Practical Regional Anesthesia Guide for Elderly Patients

Ultrasound-guided regional anesthesia is an important part of the practice of anesthesia for the elderly population, the growth of which will continue to outpace that of the younger population due to improvements in lifespan worldwide. The elderly patient is uniquely vulnerable to the effects of systemic anesthetic drugs, and our understanding of the potential toxicities that general anesthetics can have on the elderly brain and body continues to evolve. Aging impacts both the pharmacokinetics and pharmacodynamics of sedative medications and local anesthetics. Alongside the physiologic aging process often comes a myriad of pathologic co-morbidities that can accumulate with age, and result in a great variability of physiologic reserve. This variability in overall functional status is described by a newer concept termed 'frailty,' which is used to evaluate and risk-stratify elderly patients perioperatively. The choice for regional anesthesia is based on a combination of factors such as duration of surgery, pre-existing patient risk factors, and the skill and technique of the anesthesiologist. The utilization of preoperative and intraoperative sedation is now recognized as a key component in maximizing the safety and success rate of regional anesthesia. Excellent pain management with minimal to no sedation during the operation may have benefits that extend far beyond the immediate perioperative setting. Regional anesthesia is increasingly integrated as an important part of multimodal enhanced recovery after surgery (ERAS) protocols, which aim to decrease the cost, enhance safety, and improve the patient's subjective experience during and after hospitalization. Ultrasound-guided techniques, recently developed regional blocks, medications for sedation, and local anesthetics are reviewed in this article.