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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