional reserves should be optimized if possible. Nonoptimization increases the risk of failure of various organ systems and death perioperatively. Nutritional deficiencies should be corrected because they play a role in wound healing and recovery. Albumin levels of <3.2 g/dL in hospitalized elderly patients increased perioperative mortality. Mental status should be assessed preoperatively because dementia is a predictor of poor outcome perioperatively, increasing mortality by 50%. Perioperative cardiac evaluation as proposed by American College of Cardiology and American Heart Association Task Force for noncardiac surgeries to be followed.
The preoperative functional status is a reliable predictor of pulmonary complications perioperatively. Physiological changes such as increased closing volumes and decreased expiratory flow rates predispose older patients to pulmonary complications, and unoptimized pulmonary diseases increase the risk of postoperative complications and death. Other considerations to be kept in mind are preoperative renal status, maintaining volume status perioperatively, avoiding nephrotoxic drugs, prevention of hyperglycemia or hypoglycemia, and adequate prophylaxis for deep venous thrombosis. Multiple medications for other co-morbidities, is also a factor in determining the perioperative outcome in geriatric patients.,
The antiplatelet therapy instituted for the patients with CAD predisposes them to increased risk of bleeding in the perioperative region which can lead to fatal outcomes in spinal or intracranial surgeries; the problem multiplies manifolds if the surgery has to be performed in an emergency situation as was the case in all our patients. Informed consent for perioperative pulmonary and cardiac adverse events, postoperative mechanical ventilation, and tracheostomy were taken in all our cases. Well-titrated and tailored anesthetic regimen, extra vigilant monitoring, judicious replacement of fluids and blood products were the keys to successful management in our cases. All the three patients were given prophylaxis for deep vein thrombosis with pneumatic compression devices.
From the surgical perspective, in all such high-risk geriatric patients, for emergency surgeries, a preoperative discussion of the ramifications of the case should take place between the surgeon, anesthesiologist, and cardiologist. Issues such as the positioning of patient, plan of surgical excision, anticipated duration, any operative adjuncts such as neurophysiologic monitoring, neck stabilization, spine traction, requirement of elective postoperative ventilation, anticipated blood loss should be discussed in detail for optimizing the outcome.
A significant concern for the neurosurgeon, especially due to the confined space of the cranial cavity and the spinal canal presenting as the surgical field, is the ability to achieve hemostasis. As seen in all the three cases reported, large number of geriatric cases present for neurosurgical procedures with underlying bleeding diathesis (due to prescribed medications in the form of ecosprin, clopidogrel, warfarin, etc., alone or more often in combination). Neurosurgical procedure in such a bleeding substrate is fraught with danger and complications. Reversal of these states is possible but costly, time consuming, and in an emergency situation leads to very worrisome but unavoidable delays. Many a time, neurosurgical procedures need to be tapered or scaled down in scope because of these underlying states (e.g. decompressive craniectomy may have to be done without added durotomy or infartectomy). The role of recombinant factor VIIa is still unclear in most of these situations and in any way would be dangerous given the comorbidities of the cardiocirculatory system in these patients. Thus, in many such cases, a Hobson's choice may have to be made as to the timing, duration, and plan of surgery.
| Conclusion|| |
A thorough preoperative evaluation, appropriate perioperative care, titrated anesthetic management, efficient surgical skills, and planned postoperative management contribute to successful outcomes of emergency surgeries performed in elderly patients.
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Conflicts of interest
There are no conflicts of interest.
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