Ambulatory, Pediatric, and Geriatric Surgical Considerations
This content discusses ambulatory, pediatric, and geriatric surgery considerations, outlining the differences in surgeries for different age groups. It covers aspects such as prime candidates for ambulatory surgery, procedures done in ambulatory surgical centers (ASCs), staffing considerations, and specific considerations for pediatric patients at different stages. The focus is on achieving cost-effective, safe, and convenient discharge of patients to home post-operation.
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AMBULATORY, PEDIATRIC AND GERIATRIC AMBULATORY, PEDIATRIC AND GERIATRIC CONSIDERATIONS CONSIDERATIONS
Outline Ambulatory Surgery Pediatric Surgery Geriatric Surgery
Ambulatory Surgery 2001 53% in hospitals 21% free standing facilities 26% office based
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 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 Shock 2. Hypovolemic Caused by dehydration Prevention: humidifier for inspired gases and covering extremities Treatment fluid replacement Bradycardia present in child Tachycardia seen in adult 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
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 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
