High-risk patients: Sedation considerations in coexisting disease

Introduction Certain patient populations requiring sedation for procedures present the clinician with challenging decisions regarding their care and management. Some underlying medical disease states, airway abnormalities, or extremes of age require cautious pre-procedural assessment and planning when sedation is required to minimize the incidence of morbidity or mortality. It should be noted that some of these higher-risk patients should only be sedated by trained anesthesia providers. The following commonly encountered conditions are considered high risk and are associated with a higher rate of complications: old age, obesity, chronic obstructive pulmonary disease, coronary artery disease, and chronic renal failure. This chapter will discuss important features of these higher-risk patients and practice management when sedation is required. The elderly The elderly population (65 years of age or older) is a rapidly growing segment of our society. The Census Bureau predicts that by 2030 one in five Americans (71 million) will be older than 65. Currently, we have 36 million Americans who are older than 65. Although those individuals considered elderly are at higher risk for complications, the more accurate predictor of outcome may be the patient's physiologic age. This may be determined more clearly during a pre-procedure evaluation. For example, a 65-year-old patient who is wheelchair-bound may be considered higher risk than an 85-year-old marathon runner. Careful pre-procedure evaluation of the patient's coexisting diseases and medications, and a thorough physical examination, are the initial steps in risk stratification for these patients. Knowledge of the physiologic changes associated with aging is important when trying to determine a medication plan for sedation (Table 10.1).