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...

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

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

Content

1. Anatomic and functional consequences of aging

2. Common geriatric complications

3. Minimizing complications

Aging

↓Reserve Diseases

Organ Dysfunction

Medical Intervention

Invasive procedures

Polypharmacy

MorbidityComplications ↑Mortality

Copyright © 2000 by Churchill Livingstone

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

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

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

2) Respiratory system

↓Ventilatory response Hypoxia Hypercapnia

Functional change ↓T cell function ↓mucociliary clearnace ↓swallow function

Copyright © 2000 by Churchill Livingstone

3) Cardiovascular system

Anatomic change ↓elasticity

↓ β-adrenergic responsiveness

Functional change ↓ cardiac and arterial compliance ↓ maximal heart rate ↓ cardiac output

4) Nervous system

Anatomic change Loss of neuronal tissue mass Deafferentation ↓ central neurotransmitter activity

Functional change ↓ neural plasticity ↓ anesthetic requirement Impaired autonomic homeostasis

Copyright © 2000 by Churchill Livingstone

5) Renal / Hepatic system

Anatomic change ↓vascularity and perfusio

n Loss of tissue mass

Functional change 80 y/o – GFR ↓45% ↓ drug clearance Inability to withstand salt

or water loads

6) Blood and Immune system

Anatomic change Thymic involution Resorption of bone marrow

Functional change Decreased immune compe

tence Loss of hematopoietic rese

rve

Copyright © 2006 University of Chicago Hospitals

2. Common geriatric complications

1) Respiratory 2) Cardiovascular3) Nervous system and Psychiatry 4) Others

Copyright © 2000 by Churchill Livingstone

A) Respiratory system

→Respiratory failurePulmonary edemaPneumoniaCOPDSleep apnea

Clin Geriatr Med 19 (2003) 205– 224

Pulmonary edema

Heart failureRenal failureFluid overloadTransfusion ARDSPneumonia

Pneumonia

Community-acquired pneumoniaNosocomial pneumonia

Prolonged mechanical ventilationAspiration InhalationHematogenous spread

COPD – Acute exacerbation

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

Sleep apnea

↓ Slow-wave sleep↓ REM sleep periods↑ Pharyngeal resistance ↓ Pharyngeal area↑ Drug effect

Clin Geriatr Med 21 (2005) 701– 712

Clin Geriatr Med 21 (2005) 701– 712

Sleep apnea

EmergencyApnea Hypoxemia

Long term side effectsHypertensionAtrial fibrillation

B) Cardiovascular system

Silent MIPAODDVTAtrial fibrillation

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

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

PAOD

Prevalence of PAOD20% of individuals over the age of 70

J Am Geriatr Soc. 1985;33:13-18The risk of PAOD increased approximately t

wofold for every 10-year increase in ageCirculation. 1995;91:1472- 1479

PAOD

Leg ischemiaLeg ulcerInfectionAmputation↑risk

CADStroke

Deep Vein Thrombosis

Wells Score for DVT ( 3≧ →75%)

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

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

Atrial Fibrillation

Atrial Fibrillation

ChronicCardiac echo

New onsetHypoxiaMyocardial ischemiaElectrolyte imbalances↑Sympathetic nervous

system activity

C) Nervous system and Psychiatry

Delirium/DementiaDepressionAcute weaknessStroke

Delirium

Postoperative delirium incidence : 40% Arch Intern Med 1995;155(5):461– 5

80% in a university-based ICUJAMA 2001;286(21):2703– 10

Assessment:1+2+(3 or 4)1-Acute change in mental status (Agitation)2-Inattention3-Disorganized thinking4-Altered level of consciousness

Delirium

Identify and Treat the causative factors InfectionElectrolyte and metabolic abnormalitiesMajor organ failureMedications

Delirium - outcome

Prolonged hospital stay ↑ risk of developing a hospital-acquired compli

cations such as a pressure sore Decline in functional status Readmission to the ICU Death Patients who recover from delirium are more li

kely to develop dementia over a 2-year periodIntensive Care Med 2001;27(12):1892–900

J Gerontol 1993;48(5):M181– 6.

Dementia

Chronic vs.New onset Causes

1/3: Vascular dementia2/3: Alzheimer’s disease

Incidence 75-79 → 6%80-84 → 13%85-89 → 22%

Dementia and Delirium

Restraint use Goal: To prevent injury and to protect patientsGuidelines

Careful assessment Investigate and treat the cause Well-explanation Avoid pressure damage and abrasion to skinRemove periodicallyReassess the need

Depression

Low moodSadnessInability to experience pleasureChanges in sleep appetite and energyIn some geriatric patients, irritability and

anxiety may be more prominent than sadness

CNS Drugs 1998;9:17– 30

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

Acute weakness

Careful history D/D

Central nervous system Peripheral nervous systemMyopathy

Acute weakness

Critical illness myopathyCauses

SepsisNeuromuscular blockade Corticosteroid use

Prolonged recovery phase

Acute weakness

Critical illness polyneuropathyCauses

Old ageSeverely illSepsis

Self-limited processAdditional risk factors

Duration of mechanical ventilator, hyperosmolality, parenteral nutrition, neuromuscular blockades,

Acute weakness

Critical illness polyneuropathyS/S

Motor and sensory system involvementFlaccid tetraparesisMuscle atrophyReduced DTR

Treatment Supportive care Treat the underlying conditions Prolong physical

Stroke

CausesCerebral ischemic

Lacunar strokeLarge artery occlusion

Intracerebral hemorrhage Venous occlusion

D/DSeizureToxic-metabolic derangement

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)

D) Others

Wound dehiscence and infectionStress ulcerSkin and mucosal breakdownHypothermiaHerpes ZosterUrine retention

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)

Stress ulcer

1-7% of ICU patientsMucosal hypoperfusionIncreased gastric acidity Tx

PreventionEsophagogastrodudenoscopy (EGD)Angiography Surgery

Skin and mucosal breakdown

Pressure soreFeeding tube ET tubeTracheostomy tube Wound drainage or fistulas

Skin and mucosal breakdown

Risk factors Immobility Decreased oxygen delivery Impaired nutritional status Extremes of age Obesity Edema

DM Immunosuppression Infection Impaired sensation Vasopressors

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

Urine retention

BPH Drug Urethral calculus Pelvic mass Nerve injury UTI Acute genital herpes Neurogenic

Complications Irritable Hypertension Tachycardia Bladder damage Renal failure

3.Minimizing complication

AssessmentPlanning Management

Copyright © 2000 by Churchill Livingstone

Minimizing complications

Predictable vs. Unpredictable Prevent predictable complicationsPrepare for unpredictable complications

Standard of careEmergent management

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

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

Thanks for your attention