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Anesthesia Consideration for Special Populatons Pregnant Geriatric Diabetic Obese 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 The Pregnant Patient-Physiologic Changes 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 Anesthetic Considerations Elective: Cervical Cerclage Cholecystectomy C-section Emergent: *Trauma *C-section Common Surgical Procedures 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 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 Anesthetic 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 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) Anesthetic Considerations 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 The Obese Patient-Physiologic Changes 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) Anesthetic Considerations Berry & Kohn's Operating Room Technique.12th edition, by N. Phillips *http://www.whathealth.com/bmi/formula. html References