Anesthesia Consideration for Special Populatons Pregnant Geriatric Diabetic Obese Discuss the physiologic changes that occur with each of these pt populations, and then discuss the anesthesia considerations. May be some repetition of material carried over from Wednesdays class, but repetition is GOOD

The Pregnant Patient-Physiologic Changes The presence of fetus and placenta Aorta and vena caval compression Reflux and possible aspiration of gastric contents Decreased gastric motility and emptying Diaphragm displaced 4 cm by fundus Intubation difficulties Increased oxygen consumption Increased blood volume Uterus compresses the inferior vena cava and aorta Diaphragm displaced 4 cm in 3rd trimester Gallbladder is sluggish Danger of aspiration during induction for general anesthesia, cricoid always The Pregnant Patient-Physiologic Changes

Anesthetic Considerations Remember you are treating 2 patients Have fetal monitor on during surgery Treat pt as if they have a full stomach Epidural/spinal anesthetic preferred Prevent decreased blood flow to fetus by placing pt in left side down tilt In general anesthesia, position, prep and drape pt, then induce, cricoid pressure ALWAYS! Monitor urine output and temperature Fetal monitor to watch heart rate Risk for aspiration Risk for decreased blood flow to uterus and fetus if left in flat supine Decrease the amount of time under general, do all prep 1st, then induce Distended bladder can trigger labor, uterine irritability, or be injured during surgery Hypothermia can cause decreased uteroplacental perfusion and cause fetal brady Anesthetic Considerations

Common Surgical Procedures Elective: Cervical Cerclage Cholecystectomy C-section Emergent: *Trauma *C-section Incompetent cervix, Shrirodkar(under the mucosa) or mcdonalds ( on top of mucosa) procedure Indications for stat c section, fetal distress, placenta previa, maternal issues, delayed progress in labor, Common Surgical Procedures

The Geriatric Patient-Physiologic Changes Decreased subcutaneous fat Decreased muscle strength and amount Decreased chest capacity, decreased respiratory muscle strength Decreased cardiac output, stroke volume, Increased vascular resistance, dilation of veins Decreased saliva production, delayed emptying of stomach Slowed release of insulin from pancreas Slowed metabolism of drugs in liver Fluid/electrolyte imbalances Decreased renal function Impaired vision and hearing The Geriatric Patient-Physiologic Changes

Anesthetic Considerations Pre-op: Check lab work, EKG, thorough H&P Intra-op: (Due to physiologic changes) *need for lower doses of medications *induction/ventilation prolonged d/t decreased lung capacity or disease *avoid rapid decrease in BP *careful positioning and padding Post-op: *watch for drug interactions *aspiration Liver slow at metabolizing so pts respond slower to meds. Take longer to act and wear off May need time increase O2 level, take longer to bring O2 sat up, ventilate longer Potential for difficult intubation d/t dec. neck mobility Prone to rapid drop in BP and at risk for hypoxia, stroke, renal failure Frail skin, decreased muscle, bony prominences, decreased nerve sensation-= careful positioning and padding, gentle tape used, care removing bovie pad, etc. Due to the slow metabolism of drugs, interactions common, narcotics and sedatives interact with anesthetics, potential for altered mental status. Once elderly pt. undergoes surgery, can see a rapid deterioration in the function At danger of aspiration d/t decreased saliva production, , dec. esophageal peristalsis, decreased effective coughing Anesthetic Considerations

The Diabetic Patient-Physiologic Considerations Blood glucose level fluctuates/unpredictable Wounds slow to heal Increased heart rate Predisposed to coronary artery disease Peripheral edema/decreased peripheral perfusion Predisposed to infection Electrolyte imbalance Motor/sensory deficit Small vessels affected in kidneys/eyes leads to decreased function and damage The Diabetic Patient-Physiologic Considerations

Anesthetic Considerations Should be scheduled as 1st case or as early as possible Check glucose level prior to and during surgery Pre-op insulin dose may be needed for Type l Maintain adequate hydration Avoid NG tube Use of SCD(Sequencial Compression Device) leggings Careful skin preparation and padding/protecting of extremities, etc. Use hypoallergenic tape on skin (securing ET tube) 1st case of day to prevent delay and NPO status can affect the blood sugar, the longer they are NPO the inc. danger of dropping their blood sugar Pre-op area should check blood sugar and put it on the chart. If the pt. comes from the floor, call up to the RN and ask for blood sugar to be done Pt. may come down with a insulin pump. Keep on the pump. Most anesthesia don’t want a pump but not in this case IV access important NG suction can contribute to dehydration and electrolyte imbalance Use SCD due to decreased peripheral circulation Their skin can be damaged easily and they have healing problems so careful positioning and padding are important Gentle tapes should be used and sticky things should be gently removed from pts skin Anesthetic Considerations

The Obese Patient-Physiologic Changes Obesity=greater than 100 lb over ideal body weight Morbid=greater than 110%to 120% of IBW Increased demand on the heart leads to myocardial hypertrophy Hypertension Poor venous return Hypoxemia, respiratory compromise Gallbladder disease Diabetes Osteoarthritis Excess adipose tissue BMI of greater than 30 to 40 is obese Greater than 40 = morbidly obese BMI=BMI = ( kg/m² ) weight in kilograms divided by height in meters² Weight in pounds * 703 divided by height in inches2 The Obese Patient-Physiologic Changes

Anesthetic Considerations Potential for difficult intubation Potential for difficulty ventilating Slower uptake of anesthetic gas, prolonging induction High adipose tissue concentration requires higher doses of medication Recovery from effects of medications given during surgery is prolonged (longer wake-up) Decreased neck mobility Sleep apnea, common, excess tissue in airway Increased fat mass on chest makes it harder to venilate Decreased respiratory function makes it take longer for the gas to get into the system Fat soaks up the anesthetic gases and stay in the system and the meds Wake ups can take a long time… Anesthetic Considerations

Berry & Kohn's Operating Room Technique. 12th edition, by N. Phillips Berry & Kohn's Operating Room Technique.12th edition, by N. Phillips *http://www.whathealth.com/bmi/formula. html References