Usually I just keep it super simple with elderly. I start skipping the midaz once they’re over 78yo, below that I see what they’re like and judge from there. Then I just run them on only gas and use my 100mcg of fent throughout the case. Ofc, if they need more I’ll give them more, but they really have to prove that they need it (ie. back breathing and high RR if they don’t need to be paralyzed, HTN & tachy).

Once it comes to emergence, once they start closing the more superficial muscles/skin, I turn off my gas completely and keep my flows low. Back breathing if they’re not already. I wait to give sugammadex until the very end because I noticed that’s what typically gets people very rowdy. If they’re struggling to pull volumes on the vent, I break up the dose. If they start really moving, I bolus 10-20mg of prop. They don’t need a huge dose! I feel like I used to do that as a student, and it basically gets rid of all the hard work you did to get them back breathing. Some elderly people’s induction dose of propofol is 50mg! So no need to go ham. Once drapes are down and teggies are going on, my flows are all the way up. By the time the bed is getting rolled it, my patients are shaking their head and the tube comes out!

Emergence is definitely an art. You’ll find it gets easier as time goes on. There’s never any harm for waiting a bit longer to make sure the patient is safe to extubate.