Ambulatory, Pediatric and Geriatric Considerations

Ambulatory, Pediatric and Geriatric Considerations

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 Alexanders 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 Alexanders Best candidates are ASA 1 or 2 ASA 3 can be done in ASCs however require careful monitoring and planning Procedures done in ASCs Alexanders 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 preoperative 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 wont 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 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 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

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