4.3 Pediatric & Geriatric Ambulatory Care

Pediatric Ambulatory Surgery: Developmental Care, PPI & Patient Safety

Pediatric patients comprise a significant volume of ambulatory surgery cases—undergoing common procedures such as myringotomy with tympanostomy tube insertion, tonsillectomy and adenoidectomy (T&A), strabismus repair, hernia repair, and dental restoration. Children are not miniature adults; their unique anatomical, physiological, and psychosocial development demands specialized perioperative nursing expertise.

Developmental Stages, Fears, and Nursing Interventions

+----------------------------------------------------------------------------------------------------+
|                    PEDIATRIC DEVELOPMENTAL STAGES & PERIOPERATIVE NURSING INTERVENTIONS            |
+-------------------+-----------------------------+--------------------------------------------------+
| Age Group         | Core Developmental Fears    | Targeted Ambulatory Nursing Interventions        |
+-------------------+-----------------------------+--------------------------------------------------+
| Infants           | - Separation from parents   | - Maintain thermal neutrality (radiant warmers). |
| (<12 months)      | - Cold ambient environments | - Administer 24% oral sucrose with pacifier.     |
|                   | - Physical restraint        | - Swaddle snugly; minimize NPO time (breast milk |
|                   |                             |   up to 4 hours, clear liquids up to 2 hours).   |
+-------------------+-----------------------------+--------------------------------------------------+
| Toddlers          | - Peak separation anxiety   | - Keep child on parent's lap during intake.      |
| (1 to 3 years)    | - Fear of strangers / dark  | - Use transitional comfort objects (teddy bear). |
|                   | - Fear of bodily intrusion  | - Introduce equipment gently ("blood pressure arm|
|                   |                             |   hug"); avoid "taking" temperature.            |
+-------------------+-----------------------------+--------------------------------------------------+
| Preschoolers      | - Magical thinking & guilt  | - Reassure that surgery is NOT a punishment.     |
| (3 to 5 years)    | - Fear of bodily mutilation | - Medical play: decorate mask with scented oils  |
|                   | - Fear of the unknown / pain|   (bubble gum, cherry); put mask on stuffed toy. |
|                   |                             | - Explain body parts stay intact with simple words.|
+-------------------+-----------------------------+--------------------------------------------------+
| School-Age        | - Loss of bodily control    | - Offer honest, anatomically correct descriptions|
| (6 to 12 years)   | - Fear of waking up in OR   | - Give choices to promote autonomy (which arm    |
|                   | - Fear of pain and needles  |   for IV, which mask flavor, choice of bandage). |
|                   |                             | - Tour the holding bay; explain monitoring pads. |
+-------------------+-----------------------------+--------------------------------------------------+
| Adolescents       | - Loss of independence      | - Protect physical modesty during gowning/exam.  |
| (13 to 18 years)  | - Altered body image        | - Interview teen privately regarding substance use|
|                   | - Fear of peer rejection    |   and confidential urine pregnancy screening.    |
|                   | - Privacy invasions         | - Include teen directly in discharge decisions.  |
+-------------------+-----------------------------+--------------------------------------------------+

Parental Presence During Induction (PPI / PAFI)

Parental Presence During Induction (PPI), also known as Parental Assistance with Anesthesia Induction (PAFI), involves having one prepared parent or legal guardian accompany the child into the operating suite during the initiation of inhalational mask anesthesia.

• Clinical Rationale: Reduces severe child separation anxiety, minimizes traumatic physical restraint, decreases preoperative distress scores, and decreases the requirement for pre-op pharmacological anxiolytics (such as oral midazolam).
• Candidacy Criteria:
  • Child aged >= 1 year with significant separation anxiety who seeks comfort from the parent.
  • A calm, emotionally stable parent who voluntarily desires to participate and can follow instructions.
• Absolute Contraindications to PPI:
  • Highly anxious, agitated, hostile, or fainting-prone parent (who may suffer vasovagal syncope in the OR).
  • Anticipated difficult pediatric airway or severe craniofacial anomalies.
  • Rapid sequence induction (RSI) indicated for full stomach / emergency surgery.
  • ASA Physical Status IV or V child.
• Preparation & Execution Protocol:
  1. The circulating nurse pre-educates the parent outside the OR on exactly what to expect: the child will breathe scented gas through a mask; after 30 to 60 seconds, the child will enter an excitation stage where eyes may roll back, limbs may twitch or stiffen, breathing may become noisy/snoring, and the child will go completely limp.
  2. The parent dons clean OR attire (jumpsuit, hair cover, mask, shoe covers).
  3. A dedicated circulating nurse is assigned exclusively to the parent to provide continuous physical support, standing behind the OR table.
  4. The moment the child loses consciousness (eyelash reflex lost) and before advanced airway instrumentation (intubation or LMA insertion) occurs, the dedicated nurse immediately guides the parent back to the waiting lounge.

Pediatric Equipment Sizing & Metric Weight Dosing

In pediatric nursing, medication errors are prevented through universal metric weight dosing and calibrated physiological formulas:

1. Mandatory Kilogram Weight: All pediatric patients must be weighed on a calibrated metric scale in kilograms (kg) upon admission. Recording or calculating doses in pounds (lbs) is strictly banned.
2. Endotracheal Tube (ETT) Sizing Formulas:
   • Uncuffed ETT Internal Diameter (mm): (Age in years / 4) + 4
   • Cuffed ETT Internal Diameter (mm): (Age in years / 4) + 3.5
   • Always have three ETT sizes available at the bedside: the calculated size, one half-size smaller (0.5 mm), and one half-size larger (0.5 mm).
3. Holliday-Segar (4-2-1) Hourly Fluid Maintenance Rule:
   • First 10 kg: 4 mL/kg/hour
   • Second 10 kg (11 to 20 kg): 2 mL/kg/hour
   • Each kg above 20 kg: 1 mL/kg/hour
   • Example: A 24 kg child requires (10 * 4) + (10 * 2) + (4 * 1) = 40 + 20 + 4 = 64 mL/hour.

Pediatric Emergence Delirium (ED)

Emergence Delirium (ED) is a distinct, self-limiting behavioral disturbance occurring in 10% to 50% of pediatric outpatients during early emergence from volatile inhalational anesthetics (particularly sevoflurane and desflurane). The child presents with inconsolable screaming, thrashing, kicking, non-purposeful motor agitation, wide unseeing eyes, lack of eye contact, and failure to recognize parents or surroundings.

• Assessment: Evaluated utilizing the Pediatric Anesthesia Emergence Delirium (PAED) Scale (scoring eye contact, purposeful actions, awareness of surroundings, restlessness, inconsolability). A score >= 10 to 12 out of 20 indicates emergence delirium.
• Prevention & Management: Differentiating ED from acute surgical pain is critical; pre-emptive multimodal analgesia (regional nerve blocks, IV acetaminophen, NSAIDs) eliminates surgical pain as a causative trigger. Intraoperative administration of alpha-2 adrenergic agonists (dexmedetomidine 0.2 to 0.5 mcg/kg or clonidine) or a sub-hypnotic dose of propofol prior to emergence reduces ED incidence. PACU nursing care focuses on patient protection from injury, dimming ambient lighting, minimizing auditory alarms, avoiding physical restraint, and immediately reuniting the child with their parents.

Geriatric Ambulatory Surgery: Cognitive Screening, Delirium & Beers Criteria

Older adults (aged 65 years and older) represent the fastest-growing surgical demographic in ambulatory facilities. Advancements in minimally invasive laparoscopy, arthroscopy, and short-acting anesthetic pharmacotherapy have made outpatient total joint arthroplasty, hernia repair, and complex ophthalmic surgery routine in older patients. However, aging induces progressive loss of physiological organ reserve, altered pharmacokinetics, and heightened susceptibility to perioperative cognitive complications.

Age-Related Physiological Changes & Pharmacokinetics

+----------------------------------------------------------------------------------------------------+
|                   PHYSIOLOGICAL AGING & PERIOPERATIVE PHARMACOKINETIC IMPACT                       |
+-------------------+-----------------------------+--------------------------------------------------+
| Organ System      | Physiological Alteration    | Ambulatory Perioperative Nursing Impact          |
+-------------------+-----------------------------+--------------------------------------------------+
| Central Nervous   | - Decreased brain mass      | - Heightened sensitivity to anesthetics, sedatives|
| System            | - Reduced neurotransmitters |   and opioids; lower doses required.             |
|                   | - Increased BBB permeability| - Extreme risk for Postoperative Delirium (POD). |
+-------------------+-----------------------------+--------------------------------------------------+
| Renal System      | - Decreased GFR & RBF       | - Reduced clearance of water-soluble drugs and   |
|                   | - Loss of functional nephrons|   active metabolites (e.g., LMWH, opioids).      |
|                   |                             | - High risk of drug accumulation & nephrotoxicity|
+-------------------+-----------------------------+--------------------------------------------------+
| Hepatic System    | - Decreased liver blood flow| - Slower Phase I hepatic CYP450 metabolism.      |
|                   | - Reduced microsomal enzymes| - Prolonged emergence from general anesthesia.   |
+-------------------+-----------------------------+--------------------------------------------------+
| Cardiovascular    | - Arterial wall stiffening  | - Blunted baroreceptor reflex; severe orthostatic|
|                   | - Left ventricular hypertrophy|  hypotension upon initial PACU standing.         |
|                   | - Blunted beta-receptors    | - Vulnerable to fluid overload or hypovolemia.   |
+-------------------+-----------------------------+--------------------------------------------------+
| Integumentary     | - Thinning epidermis        | - Fragile skin tears from medical adhesives;     |
|                   | - Subcutaneous fat loss     |   mandates silicone tape and gentle removal.     |
|                   | - Impaired thermoregulation | - Rapid intraoperative hypothermia; mandatory    |
|                   |                             |   active pre-warming and forced-air warming.     |
+-------------------+-----------------------------+--------------------------------------------------+

Preoperative Cognitive Screening: The Mini-Cog Assessment

A critical, frequently overlooked reality in ambulatory surgery is that up to 20% to 30% of older surgical patients have undiagnosed mild cognitive impairment (MCI) or early-stage dementia. Pre-existing cognitive impairment is the single most powerful independent risk factor for developing Postoperative Delirium (POD).

To identify vulnerable elderly outpatients, ambulatory centers utilize the Mini-Cog, a validated, rapid (3-minute) cognitive screening tool administered during preoperative admission:

1. Step 1: Three-Word Registration: The nurse states three unrelated words (e.g., "Banana, Sunrise, Chair") clearly and asks the patient to repeat them.
2. Step 2: Clock Drawing Test (CDT): The nurse provides a pre-drawn circle and instructs the patient to draw the numbers on the clock face, and then draw the hands pointing to a specific time (standard: "ten minutes past eleven" [11:10]). The clock is scored as either Normal (all numbers in correct sequence and position, two distinct hands pointing to 11 and 2) or Abnormal (any error in numbers, spacing, or hand placement).
3. Step 3: Three-Word Recall: The nurse asks the patient to recall the three words from Step 1.

+----------------------------------------------------------------------------------------------------+
|                                    MINI-COG SCORING & INTERPRETATION                               |
+------------------------------------+------------------------------------+--------------------------+
| Word Recall Score (0-3 Points)     | Clock Drawing Result               | Cognitive Screen Result  |
+------------------------------------+------------------------------------+--------------------------+
| 0 Words Recalled                   | Normal or Abnormal Clock           | POSITIVE SCREEN (Impaired)|
+------------------------------------+------------------------------------+--------------------------+
| 1 to 2 Words Recalled              | Abnormal Clock Drawing             | POSITIVE SCREEN (Impaired)|
+------------------------------------+------------------------------------+--------------------------+
| 1 to 2 Words Recalled              | Normal Clock Drawing               | NEGATIVE SCREEN (Normal) |
+------------------------------------+------------------------------------+--------------------------+
| 3 Words Recalled                   | Normal or Abnormal Clock           | NEGATIVE SCREEN (Normal) |
+------------------------------------+------------------------------------+--------------------------+

Clinical Action on a Positive Mini-Cog Screen:

• Alert the surgeon and anesthesia provider to modify anesthetic depth and eliminate deliriogenic drugs.
• Enforce the mandatory presence of the designated family caregiver for all preoperative and postoperative discharge teaching.
• Provide simplified, high-repetition instructions and verify caregiver teach-back.
• Implement enhanced delirium prevention protocols in the PACU.

Postoperative Delirium (POD) Risk Mitigation in the ASC

Postoperative delirium is an acute, fluctuating disturbance of consciousness, attention, and cognitive perception that develops in up to 15% of older outpatients following surgery. It is clinically distinct from baseline dementia (which is chronic and irreversible) and emergence delirium (which is brief and occurs during immediate recovery from anesthesia in PACU). Delirium manifests in three forms: hyperactive (restlessness, agitation, hallucinations), hypoactive (lethargy, apathy, withdrawal; accounts for >60% of cases and is frequently overlooked), and mixed.

The Ambulatory Delirium Prevention Bundle:

1. Preserve Sensory Aids: Reintroduce the patient's eyeglasses, hearing aids, and dentures immediately upon arrival in the Phase I PACU. Sensory deprivation is a potent trigger for disorientation and delirium.
2. Normothermia Maintenance: Maintain core temperature >= 36.0°C throughout the perioperative stay using active forced-air warming.
3. Early Reorientation & Family Presence: Reunite the older patient with their family member or escort as early as possible in Phase II recovery. Ensure a visible clock and natural light are present.
4. Avoid Physical Restraints: Restraints accelerate acute panic, agitation, and delirium.
5. Multimodal Non-Opioid Analgesia: Control pain utilizing scheduled non-opioid analgesics (acetaminophen, regional peripheral nerve blocks, infiltration of local anesthetics) to minimize systemic opioid exposure.

The Beers Criteria & Perioperative Inappropriate Medications

The American Geriatrics Society (AGS) Beers Criteria identifies Potentially Inappropriate Medications (PIMs) whose adverse risks outweigh clinical benefits in older adults (>= 65 years). Administering Beers Criteria drugs in the perioperative setting drastically escalates the risk of acute delirium, urinary retention, oversedation, and falls.

+----------------------------------------------------------------------------------------------------+
|                   BEERS CRITERIA PERIOPERATIVE HIGH-RISK MEDICATIONS IN OLDER ADULTS               |
+------------------------------+--------------------+------------------------------------------------+
| Medication Class             | Specific Drugs     | Adverse Clinical Effects & Why to Avoid        |
+------------------------------+--------------------+------------------------------------------------+
| First-Generation             | - Diphenhydramine  | Highly anticholinergic; causes acute delirium, |
| Antihistamines               | - Hydroxyzine      | urinary retention, blurred vision, dry mouth,  |
|                              | - Promethazine     | and severe sedation. Never use for sleep/pruritus!|
+------------------------------+--------------------+------------------------------------------------+
| Benzodiazepines              | - Midazolam (Versed| Increases delirium, paradoxical agitation,     |
|                              | - Lorazepam (Ativan| profound psychomotor sluggishness, falls, and  |
|                              | - Diazepam (Valium)| prolonged PACU stay. Minimize or avoid!        |
+------------------------------+--------------------+------------------------------------------------+
| Neurotoxic Opioids           | Meperidine         | Active metabolite (normeperidine) accumulates  |
|                              | (Demerol)          | due to reduced renal clearance, triggering     |
|                              |                    | neurotoxicity, tremors, myoclonus, and seizures.|
+------------------------------+--------------------+------------------------------------------------+
| Centrally-Acting             | Scopolamine        | Severe anticholinergic properties; causes acute|
| Anticholinergic Antiemetics  | transdermal patch  | confusion, hallucinations, and urinary block.  |
|                              |                    | Use ondansetron (5-HT3 antagonist) instead.    |
+------------------------------+--------------------+------------------------------------------------+
| Skeletal Muscle Relaxants    | - Cyclobenzaprine  | Poorly tolerated; anticholinergic toxicity,    |
|                              | - Carisoprodol     | marked sedation, and high risk of fall injury. |
+------------------------------+--------------------+------------------------------------------------+
| Sliding Scale Regular        | Sliding-scale      | Higher risk of severe hypoglycemia without     |
| Insulin Alone                | regular insulin    | improving glycemic control. Basal dosing preferred.|
+------------------------------+--------------------+------------------------------------------------+

Fall Risk Stratification & Discharge Mobility Protocols

Older adults in an ASC are at immense risk for postoperative falls due to the convergence of residual anesthetic sedatives, opioid analgesics, orthostatic hypotension, regional peripheral nerve blocks (e.g., femoral or sciatic nerve blocks causing quadriceps weakness and knee buckling), unfamiliar clinic environments, and post-discharge mobility transitions.

• Preoperative Assessment: Screen using validated tools such as the Morse Fall Scale or Hendrich II Fall Risk Model.
• Ambulatory Precautions:
  • Apply a high-visibility yellow fall risk identification wristband and provide non-skid yellow footwear.
  • Maintain the stretcher in its lowest locked position with side rails elevated.
  • Never leave a high-risk geriatric patient unattended on a commode or in a bathroom.
  • Verify quadriceps motor strength and sensation prior to weight-bearing if a lower-extremity regional nerve block was placed; provide crutches, walker, or knee immobilizer as prescribed.
  • Perform assisted transfers with two staff members for initial ambulation in Phase II recovery.
  • Instruct the patient and escort that the escort must provide direct physical support during all transfers, walking, and toileting at home for the first 24 to 48 hours postoperatively.