Taken from the lecture of Dr.

Peter Figueroa “Principles of Surgery in Cognition

Pediatric and Elderly Patients” o Three-item recall
Edited without permission by: Arvin 10/03/08 o Folstein Mini mental Status exam if three-item
o recall is positive
“A child is not a miniature adult: but the elderly is an old child” Nutrition
“The child and elderly are physically and physiologically distinct yet similar o Risk factor assessment
challenges” o Subjective global assessment
o Multi-nutritional assessment
Cardiovascular system o Serum albumin
Pulmonary system
Metabolic system Estimated energy requirements for various activities
Renal system 1 MET
Trauma Can you take care of yourself?
Ethics Eat, dress, or use the toilet?
Walk indoors around the house?
Cardiovascular System 2-3 mph or 3.2-4.8 km/h?
Pediatric Elderly Do light work around the house like dusting or washing dishes?
Fetal circulation: FO: PDA Homeostenosis Climb a flight of stairs or walk up hill?
CO-rate dependent Apoptosis Walk on level ground at 4 mph or 6.4 km/h?
Cardiac volume decreased CO-volume dependent Run a short distance?
Restrictive/uncompensated Cardiac volume increased Do heavy work around the house like scrubbing floors or lifting or
Starling’s curve to left Restrictive/Decompensated moving heavy furniture?
• Compliant vessels Starling’s curve to right Participate in moderate recreational activities like golf, bowling,
• Stiff vessels dancing, doubles tennis, or throwing a baseball or football?
Participate in strenuous sports like swimming, singles tennis,
Myocardial Oxygen Balance football, basketball, or skiing?
Demand (TTI) Supply (DPTI) 10 MET

Myocardial contractility
(dp/dt & v. max.)
Heart rate
LV wall tension
Pulmonary System
Lungs not fully developed
until about 8 yrs. old
Alveoli = 30 million at birth
300 million in adult
Pulmonary tissue30% of
pulmonary wt.
Air/tissue interface = 3- 4
meter2 (75M2 adult)
Trachea – funnel shaped
Immature Alveoli = less
surfactant (type II
pneumocytes)
Nose breather
Metabolic System
Pediatrics
Temperature sensitive: large BSA;
lack of hair and subcutaneous fat
Immunodeficient with decreased
IgM and C3b
Caloric requirement high for
maintenance, physical activity &
growth = 100-120 Kcal/kg/day
WT gain = 30gms/d
Protein = 2-3.5gms/kg/d
Glucose = 4-6mg/kg/min
Fat = 2-3.5gms/kg/d
Myocardial O2 uptake Historical Findings Associated with an Increased Risk of Nutritional
Coronary flow Deficiency
Diastolic B.P. Recent weight loss
Coronary resistance Restricted dietary intake (limited variety)
L.V. Intramural Pressure Limited variety, food avoidances
Psychosocial situation
Depression, cognitive impairment, isolation, economic difficulties
Problems with eating, chewing, swallowing
Decline pulmonary functional 2° Previous surgery
changes in the thoracic cage and Increased losses due to gastrointestinal disorders such as
lung malabsorption and diarrhea
Mechanics of breathing Systemic disease interfering with appetite or eating (chronic lung,
Loss of elasticity: Alveolar collapse liver, heart and renal disease, abdominal angina, cancer)
Decreased anti-trypsin protease Excessive alcohol use
leads to alveolar hydrolysis. Medications that interfere with appetite and/or nutrient
Type I pneumocytes do not metabolism
replicate
Loss of small airway support Renal System
Mouth breather Pediatrics Elderly
Increased insensible water loss Decrease in renal cortex 40%
Fluid requirement substantial nephrons sclerotic
Urine output and osmolarity are Renal blood flow 50%
indicators of adequate fluid intake GFR 45%
Elderly Urine output=1-2ml/kg/hr. Renal tubular function
Decreased hepatocytes but LFT Can concentrate urine to a Lower urinary tract anatomical
remains maximum 700 mosm/kg (adult = changes
Immune competence declines 1200mosm/kg) Bacteriuria : host defense
Increase autoantibodies;
Monoclonal IgM and Trauma
tumorigenesis Pediatrics Elderly
Thymus involution Leading cause of death 1-15 yr. 5th leading cause of death
Comorbid disease old Aging process: Brittle
Pre-op assessment Prevention is key Prevention is key
Functional status • ABC’s unique, narrow margin • ABC’s unique, narrow margin
Cognitive status
• Nutritional status albumin Ethics
Pediatrics Elderly
Extracorporeal life support (ECLS) Patient self determination
ECMO ACT
Interact: respect - advance directives
- DNR
Predicting futility
Interact: respect

-Arvin© 10/03/08-

Simple Preoperative Assessment Tools

Function
o ASA classification
o Activities of daily living (ADLS)
o Exercise capacity in metabolic equivalent (METs)