Ambulatory, Pediatric and Geriatric Considerations

1. Ambulatory, Pediatric and Geriatric Considerations

2. Outline • Ambulatory Surgery • Pediatric Surgery • Geriatric Surgery

3. Ambulatory Surgery • 2001 • 53% in hospitals • 21% free standing facilities • 26% office based

4. Ambulatory Surgery

5. 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

6. 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

7. 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

8. Procedures done in ASCs • Alexander’s page 1192 Box 28-2

9. 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

10. Pediatric Surgery

11. 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

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

13. 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

14. 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

15. 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

16. 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

17. 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)

18. Pediatric Patient Monitoring • Oxygenation • Pulse oximetry

19. Pediatric Shock 1. 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 • Hypovolemic • Caused by dehydration • Prevention: humidifier for inspired gases and covering extremities • Treatment fluid replacement • Bradycardia present in child • Tachycardia seen in adult

20. 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

21. Geriatric Surgery

22. 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

23. Geriatric Physiological Changes • Skin • Loss of elasticity • Loss of subcutaneous tissue (fat) • Increased risk of skin tears or damage due to pressure or shearing

24. 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

25. Geriatric Physiological Changes • Cardiovascular • Coronary artery blood flow decreased • Blood pressure increases • Cardiovascular system less able to handle insults

26. Geriatric Physiological Changes • Respiratory • Lung elasticity diminished • Chest wall becomes more rigid • Tidal exchange reduced • Increased risk of pneumonia or respiratory infections

27. 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

28. 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

29. Geriatric Physiological Changes • Nervous system • Cerebral blood flow reduced • Decreased position sense in extremities • Increased risk confusion, injury

30. 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

31. Geriatric Patient Musts • Warm blankets • Careful movement • Careful positioning

32. Summary • Ambulatory Surgery • Pediatric Surgery • Geriatric Surgery