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Special Populations Objectives • Compare and contrast the surgical care considerations for pediatric, obese, diabetic, pregnant, immunocompromised, disabled, geriatric, or trauma patient. • Describe the unique physical and psychological need of each population. • Compare and contrast the intraoperative considerations for special population patients. Objectives • Evaluate the role of the surgical tech for the surgical care of each special population. • Assess the ethical commitment that is required of surgical technologists as it relates to special populations care. • Describe the general needs associated with special populations of surgical patients. Special populations • The surgical tech must be aware of the special needs of some patients and adjust the care appropriately, to provide the same quality care. – Physical – Psychological Pediatric Patients Pediatric Patients • Patient between the ages of birth and 12 years. – – – – – Neonate – First 28 days Infant – 1 - 18 months Toddler – 18 - 30 months Preschooler – 30 months – 5 years School age – 6 - 12 years Pediatric Patients • The surgical team must be familiar with differences in the pediatric patient. – Anatomy and Physiology – Vital signs – Psychological Pediatric Patients • Neonate and infants are startled easily, so a quiet environment is needed. • Unable to explain the nature of the condition, procedure, or complications to the infant. – Only a small amount to the pre-school or younger school aged child. Pediatric Patients • The surgical team is forced to focus on the physiological needs of the pediatric patient. • Efficient and effective surgical process is needed to achieve anesthesia, complete the procedure, and return the child to the family as soon as possible. Pediatric Patients • Pediatric patients may have an overwhelming feeling of anxiety or abandonment, due to separation from family. • Its important to form a bond of trust in a very short period of time to reduce this feeling. Pediatric Patients • Anxiety – Let them bring a favorite toy or stuffed animal into surgery. – Introduce key team members in a preop visit. – Surgery department tour. – Allow parents to accompany the child when transporting, in pre-op, and PACU areas as much as possible. Pediatric Patients • Fear of anesthesia – Children do not understand the meaning and may fear not waking up. – Let the child hold a mask on their face at a preop visit. – Deal in truths about needles and pain, as deceit may build distrust. – Young patients may be held during the short induction time. – A quiet operating room is a must during induction. Monitoring Pediatric Patients • Temperature – Pediatric patients have little subcutaneous fat, and poor thermal insulation. – Heat loss thru radiation, convection, and evaporation. – Incubators aid in reducing heat loss. Monitoring Pediatric Patients • Temperature – Rectal and skin temperatures are monitored. – Room temperature is increased. – Overhead radiant heaters are used. • French Fry Lights – Keep extremities covered and wrapped. Monitoring Pediatric Patients • Urine Output – Highly useful for fluid management. – Neonates and infants are not catheterized so a collection bag is used. Monitoring Pediatric Patients • Cardiac function – Small patient size makes using a blood pressure cuff difficult. – Intra-arterial monitoring. – Central venous catheters. • Umbilical or Radial artery/External jugular vein – Neonates, infants and young children • Subclavian or Internal jugular veins – Older children. Monitoring Pediatric Patients • Oxygenation – Blood oxygen saturation monitors have replaced the arterial blood gas, for monitoring oxygen levels in the blood. • Easier • Faster • Low cost • Safer Monitoring Pediatric Patients • Shock – Common to all groups is hypovolemic and septic shock. – Septic shock is most commonly seen in infants and children. Monitoring Pediatric Patients • Hypovolemic Shock – Dehydration is the most common cause. – Neonate will have bradycardia and low blood pressure/cardiac output. – Treated with quick fluid and blood replacement. • Hypotonic solution of sodium chloride. Monitoring Pediatric Patients • Septic Shock – Caused by gram negative bacteria. – Peritonitis due to intestinal perforation, urinary tract infection, or upper respiratory infection. – Treated with IV crystalliods and broad spectrum antibiotics. – Dopamine may be indicated to increase cardiac output. Monitoring Pediatric Patients • Fluids and Electrolytes – Newborns and infants do not tolerate dehydration well. – Immature kidneys can make fluid management difficult. – Insensible water loss is decreased by covering skin from heaters, and by humidifying inspired gases. Monitoring Pediatric Patients • Infection – Defense barriers and mechanisms are underdeveloped in the newborn. – Fever is usually the first sign of post-op infection. – Common sites for infection are lungs, surgical wounds, urinary tract, and vascular access sites. Monitoring Pediatric Patients • Infection – Treated by frequent wound debridement and dressing changes. – Remove catheters and treat with antibiotics. – Antibiotic treatments are given before surgery and for the following 24-48 hours. Monitoring Pediatric Patients • Antibiotics NOT to be used: – Sulfonamides (Bactrim or Septa) • Increased incidence of kernicterus. (brain damage) – Chloramphenicol • Infants skin turns gray from toxicity. – Tetracycline • Causes staining of the enamel of teeth. Monitoring Pediatric Patients • Trauma – Accidents are the number one cause of death in ages 1-15 years. – Emphasis of prevention of accidents. – Blunt head trauma causes most deaths. – Motor vehicle accidents, falls, bicycle accidents, drowning, burns, poisonings, and child abuse. Monitoring Pediatric Patients • Trauma – Reactions differ from adults. – Misleading information. – Communication of origin of pain. – Blood, heat, and water loss. – Hypothermia intensifies effects of acidosis. – Vomiting common in trauma, increases aspiration risk. Monitoring Pediatric Patients • Trauma during birth – Most common is a fracture clavicle due to shoulder dystocia. – Facial nerve paralysis due to forceps use. – Injury to liver, spleen or adrenal gland due to birth canal pressure. – Injury to sternocleidomastiod muscle causing hematoma, or torticollis. Monitoring Pediatric Patients • Child abuse – Physical and/or mental – Sexual, nutritional, verbal abuse. – Soft tissue injuries, fractures, burns, or head trauma. – Internal visceral injuries. Obese Patients • Patient who weigh 100 pounds or greater than ideal weight have an increase risk of disease and death. Obese Patients • Physiological and disease conditions: – Myocardial hypertrophy leading to congestive heart failure. – Kidney, Liver, and Gallbladder disease. – Varicose veins – Coronary artery disease. – Pulmonary disease – Osteoarthritis – Diabetes Surgical Considerations of the Obese Patient • Transporting – Large enough gurney or surgical bed – Enough personnel. – Mechanical lifting device. Surgical Considerations of the Obese Patient • Venous cutdown for IV insertion. • Anesthesia difficulties during intubation due to limited mobility of cervical spine. – Reverse trendelenburg – Venous compression device • Higher concentrations of anesthetic gases stored in adipose tissue. – Longer recovery. Surgical Considerations of the Obese Patient • Patient positioning – – – – Extra personnel to prevent falling Possibly need two O.R. tables Protect and pad all areas. Prevent tissue from being caught in the folds of the bed. – Grounding pad placement Surgical Considerations of the Obese Patient • May need longer or deeper instruments. – Retractors – Needle holders • Poor blood circulation in the obese patient may lead wound infections, dehiscence or evisceration. – Retention sutures – Montgomery straps Surgical Considerations of the Obese Patient • Complications after gastric bypass. – Internal hernia with bowel strangulation • Exploratory laparotomy – Gaseous distention in the bypassed part of the stomach leading to perforation. • Exploratory laparotomy with gastric tube insertion. Surgical Considerations of the Obese Patient • Gallstones – Often found during other surgical procedures. – STSR should be ready with instrumentation and supplies to remove the gallbladder. • Degenerative Osteoarthritis – Extra weight takes it toll on joints and bones. – Total joint replacement may be necessary. Patients with Diabetes Patients with Diabetes • Disorder of the endocrine system. • Type 1 Diabetes – Pancreas produces no or little insulin. – Insulin dependant – Patient must take daily doses of insulin. • Type 2 Diabetes – Pancreas produces different amounts of insulin. – Daily doses not required. Patients with Diabetes • Surgery can affect the caloric intake and insulin dosage of the patient. • Type 2 patients usually tolerate surgery well. • Type 1 patients metabolic control can create difficulties. Patients with Diabetes • Higher risk for: – Infections and delayed wound healing • May lead to amputation. – – – – – Retinopathy resulting in blindness Dehydration Myocardial infarction Coronary artery disease Neuropathy Surgical Considerations of the Diabetic Patient • Preoperative – Blood glucose test – Preop medication is decreased to reduce vomiting. – Insulin reduced to prevent hypoglycemia. – Adequately pad all bony prominences to prevent pressure sores. Surgical Considerations of the Diabetic Patient • Intraoperative – Insulin and glucose levels are monitored and maintained by IV fluids. – Glucose monitoring – Urine specimens to detect ketones. – Antiembolic stockings are worn to prevent thromboembolism. Surgical Considerations of the Diabetic Patient • Postoperative – Monitor for any infections and wound healing. – Provide with proper nutrients and antihyperglycemic medications. – Fitted with venous compression boots to prevent thromboembolism. Pregnant Patients Pregnant Patients • Reminder that surgery involves two patients. – Mother and fetus. • Emergent surgeries are performed immediately. • Urgent procedures are delayed until after 2nd or 3rd trimester. • Elective procedures delayed until after delivery. Pregnant Patients • Due to the size of the uterus, abdominal organs are displaced. • Diagnosis and finding landmarks can be difficult. • Pregnancy also alters vital signs. – Pulse is higher – Blood pressure is lower – Hypovolemic shock may be masked. Pregnant Patients • Postoperatively – Observe the patient for vaginal bleeding, ruptured membranes, or uterine irritability. – Preterm labor. – Monitor the fetal heart rate. Pregnant Patients • Anesthesia – Preterm labor, fetal death, and low birth weight are risked during general anesthesia. – Short acting drugs should be used as anesthetic agents cross over the placenta. – Sedatives, tranquilizers, halogenated agents, and nitrous oxide have adverse effects in the first trimester. • Pregnant patient and staff STSR Intraoperative considerations with Pregnant Patients • Move quickly to minimize anesthesia time. • Palpate uterus for contractions. • Provide cricoid pressure during intubation. • Rolled sheet under patient’s right hip in supine position. STSR Intraoperative considerations with Pregnant Patients • Accurately document amount of irrigation used. • Raise room temp/Warm blankets • Have emergency C-section instruments and supplies standing by. • Place fetal heart monitor well away from operative site. Immunocompromised Patients Immunocompromised Patients • Typically the very young and old may have compromised immune systems. • Drugs or diseases: – – – – Multiple sclerosis, Lupus Rheumatoid arthritis Immunosuppresant drugs • Transplant surgery Immunocompromised Patients • AIDS patients who are HIV positive and have opportunistic infections: – Kaposi’s sarcoma (Lesions) – Pneumocystis carinii Pneumonia – Other fungal or parasitic infections • Passed by blood or body fluids. Intraoperative considerations • Patient may not be able to move their selves. • Intubation difficulties if they have internal Kaposi’s lesion to trachea. • IV placement due to “used up” veins. • ESU and EKG pads may damage skin. • Pad bony prominences • Blankets and drapes carefully placed. Common Surgical Procedures of the Immunocompromised Patients • Diagnostic Biopsies • Bowel resections or Colostomy due to an acute GI tract perforations caused by bacterial infections. • Splenectomy due to splenomegaly. • Placement of indwelling catheter, for treating infections. Common Indications of the Immunocompromised Patients • Four clinical syndromes that require surgical intervention. – – – – Peritonitis secondary to cytomegalovirus. Non-Hodgkin's lymphoma of GI tract. Kaposi’s sarcoma of the GI tract. Mycobacterial infection of the retroperitoneum or spleen. Disabled Patients Disabled Patients • Patients may be physically, developmentally, or mentally impaired. Disabled Patients • Patients who may be partially or totally deaf are required to remove their hearing aid during surgery. • Written or hand signals may be necessary to communicate. – Interpreter • Nonverbal communication and pre-op visit will help to relieve some anxiety. Disabled Patients • Patients with visual impairments can usually hear verbal commands, but may require assistance. • An explanation of the surroundings, and description of who is in the room will help with anxiety. Disabled Patients • Physically disabled patients will need extra personnel for transferring and positioning the patient. • Extra padding and positioning devices may be needed to protect the patient. Geriatric Patients Geriatric Patients • Although not always true patients over the age of 65 may have some form of decreased physical condition. – Cardiovascular – Respiratory • Proper preoperative planning will help to be ready for possible complications. Critical Factors for Surgical Treatment of Geriatric Patients • • • • Careful preoperative planning Appropriate anesthesia and monitoring. Alterations in clinical pharmacology. Minimize post-op hypothermia, hypoxemia, and pain. • Prevention of alterations in blood pressure and heart rate. Critical Factors for Surgical Treatment of Geriatric Patients • Avoidance of fluctuations of fluid, electrolyte, and acid-base status. • Careful surgical technique. • Optimization of functional level. Trauma Patients “Golden Hour” with Trauma Patients • Military physicians became aware during past wars that the shorter the response time for treatment, increased the chance for survival. • The concept of treating someone within the first hour of traumatic injury is the “GOLDEN HOUR”. “Golden Hour” with Trauma Patients • With improved EMS (Emergency medical services), transportation to a designated trauma center has improved. – Level 1 – 24 hour complete trauma center. – Level 2 – Can treat seriously injured patients with some limits in resources. – Level 3 – Community or rural hospital, will treat and stabilize for transport to level 1 or 2. – Level 4 – Can provide advanced life support to stabilized for transport to level 1 or 2. Trauma Patients • Kinematics is defined as the Mechanism of Injury (MOI). • Action and effect of a particular force on the body. • Aids in understanding what type of injuries to be prepared for. – Exp. Bullet vs. Knife Trauma Patients • 3 important factors when dealing with trauma. – Velocity of the injuring force – Flexibility of the tissue – Shape of the injuring force • Sharp vs. Blunt trauma Blunt Trauma • Injuries from: – – – – Deceleration Acceleration Compression Shearing • Breaks in the skin are often not present making diagnosis difficult. Blunt Trauma • Motor Vehicle Accidents account for a large percentage of blunt trauma. • Spleen is most common organ damaged. Motor Vehicle Accidents • Three types of collisions can occur during a MVA. – Car collides with another object. – Person inside the car collides with objects. • Steering wheel or dash – Internal body structure collides with rigid bony surface. Penetrating Trauma • Injuries resulting from foreign objects passing through tissue. – Knives, Bullets, etc. • Extent of injury depends on: – – – – Type and Size of object Distance victim was from foreign object Body structures penetrated. Amount of velocity of foreign object. Penetrating Trauma • Bullets: – Low velocity 1000 ft/second or slower • Pistol – High velocity 3000 ft/second or faster • Rifle Penetrating Trauma • High velocity bullets will cause more damage to tissues. • The closer the victim is to the weapon, more damage will result, due to increased speed. • Different bullet shapes will result in tissue damage. • Smaller entrance wounds, Larger exit wounds. Penetrating Trauma • Stab wounds: – Low velocity wounds – Shape and size of wound dependant on shape and size of object. – Penetrating objects must not be removed at the scene, as it may provide a tamponade effect for bleeding. Trauma Scoring • Trauma patients are scored using the Revised Trauma Score. (RTS) • This score will help to triage the patient and to communicate the level of severity to other health care professionals. Trauma Patients • Severely injured patients will most likely require multiple procedures. • Some may be performed simultaneously. • Communication with surgeon will dictate order of procedures. • Typically: Head, Chest, Abdomen, Extremities. Preservation of Evidence • If the patient is a victim of violent crime, items will be preserved as evidence. • Follow hospital and law enforcement policies and procedures. • Chain of custody will document and follow the evidence. Trauma Patients • Trauma patients are often hypothermic (< 35* C) and may require raising room temperatures and warming blankets. • Traumatic wounds are often contaminated with debris and may require decontamination before surgery. – Pulse lavage may be needed. O.R. Preparation for Trauma Patients • Designated O.R. rooms with preassembled equipment and supplies. • Special x-ray compatible tables are used. • Multiple set-ups and tables may need to be used. • If no time allows to do an initial count, documentation must state so, and x-rays are taken to confirm that nothing was left in the patient. Any Questions?