Perioperative Multimodal Anesthesia Using Regional Techniques in the Aging Surgical Patient

Abstract

Background. Elderly patients have unique age-related comorbidities that may lead to an increase in postoperative complications involving neurological, pulmonary, cardiac, and endocrine systems. There has been an increase in the number of elderly patients undergoing surgery as this portion of the population is increasing in numbers. Despite advances in perioperative anesthesia and analgesia along with improved delivery systems, monotherapy with opioids continues to be the mainstay for treatment of postop pain. Reliance on only opioids can oftentimes lead to inadequate pain control or increase in the incidence of adverse events. Multimodal analgesia incorporating regional anesthesia is a promising alternative that may reduce needs for high doses and dependence on opioids along with any potential associated adverse effects. Methods. The following databases were searched for relevant published trials: Cochrane Central Register of Controlled Trials and PubMed. Textbooks and meeting supplements were also utilized. The authors assessed trial quality and extracted data. Conclusions. Multimodal drug therapy and perioperative regional techniques can be very effective to perioperative pain management in the elderly. Regional anesthesia as part of multimodal perioperative treatment can often reduce postoperative neurological, pulmonary, cardiac, and endocrine complications. Regional anesthesia/analgesia has not been proven to improve long-term morbidity but does benefit immediate postoperative pain control. In addition, multimodal drug therapy utilizes a variety of nonopioid analgesic medications in order to minimize dosages and adverse effects from opioids while maximizing analgesic effect and benefit.

The Effect of Aging on Pulmonary Function

“…97 In addition, the incorporation of regional techniques, including PCA epidural 98 for elderly patients has been shown to improve postoperative pain control and decrease hospital stay. 99,100 Postoperative epidural analgesia is superior to parenteral narcotics at reducing the rate of pulmonary complications and the need for prolonged ventilation or reintubation. Because it improves postoperative lung function and blood oxygenation, 101 epidural anesthesia should always be considered in elderly patients undergoing thoracic, abdominal, or major vascular surgery.…”

Use of Transversus Abdominis Plane (TAP) Blocks for Pain Management in Elderly Surgical Patients

“…Managing postoperative pain for these patients is equally challenging. Many anesthesia professionals use a checklist in preparing a multimodal approach to pain control for the surgical patient that includes risk reduction strategies 4 . When using a multimodal approach for the elderly patient, the following are some of the questions the anesthesia professional would consider.…”

“…Inhalation anesthetics have a 7% increase in effect for patients older than 30 years, and this effect continues to increase by 7% with each additional 10 years of age 5 . Regional blocks have the ability to target the area needed for pain relief and have been shown to have a decreased need for narcotic or sedative rescue and result in shorter stays in the postanesthesia care unit (PACU) 4 …”

“…Acetaminophen and NSAIDs also have a benefit of antipyretic and anti‐inflammatory properties 5 . By reducing parenteral narcotic use in the PACU, side effects such as nausea, vomiting, and sedation are reduced 4 …”

ISIS Alleges Inaccuracies in FDA Epidural Steroid Injection Alert

“…[38][39][40][41] Given these and other benefits of regional and neuraxial techniques, the risk-to-benefit ratio should be discussed with the patient and the surgical team as the anesthetic plan is constructed. Various studies have demonstrated that regional and neuraxial techniques are associated with decreased opioid consumption perioperatively, decreased pulmonary complications, and improved respiratory mechanics.…”