Anesthesia in the News
  • Special Anesthesia Considerations for the Older Patient with Down Syndrome

    Patients with Down syndrome live longer than they did in the past, so they will present for anesthesia and surgery more often and at older ages.

    Older adults with Down syndrome require a different approach to anesthetic management, write the authors of a case report concerning a 50-year-old surgery patient with Down syndrome. The report appeared online in the Journal of PeriAnesthesia Nursing in January 2020 and includes recommendations for both physicians and nurses involved in the perianesthetic care of these patients.

    Longer life, more likely surgery

    Patients with Down syndrome, who have many comorbid conditions that can present challenges during anesthesia, now live much longer than they did in the past. The authors note that in 1930, the life expectancy of patients with Down syndrome was about 10 years; today, their life expectancy is more than 60 years.

    This means that they will present for anesthesia and surgery more frequently and at older ages in the coming decades. Children with Down syndrome often require surgery to correct certain congenital defects, but surgery for older patients has been less common in the past.

    Specific clinical challenges

    Common comorbidities in adults with Down syndrome include an airway characterized by anatomic pathology (eg, large tongue, cervical spine instability, subglottic stenosis, tracheomalacia); a higher prevalence of obstructive sleep apnea; and impaired alveolar oxygen exchange (eg, atelectasis, respiratory infections, and impaired ability to breathe deeply), note the authors. These factors are all exacerbated by sedation, general anesthesia, and opioids, and present special challenges.

    In this case study, a 50-year-old woman with Down syndrome required C3 to C4 anterior discectomy and fusion (ACDF). Her history was remarkable for hyper-reflexia, gait disturbance requiring the use of a walker, severe canal stenosis at C3 to C4 and moderate stenosis at C4 to C7, urinary incontinence, lumbar lordosis, and hypothyroidism. She had no known drug allergies and her only outpatient medication was levothyroxine. The anesthesiologist at the presurgical evaluation clinic classified the patient as ASA-3 due to substantial functional limitations.

    Anticipatory care steps

    En route to the operating room, the anesthesiologist chose to administer IV midazolam due to the patient’s anxiety. The physicians and nurses also used a video laryngoscope with a smaller-than-average endo-tracheal tube based on the patient’s history, body size, airway examination, and surgery type. The intraoperative course was uneventful, and the anesthetic used was nearly identical to other ACDF cases at the institution. Special attention was given to positioning the upper and lower extremities because of the muscle, bone, and joint problems that are common in patients with Down syndrome.

    One case’s lessons learned

    The patient was cooperative and appeared comfortable when arriving in the recovery room. But within 15 minutes, she complained of neck pain and was administered hydromorphone 0.2 mg by the PACU nurse. During the next 30 to 60 minutes, the patient vomited, became agitated, and disconnected her neck drain, and restraints had to be used. However, 4 hours later, the patient was discharged to the hospital ward. On postoperative day 1, the patient was evaluated by both physical therapy and occupational therapy, and was subsequently discharged home.

    The authors noted that components of the anesthetic that they thought would be difficult, such as IV line placement and endotracheal intubation, were accomplished without difficulty. However, despite their best efforts, the patient nevertheless experienced both post-operative vomiting and emergence delirium.

    Access the complete case study, Muller MD, Capp AM, Hill J, at al. Anesthetic management of elderly patients with Down syndrome: A case report. J Perianesth Nurs. 2020;35(3):243-249. at