1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Berry & Kohn's Operating Room Technique. 12th edition, by N. Phillips
Berry & Kohn's Operating Room Technique.12th edition, by N. Phillips * html
References