Elderly patients are at increased risk for respiratory failure requiring mechanical ventilation.⁴ In patients who develop hypoxemia after abdominal surgery, positive pressure ventilation can be used to increase mean airway pressure, recruit collapsed alveoli, increase minute ventilation, and maintain airway patency.⁵ If patients fail to improve with noninvasive measures, endotracheal intubation is warranted. Early tracheostomy should be considered particularly in the elderly patient, because it may decrease the overall time needed for mechanical ventilation.⁶

Elderly patients are at a particularly high risk for aspiration pneumonia because of age-related physiologic changes, such as weakened respiratory muscles, cough and swallowing reflexes, mucociliary clearance mechanisms, and immune function. Not uncommonly, elderly patients will also have poor
oral hygiene, gastroesophageal reflux disease, or neurologic disease, which may exacerbate the process.⁵ Routine postoperative use of nasogastric tubes may increase the risk for aspiration, and is therefore reserved for patients requiring enteral nutrition or bowel decompression.^7,8

Older patients are also at a higher risk for perioperative PE, because of prevalent comorbidities, preoperative functional dependence, and further reduced mobility postoperatively. When assessing a geriatric patient suspected of having a PE, caution and thoughtful judgment should be exercised upon the use of contrast-enhanced computed tomography scanning or pulmonary angiography, because of the high prevalence of kidney dysfunction and an especially elevated risk of contrast-induced acute kidney injury in the elderly. When attempting to screen for PE using D-dimer levels, the physician should only rely on age-adjusted D-dimer screening cutoffs, because D-dimer levels are commonly elevated in the elderly.^9,10 Age does not affect the use of pharmacologic and/or mechanical deep vein thrombosis prophylaxis when indicated, or anticoagulation and thrombolytic treatment, as indicated, in the event of a PE. Vena cava filters are an alternative option when anticoagulation is contraindicated such as in the patient with a recent cranial hemorrhage and a concomitant deep vein thrombosis.¹¹

Myocardial ischemia and myocardial infarction are the most commonly encountered postoperative cardiovascular complications in the elderly. Elderly patients with myocardial ischemia or infarction are more likely to develop heart failure as well as other noncardiac morbidity, such as renal failure, and have an overall higher postoperative mortality risk because of these events.¹² Monitoring of this patient population should be most intense during the first 3 to 5 days after surgery, when most myocardial infarctions will occur.

Myocardial ischemic events are silent in over 80% of elderly patients, and incisional pain, residual anesthetic effects, and postoperative analgesia may mask symptoms.¹² Tachycardia, hypotension, dyspnea, respiratory failure, syncope, confusion, nausea, and excessive hyperglycemia in diabetics are all alert signals during the postoperative period, and should prompt a comprehensive evaluation that includes electrocardiography and measurements of cardiac enzymes such as CK, CK-MB isoenzyme, and troponin T and I levels. In appropriately selected high-risk patients, there may be a role for prophylactic β-blocker therapy in attenuating the impact of myocardial infarction and associated in-hospital mortality.¹³ Currently, the American College of Cardiology and the American Heart Association recommend perioperative β-blockers for patients who were already receiving β-blockers or to patients with particularly high perioperative cardiac risk a priori that are undergoing major vascular surgery.^14-16

Congestive heart failure is present preoperatively in 10% of patients over 65 years of age, and is a major risk factor for subsequent postoperative cardiopulmonary complications.¹⁷ Elective surgery should be deferred, when possible, in the setting of decompensated severe heart failure (New York Heart Association class IV symptoms) until the patient is medically optimized.⁵ Postoperative heart failure, manifesting as pulmonary edema, usually occurs by the third postoperative day, and should prompt an immediate assessment for possible myocardial ischemia. Treatment includes
angiotensin-converting enzyme inhibitors and diuretics, with special monitoring for hypotension and electrolyte disturbances. β-Blockers can be considered with caution in patients with associated myocardial ischemia, whereas digoxin is considered in patients with associated atrial fibrillation in the setting of heart failure.^12,18

Postoperative atrial arrhythmias are seen in 6% of elderly patients undergoing noncardiac surgery,¹⁹ particularly in patients undergoing thoracic lung or esophageal surgery and are commonly associated with electrolyte disturbances, MI, congestive heart failure, hemodynamic instability, postoperative acute respiratory or heart failure. Rapid diagnosis and treatment is necessary, because the elderly rely on the atrial contribution for adequate ventricular filling and cardiac output. Management of atrial fibrillation consists of heart rhythm and/or rate control and prevention of thromboembolism. The authors’ preferred medication for rhythm control is amiodarone, a class III antiarrhythmic agent. Rate control can also be achieved with intravenous β-blockers or calcium channel blockers, and risk stratification using the Congestive Heart Failure-Hypertension-Age >75-Diabetes-Stroke (CHADS2) or CHADS2-VASC score should be used to decide on the risks versus benefits of therapeutic anticoagulation with heparin or vitamin K antagonists in the immediate perioperative phase.^12,19,20