AMBULATORY, PEDIATRIC AND GERIATRIC CONSIDERATIONS

Outline

Ambulatory Surgery Pediatric Surgery Geriatric Surgery

Ambulatory Surgery

2001 53% in hospitals 21% free standing facilities 26% office based

Ambulatory Surgery

Ambulatory Surgery Goal Is: Cost effective Safe Convenient/Efficient Discharge of patients to home requires

family or significant others to be willing and able to care for patient and monitor for post-op complications

Anesthetics for the Ambulatory Surgery Patient Quick induction Short-acting Minimal effects on VS of patient

Alexander’s pg. 1193 Box 28-3 gives examples of commonly used anesthetics in ambulatory surgery settings

Prime Candidates for Ambulatory Surgery See ASA Classification Table page 223

Alexander’s Best candidates are ASA 1 or 2 ASA 3 can be done in ASCs however

require careful monitoring and planning

Procedures done in ASCs

Alexander’s page 1192 Box 28-2

ASC Staffing Considerations Excellence Flexibility Personable Clinical experts able to anticipate what is

needed in emergent situations (especially if not attached to a hospital)

Able to establish patient/family relationships in brief periods of time

Pediatric Surgery

Pediatric Patients

Patient from birth to age twelve Broken down into five stages: Neonate -first 28 days of life Infant -1 to18 months Toddler - 18 to 30 months Preschooler – 30 months to 5 years School age – 6 to 12 years

Reasons for Pediatric Surgery Congenital anomalies Disease Trauma Same as for an adult

Pediatric Considerations Language appropriate to age of child to explain

situation, environment, and procedure Neonates and infants startle easily Quiet

Environment important Allow natural sense of feeling protective of the

child Do not give too much information Focus on physiological needs Expeditious surgery goal to return child to family

ASAP Challenge to form trust in short period of time and

allay fears

Allaying Fears and Anxiety in the Pediatric Patient Allow favorite toy or stuffed animal Introduce all surgical team members during the pre-

operative visit Tour the child around the surgery department

especially the front, to see how it looks Anesthetist should show child equipment used to

perform general anesthesia (children may think won’t wake up/this is scary)

Allow parent to accompany the child to pre-op and down the hallway to surgery suite

Be honest when answering questions but do not give too much information

Anesthetist should hold the child under 2 years during induction

Allow parents into PACU after child arrives and first VS have been recorded

Quiet during induction

Pediatric Patient Monitoring Temperature Little subcutaneous fat Poor insulation Prone to hypothermia Keep room and patient warm Children under 2 will likely have an Ohio

Warmer or other type of overhead warming bed for an OR bed

Keep extremities and head covered

Pediatric Patient Monitoring Urine Output No urinary catheters! Risk urethral trauma Collection bags should be used Normal urine 1 to 2 ml per kg/ hour

Pediatric Patient Monitoring Cardiac Function Stethoscopes and sphygmomanometer

accuracy rely on correct cuff size ill children may have cardiac function

monitored by intra-arterial (radial artery cut-down) or central venous catheter (jugular vein or subclavian vein)

Pediatric Patient Monitoring Oxygenation Pulse oximetry

Pediatric Shock1. Septic Most commonly seen in

children Caused by gram

negative bacteria (peritonitis, UTI, URI)

First sign fever The following antibiotics

should NOT be given to newborns: sulfonamides, chloramphenicols, tetracyclines

Choice antibiotics are penicillins, aminoglycocides and cephalosporins

2. Hypovolemic Caused by dehydration Prevention: humidifier for

inspired gases and covering extremities

Treatment fluid replacement

Bradycardia present in child

Tachycardia seen in adult

Trauma in Pediatric Patients Accidents are the number one cause of

child death ages 1 to 15 years Head trauma due to blunt trauma accounts

for majority of mortality and morbidity in children

MVA are major cause of child trauma Other causes of trauma include: falls,

bicycle accidents, drowning, burns, poison, child abuse, and child birth trauma

Prevention is key

Geriatric Surgery

Geriatric Considerations

Patients over the age of 65 Injuries and high mortality result from

emergent surgery more so than scheduled or elective due to fact that planning is not performed

Geriatric Physiological Changes

Skin Loss of elasticity Loss of subcutaneous tissue (fat) Increased risk of skin tears or damage

due to pressure or shearing

Geriatric Physiological Changes

Musculoskeletal Bone mass loss Instability of skeletal system Spinal curvature Arthritis Diminished range of motion Skeletal system at increased risk of

fractures

Geriatric Physiological Changes

Cardiovascular Coronary artery blood flow decreased Blood pressure increases Cardiovascular system less able to

handle insults

Geriatric Physiological Changes

Respiratory Lung elasticity diminished Chest wall becomes more rigid Tidal exchange reduced Increased risk of pneumonia or

respiratory infections

Geriatric Physiological Changes

Digestive Salivary and digestive secretion reduced Decreased peristalsis Body water volume and plasma volume

decreased Risk of dysphagia, ulcers, constipation,

ileus (dead bowel) complications

Geriatric Physiological Changes

Genitourinary Nephron function decreased Tone diminished in ureters, bladder and

urethra Bladder capacity decreased Increased risk of kidney failure, urinary

tract infections, incontinence

Geriatric Physiological Changes

Nervous system Cerebral blood flow reduced Decreased position sense in extremities Increased risk confusion, injury

Eight Critical Factors for Optimal Outcomes in Geriatric Patients Careful Preop Preparation, optimizing medical and

physiological status Appropriate anesthetic and physiological

monitoring Recognition of clinical pharmacology and

alterations that result from use Minimizing post-operative stressors: hypothermia,

hypoxemia, pain Prevention of heart rate and blood pressure

alterations Maintenance of fluid, electrolyte, and acid base

status Careful surgical technique Optimization of functional level

Geriatric Patient Musts

Warm blankets Careful movement Careful positioning

Summary

Ambulatory Surgery Pediatric Surgery Geriatric Surgery