Anesthesia Student Survival Guide.pdf - Index of

376 ● AnesthesiA student survivAl Guide
should be decreased and shorter-acting agents should be used, if possible.
Induction agents should be titrated to effect. Propofol decreases peripheral
vascular resistance and can cause significant hypotension. If hemodynamic
stability is a concern, consider using ketamine or etomidate for induction.
Because thermoregulation is altered in the elderly, they are at risk for
hypothermia and its associated complications (e.g. coagulopathies, myocardial
ischemia, poor wound healing). Temperature monitoring is therefore important
in the elderly and active rewarming may be required.
There are no data to support the use of one inhalational agent over the
other, but shorter-acting agents such as desflurane are preferred to minimize
any lingering effects of the more lipid soluble anesthetics.
Shorter-acting opioid medications like fentanyl tend to cause less cumulative
effects when compared with longer-acting agents like morphine. Meperidine
has been associated with postoperative delirium and should be avoided in
elderly patients.
The duration of nondepolarizing muscle relaxants is mildly prolonged
in the elderly because of decline in metabolic function, although this is not
typically clinically significant. The pharmacokinetics of depolarizing agents
(e.g. succinylcholine) are not affected. Muscle relaxants should be adequately
reversed and patients should be extubated only after return of muscle strength
and airway reflexes. Any residual paralysis can potentiate respiratory depression,
hypoxia and hypercarbia.
General Anesthesia Versus Regional Anesthesia
Studies comparing general to regional anesthesia in the elderly have not shown
a significant difference in outcomes. Because the epidural and spinal spaces
decrease in volume with age, a similar dose of epidural local anesthetic in an
elderly patient may result in a higher sensory motor loss as compared to a
younger patient. While the incidence of postdural puncture headaches (PDPH)
is decreased in the elderly, the placement of a neuraxial block may sometimes
be difficult due to restrictions in positioning.
The Postoperative Period
The elderly are vulnerable to prolonged effects of medications and should
be closely monitored for respiratory depression, hypoxia, and hypercarbia.
Pain in the elderly may atypically present as agitation and delirium. Postoperative
delirium is commonly seen in the elderly and can be a manifestation