Age-related changes in physiology of blood circulation, breath and appropriate anaesthetic considerations in patients older than 60 years. Review

V.N. Kuklin

Ahus University Hospital, Oslo, Norway

For correspondence: Vladimir N. Kuklin — MD, PhD, Leader of Day Case Surgery Unit, Ahus University Hospital, Oslo; e-mail:

For citation: Kuklin VN. Age-related changes in physiology of blood circulation, breath and appropriate anaesthetic considerations in patients older than 60 years. Review. Annals of Critical Care. 2019;4:47–57.

DOI: 10.21320/1818-474X-2019-4-47-57


The presence of co-existing diseases and age-related physiological changes in blood circulation and breath are the main reasons for the increase in postoperative complications and 30 days mortality in patients over 60 years of age. A gradual increase in arterial blood pressure (ABP) usually begins in people older than 50 years. According to recommendations of the most anaesthesiologist societies, ABP above 180/110 mm Hg is the reason for canceling a scheduled surgical operation. However, no convincing evidences have yet been presented that high preoperative ABP as an isolated factor without some organ failures can lead to an increase in the amount of postoperative complications and early mortality. Meanwhile, low ABP both before surgery and/or during anaesthesia is a reliable proven factor in increasing the amount of postoperative complications and 30 days mortality. Surgery, which in itself carries out a high risk of the rapid development of arterial hypotension, such as for example vascular interventions with a high risk of bleeding, requires the use of an invasive measurement of ABP, which covers those temporary time pauses between measurements of non-invasive ABP. A clear advantage of one anaesthetic technique over another in reducing peri-operative arterial hypotension (PAH) and postoperative pulmonary complications in patients over 60 years of age has not been demonstrated. Based on pathogenesis of PAH for normovolemic patients, it makes no sense to correct PAH caused by vasodilation of arterioles and venules, by intravenous fluid administration, when there is a need to compensate for the missing norepinephrine. In patients at high risk of developing PAH, it is necessary to start the infusion of norepinephrine directly during induction of anaesthesia. In patients who received muscle relaxants during anaesthesia, the risk of developing postoperative pneumonia increases by 1.79 times, and in patients who received muscle relaxants without reversal with an acetylcholinesterase inhibitors the risk of developing postoperative pneumonia increases by 2.26 times. Early mobilization of elderly patients after surgery can help to prevent almost all postoperative complications.

Keywords: age-related changes in physiology of blood circulation and breath, appropriate anaesthetic considerations for patients older than 60 years

Received: 10.10.2019

Accepted: 05.11.2019


  3. Neuman M.D., Bosk C.L. The redefinition of aging in American surgery. Milbank Q. 2013; 91(2): 288–315. DOI: 10.1111/milq.12014
  4. Hamel M.B., Henderson W.G., Khuri S.F., Daley J. Surgical outcomes for patients aged 80 and older: morbidity and mortality from major noncardiac surgery. J Am Geriatr Soc. 2005; 53: 424.
  5. Turrentine F.E., Wang H., Simpson V.B., Jones R.S. Surgical risk factors, morbidity, and mortality in elderly patients. J Am Coll Surg. 2006; 203: 865.
  6. Pedersen T., Eliasen K., Henriksen E. A prospective study of mortality associated with anaesthesia and surgery: risk indicators of mortality in hospital. Acta Anaesthesiol Scand. 1990; 34: 176.
  7. Hosking M.P., Warner M.A., Lobdell C.M., et al. Outcomes of surgery in patients 90 years of age and older. JAMA. 1989; 261: 1909.
  8. Kheterpal S., OʼReilly M., Englesbe M.J., et al. Preoperative and intraoperative predictors of cardiac adverse events after general, vascular, and urological surgery. Anesthesiology. 2009; 110: 58.
  9. Chung F., Mezei G., Tong D. Adverse events in ambulatory surgery. A comparison between elderly and younger patients. Can J Anaesth. 1999; 46: 309.
  10. Fleisher L.A., Pasternak L.R., Herbert R., Anderson G.F. Inpatient hospital admission and death after outpatient surgery in elderly patients: importance of patient and system characteristics and location of care. Arch Surg. 2004; 139: 67.
  11. Miller R.D., Eriksson L.I., Fleisher L.A., et al. Millerʼs Anesthesia, 2 Volume Set. 8th Edition. ISBN: 9780323280785.
  12. Parikh J.D., Hollingsworth K.G., Wallace D., et al. Normal age-related changes in left ventricular function: Role of afterload and subendocardial dysfunction. International Journal of Cardiology. 2016; 223: 306–312.
  13. Chambers D., Huang C., Matthews G. Basic Physiology for Anaesthetists, 1st Edition, ISBN-13: 978–1107637825.
  15. Pinto E. Blood pressure and ageing. Postgrad Med J. 2007; 83: 109–114. DOI: 10.1136/pgmj.2006.048371
  16. Blacher J., Staessen J.A., Girerd X., et al. Pulse pressure not mean pressure determines cardiovascular risk in older hypertensive patients. Arch Intern Med. 2000; 160: 1085–1089.
  17. Vaccarino V., Berger A.K., Abramson J., et al. Pulse pressure and risk of cardiovascular events in the Systolic Hypertension in the Elderly Program. Am J Cardiol. 2001; 88: 980–986.
  18. Lacey B., Lewington S., Clarke R., et al. China Kadoorie Biobank collaborative group. Age-specific association between blood pressure and vascular and non-vascular chronic diseases in 0·5 million adults in China: a prospective cohort study. Lancet Glob Health. 2018; 6(6): e641–e649. DOI: 10.1016/S2214–109X(18)30217–1
  19. Whelton P.K., Appel L.J., Espeland M.A., et al. Sodium reduction and weight loss in the treatment of hypertension in older persons. A randomised controlled trial of non-pharmacological interventions in the elderly (TONE). JAMA.1998; 279: 839–846.
  20. Strazzullo P. Salt-sensitivity, hypertension and cardiovascular ageing: broadening our view without missing the point. J Hypertens. 2002; 20(4): 561–563.
  21. Appel L.J., Espeland M.A., Easter L., et al. Effects of reduced sodium intake on hypertension control in older individuals: results from the Trial of Nonpharmacologic Interventions in the Elderly (TONE). Arch Intern Med 2001; 161(5): 685–693.
  22. Adrogué H.J., Madias N.E. Sodium and potassium in the pathogenesis of hypertension. N Engl J Med. 2007; 356(19): 1966–1978.
  23. Krishna G. Effect of Potassium Intake on Blood Pressure. J Am Soc Nephrol. 1990; 1: 43–52.
  24. D’Agostino R.B., Belanger A.J., Kannel W.B., Cruickshank J.M. Relation of low diastolic blood pressure to coronary heart disease death in presence of myocardial infarction: the Framingham Study. BMJ. 1991; 303: 385–389.
  25. Bangalore S., Fayyad R., Laskey R., et al. Lipid lowering in patients with treatment-resistant hypertension: an analysis from the Treating to New Targets (TNT) trial. Eur Heart J. 2014; 35: 1801–1808.
  26. van Klei W.A., van Waes J.A., Pasma W., et al. Relationship Between Preoperative Evaluation Blood Pressure and Preinduction Blood Pressure: A Cohort Study in Patients Undergoing General Anesthesia. Anesth Analg. 2017; 124(2): 431–437. DOI: 10.1213/ANE.0000000000001665
  27. Venkatesan S., Myles P.R., Manning H.J., et al. Cohort study of preoperative blood pressure and risk of 30-day mortality after elective non-cardiac surgery. British Journal of Anaesthesia. 2017; 119(1): 65–77. DOI: 10.1093/bja/aex056
  28. Hartle A., McCormack T., Carlisle J., et al. The measurement of adult blood pressure and management of hypertension before elective surgery: Joint Guidelines from the Association of Anaesthetists of Great Britain and Ireland and the British Hypertension Society. Anaesthesia. 2016; 71(3): 326–337. DOI: 10.1111/anae.13348
  29. Howell S.J., Sear J.W., Foëx P. Hypertension, hypertensive heart disease and perioperative cardiac risk. Br J Anaesth. 2004; 92(4): 570–583.
  30. Walsh M., Devereaux P.J., Garg A.X., et al. Relationship between Intraoperative Mean Arterial Pressure and Clinical Outcomes after Noncardiac Surgery: Toward an Empirical Definition of Hypotension. Anesthesiology. 2013; 119(3): 507–515. DOI: 10.1097/ALN.0b013e3182a10e26
  31. Lassen N.A. Cerebral blood flow and oxygen consumption in man. Physiol Rev. 1959; 39: 183–238.5.
  32. Moyer J.H., Morris G., Smith C. Cerebral hemodynamics during controlled hypotension induced by the continuous infusion of ganglionic blocking agents (hexamethonium, Pendiomide and Arfonad. J Clin Invest. 1954; 33:1081–1088.
  33. Strandgaard S. Autoregulation of cerebral blood flow in hypertensive patients. The modifying influence of prolonged antihypertensive treatment on the tolerance to acute, drug-induced hypotension. Circulation. 1976; 53: 720–727.
  34. Waldemar G., Schmidt J.F., Andersen A.R., et al. Angiotensin converting enzyme inhibition and cerebral blood flow autoregulation in normotensive and hypertensive man. J Hypertens. 1989; 7: 229–235.
  35. Larsen F.S., Olsen K.S., Hansen B.A., et al. Transcranial Doppler is valid for determination of the lower limit of cerebral blood flow autoregulation. Stroke. 1994; 25: 1985–1988.
  36. Olsen K.S., Svendsen L.B., Larsen F.S., et al. Effect of labetalol on cerebral blood flow, oxygen metabolism and autoregulation in healthy humans. Br J Anaesth. 1995; 75: 51–54.
  37. Olsen K.S., Svendsen L.B., Larsen FS. Validation of transcranial near-infrared spectroscopy for evaluation of cerebral blood flow autoregulation. J Neurosurg Anesthesiol. 1996; 8: 280–285.
  38. Joshi B., Ono M., Brown C., et al. Predicting the limits of cerebral autoregulation during cardiopulmonary bypass. Anesth Analg. 2012; 114: 503–510.
  39. Morris G.C.Jr., Moyer J.H., Synder H.B., et al. Vascular dynamics in controlled hypotension; a study of cerebral and renal hemodynamics and blood volume changes. Ann Surg. 1953; 138: 706–711.
  40. McCall M.L. Cerebral circulation and metabolism in toxemia of pregnancy; observations on the effects of veratrum viride and apresoline (1-hydrazinophthalazine). Am J Obstet Gynecol. 1953; 66: 1015–1030.
  41. Rivera-Lara L., Zorrilla-Vaca A., Geocadin R.G., et al. Cerebral autoregulation-oriented therapy at the bedside: a comprehensive review. Anesthesiology. 2017; 126: 1187–1199.
  42. Tan C.O. Defining the characteristic relationship between arterial pressure and cerebral flow. J Appl Physiol (1985). 2012; 113: 1194–1200.
  43. Drummond J.C. Blood Pressure and the Brain: How Low Can You Go? 2019; 128(4):759–771.
  44. Murphy G.S., Greenberg S.B., Szokol J.W. Safety of Beach Chair Position Shoulder Surgery: A Review of the Current Literature. Anesth Analg. 2019; 129(1): 101–118. DOI: 10.1213/ANE.0000000000004133
  45. Pohl A., Cullen D.J. Cerebral ischemia during shoulder surgery in the upright position: a case series. J Clin Anesth. 2005; 17: 463–469.
  46. Drummond J.C., Lee R.R., Howell J.P. Jr. Focal cerebral ischemia after surgery in the “beach chair” position: the role of a congenital variation of circle of Willis anatomy. Anesth Analg. 2012; 114: 1301–1303.
  47. Lee L., Caplan R. APSF workshop: cerebral perfusion experts share views on management of head-up cases. APSF Newsletter Winter. 2009–2010; 24: 45–68.
  48. Villevieille T., Delaunay L., Gentili M., et al. Arthroscopic shoulder surgery and ischemic cerebral complications. Ann Fr Anesth Reanim. 2012; 31: 914–918.
  49. Roshanov P.S., Rochwerg B., Patel A., et al. Withholding versus Continuing Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers before Noncardiac Surgery: An Analysis of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN Prospective Cohort. Anesthesiology. 2017;126(1): 16–27.
  50. Hollmann C.L., Fernandes N.L., Biccard B.M. A Systematic Review of Outcomes Associated With Withholding or Continuing Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers Before Noncardiac Surgery. Anesth Analg. 2018; 127(3): 678–687. DOI: 10.1213/ANE.0000000000002837
  51. Setty S., Orza D., Belani K.G. Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers Before Elective Noncardiac Surgery: An Ongoing Dilemma. Anesth Analg. 2018; 127(3): 598–600. DOI: 10.1213/ANE.0000000000003516
  52. Ritter J.M. Dual blockade of the renin-angiotensin system with angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). Br J Clin Pharmacol. 2011; 71: 313–315.
  53. Mets B. Management of hypotension associated with angiotensin-axis blockade and general anesthesia administration. J Cardiothorac Vasc Anesth. 2013; 27: 156–167.
  54. Maheshwari K., Khanna S., Bajracharya G.R., et al. A Randomized Trial of Continuous Noninvasive Blood Pressure Monitoring During Noncardiac Surgery. Anesth Analg. 2018;127(2): 424–431. DOI: 10.1213/ANE.0000000000003482
  55. Tsikas D., Jordan J., Engeli S. Blood pressure-lowering effects of propofol or sevoflurane anaesthesia are not due to enhanced nitric oxide formation or bioavailability. Br J Clin Pharmacol. 2015; 79(6): 1030–1033.
  56. Ebert T.J., Kanitz D.D., Kampine J.P. Inhibition of sympathetic neural outflow during thiopental anesthesia in humans. Anesthesia and analgesia 1990; 71: 319–26.
  57. Glick D. Chapter 12 — The autonomic nervous system. In: Ronald D. Miller. Miller’s Anesthesia, 7th Edition, Philadelphia: Elsevier, 2009: 261–304.
  58. Xuan С., Li Y., Yan W., Ma H. Inhibition of GABAA receptors in the nucleus tractus solitarius induced cardiovascular depression during isoflurane inhalation anesthesia. Int J Clin Exp Med. 2016; 9(3): 5746–5754.
  59. Miller T.E., Roche A.M., Mythen M. Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS). Can J Anaesth. 2015; 62(2): 158–168. DOI: 10.1007/s12630-014-0266-y
  60. Drobin D., Hahn R.G. Volume kinetics of Ringer’s solution in hypovolemic volunteers. Anesthesiology. 1999; 90: 81–91.
  61. Olsson J., Svensén C.H., Hahn R.G. The volume kinetics of acetated Ringer’s solution during laparoscopic cholecystectomy. Anesth Analg. 2004; 99: 1854–1860.
  62. Hahn R.G., Lyons G. The half-life of infusion fluids: an educational review. Eur J Anaesthesiol. 2016; 33: 475–482.
  63. Matot I., Paskaleva R., Eid L., et al. Effect of the volume of fluids administered on intraoperative oliguria in laparoscopic bariatric surgery: a randomized controlled trial. Arch Surg. 2012; 147: 228–234.
  64. Hahn R.G. Arterial Pressure and the Rate of Elimination of Crystalloid Fluid. Anesth Analg. 2017; 124(6): 1824–1833. DOI: 10.1213/ANE.0000000000002075
  65. Li Y.H., Zhu H.B., Zheng X., et al. Low doses of esmolol and phenylephrine act as diuretics during intravenous anesthesia. Crit Care. 2012; 16: R18.
  66. Mets B. Should Norepinephrine, Rather than Phenylephrine, Be Considered the Primary Vasopressor in Anesthetic Practice? Anesth Analg. 2016 May;122(5): 1707–14. DOI: 10.1213/ANE.0000000000001239
  67. Hassani V., Movaseghi G., Safaeeyan R., et al. Comparison of Ephedrine vs. Norepinephrine in Treating Anesthesia-Induced Hypotension in Hypertensive Patients: Randomized Double-Blinded Study. Anesth Pain Med. 2018; 8(4): e79626. DOI: 10.5812/aapm.79626
  68. Vallee F., Passouant O., Le Gall A., et al. Norepinephrine reduces arterial compliance less than phenylephrine when treating general anesthesia-induced arterial hypotension. Acta Anaesthesiol Scand. 2017; 61(6): 590–600. DOI:10.1111/aas.12905
  69. Janssens J.P., Pache J.C., Nicod L.P. Physiological changes in respiratory function associated with ageing. Eur Respir J. 1999; 13(1): 197–205
  70. Janssens J.P. Aging of the respiratory system: impact on pulmonary function tests and adaptation to exertion. Clin Chest Med. 2005; 26(3): 469–484, vi-vii.
  71. Sprung J., Gajic O., Warner D.O. Review article: age related alterations in respiratory function — anesthetic considerations. Can J Anaesth. 2006; 53(12): 1244–1257.
  72. Tran D., Rajwani K., Berlin D.A. Pulmonary effects of aging. Curr Opin Anaesthesiol. 2018; 31(1): 19–23. DOI: 10.1097/ACO.0000000000000546
  73. Rock P., Rich P.B. Postoperative pulmonary complications. Curr Opin Anaesthesiol. 2003; 16(2): 123–131.
  74. Braga M., Pecorelli N., Scatizzi M., et al. PeriOperative Italian Society. Enhanced Recovery Program in High-Risk Patients Undergoing Colorectal Surgery: Results from the PeriOperative Italian Society Registry. World J Surg. 2017; 41(3): 860–867. DOI: 10.1007/s00268-016-3766-9
  75. Bulka C.M., Terekhov M.A., Martin B.J., et al. Nondepolarizing neuromuscular blocking agents, reversal, and risk of postoperative pneumonia. Anesthesiology. 2016; 125: 647–655.
  76. Murphy G.S., Kopman A.F. “To reverse or not to reverse?” The answer is clear! Anesthesiology. 2016; 125: 611–614.