The perioperative management of the geriatric patient with critical illness is a challenge for even the most skilled anesthesiologist. Careful preoperative assessment and preparation are essential. Optimal therapy requires application of appropriate monitoring, accurate interpretation of hemodynamic data, and appropriate selection and administration of anesthetics and therapeutic interventions. The hemodynamic compromise of critical illness is compounded by underlying pathophysiology in the aged. These factors lend a complexity to the treatment of the geriatric patient with hemodynamic instability that necessitates the anesthesiologist's implementation of the most current technological and pharmacological modalities in the operating room and intensive care unit.