FOR THE ELDERLY

• Take into account longer duration of action in elderly

• Neuromuscular blocking agents

• Duration prolonged by ↑ age (if steroid based), mild hypothermia, increased density of block (train-of-four ratio ≤1 during anesthetic), potent inhaled agents, diabetes mellitus, obesity (if dose based on TBW), respiratory acidosis (spontaneous ventilation prior to reversal of block)

• Avoid pancuronium in patients who are to be extubated at case end

• Difficult to reverse and sustain train-of-four ratio ≥ 0.9 in PACU

• Use short- or intermediate-acting neuromuscular blockers

• Consider cisatracurium if ↑ creatinine

• Do not follow rocuronium with cisatracurium (significant potentiation and prolongation of effect)

• Meperidine: Avoid meperidine (except 10–20 mg IV to treat shivering)

• Accumulates with repeat dosing

• Active, toxic (seizures) metabolite

• Anticholinergic activity → tachycardia, agitation

• Acute serotonergic syndrome with MAO inhibitors

• Midazolam: Drastically reduce dose/eliminate in patients 75 yrs

• Specific anesthetic adjuvants