Quid novi in the eldery patient’s anesthesia
© Lettieri et al; licensee BioMed Central Ltd. 2011
Published: 24 August 2011
Today the availability of new local anesthetics and the use of analgesics, allow the modulation of the analgesia, maintaining a state of consciousness.
the modulation of the level of analgesia at different stages of surgery due to the availability of analgesic action, but with rapid onset-time
the additional analgesia using local anesthetics with prolonged effect without the use of noradrenaline, dangerous for elderly patients
Conscious Sedation (MAC)
Protective reflexes intact and active
Protective reflexes decreased; airway obstruction may occur
Ventilation: hypoxia, hypercapnia
Cardiovascular system: , hypotension, hypertension, bradycardia, tachycardia
Stable vital signs
Unstable vital signs
Analgesia may be present; need for regional analgesia / local or systemic
Pain controlled centrally; does not require regional analgesia
Limited stay in the units of observation
Requiring hospitalization or prolonged hospitalization
Low risk of complications
High risk of complications
Infrequent postoperative complications
Frequent postoperative complications
Patients with psychiatric problems or mental deficiency may be difficult to manage
May be needed to manage patients with mental deficiency
Materials and methods
With this study we tested the efficacy, safety and limitations of the MAC.
Patients’ criteria of homogeneity.
Patients’ criteria of homogeneity
same level of gravity ASA II/III
NYHA II class
same duration of surgery (40 min ± 10 min
Weight 69 ± 6 Kg
Informed consent for MAC procedures
ASA II/III with stabilized cardio-circulatory impairments and respiratory parameters: pO2 ≤ 70 e pCO2 < 45 mmHg
Patients undergoing operations can be managed only with the cooperation of the patient
Age > 75 years
ASA III impairment of vital organs in acute and evolutionary phase
Patients with unexpected rapid intubation
Patients with high risk of bleeding
Severe neurological disorders
Observational data (Table 5).
Observer’ s assessment of alertness/sedation scale (oaa/s scale).
Ready to the call, normal tone
Torpid to the call, normal tone
Only for repeat calls with high tone
Only if shaken
Not understandable words
No answers, even if shaken
O2 inhalation (SpO2 > 98 and normocapnia)
during surgical manipulation a continuous infusion of remifentanil: 0.03 to 0.06 mg / kg / h was activated
group P (45 patients): starter bolus of 0.5 mg / kg propofol (to fill the central compartment) → P infusion of 1-2 mg / kg / h (to offset the rapid deployment)
group M (41 patients): bolus starter from 0.03 to 0.05 mg / kg midazolam (average dose of 2-4 mg) infusion of 1-2 mg / kg / h
objective parameters based on Ramsay Scale (Table 6).
Patient anxious and agitated or restless, or both
Patient co-operative, orientated and tranquil
Patient responds to commands only
Brisk response to a light glabellar tap or auditory stimulus
Sluggish response to a light glabellar tap or auditory stimulus
No response to the stimuli mentioned in items 4 and 5
Average values of clinical and instrumental group P.
Average values of clinical and instrumental group M.
Propofol, Midazolam, Remifentanil during MAC.
onset of sedation
resolution pharmacological effects
intraoperative and postoperative pain
mild desaturation (<30%)
The combination midazolam-remifentanil presented a lower synergistic effect compared with propofol-remifentanil. The first fact documented a mean BIS of 62.5 +3 vs. 64.7 +4 midazolam-remifentanil association and has finally, although sporadic, incidents of desaturation content and never > 30%. The evaluation of the kinetic values of BIS, the interesting fact that emerges concerns the values> 70, which represented a significant predictor in the study to better recovery of consciousness, which has helped the fast-traking ongoing day-surgery.
- Kenny DN: Patient sedation: technical problems and developements. Eur J Anesth. 1996, 13: 18-21. discussion 22-5Google Scholar
- Liu J, Singh H, White PF: EEG: BIS correlates with intraoperative recall and depth of propofol induced sedation. Anesth Analg. 1997, 84 (1): 185-9.PubMedGoogle Scholar
- Dexter F, Aker J, Wright WA: Development of a measure of patient satisfaction with monitored anesthesia care:the Jawa Satisfaction with Anesthesia Scale. Anesthesiology. 1997, 87 (4): 865-73. 10.1097/00000542-199710000-00021.View ArticlePubMedGoogle Scholar
- Murdoch JA, Hyde RA, Kenny GN: Target-controlled remifentanyl in combination with propofol for spontaneously breathing day-care patients. Anaesth. 1999, 54 (11): 1028-31. 10.1046/j.1365-2044.1999.00951.x.View ArticleGoogle Scholar
- Rego JA, White MM: What is new in monitored anesthesia care?. Anesth. 1998, 11: 601-6.Google Scholar
- Corck RC, Guillory EA: Effect of patient –controlled sedation on recovery from ambulatory monitored anesthesia care. An J Anesth. 1995, 22 (2): 94-100.Google Scholar
- Twersy SR: The ambulatory anesthesia handbook. St. Louis, Ed.Mosby. 1997Google Scholar
This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.