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James B. Fink, MS, RRT
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*James B. Fink, MS, RRT, was the moderator for this section of the conference, and the participants were Roger Oskvig, MD; and Alan T. Lefor, MD.

Correspondence to: James B. Fink, MS, RRT, Medical Service (111), Edward Hines Jr. VA Hospital, Room 1416 Bldg 200, Hines, IL 60141; e-mail: james.fink@med.va.gov

Chest. 1999;115(suppl_2):50S. doi:10.1378/chest.115.suppl_2.50S
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Geriatic Population

A multidisciplinary group reviewed the perioperative factors affecting the elderly patient. In the preoperative phase, evidence suggests that there is a functional impact of Ca++ blockers on mental function in the elderly, and they should be avoided when possible. Preoperative teaching of patients and families should emphasize that the treatment of pain interferes with function and recovery of the patient postoperatively. The impact of underlying disease or treatment on the reserve capacity of organs should be considered. With postoperative delirium rates as high as 50%, it is important to identify an alternate decision maker preoperatively. No laboratory tests, radiographs, or ECGs should be ordered based on age alone.

Intraoperatively, older patients need less narcotic and sedative agents, and inhalation anesthetic dose should be reduced with age. These agents take longer to clear in the elderly. Older patients cool faster and take longer to rewarm. Elderly patients are more sensitive to changes in heart rate, fluid changes, and vascular tone. There is no preferential anesthetic agent or technique based on age alone.

Evidence supports early postoperative mobilization and positioning the patient to improve lung function (eg, sitting). Oxygen should be administered even with normal saturations, secondary to decreased reserve and delayed response to hypoxemia. Restraints are generally not indicated in that they predict injury when used, and have an adverse effect on postoperative delirium. The panel stressed the need for early recognition of delirium, with treatment of the underlying cause. Hypertension should not be overmanaged in the elderly patient. Only clearly indicated drugs should be used. There was consensus that the drugs identified by the panel on aging should be avoided in the elderly. The panel could not agree on the role of nonnarcotic analgesics in the elderly patient.

Recommendations for Future Directions in Research

  1. Establish better nomograms of pulmonary function for aging, healthy, nonsmoking adults.

  2. The impact of nitrous oxide on mental function, memory deficit, and delirium in the aged.

Preoperative evaluation should focus on tumor-specific factors and patient factors. The location of the tumor, type of tumor, and prior therapy must be given consideration:

Evaluation of anterior mediastinal tumors should include CT scan and flow-volume loop and echocardiogram. Patients who have received doxorubicin require evaluation of left ventricular function and echocardiogram.

Patients with pheochromocytomas should generally receive α-blockers for 10 days prior to surgery, followed in some cases by β-blocker administration.

In patients with carcinoid tumors, careful attention must be paid to fluid and electrolyte status. Chemotherapy merits a CBC count, and steroids merit replacement.

Patients who have received bleomycin should undergo careful pulmonary evaluation. Intraoperative fraction of inspired oxygen should be kept as low as is compatible with adequate oxygenation.

Recommendations for Future Directions in Research

  1. Do results from diffusion of carbon monoxide change practice or outcome with bleomycin?

  2. Is there a difference in outcomes with arterial blood gas or pulse oximeter?




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