Special Populations Flashcards
Indications in bariatric surgery
Extreme obesity: (>40 BMI or >35w/ serious problems)
Cannot lose weight by other means
Suffer from serious, health related problems
Youth:
> 6 months attempted weight loss
Bariatric surgery types
Roux En Y: most common but decreasing
Primary restrictive but also malabsorptive
Small stomach –> bypasses duodenum into (straght into jejunum)
Vertical banded gastroplasty
Stapled 30mL pouch off lesser curvature
Rare
Gastic band (AGB, LAGB) Purely restrictive, band at entrance to stomach High rate of revision/recidivism No staple line, avoidance of stromal stenosis
Mini gastric bypass
Division of stomach, jejunal anatomosis, restrictive and malabsorptive
Preoperative assessment of bariatric surgery
Nutritionist Medical bariatric specialist Psychologist Specialized nurse Surgeon, PA Anesthesia risks
Pediatric surgery
Pyloric stenosis (hypertrophy); pyloromotomy (Ramstedt), cb lap Prostaglandins: can lead to pyloric stenosis, goes away on own
Inguinal hernia: especially premies; most common surgery in peds
Hydocele vs hernia vs incarcerated (operate w/in 48h if reducible; not reducible OR now) vs strangulated (necrotic, emergency)
Hasselbach’s triangle anatomy
R > L, M > F, Cb bilat
NPO for elective
Infants: 4 hr
> 6mo: 6 hrs
Clear liquids: 3hr
Maintenance IVF: D5 1/2 NS w KCl
Add O2 early, consider IO sooner
Hernias
Esophageal (sliding vs paraesophageal)
Indirect: congenital
Direct: more likely adults; weakening/tear msk in rectus muscles
High CO2
Increase bloodflow
Normal HR in Peds
hypotension very late
Elderly
Pts >65: 40%
> 85: 8% (often to SNF)
Longer, PNA, CV complications
Interdisciplinary: music therapy, chaplain
Common geriatric surgeries:
joint replacement
GU
CV
Bowel
Recurrent/current steroid use
Suspress hypothalamic-pituitary access, possible inadequate stress response
Impaired wound healing, skin/tissue friability, GI hemorrhage
Hyperglycemia, hypertension, fluid retention, PUD/GI Hemorrhage
More likely GI prophylaxis
Does not need coverage:
prednisone 5mg/day or less
less than 3 weeks
continue reg dose if still on
Extra coverage likely:
> 20mg/day more than 3 weeks
Hx Cushing’s syndrome
Possible:
> 5mg day esp PM dosing
pre-op eval of axis
GC high use/prolonged in last year
Inhaled:
>750mcg Fluticasone > 3 weeks (esp children)
Eval: morning serum cortisol, ACTH stim
Anesthesia administration
IV induction: common in adults, propofol
RSI: risk of aspiration (not NPO)
Inhalational: common peds, inhaled such as sevoflurane
Intubation Premed: Versed/fentanyl O2 5 minutes pre-oxygenate Induction: propofol and opioid NM Blockade: if yes need ET tube, if not can use LMA
Anesthesia complications/risks
Nausea and Vomiting (PONV) (10-30%) 23% • Upper Airway Problems 6.9% • Hypotension 2.7% • Hypothermia/Shivering 40% • Dysrhythmias 1.4% • Hypertension 1.1% • Altered Mental Status 0.6% • Major Cardiac Events 0.6% • Respiratory Depression
Immediate: respiratory/hypoventilation, airway obstruction, depression/opioids, residual NM blockade, increased pain
PONV
Premedicate is always better: 24-48 hours
Zofran Dexamethasone 4mg (ehh)
Fluids in Surgery
D5W: 9% stays intravascular
Calcium/Parathyroid
Give calcium gluconate (can give peripheral)
Parathyroid removal –> hypocalcemia
