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Hormone replacement therapy and Alzheimer’s disease
242 Perioperative Care of the Elderly at high risk for perioperative complications. Despite regional anesthesia has a better postoperative outcome, hypotension is common and increases the risk of myocardial ischaemia. Haemodynamic effects of spinal anesthesia was mostly studied observing arterial pressure and heart rate. The aim of this study was to survey haemodynamic change following spinal anesthesia with high time-resolution. Materials and Methods: We investigated 10 ASA 3 patients aged over 80 years scheduled for hip fracture repair. Haemodynamic assessment was achieved using a pulse wave algorithm derived from the radial artery pressure curve, after calibration with lithium chloride (LiDCOplus). Data were collected until the end of the surgery. Reduction in mean arterial pressure (MAP) < 15% of baseline value or in cardiac output was treated with hydroxyethyl starch 250 ml, then with bolus of ephedrine (5 mg). We used Ringer lactate solution for manteinance (3 ml/kg/h). Results and Discussion: The main effect of spinal anesthesia was the reduction of systemic resistances (SVRI) which were reduced by 18% ± 17,2%. The average cardiax index (CI) was initially reduced by 6,6 ± 5,2 %, and it was persistently reduced during the surgical period. Stroke volume index (SVI) had the most important effect on MAP, compared to the HR. The average MAP was manteined within 15% of baseline value for 69,7 ± 14,4 % of the surgical time. Just 4 patients were initially considered “fluid responders” because of a rising of SVI more than 15% after fluid challenge and they received fluids as first line treatment of hypotension. Hypotension occurred to “fluid non responders” was treated with ephedrine. Patients “fluid responders” had a smaller CI reduction after spinal anesthesia compared to “non responders” (p = 0,02).
Conclusion(s): The effects of monolateral spinal anesthesia are complex and not just related to SVRI reduction. Continuous hemodinamic monitoring in elderly high risk patients receiving spinal anesthesia is crucial for a correct treatment of hypotension in order to avoid an excessive and probably useless fluids consumption.
(20%) replacement, femur fractures (17.5%) and spinal fusion (9.4%). The prevalence of preoperative anaemia (Hb < 10g/dl) was 9.5% and the overall perioperative transfusion rate was 32%. The incidence of postoperative complications was 16.5% and the overall mortality was 2.8%. Twenty percent of cohort was urgent surgery patients and they were significantly more elderly, with lower BMI and higher comorbidity. The surgical time was lower but the bleeding rate was similar. The transfusion rate was not significantly higher (38.8% vs 29.8%; p 0.81), even tough there were more patients with severe anaemia. Postoperative complications (14.6% vs 23.8%; p < 0.05) and mortality (1.6% vs 7.5%; p 0.01) were significantly higher in orthopaedic urgent surgery. Conclusion(s): Orthopaedic surgery of moderately-severe complexity had a high transfusion rate and carries a high risk of postoperative complications. The emergency surgery affects older patients with greater comorbidity. Despite this surgery had less bleeding and surgical time is associated with higher risk of perioperative complications and higher mortality.
18AP1-6 The efficacy of an algorithm for goal-directed haemodynamic treatment (GDHT) to elderly patients with proximal femoral fracture L.E. Andersson, E. Bartha, E. Fernlund, C. Arfwedson, S. Kalman Department of Anaesthesiology and Intensive Care, Karolinska University Hospital, Huddinge and CLINTEC, Karolinska Institute, Stockholm, Sweden Background and Goal of Study: Among the elderly population in Sweden the postoperative three-months’ mortality after femoral neck fracture is 15-20%. By optimizing the cardiac performance using repeated intravenous fluid volume loading length of hospital stay may be shortened1. The haemodynamic profile for this group of patients has not previously been described and the optimal DO2I is not known. We aimed to study the efficacy of an algorithm for GDHT compared to routine care directed by blood pressure and heart rate. Primary outcome was change in stroke volume (SV) and secondary outcome was number of patients that achived the oxygen delivery index (DO2I) < 350 ml/min/m2. Materials and Methods: Patients > 70 years, scheduled for operation of proximal femoral fracture were randomised prospectively. Both groups were monitored by the Litium Dilution Cardiac Output (LiDCO) monitor, but in the routine group a standardised protocol (fluid and vasopressors) was used and the LiDCO parameters were not available for the anaesthesiologist. In the GDHT group stepwise volume loading was given to increase the SV by 10%. If SV response was < 10% and DO2I < 350 ml/min/m2, inotropic support was given. Results and Discussion: 37 patients were successfully randomised. Patient characteristics were similar (figure 1). The SV was significantly increased in the GDHT group (figure 1). In 12 of 37 patients DO2I<350 ml/min/m2 was found as an initial value which could indicate heart failure2. Five patients in GDHT recieved inotropic support and of these two did not reach predefined goals mainly because of a slow increase in dose of inotropics.
18AP1-5 Morbimortality of patients scheduled for major orthopaedic surgery R. Arroyo, E. Bisbe, S. Sabaté, J. Castillo, J. Canet Department of Anaesthesiology, Raquel Arroyo, Barcelona, Spain Background and Goal of Study: Major orthopaedic surgery of moderate to severe complexity (total hip and knee arthroplasty, hip fracture and spinal fusion) is highly prevalent and affects elderly patients with associated comorbidity and high transfusion risk. The aim of this study is to evaluate postoperative complications and mortality of patients undergoing this type of surgery and the different evolution if it’s urgent or elective. Materials and Methods: Data from a prospective multicenter cohort study (ARISCAT) performed in 59 hospitals (Catalonia, Spain) during seven randomly selected days in 2006, were analyzed. We selected the cohort of patients undergoing major orthopaedic surgery, urgent or elective. The study variables were: sex, age, BMI, physical status according to ASA score, amount of bleeding, transfusion, surgical time, postoperative complications and 30-day mortality. Xi2 or t-Student were used to statistical analysis. Results and Discussion: We included 389 major orthopaedic surgery patients (15.8% of 2464 in patient surgery), with a mean age of 70 years old and 66% female. The distribution by type of surgery was: total knee (41%) and total hip
Conclusion(s): Goals for GDHT were not reached suggesting that the algorithm should allow an earlier and more rapid increase in inotropic support in this elderly group of patients References: 1 Price JD, Sear JW, Venn RM. Cochrane Database Syst Rev 2004: CD003004. 2 Ponschab M, Hochmair N, Ghazwinian N, Mueller T, Plochl W. Eur J Anaesthesiol 2008; 25: 627-33.
Conclusion(s): The effects of monolateral spinal anesthesia are complex and not just related to SVRI reduction. Continuous hemodinamic monitoring in elderly high risk patients receiving spinal anesthesia is crucial for a correct treatment of hypotension in order to avoid an excessive and probably useless fluids consumption.
(20%) replacement, femur fractures (17.5%) and spinal fusion (9.4%). The prevalence of preoperative anaemia (Hb < 10g/dl) was 9.5% and the overall perioperative transfusion rate was 32%. The incidence of postoperative complications was 16.5% and the overall mortality was 2.8%. Twenty percent of cohort was urgent surgery patients and they were significantly more elderly, with lower BMI and higher comorbidity. The surgical time was lower but the bleeding rate was similar. The transfusion rate was not significantly higher (38.8% vs 29.8%; p 0.81), even tough there were more patients with severe anaemia. Postoperative complications (14.6% vs 23.8%; p < 0.05) and mortality (1.6% vs 7.5%; p 0.01) were significantly higher in orthopaedic urgent surgery. Conclusion(s): Orthopaedic surgery of moderately-severe complexity had a high transfusion rate and carries a high risk of postoperative complications. The emergency surgery affects older patients with greater comorbidity. Despite this surgery had less bleeding and surgical time is associated with higher risk of perioperative complications and higher mortality.
18AP1-6 The efficacy of an algorithm for goal-directed haemodynamic treatment (GDHT) to elderly patients with proximal femoral fracture L.E. Andersson, E. Bartha, E. Fernlund, C. Arfwedson, S. Kalman Department of Anaesthesiology and Intensive Care, Karolinska University Hospital, Huddinge and CLINTEC, Karolinska Institute, Stockholm, Sweden Background and Goal of Study: Among the elderly population in Sweden the postoperative three-months’ mortality after femoral neck fracture is 15-20%. By optimizing the cardiac performance using repeated intravenous fluid volume loading length of hospital stay may be shortened1. The haemodynamic profile for this group of patients has not previously been described and the optimal DO2I is not known. We aimed to study the efficacy of an algorithm for GDHT compared to routine care directed by blood pressure and heart rate. Primary outcome was change in stroke volume (SV) and secondary outcome was number of patients that achived the oxygen delivery index (DO2I) < 350 ml/min/m2. Materials and Methods: Patients > 70 years, scheduled for operation of proximal femoral fracture were randomised prospectively. Both groups were monitored by the Litium Dilution Cardiac Output (LiDCO) monitor, but in the routine group a standardised protocol (fluid and vasopressors) was used and the LiDCO parameters were not available for the anaesthesiologist. In the GDHT group stepwise volume loading was given to increase the SV by 10%. If SV response was < 10% and DO2I < 350 ml/min/m2, inotropic support was given. Results and Discussion: 37 patients were successfully randomised. Patient characteristics were similar (figure 1). The SV was significantly increased in the GDHT group (figure 1). In 12 of 37 patients DO2I<350 ml/min/m2 was found as an initial value which could indicate heart failure2. Five patients in GDHT recieved inotropic support and of these two did not reach predefined goals mainly because of a slow increase in dose of inotropics.
18AP1-5 Morbimortality of patients scheduled for major orthopaedic surgery R. Arroyo, E. Bisbe, S. Sabaté, J. Castillo, J. Canet Department of Anaesthesiology, Raquel Arroyo, Barcelona, Spain Background and Goal of Study: Major orthopaedic surgery of moderate to severe complexity (total hip and knee arthroplasty, hip fracture and spinal fusion) is highly prevalent and affects elderly patients with associated comorbidity and high transfusion risk. The aim of this study is to evaluate postoperative complications and mortality of patients undergoing this type of surgery and the different evolution if it’s urgent or elective. Materials and Methods: Data from a prospective multicenter cohort study (ARISCAT) performed in 59 hospitals (Catalonia, Spain) during seven randomly selected days in 2006, were analyzed. We selected the cohort of patients undergoing major orthopaedic surgery, urgent or elective. The study variables were: sex, age, BMI, physical status according to ASA score, amount of bleeding, transfusion, surgical time, postoperative complications and 30-day mortality. Xi2 or t-Student were used to statistical analysis. Results and Discussion: We included 389 major orthopaedic surgery patients (15.8% of 2464 in patient surgery), with a mean age of 70 years old and 66% female. The distribution by type of surgery was: total knee (41%) and total hip
Conclusion(s): Goals for GDHT were not reached suggesting that the algorithm should allow an earlier and more rapid increase in inotropic support in this elderly group of patients References: 1 Price JD, Sear JW, Venn RM. Cochrane Database Syst Rev 2004: CD003004. 2 Ponschab M, Hochmair N, Ghazwinian N, Mueller T, Plochl W. Eur J Anaesthesiol 2008; 25: 627-33.