Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_827_Библиотеки_им_академика_М_И_Перельмана

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19. Sampson EL, Raven PR, Ndhlovu PN et al (2007) A randomized, double-blind, placebo-controlled trial of donepezil hydrochloride (Aricept) for reducing the incidence of postoperative delirium after elective total hip replacement. Int J Geriatr Psychiatry 22:343–349

21. Tinetti ME (2003) Clinical practice: preventing falls in elderly per­sons. N Engl J Med 348:42–49

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80. Roche JJW, Wenn RT, Sahota O et al (2005) Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ 331:1374–1378

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In addition, geriatric patients had significantly fewer

ICU survivors. Rockwood and coworkers interviewed 143 geriatric (³65 years) and 225 younger (<65 years) ICU survivors. They found no significant differences between the groups in self-evaluation of health

Changes in Pulmonary Function Associated with Aging

status (top figure). However, they did find a statistically significant dif­ference between groups (asterisk) in the number of respondents who were satisfied with their present state of health (data from Rockwood et al. [28]).

While the techniques of mechanical ventilation and weaning may not differ in the elderly, they may require a longer period of support, given the impairments imposed by age, comor­bidity, and acute illness. Caution should be exercised when liberating elderly patients from mechanical ventilation. Parameters used to predict successful weaning from mechan­ical ventilation in young patients appear less reliable in the elderly [46]. Even after successfully undergoing a trial of spontaneous breathing prior to extubation, elderly patients may not do as well as younger patients. The ARDSnet inves­tigators examined age as a factor affecting outcome from acute lung injury and ARDS [47]. They found that although patients >70 years of age were able to breathe spontaneously for 2 h without ventilator assistance – a commonly accepted weaning parameter – at a similar time point to younger patients, the older patients had inferior outcomes, such as higher reintubation rates, longer ICU and hospital stays, and lower survival rates at 28 days.

Delirium

The use of sedative and analgesic medications deserves special attention. Nearly all patients in the ICU receive these medications. However, their use is not without detrimental effects. These effects include prolonged mechanical ventila­tion and an increased utilization of diagnostic studies for altered mental status when sedatives are used in a continuous, rather than intermittent, fashion. Daily interruption of seda­tion is one method used to avoid this complication [54]. Benzodiazepines and anticholinergics have been consistently linked to delirium in the elderly [55]. Pisani and coworkers recently published data showing that use of a benzodiazepine or opioid was associated with increased delirium duration, especially the first episode (relative risk of 1.64 with a 95% confidence interval of 1.27–2.10) [56]. Trials of newer agents have shown some promise. In a 2007 trial by Pandharipande et al., the use of dexmedetomidine (an alpha 2 agonist) was compared to lorazepam in mechanically ventilated patients. The use of dexmedetomidine was associated with more delirium-free days than lorazepam [57]. The data regarding the use of opioids is less clear. A study by Ouimet and coworkers demonstrated higher daily use of opioids in ICU patients without delirium [58]. Similarly, in a study of hip­fracture patients, Morrison and coauthors found that patients treated liberally with opioid analgesics were less likely to

develop delirium than those who received less analgesia [59]. Meperidine is the exception, as it is consistently linked to the development of delirium, especially in the aged [60–62]. These findings point to the need for careful use of these agents with attention to providing adequate pain relief while avoiding oversedation.

Resuscitation with crystalloid, blood and the administra­tion of vasopressors are all methods to improve tissue oxygen delivery [58]. Guidelines for the optimal use of these tech­niques are varied, and each approach is not without compli­cations. Early restoration of circulating blood volume with blood products and crystalloid is crucial, especially in the elderly who are more dependent on effective ventricular filling to maximize cardiac output. In the early phase of resuscita­tion, fluids are probably superior to vasopressors for the maintenance of blood pressure [78]. Care, however, must be taken to avoid excessive amounts of crystalloid as this has been linked to cardiac and pulmonary complications, coagu­lopathy, and acid–base disturbances [79]. Transfusion of blood to restore adequate oxygen carrying capacity is vital in cases of frank anemia, but exact triggers for transfusion in the elderly are still debated. The Hebert study suggests a transfusion threshold value of <7 g/dl of hemoglobin, and this recommendation has been widely adopted. This study, however, excluded patients with chronic anemia, ischemic heart disease, or any patient in whom the attending physician was unwilling to tolerate a transfusion trigger of <7 g/dl [80]. In elderly patients with acute myocardial infarction, a lower 30-day mortality was associated with blood transfusion for hematocrit values <30% [81]. A hematocrit of <30% during operation is predictive of postoperative delirium [82]. Other studies have documented increased myocardial ischemia when intraoperative or postoperative hematocrit fell below 28% [83, 84]. Given the high incidence of ischemic cardiac disease – often silent in the elderly – care should be taken in setting a “one-size-fits-all” transfusion trigger in the geriatric population.