I have off and on come across situations where elderly patients needed to be operated under general anaesthesia but were unaware of their cardiac compromise. Most of these patients were above 70 years and more often than not females with morbid obesity, had no regular medical checkups and from relatively poor economic background. They has breathlessness and pedal oedema and had varied abnormalities in their ECG. However, their physical disability was neglected by being ascribed to their advanced age. 

Keeping in view   their poor cardiac reserve , the primary aim while putting the patient under was to minimize any haemodynamic changes associated with the inducing drugs, those being the most probably agents to cause so. As such , a combination of low doses Midazolam (0.025 mg/kg) , Ketamine (1 mg/kg)  and Propofol (1mg/kg) gave excellent results. The  baseline h.r , BP and SpO2 remained practically unchanged and no change in ECG was noticed. Muscle relation was provided as usual with atracurium safely. 

Maintenance was achieved as with routine case with inhalational agent ( hal / iso ) , 50 % oxygen:nitrous mixture and IPPV.

Analgesia and reversal provided no hurdles.

Patients woke up within 10 minutes of switching off inhalational agents and reversal was achieved as usual with Neostigmine & Atropine. 

I think a cocktail of Midazolam:Ketamine:Propofol is a very good choice at places like mine where ultra-short opioids like Remifentanil are unavailable.

Bye . Take Care