tennis courts Will the following see an increase or a decrease due to aging-related lung changes? - Vital Capacity - Closing Capacity - Residual Volume - Total Lung Capacity

- ↓ VC - ↑ CC - ↑ RV - TLC about the same S15

Exam 2: Old peeps Flashcards by Kyle & Marlea

What is Aging?

Universal and progressive physiologic process
* Decreasing end-organ reserve
* Decreased functional capacity
* Increased homeostatic imbalance
* Increasing incidence of pathophysiologic processes

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Nervous system and aging

Memory decline is related to inability to complete ____.

ADL’s
*40% of people > 60 y/o
Not inevitable

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Nervous system and aging

Changes in the nervous system associated with aging include what three things?

Cerebral Atrophy
↓ Gray matter (neuronal shrinkage - there’s only a small amount of loss)
↓ White matter (increase in ventricular size on kahoot, and progressive loss of memory, balance and mobility)

WAG

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Brain ventricle size will ____ with age.

increase

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Nervous system and aging

Which of the following neurotransmitters show a decrease associated with aging?

Dopamine
ACh
NE
Serotonin
Glutamate

Dopamine
ACh
NE
Serotonin
Glutamate is unchanged

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Coupling of CMRO₂, CBF, and EEG is increased or decreased due to aging?

Trick question. CMRO₂ and CBF, decrease in a parallel fashion therefore the EEG remains unchanged secondary to aging.

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Neuraxial changes

Is epidural space increased or decreased due to aging?

Decreased

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Neuraxial changes

What occurs with dura permeability secondary to aging?

Dura permeability increases. therefore less of a dose to get to therapeutic level

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Neuraxial changes

What occurs with CSF volume secondary to aging?

Volume of CSF decreases. less dilution of agent

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neuraxial changes

What two changes are seen in myelinated fibers of dorsal and ventral nerve roots secondary to aging?

↓ diameter of roots
↓ number of roots
this increases susceptibility of block

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Elderly patients are more/less sensitive to neuraxial and peripheral nerve blocks?

more sensitive

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Peripheral

Decreases in what two characteristics of the peripheral nervous system are noted secondary to aging?

Inter-Schwann cell distance
Conduction velocity

A shorter internodal length leads to fewer “jumps” and therefore a slower conduction velocity

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thump-thump

What cardiac changes are noted due to aging?

↓ myocyte number
↓ SA node cells (tachy or brady syndromes)
↓ conduction velocity
Thickened LV & aortic valve
↓ contractility
↓ β-adrenergic sensitivity
ventricular stiffness which leads to higher filling pressures

Maya Sits Very Left And Contradicts Bill’s Views

S10-11

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thump-thump

What happens to vasculature as we age? Why?

Vessels become more stiff

↓ collagen & elastin
↓ Nitric Oxide vasodilation
early wave deflection - increased afterload, diastolic dysfunction

NO Catching Waves

s12

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The tennis court

What two physiologic factors are decreased in the lungs as we age?

↓ Elastic recoil
↓ Surfactant

S13

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Tennis court

What anatomic structures of the lungs become enlarged as we age? What is the result?

Bronchioles and alveolar ducts become enlarged
early collapse of small airways during exhalation.
- ↑ anatomic dead space
- ↑ closing capacity (AKA the CC volume is greater than a young lung)
- impaired gas exchange

S13

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tennis court

Loss of vertebral height and calcification of vertebrae lead to what three respiratory system consequences?

Barrel chest
Diaphragmatic flattening
Chest wall stiffening (increased WOB)

CBD

S14

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tennis courts

Will the following see an increase or a decrease due to aging-related lung changes?

Vital Capacity
Closing Capacity
Residual Volume
Total Lung Capacity

↓ VC
↑ CC
↑ RV
TLC about the same

S15

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tennis courts

Decreased muscle mass and increased closing capacity will make FEV₁ decrease by ____% per decade.

6-8%

S16

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tennis courts

What are the results of weaker pharyngeal muscles from aging-related changes?

↓ secretion clearance
↓ esophageal motility (aspiration risk)
↓ protective upper airway reflexes
Inefficient coughing (suction aggressively)

SEPI

S16

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tennis courts

Whats the most important mechanism of action for aging-related A-a gradient changes? (V/Q)

FRC & CC mismatch increasing

Increasing shunt w/ decreasing arterial oxygenation.

S17

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The beans

What renal consequences are there to aging?

↓ GFR (comorbidities may exacerbate)
↑ Urinary retention
↑ UTI’s
Blunted response to aldosterone, vasopressin & renin (trouble adjusting to fluid and e-lytes)

UUG RAV

S18

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GFR drops about ____ per decade over 50 yo

10 mL/min

lecture Dr M

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Butts and guts

Which phase of liver metabolism is more affected by aging?

Phase I more impaired: oxidation, reduction, hydroysis via CYP450)
Phase II ok: acetylation and conjugation

S19

I guess I remember these words 😅

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# butts and guts What are the components of Phase I liver metabolism?

- Oxidation-Reduction - CYP450 Hydrolysis *meds that are metabolized through phase 1 have the most compromise **anesthesia and narcotics will have a prolonged affect*** | S19

# butts and guts What is the mechanism for increased PONV in the elderly?

Trick question. **Less PONV in the elderly.** *Avoid Prochlorperazine, promethazine, & metoclopramide*. **zofran is your BFF for the oldies** | S19

# dem bones With aging, muscle mass and strength will ____ while subcutaneous fat will ____. With the msk system we also see ____ wound healing and ____ of dem bones

* decrease * decrease (hard to thermoregulate) * impaired * osteoarthritis | S20

What is the vasoconstriction threshold?

Thermoregulation and the temp in which the body begins to vasoconstrict * is it comparable in infants, children and adults * **1 degree C less for adults over 60yo** | S21

# operative risk FYI slide

* US adults aging >65 increasing rapidly over next 3 decades * What is ”old age” * Denney/Denson….high mortality 90 y/o and up * Djokovi/Hedley-Whyte….ASA status predicted mortality * Del Guercio/Cohn…uncorrectable comorbidity in SICU; 100% mortality * Finlayson et al. high mortality from nursing home residents | S23

What are 6 significant predictors of 6month & 1 year mortality for the elderly?

- Impaired cognition - Recent fall - ↓ Albumin - Anemia - Functional dependence - Comorbidities FACIA-R | S24

# the vulnerable brain How does neuroinflammation happen with the eldery in surgery?

| S25

# Neurotoxicity factors What four factors are thought to be involved in the pathogenesis of dementia?

- Amyloid beta plaques - Tau - Ca⁺⁺ - Neuroinflammation (TNF and IL) CANT | S25-26

Where do amyloid beta plaques accumulate intracellularly?

Trick question. Amyloid accumulates extracellulary. | S27

What are amyloid plaques thought to do in the CNS?

* Originally thought to be toxic (now not so much?) * May Disrupt cell membranes * they are a fragment of synaptic origin *Function actually unknown, synaptic origin*. | S27

What results were seen (regarding amyloid β) with mice who were administered volatile anesthetic?

- Studied with halothane - Young mice had improved memory/learning after halothane exposure - Old mice had accelerated dementia *More study necessary - unclear translation to humans.* | S28

What medication class can cause a significant increase in amyloid plaques?

Volatiles Anesthetics | S28

# Tau What is the neurofibrillary tangle?

* Phosphorylated and aggregated 𝜏 protein * Destabilizes microtubules * Decreases in temperature 2-3 degrees C increases amount of 𝜏 *tauopathy* PAMT | S29

# Tau What is destabilized by neurofibrillary tangles?

Microtubules | S29

# Tau Decreases in temperature by ___ °C will increase the amount of τ protein.

2-3 °C | S29

# Tau Repeated exposure to what drug class will cause an increase in phosphorylated τ protein?

volatile anesthetics (specifically halothane, isoflurane, & sevo) *increases phosphorylated tau* | S29

Flip card to see graph of Amyloid and Tau relations to symptoms.

| S30

Release of what ion is exaggerated due to anesthesia? What receptors are involved?

Release of Ca⁺⁺ from ryanodine and IP₃ receptors of endoplasmic reticulum. | S31

Exaggerated Ca⁺⁺ release in the brain is thought to be linked to ______________.

neurotoxicity | S31

Volatile anesthetics are known to cause malignant hyperthermia, how does this relate to Ca release and neurotoxicity?

* Neurotoxicity d/t increased calcium is hypothesized to be a less dramatic release of Ca++ * if we inhibit the Ca++ release, will this delay or decrease the neurotoxicity? * one school of thought is that the pt may have a genetic sensitivity that may have a RYR defect - but less dramatic than MH * dantrolene? as a Ca++ inhibitor prophylactcally? | S31

Does dantrolene cross the blood brain barrier?

No | S31

Neuroinflammation contributes to cognitive decline through the release of which three inflammatory factors?

- Cytokines - IL-6 - TNFα | S32

What anesthetic drugs (mentioned in lecture) could be used to counteract inflammation? *Sus, because I checked and only one of these crosses the BBB*.

Dexamethasone Ketorolac Lidocaine (actually can cross BBB) | S32

General anesthesia (especially in older populations) is thought to contribute to ______.

POCD (Post-op cognitive dysfunction) *depends on the drug, duration of exposure and magnitude of exposure* | S33

What gas is thought to contribute the most to POCD?

Isoflurane > desflurane > propofol | S33

What studies support the theory of anesthesia related to post-operative cognitive dysfunction?

Bedford 1955 “Adverse cerebral effects of anesthesia on old people” 1193 patients > 50 y/o Received general anesthesia Mental deterioration in 10% of these pts…long-term or permanent | S34-35

Anesthesia is ____ for POCD, whilst surgery is likely ____.

Causative; additive | Dr M

7 Anesthesia implications for the oldies

1. Using neuraxial/regional anesthesia when possible 2. Avoid long-acting NMBD and reverse adequately 3. Opioid sparing strategies 4. Neutralization of stomach acid with non-particulants 5. Consider using EEG based titration 6. Avoid hypotension 7. Pad skin and nerves (pay special attention to body temp) | S37

What occurs to drugs due to decreased cardiac output secondary to aging?

- Slower distribution to site of action - Slower redistribution - Slower distribution to metabolic organs | S38

What neuromuscular junction changes contribute to drug challenges in an aging patient?

- ↑ distance between axon and motor end plate - ↓ concentration of ACh receptors - ↓ ACh in presynaptic vesicle - ↓ ACh release | S39

What drug changes are seen in an aging patient regarding kidney/liver dependent metabolism?

- Prolonged drug effect - Decreased drug need during maintenance - Delayed recovery phase for non-depolarizing NMB's | S40

What drug changes do we see if the drug is not dependent on Kidney or liver metabolism?

* No significant prolongation of effect * Essentially same requirements during maintenance * Essentially no delay in recovery phase | S40

What do we see specifically with pulmonary resection and the elderly?

* Mortality 80-92 y/o 3% * Respiratory complications 40% (2x more than younger population) * Cardiac complications 40% (3x more than younger population) * Lobectomy mortality is more acceptable (especially with newer techniques) * Pneumonectomy mortality excessive | S41

What is the algorithm for preoperative assessment of Thoracic surgery patients?

| S42

How is predicted post-operative FEV₁ (PPO FEV₁) calculated?

(Preop FEV₁ %) x (1 - % of lung tissue removed/100) | S43 ## Footnote If: Preop FEV1 70% and RLL removed ppoFEV1 = 70 x (1-29/100) = 50%

How many lung segments are there?

42 total | S43

How many lung segments are in the LUL?

10 | S43

How many lung segments are in the RLL?

12 | S43

How many lung segments are in the RUL?

6 | S43

How many lung segments are in the RML?

4 | S43

The right middle lobe and right lower lobe are resected in a critically ill patient. How much lung tissue was removed in this surgery?

16/42 = 38% | S43

Predict the post-operative FEV₁ for a patient who had their right lower lobe removed. The patients preoperative FEV₁ is 70%.

(Preop FEV₁ %) x (1 - % of lung tissue removed/100) PPO FEV₁ =70 x ( 1 - 28/100) = **50** | S43

What is the "triad" of preoperative thoracotomy assessment?

| S44

How would the CRNA manage extubation on a post-thoracotomy patient if the PPO FEV₁ is >40% ?

If > 40%, extubate in OR if awake, warm, & comfortable (AWaC) | S45

How would the CRNA manage extubation on a post-thoracotomy patient if the PPO FEV₁ is 30 - 40% ?

Consider extubation based on: - Exercise tolerance - D_LCO - V/Q - Comorbidities | S45

How would the CRNA manage extubation on a post-thoracotomy patient if the PPO FEV₁ is <30% ?

- Staged weaning from ventilator - Consider extubation if >20% **plus** thoracic epidural anesthesia in place. | S45

Exam 2: Old peeps Flashcards

(70 cards)