Transcript Special Populations

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.
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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
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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.
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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:
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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.
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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
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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:
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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:
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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?