Abstract
Fractures in the elderly are common. There is frequent need for surgical intervention. Anesthesiologists can safely use a variety of techniques to assist the orthopedic surgeon and help provide the kind of postoperative pain relief that is necessary for patients to recover successfully. General anesthesia, systemic analgesics, and regional techniques for operative anesthesia or postoperative pain relief all represent important tools in the total process, from injury to rehabilitation.
As a discipline, anesthesiology has been slow to embrace the idea of specialized geriatric care. The American Society of Anesthesiologists (ASA) and The Society for the Advancement of Geriatric Anesthesia (SAGA) have made progress in correcting that deficiency. There is a notable lack of evidence upon which to base anesthetic practices. Except for clear guidelines about neuraxial blockade when patients are anticoagulated, we are left to propose plans that draw on our knowledge of anesthesia broadly, interpreting it with what we know about physiologic changes that occur with aging. If we knew how anesthesia worked in the brain, and what its possible toxic effects on tissues were, it would be easier to posit explanations and justifications for what is best for geriatric patients.
What we do know is that older patients have decreased functional reserve in nearly all organ systems. They are more fragile than younger patients. However, age alone is not a significant risk factor for general anesthesia but the higher incidence of co-morbidities is, especially those that affect the most vital organs. Polypharmacy also is an issue. The nature of orthopedic injuries is such that the surgeon typically needs to intervene sooner rather than later. This can leave little time for extensive preoperative evaluation, so investigations should focus on functional status. In situations where further workup might alter anesthetic plans, and these are rare, the quickest and least invasive testing should be utilized. Routine tests have little value except when targeted at specific conditions or when needed for a baseline set of values; they rarely influence anesthetic management.
All general anesthetics are cardiac depressants, contribute negatively to gas exchange in the lungs, and affect the brain in undefined ways. The liver and the kidney play a critical role in the clearance of intravenous anesthetic drugs and systemic analgesics that frequently have unpredictable distribution and protein binding because of changing body composition, often accompanied by poor nutritional status in elderly people. To avoid the need for general anesthesia some practitioners use regional techniques, although “casual empiricism” indicates that training programs have focused less and less on these methods in the past 15 years. Even with regional anesthesia, many patients will require sedation and get exposed to anesthetic drugs anyway. Some practitioners combine regional techniques with general anesthesia to avoid deep levels and to provide pain relief in the postoperative period. All practitioners should expect perioperative cardiovascular and neurologic instability to which older patients are predisposed. Interestingly, neither hypotension nor hypoxemia independently seems to cause adverse outcomes. No investigations have demonstrated that regional anesthesia is superior to general anesthesia for surgery, for postoperative analgesia, or for preventing postoperative cognitive dysfunction (POCD). Anesthesia providers should provide care with which they are familiar. Good postoperative analgesia plays a prominent role in reaching rehabilitative milestones; inadequate analgesia is a risk factor for the development of POCD. There are scant, but emerging, data to indicate that a “multimodal” approach to postoperative analgesia positively influences long-term recovery. However, this enthusiasm should be tempered by the fact that good systemic analgesia may do the same in most circumstances; many modalities and medications are available. The fundamental principles of good pain relief revolve around frequent and adequate assessment in an attempt to provide baseline analgesia plus the means by which to treat incident pain associated with activity.
The realities of the operating room, the time constraints surrounding surgical correction of orthopedic injuries, the skill sets of the involved practitioners, all dictate that decisions about perioperative care of geriatric patients should be made cooperatively, always taking into account patient preferences. The rule for the anesthesiologist in the operating room is to do what we do best – take things slowly, know our limits, and be vigilant. One hopes that recent efforts to promote geriatric anesthesia enjoy success.
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsReferences
Liu, L. and J. Leung. Perioperative complications in elderly patients. Syllabus on geriatric anesthesiology. 2001 August 2007 [cited 2007 August]; Available from: http://www.asahq.org/clinical/geriatrics/perio_comp.htm.
Klopfenstein, C.E., et al., The influence of an aging surgical population on the anesthesia workload: a ten-year survey. Anesthesia and Analgesia, 1998. 86(6): p. 1165–70.
Anesthesiology, C.o.G. Syllabus on geriatric anesthesiology. [web-based] 2001 [cited 2007 August]; Available from: http://www.asahq.org/clinical/geriatrics/syllabus.htm.
Anesthesia, S.f.t.A.o.G. Syllabus on geriatric anesthesia. 2007 [cited 2007 August]; Available from: http://10085.hostinglogin.com/saga1/.
Muravchick, S., The biology of aging and preoperative evaluation, in Geroanesthesia: principles for management of the elderly patient, L. Craven, Editor. 1997, Mosby-Year Book, Inc: St. Louis. p. 1–34.
Cleroux, J., et al., Decreased cardiopulmonary reflexes with aging in normotensive humans. American Journal of Physiology, 1989. 257: p. H961–8.
Collins, K., et al., Functional changes in autonomic nervous responses with ageing. Age Ageing, 1980. 9: p. 17–24.
Franklin, S., et al., Hemodynamic patterns of age-related changes in blood pressure. The Framingham Heart Study. Circulation, 1997. 96: p. 308–15.
Landahl, S., et al., Age-related changes in blood pressure. Hypertension, 1986. 8: p. 1044–9.
Aronow, W.S., et al., Resting left ventricular ejection fraction in elderly patients without evidence of heart disease. American Journal of Cardiology, 1989. 63(5): p. 368–9.
Kawaguchi, M., et al., Combined ventricular systolic and arterial stiffening in patients with heart failure and preserved ejection fraction: implications for systolic and diastolic reserve limitations. Circulation, 2003. 107(5): p. 714–20.
Rodeheffer, R.J., et al., Postural changes in cardiac volumes in men in relation to adult age. Experimental Gerontology, 1986. 21(4–5): p. 367–78.
Rodeheffer, R.J., et al., Exercise cardiac output is maintained with advancing age in healthy human subjects: cardiac dilatation and increased stroke volume compensate for a diminished heart rate. Circulation, 1984. 69(2): p. 203–13.
Folkow, B. and A. Svanborg, Physiology of cardiovascular aging. Physiological Review, 1993. 73: p. 725–64.
Kitamura, H., T. Sawa, and E. Ikezono, Postoperative hypoxemia: the contribution of age to the maldistribution of ventilation. Anesthesiology, 1972. 36: p. 244–52.
Kronenberg, R. and C. Drage, Attenuation of the ventilatory and heart rate responses to hypoxia and hypercapnia with aging in normal men. Journal of Clinical Investigation, 1973. 52: p. 1812–8.
Lynne-Davies, P., Influence of age on the respiratory system. Geriatrics, 1977. 32: p. 57–60.
Zaugg, M. and E. Lucchinetti, Respiratory function in the elderly. Anesthesiology Clinics of North America, 2000. 18: p. 47–56, vi.
Peterson, D.D., et al., Effects of aging on ventilatory and occlusion pressure responses to hypoxia and hypercapnia. American Review of Respiratory Disease, 1981. 124(4): p. 387–91.
Arunasalam, K., et al., Ventilatory response to morphine in young and old subjects. Anaesthesia, 1983. 38: p. 529–33.
Clayer, M. and J. Bruckner, Occult hypoxia after femoral neck fracture and elective hip surgery. Clinical Orthopaedics and Related Research, 2000. (4): p. 265–71.
Sari, A., et al., The magnitude of hypoxemia in elderly patients with fractures of the femoral neck. Anesthesia and Analgesia, 1986. 65: p. 692–4.
Allen, S., Respiratory considerations in the elderly surgical patient. Clinics in Anesthesiology, 1986. 4: p. 899–930.
Benumof, J. and D. Alfery, Anesthesia for thoracic surgery, in Anesthesia, R. Miller, Editor. 2000, Elsevier Churchill Livingstone: Philadelphia. p. 1686–8.
Pfeifer, M.A., et al., Differential changes of autonomic nervous system function with age in man. American Journal of Medicine, 1983. 75(2): p. 249–58.
Phillips, P., G. Hodsman, and C. Johnston, Neuroendocrine mechanisms and cardiovascular homeostasis in the elderly. Cardiovascular Drugs Therapy, 1991. 4(Suppl 6): p. 1209–13.
Rowe, J. and B. Troen, Sympathetic nervous system and aging in man. Endocrine Reviews, 1980. 1(167–179).
Ozaki, M., et al., The threshold for thermoregulatory vasoconstriction during nitrous oxide/sevoflurane anesthesia is reduced in the elderly. Anesthesia and Analgesia, 1997. 84(5): p. 1029–33.
Kurz, A., et al., The threshold for thermoregulatory vasoconstriction during nitrous oxide/isoflurane anesthesia is lower in elderly than in young patients. Anesthesiology, 1993. 79(3): p. 465–9.
Carpenter, R.L., et al., Incidence and risk factors for side effects of spinal anesthesia. Anesthesiology, 1992. 76(6): p. 906–16.
Frank, S.M., et al., Epidural versus general anesthesia, ambient operating room temperature, and patient age as predictors of inadvertent hypothermia. Anesthesiology, 1992. 77(2): p. 252–7.
Frank, S.M., et al., Core hypothermia and skin-surface temperature gradients. Epidural versus general anesthesia and the effects of age. Anesthesiology, 1994. 80(3): p. 502–8.
Lamb, E.J., S.E. O’Riordan, and M.P. Delaney, Kidney function in older people: pathology, assessment and management. Clinica Chimica Acta, 2003. 334(1–2): p. 25–40.
Lindeman, R.D., Renal physiology and pathophysiology of aging. Contributions to Nephrology, 1993. 105: p. 1–12.
Jansen, P.L.M., Liver disease in the elderly. Best Practice and Research in Clinical Gastroenterology, 2002. 16(1): p. 149–58.
Wakabayashi, H., et al., Evaluation of the effect of age on functioning hepatocyte mass and liver blood flow using liver scintigraphy in preoperative estimations for surgical patients: comparison with CT volumetry. Journal of Surgical Research, 2002. 106(2): p. 246–53.
Krzanowska, E.K., et al., Potency ratios of morphine and morphine-6beta-glucuronide analgesia elicited from the periaqueductal gray, locus coeruleus or rostral ventromedial medulla of rats. Brain Research, 1998. 799(2): p. 329–33.
Shimomura, K., et al., Analgesic effect of morphine glucuronides. Tohoku Journal of Experimental Medicine, 1971. 105(1): p. 45–52.
Dean, M., Opioids in renal failure and dialysis patients. Journal of Pain and Symptom Management, 2004. 28(5): p. 497–504.
Kurella, M., W.M. Bennett, and G.M. Chertow, Analgesia in patients with ESRD: a review of available evidence. American Journal of Kidney Diseases, 2003. 42(2): p. 217–28.
Lotsch, J., Opioid metabolites. Journal of Pain and Symptom Management, 2005. 29(5 Suppl): p. S10–24.
Lamy, P. and T. Wiser, Geriatric anesthesia, in Pharmacotherapeutic considerations in the elderly surgical patient, M. Katlic, Editor. 1990, Urban & Schwarzenberg, Inc: Baltimore. p. 209–39.
Bressler, R. and J.J. Bahl, Principles of drug therapy for the elderly patient. Mayo Clinic Proceedings, 2003. 78(12): p. 1564–77.
Turnheim, K., When drug therapy gets old: pharmacokinetics and pharmacodynamics in the elderly. Experimental Gerontology, 2003. 38(8): p. 843–53.
Cepeda, M.S., et al., Side effects of opioids during short-term administration: effect of age, gender, and race. Clinical Pharmacology and Therapeutics, 2003. 74(2): p. 102–12.
Aubrun, F., et al., Postoperative morphine consumption in the elderly patient. Anesthesiology, 2003. 99(1): p. 160–5.
Woodhouse, A. and L.E. Mather, The influence of age upon opioid analgesic use in the patient-controlled analgesia (PCA) environment. Anaesthesia, 1997. 52(10): p. 949–55.
Dundee, J., et al., Sensitivity to propofol in the elderly. Anaesthesia, 1986. 41: p. 482–5.
Jacobs, J., et al., Aging increases pharmacodynamic sensitivity to the hypnotic effects of midazolam. Anesthesia and Analgesia, 1995. 80: p. 143–8.
Homer, T., et al., The effect of increasing age on thiopental disposition and anesthetic requirement. Anesthesiology, 1983. 62: p. 714–24.
Morris, J. and D. McManus, The neurology of aging: normal versus pathologic change. Geriatrics, 1991. 46: p. 47–48.
Creasey, H. and S.I. Rapoport, The aging human brain. Annals of Neurology, 1985. 17: p. 2–10.
Arvidsson, S., et al., Predicting postoperative adverse events. Clinical efficiency of four general classification systems. The project perioperative risk. Acta Anaesthesiologica Scandinavica, 1996. 40: p. 783–91.
Tiret, L., et al., Complications associated with anaesthesia – a prospective survey in France. Canadian Anaesthesia Society Journal, 1986. 33: p. 336–44.
Thomas, D. and C. Ritchie, Preoperative assessment of older adults. Journal of American Geriatric Society, 1995. 43: p. 811–21.
Vaz, F. and D. Seymour, A prospective study of elderly general surgical patients: I. Pre-operative medical problems. Age Ageing, 1989. 18: p. 309–15.
Kaplan, E., et al., The usefulness of preoperative laboratory screening. JAMA, 1985. 253: p. 3576–81.
Narr, B., et al., Outcomes of patients with no laboratory assessment before anesthesia and a surgical procedure. Mayo Clinic Proceedings, 1997. 72: p. 505–9.
Perez, A., et al., Value of routine preoperative tests: a multicentre study in four general hospitals. British Journal of Anaesthesia, 1985. 74: p. 250–6.
Turnbull, J. and C. Buck, The value of preoperative screening investigations in otherwise healthy individuals. Archives of Internal Medicine, 1987. 147: p. 1101–5.
Sewell, J.M., L.L. Spooner, A.K. Dixon, and D. Rubenstein, Screening investigations in the elderly. Age Ageing, 1981. 10: p. 165–8.
Seymour, D., R. Pringle, and W. MacLennan, The role of the routine pre-operative electrocardiogram in the elderly surgical patient. Age Ageing, 1983. 12: p. 97–104.
Seymour, D., R. Pringle, and J. Shaw, The role of the routine pre-operative chest X-ray in the elderly general surgical patient. Postgraduate Medical Journal, 1982. 58: p. 741–5.
Berg, C., et al., Perioperative beta-blocker therapy and heart rate control during noncardiac surgery. American Journal of Surgery, 2007. 194(2): p. 189–91.
Feringa, H.H.H., J.J. Bax, and D. Poldermans, Perioperative medical management of ischemic heart disease in patients undergoing noncardiac surgery. Current Opinion in Anaesthesiology, 2007. 20(3): p. 254–60.
Levine, W.C., V. Mehta, and G. Landesberg, Anesthesia for the elderly: selected topics. Current Opinion in Anaesthesiology, 2006. 19(3): p. 320–4.
Cook, D. Geriatric anesthesia. American Geriatrics Society RASP Project 2003 [cited 2007 August]; Available from: http://www.frycomm.com/ags/rasp/chapter.asp?ch=2.
Fleisher, L., Risk of anesthesia, in Miller’s anesthesia, R. Miller, Editor. 2005, Elsevier Churchill Livingstone: Philadelphia. p. 893–925.
Rosenberg, H. Mortality associated with anesthesia. circa 2001 [cited 2007 August]; Available from: http://expertpages.com/news/mortality_anesthesia.htm.
Moore, D., Regional block: a handbook for use in the clinical practice of medicine and surgery. 1953, Charles C. Thomas: Springfield, IL.
Covert, C.R. and G.S. Fox, Anaesthesia for hip surgery in the elderly. Canadian Journal of Anaesthesia, 1989. 36(3 Pt 1): p. 311–9.
Mitchell, D., et al., Prevention of thromboembolic disease following total knee arthroplasty. Epidural versus general anesthesia. Clinical Orthopaedics and Related Research, 1991. (269): p. 109–12.
Wickstrom, I., I. Holmberg, and T. Stefansson, Survival of female geriatric patients after hip fracture surgery. a comparison of 5 anesthetic methods. Acta Anaesthesiologica Scandinavica, 1982. 26(6): p. 607–14.
Williams-Russo, P., et al., Randomized trial of epidural versus general anesthesia: outcomes after primary total knee replacement. Clinical Orthopaedics and Related Research, 1996 (331): p. 199–208.
Williams-Russo, P., et al., Cognitive effects after epidural vs general anesthesia in older adults. A randomized trial. JAMA, 1995. 274(1): p. 44–50.
Wu, C.L., et al., Effect of postoperative epidural analgesia on morbidity and mortality after total hip replacement surgery in medicare patients. Regional Anesthesia and Pain Medicine, 2003. 28(4): p. 271–8.
Wu, C.L., et al., Effect of postoperative epidural analgesia on morbidity and mortality following surgery in medicare patients. Regional Anesthesia and Pain Medicine, 2004. 29(6): p. 525–33; discussion 515–9.
Koval, K.J., et al., Does blood transfusion increase the risk of infection after hip fracture? Journal of Orthopaedic Trauma, 1997. 11(4): p. 260–5; discussion 265–6.
Emery, G., et al., Incidence of phrenic nerve block and hypercapnia in patients undergoing carotid endarterectomy under cervical plexus block. Anaesthesia and Intensive Care, 1998. 26(4): p. 377–81.
Knoblanche, G.E., The incidence and aetiology of phrenic nerve blockade associated with supraclavicular brachial plexus block. Anaesthesia and Intensive Care, 1979. 7(4): p. 346–9.
Urmey, W.F., K.H. Talts, and N.E. Sharrock, One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesthesia and Analgesia, 1991. 72(4): p. 498–503.
Bigeleisen, P.E., Anatomical variations of the phrenic nerve and its clinical implication for supraclavicular block. British Journal of Anaesthesia, 2003. 91(6): p. 916–7.
Dullenkopf, A., et al., Diaphragmatic excursion and respiratory function after the modified Raj technique of the infraclavicular plexus block. Regional Anesthesia and Pain Medicine, 2004. 29(2): p. 110–4.
Bashein, G., H.T. Robertson, and W.F. Kennedy Jr., Persistent phrenic nerve paresis following interscalene brachial plexus block. Anesthesiology, 1985. 63(1): p. 102–4.
Bennani, S.E., et al., An attempt to prevent spread of local anaesthetic to the phrenic nerve by compression above the injection site during the interscalene brachial plexus block. European Journal of Anaesthesiology, 1998. 15(4): p. 453–6.
Pere, P., The effect of continuous interscalene brachial plexus block with 0.125% bupivacaine plus fentanyl on diaphragmatic motility and ventilatory function. Regional Anesthesia, 1993. 18(2): p. 93–7.
Pere, P., et al., Effect of continuous interscalene brachial plexus block on diaphragm motion and on ventilatory function. Acta Anaesthesiologica Scandinavica, 1992. 36(1): p. 53–7.
Medicine, A.S.o.R.A.a.P. Regional anesthesia in the anticoagulated patient: defining the risk. Second Consensus Conference on Neuraxial Anesthesia and Anticoagulation 2002 [cited 2007 August]; Consensus statement]. Available from: http://www.asra.com/consensus-statements/2.html.
Horlocker, T.T., et al., Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Regional Anesthesia and Pain Medicine, 2003. 28(3): p. 172–97.
Gray, A.T., Ultrasound-guided regional anesthesia: current state of the art. Anesthesiology, 2006. 104(2): p. 368–73.
Horlocker, T.T. and D.J. Wedel, Ultrasound-guided regional anesthesia: in search of the holy grail.[comment]. Anesthesia and Analgesia, 2007. 104(5): p. 1009–11.
Marhofer, P. and V.W.S. Chan, Ultrasound-guided regional anesthesia: current concepts and future trends. Anesthesia and Analgesia, 2007. 104(5): p. 1265–9.
Marhofer, P., M. Greher, and S. Kapral, Ultrasound guidance in regional anaesthesia. British Journal of Anaesthesia, 2005. 94(1): p. 7–17.
Peterson, M.K., F.A. Millar, and D.G. Sheppard, Ultrasound-guided nerve blocks.[comment]. British Journal of Anaesthesia, 2002. 88(5): p. 621–4.
Lynch, E.P., et al., The impact of postoperative pain on the development of postoperative delirium. Anesthesia and Analgesia, 1998. 86(4): p. 781–5.
Wang, Y., et al., The effects of postoperative pain and its management on postoperative cognitive dysfunction. American Journal of Geriatric Psychiatry, 2007. 15(1): p. 50–59.
Busch, C.A., et al., Efficacy of periarticular multimodal drug injection in total knee arthroplasty. A randomized trial. Journal of Bone and Joint Surgery – American Volume, 2006. 88(5): p. 959–63.
Kehlet, H. and J.B. Dahl, The value of “multimodal” or “balanced analgesia” in postoperative pain treatment. Anesthesia and Analgesia, 1993. 77(5): p. 1048–56.
Kelly, D.J., M. Ahmad, and S.J. Brull, Preemptive analgesia I: physiological pathways and pharmacological modalities. Canadian Journal of Anaesthesia, 2001. 48(10): p. 1000–10.
Kelly, D.J., M. Ahmad, and S.J. Brull, Preemptive analgesia II: recent advances and current trends. Canadian Journal of Anaesthesia, 2001. 48(11): p. 1091–101.
Skinner, H.B., Multimodal acute pain management. American Journal of Orthopedics, 2004. 33(5 Suppl): p. 5–9.
Adults, A.G.S.A.P.o.P.P.i.O., The management of persistent pain in older adults. JAGS, 2002. 50(6 Suppl): p. S205–24.
Burd, T.A., M.S. Hughes, and J.O. Anglen, Heterotopic ossification prophylaxis with indomethacin increases the risk of long-bone nonunion. Journal of Bone and Joint Surgery – British Volume, 2003. 85(5): p. 700–5.
Endo, K., et al., Cyclooxygenase-2 inhibitor delays fracture healing in rats. Acta Orthopaedica, 2005. 76(4): p. 470–4.
Giannoudis, P.V., et al., Nonunion of the femoral diaphysis. The influence of reaming and non-steroidal anti-inflammatory drugs. Journal of Bone and Joint Surgery – British Volume, 2000. 82(5): p. 655–8.
Clarke, S. and F. Lecky, Best evidence topic report. Do non-steroidal anti-inflammatory drugs cause a delay in fracture healing? Emergency Medicine Journal, 2005. 22(9): p. 652–3.
Mullis, B.H., et al., Effect of COX-2 inhibitors and non-steroidal anti-inflammatory drugs on a mouse fracture model. Injury, 2006. 37(9): p. 827–37.
Bhattacharyya, T., et al., Nonsteroidal antiinflammatory drugs and nonunion of humeral shaft fractures. Arthritis and Rheumatism, 2005. 53(3): p. 364–7.
Langford, R.M. and V. Mehta, Selective cyclooxygenase inhibition: its role in pain and anaesthesia. Biomedicine and Pharmacotherapy, 2006. 60(7): p. 323–8.
Wheeler, P. and M.E. Batt, Do non-steroidal anti-inflammatory drugs adversely affect stress fracture healing? A short review. British Journal of Sports Medicine, 2005. 39(2): p. 65–9.
Dolin, S.J., J.N. Cashman, and J.M. Bland, Effectiveness of acute postoperative pain management: I. Evidence from published data. British Journal of Anaesthesia, 2002. 89(3): p. 409–23.
Everett, B. and Y. Salamonson, Differences in postoperative opioid consumption in patients prescribed patient-controlled analgesia versus intramuscular injection. Pain Management Nursing, 2005. 6(4): p. 137–44.
Kluger, M.T. and H. Owen, Patients’ expectations of patient-controlled analgesia. Anaesthesia, 1990. 45(12): p. 1072–4.
Lehmann, K.A., Recent developments in patient-controlled analgesia. Journal of Pain and Symptom Management, 2005. 29(5 Suppl): p. S72–89.
Ripamonti, C. and E. Bruera, Current status of patient-controlled analgesia in cancer patients. Oncology, 1997. 11(3): p. 373–80, 383–4; discussion 384–6.
Rowbotham, D.J., The development and safe use of patient-controlled analgesia [comment]. British Journal of Anaesthesia, 1992. 68(4): p. 331–2.
Shapiro, B.S., D.E. Cohen, and C.J. Howe, Patient-controlled analgesia for sickle-cell-related pain. Journal of Pain and Symptom Management, 1993. 8(1): p. 22–8.
Sidebotham, D., M.R. Dijkhuizen, and S.A. Schug, The safety and utilization of patient-controlled analgesia. Journal of Pain and Symptom Management, 1997. 14(4): p. 202–9.
Maddox, R.R., C.K. Williams, and M. Fields, Respiratory monitoring in patient-controlled analgesia. American Journal of Health-System Pharmacy, 2004. 61(24): p. 2628.
Organization, W.H. Tools and techniques to assess pain and other symptoms in elderly patients. Cancer Pain Release 2007 [cited 2007 August]; Available from: http://www.whocancerpain.wisc.edu/eng/17_1–2/Tools.html.
Marcantonio, E.R., et al., The relationship of postoperative delirium with psychoactive medications. JAMA, 1994. 272(19): p. 1518–22.
Bernards, C.M., et al., Epidural, cerebrospinal fluid, and plasma pharmacokinetics of epidural opioids (part 2): effect of epinephrine. Anesthesiology, 2003. 99(2): p. 466–75.
Barre, J., P. Lefort, and M. Payen, [Locoregional anesthesia for injuries of the lower limbs]. Cahiers d Anesthesiologie, 1996. 44(3): p. 197–201.
Dunwoody, J.M., C.C. Reichert, and K.L. Brown, Compartment syndrome associated with bupivacaine and fentanyl epidural analgesia in pediatric orthopaedics. Journal of Pediatric Orthopedics, 1997. 17(3): p. 285–8.
Morrow, B.C., I.N. Mawhinney, and J.R. Elliott, Tibial compartment syndrome complicating closed femoral nailing: diagnosis delayed by an epidural analgesic technique – case report. Journal of Trauma-Injury Infection and Critical Care, 1994. 37(5): p. 867–8.
Pacheco, R.J., et al., Gluteal compartment syndrome after total knee arthroplasty with epidural postoperative analgesia. Journal of Bone and Joint Surgery – British Volume, 2001. 83(5): p. 739–40.
Price, C., J. Ribeiro, and T. Kinnebrew, Compartment syndromes associated with postoperative epidural analgesia. A case report. Journal of Bone and Joint Surgery – American Volume, 1996. 78(4): p. 597–9.
Sorrentino, F., et al., [Missed compartment syndrome after anterior cruciate ligament-plasty following continuous peridural anesthesia]. Unfallchirurg, 1998. 101(6): p. 491–4.
Beerle, B.J. and R.J. Rose, Lower extremity compartment syndrome from prolonged lithotomy position not masked by epidural bupivacaine and fentanyl. Regional Anesthesia, 1993. 18(3): p. 189–90.
Montgomery, C.J. and L.B. Ready, Epidural opioid analgesia does not obscure diagnosis of compartment syndrome resulting from prolonged lithotomy position. Anesthesiology, 1991. 75(3): p. 541–3.
Mubarak, S.J. and N.C. Wilton, Compartment syndromes and epidural analgesia. Journal of Pediatric Orthopedics, 1997. 17(3): p. 282–4.
Grape, S. and M.R. Tramer, Do we need preemptive analgesia for the treatment of postoperative pain? Best Practice and Research. Clinical Anaesthesiology, 2007. 21(1): p. 51–63.
Gottschalk, A. and D.S. Smith, New concepts in acute pain therapy: preemptive analgesia. American Family Physician, 2001. 63(10): p. 1979–84.
Katz, J., et al., Preemptive analgesia. Clinical evidence of neuroplasticity contributing to postoperative pain. Anesthesiology, 1992. 77(3): p. 439–46.
Frerichs, J.A. and L.R. Janis, Preemptive analgesia in foot and ankle surgery. Clinics in Podiatric Medicine and Surgery, 2003. 20(2): p. 237–56.
Bugedo, G.J., et al., Preoperative percutaneous ilioinguinal and iliohypogastric nerve block with 0.5% bupivacaine for post-herniorrhaphy pain management in adults. Regional Anesthesia, 1990. 15(3): p. 130–3.
Cooper, J., et al., Sciatic nerve blockade improves early postoperative analgesia after open repair of calcaneus fractures. Journal of Orthopaedic Trauma, 2004. 18(4): p. 197–201.
Farris, D.A. and M.A. Fiedler, Preemptive analgesia applied to postoperative pain management. AANA Journal, 2001. 69(3): p. 223–8.
Kararmaz, A., et al., Intraoperative intravenous ketamine in combination with epidural analgesia: postoperative analgesia after renal surgery. Anesthesia and Analgesia, 2003. 97(4): p. 1092–6.
Katz, J., et al., Postoperative morphine use and hyperalgesia are reduced by preoperative but not intraoperative epidural analgesia: implications for preemptive analgesia and the prevention of central sensitization. Anesthesiology, 2003. 98(6): p. 1449–60.
Ke, R.W., et al., A randomized, double-blinded trial of preemptive analgesia in laparoscopy. Obstetrics and Gynecology, 1998. 92(6): p. 972–5.
Lee, I.O. and I.H. Lee, Systemic, but not intrathecal, ketamine produces preemptive analgesia in the rat formalin model. Acta Anaesthesiologica Sinica, 2001. 39(3): p. 123–7.
Richmond, C.E., L.M. Bromley, and C.J. Woolf, Preoperative morphine pre-empts postoperative pain. Lancet, 1993. 342(8863): p. 73–5.
Tverskoy, M., et al., Postoperative pain after inguinal herniorrhaphy with different types of anesthesia. Anesthesia and Analgesia, 1990. 70(1): p. 29–35.
Yukawa, Y., et al., A prospective randomized study of preemptive analgesia for postoperative pain in the patients undergoing posterior lumbar interbody fusion: continuous subcutaneous morphine, continuous epidural morphine, and diclofenac sodium. Spine, 2005. 30(21): p. 2357–61.
McQuay, H.J., Pre-emptive analgesia: a systematic review of clinical studies. Annals of Medicine, 1995. 27(2): p. 249–56.
Grube, J.O., M.P. Milad, and J. Damme-Sorenen, Preemptive analgesia does not reduce pain or improve postoperative functioning. Journal of the Society of Laparoendoscopic Surgeons, 2004. 8(1): p. 15–8.
Moiniche, S., et al., The effect of balanced analgesia on early convalescence after major orthopaedic surgery. Acta Anaesthesiologica Scandinavica, 1994. 38(4): p. 328–35.
Ong, C.K.S., et al., The efficacy of preemptive analgesia for acute postoperative pain management: a meta-analysis. Anesthesia and Analgesia, 2005. 100(3): p. 757–73.
Katz, J., Phantom limb pain [erratum appears in Lancet 1998 Feb 21;351(9102):604]. Lancet, 1997. 350(9088): p. 1338–9.
Katz, J., Prevention of phantom limb pain by regional anaesthesia. Lancet, 1997. 349(9051): p. 519–20.
Bach, S., M.F. Noreng, and N.U. Tjellden, Phantom limb pain in amputees during the first 12 months following limb amputation, after preoperative lumbar epidural blockade. Pain, 1988. 33(3): p. 297–301.
Devoghel, J., Small intrathecal doses of lysine acetylsalicylate relieve intractable pain in man. Journal of International Medical Research, 1983. 11: p. 90–91.
Ramwell, P., J. Shaw, and R. Jessup, Spontaneous and evoked release of prostaglandins from frog spinal cord. American Journal of Physiology, 1966. 211: p. 998–1104.
Willer, J., T. De Brouke, and B. Bussel, et al., Central analgesic effect of ketoprofen in humans: Electrophysiologic evidence for a supraspinal mechanism in a double-blind cross over study. Pain, 1989. 38: p. 1–7.
Yaksh, T., Central and peripheral mechanisms for the antialgesic action of acetylsalicylic acid, in Acetylsalicylic acid; new uses for an old drug, H. Barnett, J. Hirsh, and J. Mustard, Editors. 1982, Raven Press: New York. p. 137–51.
Lawrence, A.J., et al., Evidence for analgesia mediated by peripheral opioid receptors in inflamed synovial tissue. European Journal of Clinical Pharmacology, 1992. 43(4): p. 351–5.
Parsons, C.G., et al., Peripheral opioid receptors mediating antinociception in inflammation. Activation by endogenous opioids and role of the pituitary-adrenal axis. Pain, 1990. 41(1): p. 81–93.
Smith, T.W. and P. Buchan, Peripheral opioid receptors located on the rat saphenous nerve. Neuropeptides, 1984. 5(1–3): p. 217–20.
Stein, C., et al., Peripheral opioid receptors mediating antinociception in inflammation. Evidence for involvement of mu, delta and kappa receptors. Journal of Pharmacology and Experimental Therapeutics, 1989. 248(3): p. 1269–75.
Stein, C., M. Schafer, and A.H. Hassan, Peripheral opioid receptors. Annals of Medicine, 1995. 27(2): p. 219–21.
Tverskoy, M., et al., The peripheral effect of fentanyl on postoperative pain. Anesthesia and Analgesia, 1998. 87(5): p. 1121–4.
Stefansson, T., I. Wickstrom, and H. Haljamae, Hemodynamic and metabolic effects of ketamine anesthesia in the geriatric patient. Acta Anaesthesiologica Scandinavica, 1982. 26(4): p. 371–7.
Neumark, J. and I. Halbgebauer, [Ketamine-halothane combination anesthesia in geriatric and accident surgery]. Wiener Medizinische Wochenschrift, 1973. 123(31): p. 495–8.
Bergmans, L., et al., Methadone for phantom limb pain. Clinical Journal of Pain, 2002. 18(3): p. 203–5.
Gottschalk, A. and E.A. Ochroch, Preemptive analgesia: what do we do now? Anesthesiology, 2003. 98(1): p. 280–1; author reply 281.
Bedford, P., Adverse cerebral effects of anaesthesia on old people. Lancet, 1955. 269: p. 259–63.
Newman, M., et al., Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. New England Journal of Medicine, 2001. 344: p. 395–402.
Johnson, T., et al., Postoperative cognitive dysfunction in middle-aged patients. Anesthesiology, 2002. 96(6): p. 1351–7.
Maze, M. and M. Todd, Special issue on postoperative cognitive dysfunction: selected reports from the journal-sponsored symposium. Anesthesiology, 2007. 106(3): p. 418–20.
Moller, J.T., et al., Long-term postoperative cognitive dysfunction in the elderly ISPOCD1 study. ISPOCD investigators. International Study of Post-Operative Cognitive Dysfunction. Lancet, 1998. 351(9106): p. 857–61.
Canet, J., et al., Cognitive dysfunction after minor surgery in the elderly. Acta Anaesthesiologica Scandinavica, 2003. 47(10): p. 1204–10.
Bowman, A.M., Sleep satisfaction, perceived pain and acute confusion in elderly clients undergoing orthopaedic procedures. Journal of Advanced Nursing, 1997. 26(3): p. 550–64.
Monk, T., et al., Predictors of postoperative cognitive dysfunction following major surgery. Anesthesiology, 2001. 95: p. A50.
Biedler, A., et al., Postoperative cognition disorders in elderly patients. The results of the “International Study of Postoperative Cognitive Dysfunction” ISPOCD 1. Anaesthesist, 1999. 48: p. 12884–95.
Monk, T., et al., Cerebral oxygen desaturations are associated with postoperative cognitive dysfunction in elderly patients. Anesthesiology, 2002. 96: p. A40.
Lennmarken, C., et al., Confirmation that low intraoperative BISª levels predict increased risk of postoperative mortality. Anesthesiology, 2003. 99(Suppl): p. A303.
Williams-Russo, P., et al., Post-operative delirium: predictors and prognosis in elderly orthopedic patients. Journal of the American Geriatrics Society, 1992. 40(8): p. 759–67.
Hudetz, J., et al., Postoperative cognitive dysfunction in older patients with a history of alcohol abuse. Anesthesiology, 2007. 106(3): p. 423–30.
Bryson, G. and A. Wyand, Evidence-based clinical update: general anesthesia and the risk of delirium and postoperative cognitive dysfunction. Canadian Journal of Anaesthesia, 2006. 53(7): p. 669–677.
Rasmussen, L., et al., Does anaesthesia cause postoperative cognitive dysfunction? A randomised study of regional versus general anaesthesia in 438 elderly patients. Acta Anaesthesiologica Scandinavica, 2003. 47(3): p. 260–6.
Rasmussen, L., Postoperative cognitive dysfunction: incidence and prevention. Best Practice and Research Clinical Anaesthesiology, 2006. 20(2): p. 315–30.
Wu, C.L., et al., Postoperative cognitive function as an outcome of regional anesthesia and analgesia. Regional Anesthesia and Pain Medicine, 2004. 29(3): p. 257–68.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2011 Springer Science+Business Media, LLC
About this chapter
Cite this chapter
Gavrin, J.R. (2011). Anesthesia and Postoperative Pain Control. In: Pignolo, R., Keenan, M., Hebela, N. (eds) Fractures in the Elderly. Aging Medicine. Humana Press. https://doi.org/10.1007/978-1-60327-467-8_7
Download citation
DOI: https://doi.org/10.1007/978-1-60327-467-8_7
Published:
Publisher Name: Humana Press
Print ISBN: 978-1-60327-466-1
Online ISBN: 978-1-60327-467-8
eBook Packages: MedicineMedicine (R0)