Intraoperative Care

The elderly often have multiple disorders or may be frail; they often require special assistance during intraoperative care. Equipment (eg, step stools, grab bars) should be available to help those patients with limitations move safely from the bed to a stretcher or from the stretcher to an operating table. Patients who feel pain during movement (eg, those with a hip fracture) should be given an analgesic before they are moved. On the operating table, a bolster can be placed under the knees to relieve stretch on back muscles. Foam padding, available in most operating rooms, can be placed between specific pressure points and the operating table to prevent direct contact, which can lead to pressure sores. Extremities are positioned carefully to avoid injury. Patients with spinal curvature or limited motion need padding placed in a manner that distributes pressure over as large an area as possible, avoiding small pressure points. Arthritic changes can make positioning and intubation difficult. Because the elderly have more fragile skin, they are prone to injury from restraining devices, tape, Bovie pads, and adhesive monitoring devices (eg, ECG electrodes).

Monitoring

Intraoperative monitoring of blood pressure, heart rate and rhythm, ventilation, fluid status, and urinary output is similar in patients of all ages. For frail patients with fragile skin, the blood pressure cuff should be applied with care, using a thin layer of cotton undercast padding to protect the skin if needed.

Oxygen saturation is monitored with a pulse oximeter, typically placed on the finger. However, the signal quality at this site may be inadequate because of decreased pulsatile flow in the elderly. If quality is inadequate, the probe can be placed on the earlobe. Anesthetics or sedatives should be administered only if an accurate pulse oximeter reading is obtained.

Core body temperature is measured and recorded--usually with an esophageal or rectal probe--during long operations, particularly those in which the viscera are exposed. In many elderly patients, core body temperature is lower and more difficult to maintain than in younger patients. For the elderly, the normal mechanisms used to increase body temperature (eg, shivering) can generate excessive oxygen consumption, increasing the metabolic cost of rewarming the body. Therefore, specific intraoperative measures are required to maintain a reasonable body temperature. These measures include using convection warming systems and warmed IV and lavage fluids, maintaining adequate operating room temperature, and minimizing exposure of the abdominal viscera. Despite these measures, elderly patients may lose significant body heat. For elderly patients given general anesthetics, body temperature should be within 0.5° C (0.9° F) of their baseline core body temperature before extubation.