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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