What are the recommended postoperative management steps for patients aged 65 years and older after any type of anesthesia?

Postoperative Management of Elderly Patients After Anesthesia

All patients aged 65 years and older require a structured end-of-surgery assessment bundle and age-adjusted postoperative care protocols to reduce morbidity and mortality, with particular emphasis on preventing delirium, optimizing pain control through multimodal analgesia, and determining appropriate level of postoperative monitoring. 1

Pre-Discharge Assessment Bundle (Before Leaving Operating Theatre)

Before any elderly patient leaves the operating theatre, the following must be verified and documented 1:

• Core temperature measurement - hypothermia increases complications 1
• Hemoglobin concentration - anemia contributes to myocardial ischemia, falls, and poor wound healing 1
• Age-adjusted and renal function-adjusted analgesia prescribed - standard adult doses cause overdose 1
• Postoperative fluid plan documented - elderly patients have reduced homeostatic compensation 1
• Risk stratification completed (P-POSSUM score) to determine appropriate destination: general ward, high-dependency unit, or intensive care 1
• Lactate or base deficit measured - identifies occult hypoperfusion 1
• Neuromuscular blockade fully reversed - residual blockade causes respiratory complications 1, 2

Postoperative Care Level Determination

Patients with predicted perioperative mortality >10% should be admitted to level 2 or 3 critical care facilities if this will reduce morbidity or mortality, or if identifiable organ support is required. 1 Risk assessment should be performed routinely at the end of surgery rather than discriminating based on age alone 1.

Basic monitoring must continue upon ward return, with Modified Early Warning Scores implemented and Critical Care Outreach teams available 1.

Pain Management Strategy

Inadequate analgesia directly causes postoperative delirium, cardiorespiratory complications, and failure to mobilize in elderly patients 1. Pain is frequently underassessed and undertreated, particularly in cognitively impaired patients who may not report pain 1.

Multimodal Analgesia Algorithm

First-line therapy:

• Paracetamol (acetaminophen) scheduled every 6 hours - safe and should be considered first-line 1, 3

Second-line additions:

• Regional nerve blocks - highly effective for site-specific pain (hip fractures, rib fractures, extremity surgery) 1, 4
• NSAIDs - use cautiously at lowest doses for shortest duration with proton pump inhibitor protection and renal function monitoring 1, 4

Third-line for breakthrough pain:

• Morphine - administer cautiously, particularly in patients with poor renal or respiratory function and cognitive impairment 1
• Co-administer laxatives and antiemetics as required 1
• Avoid IM narcotics due to high peak/low trough profile causing respiratory depression cycles 4

Non-pharmacologic measures:

• Postural support, pressure care, patient warming, immobilizing limbs, ice packs 1

Critical Pain Management Pitfalls

Avoid these medications that precipitate delirium: 3, 5

• Benzodiazepines
• Anticholinergics (including antihistamines, atropine)
• Meperidine
• Sedative-hypnotics
• Routine antiemetics (especially phenothiazines) 4

Gabapentinoids (pregabalin/gabapentin) caution: Recent evidence shows no clinically significant pain benefit but significantly increased dizziness, visual disturbance, and sedation risk in elderly patients 6. Should be avoided or used with extreme caution, especially in patients who have demonstrated opioid sensitivity 6.

Delirium Prevention and Detection

Implement multicomponent nonpharmacologic interventions as first-line approach: 3, 5

• Frequent reorientation to time, place, person
• Early mobilization
• Adequate hydration and nutrition
• Normal sleep-wake cycle promotion (reduce nighttime disruptions)
• Ensure sensory aids (glasses, hearing aids) available and functional
• Daily family presence when possible

Screen for delirium in recovery area using DSM-IV criteria or short-CAM (Confusion Assessment Method), as recovery room delirium strongly predicts postoperative delirium 3, 5.

Pharmacologic management of severe agitation:

• Antipsychotics may be considered at lowest effective dose for shortest duration only when patients pose risk to themselves or others 3
• Do NOT use: cholinesterase inhibitors (ineffective), benzodiazepines as first-line (worsen delirium) 3

Monitoring and Ongoing Care

Continue basic monitoring on ward with: 1

• Modified Early Warning Scores
• Regular delirium screening using validated tools 3
• Assessment of pain using age-appropriate tools (including for cognitively impaired patients) 1

Nutritional support:

• Continue or institute early enteral nutrition postoperatively to improve wound healing and recovery 5

Mobilization:

• Early mobilization is critical to prevent complications, reduce delirium risk, and maintain functional status 3, 5, 7

Special Considerations for High-Risk Procedures

For major orthopedic surgery (hip fractures):

• Peripheral nerve blocks at presentation reduce preoperative and postoperative opioid use 1
• Consider epidural or regional anesthesia when feasible 1, 8

For rib fractures:

• Thoracic epidural or paravertebral blocks with systemic analgesia provide adequate pain control, improve respiratory function, reduce opioid consumption, and decrease infections and delirium 1

For major thoracic/abdominal procedures:

• Routinely consider epidural or spinal analgesia for postoperative pain management if skills available 1
• Carefully evaluate neuraxial/plexus blocks in patients on anticoagulants 1

Key Principles

The quality of anesthetic care administered matters more than the type (regional vs. general), with sympathetic administration according to pathophysiological status being paramount 1, 8. Elderly patients require lower anesthetic doses but commonly receive standard doses, leading to relative overdose, prolonged hypotension, and increased cognitive dysfunction risk 1, 3, 5, 2, 9.