Clinical pearls in the anaesthetic management of elderly patients

Recently published information is changing the approach of anaesthetists to pulmonary aspiration prophylaxis, drug dosing, hypertension during general anaesthesia, hypotension during spinal and epidural anaesthesia, intraoperative hypothermia, and postoperative ileus in elderly patients. Routine aspiration prophylaxis is no longer recommended. Lower drug doses are required to achieve the same endpoints in the elderly as in younger patients. Greater use of antihypertensive drugs rather than additional doses of anaesthetic agents is recommended during general anaesthesia to avoid myocardial depression or prolonged emergence. Routine preoperative volume loading prior to spinal and epidural anaesthesia is being questioned. Tolerance of mean arterial pressures of 65 mmHg during spinal and epidural anaesthesia is encouraged even in patients with hypertension. The adverse effects of inadvertent intraoperative hypothermia are discussed, including the conversion of vecuronium from an intermediate to a long-acting neuromuscular blocking agent. Spinal or epidural local anaesthetics with or without spinal or epidural opioids and ketorolac are associated with less postoperative ileus than postoperative analgesia based on opioids administered intravenously or intramuscularly. Finally, improving postoperative care will reduce perioperatively mortality to a greater extent than reducing intraoperative anaesthesia-related complications.