Preventing Perioperative

Complications
in Special Populations

By Debra Dunn, RN, CNOR, MBA

From: Nursing2005, November

3.0 ANCC/AACN contact hours
Online: http://www.nursing2005.com

2005 Lippincott Williams & Wilkins

Pediatric patients

Age range: birth to 18.

Considerage-appropriate growth and

development levels when creating plan
of care.
Pediatric patients:
Preop considerations
New NPO standards
--No milk products/solid food for 6 to 8 hours preop.
--Breast milk may be given up to 2 hours preop.
--Current research supports clear liquids up to 2 hours
before elective procedures.

Benefits
--Keeps the patient more comfortable.
--Relieves anxiety.
--Decreases potential for hypovolemia and hypoglycemia.
Pediatric patients:
Preop considerations (cont)
Stress for the child
Separation anxiety, fear of pain, fear of
loss of control.
Help child cope
Assess cognitive level/psychological status/
emotional and developmental level during
preop interview.
Pediatric patients:
Preop considerations (cont)
Use age-appropriate interventions to ease anxiety
Infants (birth to 1 year)
Encourage parent participation, rock and sing to the infant,
avoid overstimulation.
Toddlers (1 to 3 years)
Encourage parental support, favorite toy,
distraction, explain in simple terms.
Preschoolers (3 to 6 years)
Encourage imaginary play, let child participate in
care, parents present for anesthesia induction/recovery.
Pediatric patients:
Preop considerations (cont)

School age (6 to 12 years)

Explain procedures in advance, respect childs sense of
modesty, give choices.
Teens (12 to 18 years)
Establish trust by listening, provide privacy.
Pediatric patients:
Preop preparation
Size matters: Obtain accurate weights for
correct drug dosage.
Use appropriate size equipment
--BP cuffs
--Pulse oximeter sensors
--Positioning aids
--Emergency supplies.
Pediatric patients:
Preop preparation (cont)
Document patients history
Note co-morbidities: Asthma, diabetes mellitus, apnea,
sickle-cell disease.
Adolescents are at increased risk of
periop complications if they:
--use alcohol (prolongs sedative effects)
--smoke (compromises respiratory status, causes
vasoconstriction, anesthesia risks)
--use cocaine (elevates BP, causes tachycardia)
--use anabolic steroids (impairs kidney function)
Pediatric patients:
Periop considerations (cont)
Airway issues:
Premature infants are at greater risk for apnea
after anesthesia.
Children have short necks and large tongues,
making intubation a challenge.
7% to 10% of children have asthma, which causes
hyperirritability of their airway.
Pediatric patients:
Periop considerations (cont)
Temperature changes
Infants and children are at greater risk for
temperature-related changes.
Nursing interventions
Use warm, forced-air blankets
Apply head wraps
Use radiant heaters
Warm I.V. fluids and irrigating solutions
Pediatric patients:
Periop considerations (cont)
Fluid management
Both dehydration and fluid overload can be
devastating to a child.
Meticulous intake and output (I&O)--including loss
thru diarrhea, vomiting, blood loss
I.V. fluids given via volume control/infusion pump
Childs urine output should be 1 ml/kg/hour
I&O should balance.
Pediatric patients:
Postop care
Most common postop complication in children
is fever (within 24 hours of surgery); notify
surgeon.
Fever 5-10 days later is probably due to
wound infection.
Postop disorientation common in child--offer
toy if appropriate, get parents involved.
Assess and manage postop pain.
Pediatric patients:
Postop care (cont)
Patient/family teaching
Nausea and vomiting treatment
Pain management: Warn parents not to give
aspirin due to possible Reyes syndrome
Wound care if applicable
Obese adult patients
The American Heart Associations definition of
obesity:
body mass index (BMI) greater than 30
Complications of obesity can increase
surgical risks and impair wound healing
hypertension, diabetes mellitus, obstructive sleep
apnea, lung disease
Obese adult patients:
Preop considerations
Venous access may be more difficult--
venous cutdown or central lines may be
necessary.
Risk of failure to wean from mechanical
ventilation.
Obese adult patients:
Preop preparation
Document patient history and allergy status.
Use appropriate size equipment:
--large BP cuffs
--wide stretchers
--larger operating table
--lift devices.
If patient uses sleep apnea equipment at home,
have available for postop care.
Obese adult patients:
Periop considerations
Airway issues:
Challenge due to shorter neck with increased
adipose tissue.
Anesthesia meds may re-sedate the patient later
due to its lipophilic properties.
Regional anesthesia may be difficult due to
inability to locate landmarks.
Obese adult patients:
Periop considerations
Proper positioning
--Lateral decubitus position is recommended,
if possible.
--Helps prevent skin breakdown and nerve
damage.
Obese adult patients:
Periop complications
Cardiovascular systemmyocardial
infarction, heart failure, arrhythmias,
hypertension.
Respiratory systempneumonia,
atelectasis.
Obese adult patients:
Postop care
Encourage coughing/deep breathing
exercises
Use incentive spirometry
Place patient in semi-recumbent position; use
appropriate beds and chairs
Early ambulation
Give short-acting opioids/regional anesthetics
for pain management
Obese adult patients:
Postop complications
Among patients with diabetes: Maintain blood
glucose level between 80 and 110 mg/dl.
Development of deep vein thrombosis: Use
compression devices, anticoagulants, and
encourage early ambulation.
Delayed wound healing: Monitor skin for
wound infection, dehiscence, evisceration.
Diminished effectiveness of drugs: Monitor
effects.