School Age

6-12 years

Adolescent

13-18 years

Temperature Regulation for Pediatric Pt.

Child less than 6 months of age cannot shiver and therefore at risk for hypothermia, bradycardia, and acidosis

Sinuses for Pediatric Pt.

only ethmoid and maxillary sinuses present at birth

Frontal sinuses develop at 7 years

Sphenoid sinuses develop after puberty

What has happened since the development of rapid induction?

the child no longer has to be subjected to long induction times. Patients who are 2 years of age and younger are usually held by the anesthesia provider during induction. The circulator should stand nearby to assist the anesthesia provider by holding the mask on the face of the child or by holding the child’s hands or arms, and by making sure that the room is kept very quiet during the induction.

Urine Output

For fluid management, measurement is highly useful for all patient age groups. Neonates and infants are not usually catheterized due to the high risk of trauma to the small urethra; a collection bag is just as useful in obtaining an accurate measurement. An appropriate urine output is 1 to 2 mL/kg/hr.

Cardiac function

When no cardiac abnormalities are present, a central venous catheter is inserted percutaneously into the sub-clavian or internal jugular vein in older children. In neonates and infants, a cutdown approach to the external jugular vein is preferred. Due to higher incidences of contamination when procedures are performed in the groin region, the saphenous vein is the route least used.

Central Venous Catheter

a catheter passed through a peripheral vein and ending in the thoracic vena cava. It is used to measure venous pressure or to infuse concentrated solutions

Oxygenation

The standard for all age groups of surgical patients is measuring the arterial blood gases (ABGs). However, with the introduction of pulse oximetry, this has been made considerably easier. Its advantages include immediate blood oxygen saturation information and low cost. The elimination of the necessity for an indwelling probe also decreases the possibility of infection. In surgery, it can be difficult to obtain a blood specimen from the small artery of a neonate or infant; consequently, pulse oximetry has reduced the waiting time for collecting monitoring data.

Two common types of shock seen in all ages groups are

Septic and hypovolemic

In infants and children the most common type of shock is

septic shock

What is highly important for the surgical tech to be aware of

that the neonate and infant respond to shock differently from the older child and adult

Difference between Neonate shock and adult shock

For the neonate affected by hypovolemic shock, bradycardia is a physiological response, whereas tachycardia is the typical adult response.

What does shock do to neonates blood pressure

blood pressure is normally low, so shock does not significantly decrease the blood pressure. However, hypovolemia does result in decreased venous return that lowers cardiac output and leads to poor tissue perfusion with eventual lactic acidosis.

What is the most common cause of shock in infants and how is it treated

dehydration is the most common cause of hypo-volemic shock; therefore, the main treatment of hypovolemic shock is quick fluid and blood replacement. As a rule of thumb, more water is lost than electrolytes. Emergency treatment is the infusion of a hypotonic solution of sodium chloride.

What causes septic shock

gram-negative bacteria. Peritonitis due to intestinal perforation is a common cause of shock in neonates and infants. Other causes include urinary tract infection (UTI), upper respiratory infection (URI), and a contaminated intravascular catheter.

What are three differences for infection between adults and children

1. Sulfonamides (such as Bactrim or Septra) are associated with an increased incidence of kernicterus in neonates. Kernicterus is an excess of bilirubin in the blood. Sulfon-amides should not be administered to newborns.
2. Chloramphenicol (Chloromycetin) is the synthetic form of an antibiotic originally isolated from Streptomyces venezuelae and is associated with the cause of “gray syndrome” in which the infant’s skin turns gray from drug toxicity. Chloramphenicol should not be administered to newborns.
3. Tetracycline causes staining and hypoplasia of the enamel of the developing teeth; therefore, it should not be administered to children.

pseudomembranous enterocolitis,

Practically every antibiotic has been associated with the development

most likely from the overgrowth of Clostridium difficile due to antibiotic suppression of the growth of normal bacteria in the colon.

One treatment consists of discontinuing the antibiotic that contributed to the cause of the enterocolitis (infection of the small and large bowel), and oral administration of vancomycin.

What is the number one cause of death in children 1-15

Accidents

2007: 2,800 children aged 1-14 died from an unintentional injury

Major cause in trauma in childern

Motor Vehicle Accidents

Hyperventilation

is a common response by children to injury, resulting in gastric dilatation. This is easily resolved by inserting a nasogastric tube.

Most common bone fracture during child birth

Clavicle usually a result of Dystocia

Dystocia

term used for difficult labor or delivery of a baby

Shoulder Dystocia is caused by

when the baby’s head is delivered, but the shoulders cannot be delivered because they are too wide and are stuck behind the mother’s pubic bone or the opening to the birth canal.

Injury to the liver, spleen, or adrenal glands are caused by

direct pressure on the infant’s abdomen from the mother’s birth canal. However, this rarely requires surgical intervention.

What can birth trauma injure and what does it cause

can injure the sternocleidomastoid muscle, which leads to the formation of a hematoma and torticollis (a contracted state of the muscle). Surgery is necessary if the injury is not recognized in time to correct the condition.

Morbid Obesity

refers to patients whose body weight is 100 pounds greater than ideal body weight and have an increased susceptibility to morbidity and mortality caused by the physical difficulties of carrying extra weight.

Physiological and disease conditions related to obesity

• Myocardial hypertrophy (enlargement of the heart) due to the increased demands placed on the heart, leading to congestive heart failure
• Coronary artery disease (CAD)
• Hypertension (high blood pressure) and vascular changes in the kidneys, affecting elimination of protein wastes and the maintenance of normal fluid and electrolyte balance
• Varicose veins and edema in lower extremities due to poor venous return (venous pooling can lead to thromboembolism and thrombophlebitis)
• Pulmonary function complications, including decreased tidal volume leading to hypoxemia, shortness of breath, sleep apnea, and decrease in lung expansion, making the patient susceptible to postoperative pulmonary infection and embolism
• Liver and gallbladder disease
• Osteoarthritis
• Diabetes mellitus
• Pituitary abnormalities
• Arteriosclerosis
• Dysfunctional uterine bleeding

Venous Cutdown

may be required to insert an intravenous (IV) line if peripheral veins are not visible

Why is incubation difficult in obese patients

due to limited mobility of the cervical spine.

Due to decreased pulmonary functions what do they use in surgical procedures

(obese pt)

lower concentrations of anesthetic gases reach the lungs, therefore increasing the induction time. Higher concentrations of anesthetic agents are required due to their uptake by large amounts of adipose tissue; therefore, postoperative anesthesia recovery time is increased because adipose tissue retains fat-soluble anesthetic agents. In addition, poor blood supply to adipose tissue contributes to the slow elimination of these agents.

Tissue must be protected from injury because......

(Obese Pt.)

folds of tissue can be caught in the crevices of the operating table. Skin wrinkles should be smoothed out when positioning to avoid cutting off the blood supply to the tissue, possibly causing skin ulcers and tissue necrosis.

Healing complications with obese pts.

healing is delayed due to the poor blood supply to the adipose tissue. are prone to an increased incidence of postoperative wound infections. They are also more disposed to wound disruptions, such as wound dehiscence or evisceration

What should the surgical technologist prepare for when closing obese pt. wounds

should be prepared for various closure preferences of surgeons, such as the use of Montgomery straps or retention suture devices such as retention suture bridges and looped sutures.

Setting up the room for Bariatric Surgery

the surgical technologist should make sure that a venous compression device is in the room and that the patient is fitted with intermittent venous compression boots.

What are obese pt's at risk for

deep venous thrombosis (DVT). This risk increases with a prolonged surgical procedure or postoperative period in which the patient is immobile and when the patient is in the supine position during surgery.

What does the reverse trendelenburg position improve in obese patient surgeries?

pulmonary function, but intermittent venous compression boots must be used to reduce the incidence of DVT. The patient should also attempt to walk as soon as possible postoperatively to aid the prevention of thrombosis.

3 most common complications after gastric bypass surgery

abdominal catastrophes, internal hernia, and acute gastric distention.

What is typically found during surgery with obese patients

gallstones are often found (in addition to the original pathology) and the gallbladder is removed. Therefore, when performing an abdominal procedure on these patients, the surgical technologist should have the instrumentation and other supplies available for a cholecystectomy with possible cholangiography.

Diabetes Millitus

is a disorder of the endocrine system. It affects the production of insulin in the pancreas and glucose tolerance in the body. Insulin is the hormone that aids in breaking down sugars and carbohydrates. The origin of the disorder is most often genetic.

2 types of Diabetes

1. Type 1—insulin-dependent diabetes mellitus (IDDM): The pancreas produces little or no insulin, and the individual must have daily, regular doses of insulin.
2. Type 2—non–insulin-dependent diabetes mellitus (NIDDM): The pancreas produces different amounts of insulin. The individual is not required to take insulin and blood glucose levels are usually controlled by diet.

When doing surgery a diabetic patient is at higher risk for?

• Infection (Ulcers that develop on the extremities, particularly the foot, heal slowly or not at all and are prone to infection. Many elderly patients with diabetes must undergo extremity amputation to control an infection of the extremity that is not responding to antibiotics or other surgical interventions.)
• Dehydration
• Poor circulation combined with vascular disease
• Hypertension and myocardial infarction
• Delayed wound healing and infection
• Nephropathy
• Control of postoperative blood glucose level
• Neuropathic musculoskeletal disease resulting in severe bone destruction
• Neurogenic bladder resulting in frequent (UTIs)
• Retinopathy resulting in blindness
• Coronary artery disease
• Thrombophlebitis and peripheral edema
• Tachycardia
• Peripheral edema

Normal dosage of preoperative medication for a patient with diabetes

is decreased since narcotics can induce vomiting, which predisposes the patient to fluid and electrolyte imbalance, causing a hypoglycemic reaction.

What is important during surgery with diabetes pts

Monitoring, especially during long procedures, is important to avoid a metabolic crisis. Monitoring is necessary to determine the patient’s needs for insulin, glucose, or both. A glucometer is used to measure the blood glucose level. Urine specimens are monitored for the presence of ketones.

What is most common postoperative in diabetes patients

An increased rate of infection primarily due to diminished levels of blood flow to the affected area.

When are abdominal procedures best performed during pregnacy

in the second trimester. In the second trimester, the fetus is stable and the tissue of major organs is well differentiated. In addition, since the uterus has not greatly enlarged, the abdominal organs have not been displaced from their normal position to any great degree, making it easier to expose the wound, retract, and manipulate the organs

What is the risk of surgery in the 3rd trimester

there is a 40% risk of premature labor, and further difficulties are encountered due to the displacement of organs by the enlarged uterus.

What happens to the size of a late term uterus

the abdominal organs are displaced from their normal anatomical location; additionally, anatomical landmarks are difficult to locate.

3 important items to remember when general anesthesia must be used

are the increase in preterm labor, fetal death, and low birth weight

Intraopertative considerations a surgical tech must remember with pregnant patients

The surgical technologist should aid the surgeon by palpating the uterus during the surgical procedure to detect contractions.

When positioning the patient in the supine position, a small rolled sheet or pad should be placed under the right hip to slightly laterally shift the uterus to the left (Figure 4-1). Additionally, the operating room table may be tilted 30 degrees to the left and placed in slight Trendelenburg position to aid with venous return. This takes the weight of the uterus off the vena cava and abdominal aorta to aid in maintaining a normotensive level.

autoimmune disease

multiple sclerosis, lupus erythematosus, and rheumatoid arthritis. Immunosuppressant drugs are also administered to recipients of organ transplants to prevent the recipient’s immune system from rejecting the newly transplanted organ.

A disease that attacks the body's own tissue

Patients with Aids

have tested positive for the human immunodeficiency virus (HIV) and are symptomatic, usually of an opportunistic disease that the compromised immune system has allowed to take hold.

HIV

virus that causes AIDS

Infections Associated with AIDS

Kaposi’s sarcoma, severe psoriasis rash of the body, Pneumocystis carinii pneumonia (PCP), and other fungal and parasitic infections.

Karposi's sarcoma

A cancer that produces painful external and internal lesions; internally, the lesions can cause complications, such as difficulty in swallowing (if present in the esophagus) or bowel obstruction (when present in the intestine)

History of AIDS and how its changed

was considered an exclusive disease of homosexual male behavior, intravenous drug users, or recipients of transfused blood containing HIV. We now know that anyone is susceptible to transmission, especially during unprotected sex or through the sharing of contaminated needles. In addition, infected pregnant females can transmit the virus to the unborn fetus.

What should all members of the surgical team show to AIDS patients going into surgery

compassion, empathy, and professionalism without allowing personal feelings about the stigma attached to AIDS to impact the care that they are providing.

Common Surgical procedures for AIDS patients

diagnostic biopsies (such as bronchoscopy) and treatment of complications of malignancies and infections. Cryptosporidiosis and cytomegalovirus infections frequently occur in the biliary tree, causing acute cholecystitis and cholangitis, requiring emergency repair (a choledochoenteric bypass may also be performed).

Complications with AIDS patients

Thrombocytopenia, Splenectomy (removal of the spleen) obtains very good results in these patients and for those experiencing splenomegaly (enlargement of the spleen)

Physically challenged or sensory impaired patients

Patients with hearing impairments may be totally deaf or impaired to varying degrees. Patients who are partially deaf are typically required to remove their hearing aid devices prior to surgery, so they may not be able to understand spoken commands

What may require surgical patients to take extra precautions when moving physically challenged patients

absence of an extremity or severe arthritis, contractures, deformities, paralysis, tremors, and stiffness,

Parents of legal guardian of Down Syndrome patients

should be present while transporting to the surgery department, and allowed in preoperative holding and brought into PACU as soon as feasible.

What do Down Syndrome Patients typically have that may cause the anesthesiaologist to take into consideration

microgenia, muscle hypotonia, a flat nasal bridge, macroglossia, a short neck, and excessive joint laxity

Isolation Patients: Who establishes policies and regulations for hospitals to implement

The Occupational Safety and Health Administration (OSHA) along with the Centers for Disease Control and Prevention (CDC) and its division, the National Institute for Occupational Safety and Health (NIOSH),

Primary routes of transmission

• Contact: direct or indirect
• Droplet
• Airborne
• Common vehicle (food, water, medications, medical devices, and equipment)
• Vector-borne (mosquitoes, flies, rats)

What type of PPE should be worn for Isolation patients

is mandated by the OSHA bloodborne pathogens final rule. However, the CDC also requires the wearing of a NIOSH-certified respirator through its tuberculosis standards.

What must be taken into considerations when achieving the proper fit of the respirator

The facial size and characteristics of the health care worker

Why do the geriatric patients represent a challenge for the entire surgical team

approximately 80% of geriatric patients present with one or more comorbid conditions when entering the surgical environment.

What do Substance abuse patients suffer from

Studies suggest that 30% to 80% from coexisting psychiatric illness

What would the surgical team benefit from in a surgical procedure of a substance abuse patient

the presence of a counselor or social worker to provide assistance to the team and patient.

The Golden Hour

Military physicians became aware, when treating those injured during war (e.g., World Wars I and II, the Korean and Vietnam conflicts), that the shorter the response time, the greater is the chance for survival of the trauma patient. Recent studies have also shown that the sooner CPR is begun for a heart attack victim, the greater is the chance that the heart rhythm will return to normal with less damage to the heart muscle. This concept, when applied to the civilian population, is classically referred to as the golden hour, meaning that reaching the trauma victim and providing treatment within the first hour following injury is critical in determining the patient’s outcome.

What is the golden hour

Concept that medical treatment of a trauma victim within the first hour following injury improves patient outcomes

level 1 Trauma centers

Can meet all needs required for treating trauma patients, including qualified personnel and equipment on a 24-hour basis, offering a comprehensive service and the highest level of surgical care.

ie: Good sam

Level 2 Trauma Centers

Can treat seriously injured or ill patients, but does not have all of the resources that a Level I facility would have. Level II trauma centers work in collaboration with Level I centers.

Level 3 Trauma centers

Most often a community or rural hospital in an area that does not have a Level I or II facility. These centers offer limited care and have resources for immediate care until the trauma patient is stabilized and then transported to a Level I or II hospital.

Level 4 Trauma Centers

Available in some states, the center can provide advanced trauma life support to stabilize the patient before the patient is transported to a Level I or II hospital. It provides initial evaluation, stabilization, diagnostic capabilities, and transfer to a higher level of care.

What provides valuable information?

kinematics or mechanism of injury (MOI).

Kinematics

An attempt to understand the mechanism of injury and the action and effect of a particular type of force on the human body

MOI

action and effect of a particular type of force on the human body. By knowing the types of injuries caused by certain types of forces, the health care team can be better prepared to treat the trauma patient.

Blunt Trauma

results from forces such as deceleration, acceleration, compression, and shearing.

Number one organ injured in a MVA

Spleen

3 Types of collisions

1. Car collides with another object.
2. Person inside car collides with objects such as steering wheel or dashboard.
3. Internal body structure collides with a rigid bony surface. For example, a motorcyclist is thrown from the motorcycle and hits a tree. The brain is accelerating forward and when the person hits the tree, the brain tissue rapidly decelerates by colliding with the frontal portion of the cranium, causing severe blunt trauma.

Bullet Injuries

(Save bullet for police)

are classified as being low velocity (bullet travels 1,000 feet per second or slower) or high velocity (3,000 feet per second; commonly seen with military weapons).

Factors that affect the extent of the injury (Bullet patients)

• High-velocity bullets, obviously, will cause more damage to tissue.
• The closer the victim is to the bullet as it leaves the weapon, the more damage that will result due to the increased speed of the bullet.
• Different bullets result in different types and severities of injury. For example, a hollow-point bullet mushrooms on impact, causing more tissue damage than other types of bullets.

What is RTS and what does it involve

A scoring system used to asses the severity of a traumatic wound and the condition of the patient

involves the Glasgow Coma Scale as well as other physiological factors.

General Recommendations for preserving evidence

• Hair, tissue, and gunpowder residue may be found on the hands of the victim. If the hand(s) does not require surgery, a bag should be placed around the hand(s) and taped in place.
• Bullets must be carefully handled since the lead can be easily scratched. They should not be handled with metal forceps or clamps so as not to alter the ballistic markings. After removal, the surgical technologist should place the bullet(s) on a clean gauze sponge and pass it from the sterile field to the circulator for placement in a dry plastic specimen container.

What types of tables are used in the or?

fluoroscopic operating table to facilitate taking radiographs during surgery. The table also aids in positioning the patient. Positioning is always a concern in surgery, but for trauma patients it is of utmost concern, particularly if they have been involved in a situation such as an MVA in which the spine may have been injured. Before the patient is removed from the backboard to the operating table, the surgical team must confirm that the surgeon has communicated that the spine is either injury free or is injured, requiring extra positioning precautions.

PTSD

is the result of prolonged exposure to traumatic situations or a series of traumatic situations that is characterized by the patient suffering from long-lasting emotional, psychological, and social problems. Vietnam veterans who have symptoms were at the time of the war said to have “post-Vietnam syndrome.” However, since 1980 it has been recognized as a formal diagnosis and officially changed the name