• 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
• Metoclopramide, droperidol: May → extrapyramidal effects
• Ketorolac: Avoid in elderly with ↑ serum creatinine