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


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 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 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
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
