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Special Populations Donna Voldan, BSN, RN, CAPA Special Populations • Care of the patient with Chronic Disorders • Care of the Pediatric patient • Care of the Geriatric patient • Care of the Pregnant patient Objectives • Identify special anatomic and physiologic differences in the chronic disorders, pediatric, geriatric and pregnant patient, in reference to perianesthesia care Care of the Patient with Chronic Disorders Chronic Disorders/ Special Populations • • • • • • Chronic Obstructive Pulmonary Disease (COPD) Obstructive Sleep Apnea (OSA) Diabetes Sickle Cell Myasthenia Gravis Hereditary coagulopathies - Hemophilia - Von Willebrand Disease • Pseudocholinesterase Deficiency COPD • Progressive development of airflow obstruction that is not fully reversible • Term includes chronic bronchitis and emphysema • Significance: hypoxia, hypercapnia, pneumonia, respiratory failure, bronchospasm, atelectasis • Etiology: cigarette smoking, air pollution, occupational exposure Chronic bronchitis Blue Bloater! • Chronic productive cough caused by excess bronchial mucus secretions • Reduction in expiratory flow rate • Signs include: hemoptysis, cough, increased sputum, dyspnea and wheezing Emphysema Pink Puffer! • Abnormal permanent enlargement of air spaces distal to terminal bronchioles • Increased minute ventilation • Barrel chest, pursed lip breathing, decreased lung sounds Risk reduction for patients with COPD • Pre Operative - Encourage smoking cessation for at least 8 wks - Ask to bring inhalers day of surgery - Treat infection with antibiotics - Initiate patient education- pre op regarding lung volume expansion maneuvers COPD risk reduction Intra Op • Minimally invasive surgery • Use regional anesthesia • Avoid long acting neuromuscular blocking drugs (These patients rely on intercostals and abdominal muscles) • Avoid surgical procedures > 3 hrs COPD Post Op • Institute deep breathing, incentive spirometry, continuous positive airway pressure • Treat with bronchodilators and corticosteroids • Nasal cannula < 3L if possible - COPD patient’s respirations are controlled by hypoxic drive • High flow and high concentration oxygen may produce apnea OSA • Repetitive episodes of upper airway occlusion during sleep - Often oxygen desaturation - Apnea defined as cessation of airflow at mouth for > 10 seconds OSA facts • 80% cases undiagnosed • Greater incidence in men • Incidence: Obesity with large neck circumference • Systemic and pulmonary hypertension • High risk of post op complications with general anesthesia Perianesthesia considerations OSA • Have patient bring in CPAP mask from home • Treat preop with histamine blockers and antacids for morbidly obese • Potential airway obstruction at induction and on extubation • Aspiration risk • Repetitive apnea can occur with opioids and benzodiazepines • Risk for post operative thromboembolism Diabetes Mellitus • Deficits in insulin secretion, action or both • Chronic, progressive disease characterized by the body’s inability to metabolize carbohydrates, fats and proteins leading to hyperglycemia • Two types: - Insulin dependent (Type I) - Non insulin dependent (Type II) Diabetes Symptoms • • • • • • • • Increased thirst, frequent urination Extreme hunger Unexplained weight loss, nausea Presence of ketones in the urine Fatigue Blurred vision Slow-healing sores, frequent infections High blood pressure Diabetes Type I Insulin Dependent • • • • • Formerly called juvenile onset diabetes Children and young adults Rarely obese Causes: genetic, environmental Treatment: meal planning, exercise and insulin administration Diabetes Type II Non-Insulin Dependent • Causes/ Characteristics: - Overweight/ obese, inactivity, age and hypertension • 90-95% of population with Diabetes • Impaired insulin secretion or peripheral resistance to one’s own insulin • Treatment: meal planning, exercise, weight loss, oral hypoglycemics and insulin products Diabetes Pre Op • All diabetes medication guidelines should be discussed with the patients primary care physician pre operatively • In general, advised to hold oral meds the evening before or the day of surgery to prevent hypoglycemia - Persons with Type I DM may be advised to reduce bedtime insulin Metformin • Metformin is held to prevent the possibility of lactic acidosis - *Hold metformin 48 hrs after IV contrast to prevent renal failure Diabetes Post Op Care Plan • • • • **Monitor serum glucose **Monitor Intake and Output Assess level of consciousness Manage oxygenation/ assess for distress - hypoxemia • Assess for dysrhythmias - Electrolyte imbalance • Monitor for signs of infection Sickle Cell Disease • Definition: Chronic hemoglobinopathy - Vascular occlusion - Compromised tissue oxygenation • Inherited hemolytic anemia • Sickle cell trait is found in about 8-12% of the African- American population Sickle Cell Disease cont’d • Marked by exacerbations • Clinical manifestations based entirely on sickling of red blood cells (distortion of shape) - Caused by hemoglobin exposed to low oxygen Sickle Cell Anesthesia Implications • Anesthesia not generally hazardous to patients with sickle cell trait - Although, adverse hypoxic conditions can precipitate a crisis • Most important factor related to this syndrome is that hypoxemia generally occurs during emergence • Local anesthesia or nerve block is the technique of choice - Avoid epidurals and spinals because of the possibility of hypotension Sickle Cell Post Op • Minimize factors that cause sickling : - Abnormal temperature regulation • Hypothermia: Cold reduces body metabolism crisis • Hyperthermia: Excess sweating can lead to dehydration crisis Other Sickle Cell Considerations Post op • Avoid acidosis from hypoventilation - Maintain oxygen! • Bag valve mask for decreased saturations • Avoid pain: use analgesics • Maintain intravascular fluid volume - prevent hypovolemia sickling Myasthenia Gravis • Chronic autoimmune disease of neuromuscular junction • Fatigue and diminished muscle strength • 5 types with escalating severity • Treatment includes anticholinesterase drugs Myasthenia Gravis Types • Type I: Involvement of only extraocular eye muscles • Type IIA: Slow, progressive mild skeletal muscle weakness without resp. involvement • Type IIB: Severe, rapidly progressive skeletal muscle weakness with resp. muscle weakness • Type III: Acute onset, rapid deterioration of skeletal muscle strength with high mortality • Type IV: Severe skeletal muscle weakness from progression of type I or II Myasthenia Gravis Considerations • Not appropriate for ambulatory surgery if type IIB, III or IV • Will likely require prolonged postoperative ventilatory support • Anticholinesterase drugs alter effects of NDMR (non depolarizing muscle relaxants) • Susceptible to respiratory depression and aspiration when muscle weakness is involved • Consider epidural analgesics Hereditary Coagulopathies • Hemophilia: Sex linked clotting factor deficiency affecting men • Von Willebrand’s Hemophilia Types • Hemophilia A - Clotting factor VIII lacking - Potential for bleeding into tissues and joints - PTT prolonged and PT normal • Hemophilia B (Christmas disease) - Clotting Factor IX lacking - Prevents formation of stable clots - May need cryo or FFP - PTT and PT normal Von Willebrand’s disease • Common disorder affecting men and women with mucous membrane bleeding, increased menstrual bleeding, epistaxis, mild bruising • Defective Von Willebrand factor • Reduced activity of Factor VIII: increased PTT • Platelet “stickiness” impaired • Pre Operative - DDAVP (desmopressin) given to increase factor - Cryoprecipitate (has Factor VIII) Perianesthesia Implications for Coagulopathies • For significant disease: Unlikely candidate for outpatient surgery with discharge home • Pre Op: - Document most recent anticoagulant medication - Increased risk for spinal/ epidural hematoma if anticoagulated patient receives regional anesthesia Post Op Considerations for Coagulopathies • Observe for insidious bleeding • Increasing abd girth • Oozing and bruising from incisions and venipuncture sites • Link vital sign changes and oxygenation changes with bleeding potentials Pseudocholinesterase Deficiency • Affected individuals are very sensitive to several anesthetic agents, such as succinylcholine and mivacurium • The muscles that work the lungs may become paralyzed • Mechanical ventilation is essential until the excess anesthetic agent is metabolized and normal breathing is resumed • The patient may emerge from anesthesia may be lengthy (ie: slow wake up) • Regional Anesthesia (blocks) may be prolonged Pediatric Patients Developmental Stages • Premature Neonate- born prior to 40 weeks gestation • Newborn- < 72 hours old • Infancy (Birth to 1 year) • Toddler hood (1-3 years) • Early childhood (3-6 years) • Middle childhood (6-12 years) • Adolescence (12-18 years) Erikson’s Stages of Development • Trust vs. Mistrust (1 month-1 year) • Autonomy vs. Shame and Doubt (1-3 yrs) • Initiative vs. Guilt (3-5 yrs) • Industry vs. Inferiority (5-13 yrs) • Identity vs. Role Confusion (13-18 yrs) Infants Trust vs. Mistrust Fears: Separation and strangers • Minimize separation from parents • Provide consistent caregivers • Decrease parents’ anxiety Toddler Autonomy vs. Shame Fears: Separation and loss of control • Advance preparation for surgery produces more anxiety • Keep explanations simple • Let toddler play with equipment Preschool Initiative vs. Guilt Fears: Bodily injury, loss of control, the unknown, being left alone • Prepare days in advance for major events • Keep explanations simple • Emphasize that they will wake up after surgery • Use play and pictures • Repeat that they are not being punished • Give them choices School Age Industry vs. Inferiority Fears: Loss of control, bodily injury and death • • • • • • Prepare in advance for major events Ask what they understand Use pictures and models Emphasize normalcy with friends Give choices Reassure that not being punished Adolescent Identity vs. Role Confusion Fears: Loss of control, altered body image and separation from peers • • • • • • • • Prepare in advance Provide tours Allow them to be a part of decision making Give information sensitively Stress their independence Give choices Maintain peer contact Teach coping techniques Pediatric Respiratory Considerations: Infants • Head larger in proportion to body • Larynx is high, funnel shaped and easily compressed • Trachea located downward and posterior with small diameter • Epiglottis is short, stiff and u-shaped • Obligatory nose breather • Accessory musculature poorly developed Respiratory Considerations: Infants and Children • Large tongue and narrow nares • Smaller airway opening and shorter neck • Tonsillar tissue normally enlarged until school age • Poor accessory and intercostal musculature • Respiratory rate decreases with increasing age ** Optimal airway position for infant is neutral or “sniffing” position Pediatric Respiratory Rates • • • • • • Newborn Infants Toddlers Preschool School age Adolescents 30-50 bpm 30-60 bpm 24-40 bpm 22-34 bpm 18-30 bpm 12-16 bpm ***Respiratory rate of 60 bpm or more, is a sign of distress in a child of ANY age Pediatric Respiratory Distress •Increased respiratory rate (tachypnea) - Tachypnea is often first sign of respiratory distress in infants •Falling oxygen saturation •Cyanosis, mottled color •Tachycardia •Retractions, nasal flaring, grunting •Change in responsiveness Late Signs of Respiratory Distress/Failure • • • • • Poor air entry Weak cry Apnea, gasping Bradycardia Deteriorating systemic perfusion Airway/Respiratory Complications: • • • • • • Laryngospasm Bronchospasm Croup Stridor Non cardiogenic pulmonary edema Aspiration Laryngospasm: Involuntary muscle contraction of the laryngeal muscles that causes the vocal cords to close -Preexisting irritable airway -Manipulation of airway (ETT or oral) -Excessive or aggressive suctioning -Irritant trigger/anesthetic gases -Secretions/blood on vocal cords Laryngospasm Signs and Symptoms • Dyspnea • Crowing sound on inspiration • Rocking motion of chest/ Use of accessory muscles • Aphonia (no sound) Laryngospasm Nursing Intervention • • • • Administer humidified 100% oxygen Positive pressure mask ventilation Oropharyngeal suctioning Medications - Muscle relaxants (Succinylcholinedepolarizing muscle relaxant) - Racemic epinephrine via nebulizer - Dexsamethasone - Lidocaine Bronchospasm: Sudden constriction of the muscles in the walls of the bronchioles - Preexisting airway disease (asthma) - Allergy, anaphylaxis - Aspiration - Foreign body Bronchospasm Signs and Symptoms • • • • • High pitched wheezing Coarse rales Increased respiratory rate Dyspnea Retractions Bronchospasm Interventions: • Administer humidified oxygen • Suction secretions • Bronchodilators - Albuterol via nebulizer • Potential reintubation Croup A group of conditions involving inflammation of the upper airway - Post intubation croup • Common in presence of upper respiratory infection • Usually occurs within 1 hour after extubation • May intensify within 4 hours • Completely resolved in 24 hrs Croup causes • Increased incidence in children from 14 yrs. old, due to small laryngeal lumen • Traumatic, prolonged or repeated intubations • Coughing with ETT in place • Surgical procedure greater than 1 hour in duration Croup signs and symptoms • Bark-like cough • Hoarseness • Respiratory distress Croup Nursing Interventions • Humidified oxygen • Steroids • Aerosol epinephrine (racemic epi) • Hydration • Observe for further evaluation Stridor A high pitched sound produced by turbulent airflow through a narrowed segment of the upper airway •Calm reassurance •Cool humidified oxygen •Elevate head of bed •Notify MD if indicated •MD may order racemic epi nebulizer Non Cardiogenic Pulmonary Edema Coughing on a closed epiglottis which causes increased intra thoracic pressure - Pink frothy sputum - Decreased oxygen saturation which can not be explained - Dyspnea - Confirmed with CXR Aspiration • Bilious secretions in the tracheobronchial tree • Most prevalent symptom is hypoxemia - also wheezing, rhonchi, coughing • Reposition patient- turn head to the side Pediatric Cardiovascular System • Respiratory and heart rate decrease with age (see attachment) • Blood pressure increases with age (see attachment) • In children, heart rate is the dominant factor for cardiac output - Monitor apical pulse until age six • When bradycardia occurs, cardiac output quickly falls leading to serious cardiac complications Bradycardia in Peds Causes: • Congenital anomalies • Hypoxia • Hypothermia • Medications/anesthesia • Vagal stimulation • Increased intracranial stimulation ** This may be the first sign of CV dysfunction/decompensation Tachycardia in Peds Causes: • Elevated temperature • Pain • Hypovolemia • Early respiratory distress • Medications (atropine, glyco, epi, ketamine) • Decreased perfusion/impending shock **Treat the cause Developmental Stage/Age Respirations Heart Rate Systolic BP Diastolic BP Neonate Birth-1 month 30-50 110-160 60-80 40-50 Infant 30-60 1 month- 1 year 100-160 70-100 50-70 1-3 years 20-30 80-125 78-114 46-78 3-5 years 22-30 80-110 78-114 46-78 6-12 years 20-26 70-100 78-118 54-78 13-18 years 18-20 50-100 Less than 120 Less than 80 Adult 18-20 60-100 Less than 130 Less than 80 Thermoregulation in Peds • Large surface areas relative to body mass • Infants/children do not shiver, so inability to produce heat • Lack adipose tissue to insulate against heat loss Hypothermia in Peds • Increase pulmonary and peripheral vasoconstriction • Increased oxygen demandtachypnea • Increased fat metabolism • Metabolic acidosis Hypothermia Causes: • Vasodilating anesthetic agents, muscle relaxants • Environmental causes (cool environment, transport) Assessment: • Core temp <36 C • Peripheral vasoconstriction, piloerection Hypothermia can delay emergence Hyperthermia in Peds Causes: • Fever • Dehydration • Infection • MH triggers: Volatile inhalation anesthetics (halothane, sevoflurane etc.) Hyperthermia cont’d Assessment: • Tachycardia • Tachypnea • Diaphoresis/ flushed skin Treatment: • Lower temperature gradually, do not uncover completely • Apply ice packs/cool compresses to groin and axilla GI Peds • Increased salivation- allow to “spit out” secretions without coughing or clearing excessively - Excessive swallowing and clearing of throat post tonsillectomy may be a sign of bleeding • Increased peristalsis increased gastric secretions • Immature esophageal sphincterprone to reflux Post Anesthesia Care Peds • Regression/crying is common • Use appropriate pain scale/tool (faces, numeric, FLACC) • Multimodal technique for pain control is beneficial - Oral and parenteral opioids, NSAIDS, regional anesthesia and PCA’s • Have appropriate sized equipment available Faces Pain Scale Peds Emergence Delirium/ Agitation Pediatric Population State of restlessness and mental distress • Restlessness may be extreme • Child may be vocal and difficult to manage • Occurs in 18% of all children emerging • No response to verbal commands • Maintain safety, offer parental visitation (with explanation to parents) • Medicate for pain, treat homodynamic instability, offer support for full bladder • Sedate as needed per MD’s orders Geriatric Patient Geriatric Patient • Definition: Age 65 or older and qualifies for retirement - Number of older adults in U.S. is increasing - Life expectancy: • Men 81 yrs., Women 84 yrs. - Older adults account for 1/3 of all health care costs Physiologic Changes with Aging • • • • Respiratory Cardiovascular Renal Other changes Respiratory Changes in the Geriatric Patient • • • • Increased A-P diameter Decreased strength of diaphragm Increased chest wall rigidity Loss of skeletal muscle mass - Wasting of diaphragm and skeletal muscles • Loss of teeth changes jaw structure Geriatric Patients Post Operative Resp. Implications • More likely to develop apnea in response to opioids and benzodiazepines • Decreased cough and gag reflex - Risk of aspiration • Increased risk of postoperative hypoxemia - May contribute to myocardial ischemia and infarction • Potential for increased airway obstruction - Due to jaw structure changes Geriatric Patients Cardiovascular System • CV disease leading cause of death in older patients • Arteriosclerosis prevalent • Decreased organ perfusion • Increase in systolic BP • Decreased HR • Impaired peripheral circulation • Increase in dysrhythmias and blocks CV Nursing Implications Geriatric Patient • Encourage deep breathing • Watch for fluid overload, while ensuring hydration • Slow position changes/orthostatic changes • Gentle venipunctures • Minimize automatic BP devices • Provide warm blankets/loss of fat Renal Changes Geriatric Patient • Decreased bladder capacity (200 ml) • GFR decreases 30-50% - Decreased clearance of medications • Weakened sphincters • Enlarged prostate - Urinary incontinence and retention • Increased fluid/electrolyte imbalance Other Changes with Aging • Memory/cognition - Alzheimer’s, stroke, dementia, depression • Visual - Retinal changes, cataracts, glaucoma, decreased acuity • Auditory - Impairment of sound localization and perception • Skin - Importance of preoperative assessment • Loss of fat - Decreased thermoregulation Signs of Elder Abuse • • • • • Poor hygiene Malnourished/dehydrated Burns, pressure sores, bruises Patient fears caregiver Caregiver reluctant to leave pt. with staff ** Caregiver must report per State/facility protocol Pregnant Patient Cardiac Implications Pregnant Patient • • • • Heart displaced upward and to the left Stroke volume increase Cardiac output increases 30-50% HR increases 15-20 beats/minute - Returns to normal 6 wks post partum • BP decreases until mid-pregnancy • Total blood volume and body water increases • Peripheral edema Respiratory Changes Pregnant Patient • Respiratory rate increases 15% • Oxygen consumption increases 15-25% - Oxygen, oxygen, oxygen! • Diaphragm elevated • Acid base changes - Pregnancy is a state of compensated respiratory alkalosis • Nasal epistaxis and congestion may obstruct nasal airway GI Changes Pregnant Patient • Gastric emptying slows - Stomach is displaced - Reflux and esophagitis • Gastric volume increases during pregnancy and postpartum (hrs 1-8) - Post anesthesia -risk for vomiting/aspiration - Side lying position important Hematological system Pregnant Patient • Pregnancy is a natural hypervolemic state - Renal sodium and water retention • Plasma volume increases 40-50% - Responsible for hemodilutional changes • *****“Dilutional anemia” Pregnant Patient Nursing Implications • Prevent aortocaval compression - Place in left lateral decubitus position • BP not a reliable indicator of hypovolemia or shock - Blood loss may reach 35% before hypovolemic shock occurs - Earliest sign-mild tachycardia without changes in BP • HIV can be transmitted through vaginal secretions and amniotic fluid Group B Strep • • • • • Group B strep is a type of bacteria that is often found in the vagina and rectum of healthy women In the United States, about 1 in 4 women carry this type of bacteria Being a carrier does not mean you have an infection Passed from a mother to her baby during childbirth, can cause serious illness in newborns Group B strep infections in newborns can be prevented—antibiotics ***This is different than Group A Strep The End References • American Board of PeriAnesthesia Nursing Certification, Inc. (2013). Certification Candidate Handbook. http://www.cpancapa.org/pdfs/CPAN_CAPA_Certification_H andbook2013.pdfCertification for the Perianesthesia Nurse • American Society of PeriAnesthesia Nurses. (2009). Competency Based Orientation. • American Society of PeriAnesthesia Nurses (2012). ASPAN Standards and Practice Recommendations 2012-2014. • Odom-Forren, J. (2013). Drain’s PeriAnesthesia Nursing: A Critical Care Approach (6th ed.). St. Louis, MO: Elsevier, Inc. • Schick, L. and Windle, P. E. (2010) PeriAnesthesia Nursing Core Curriculum: Preprocedure, Phase I and Phase II PACU Nursing (2nd ed.). St. Louis, MO: Elsevier, Inc.
