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 2. 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