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A child is not a
miniature adult:
but the elderly
is an old child
The child and elderly
are physically and
physiologically
distinct yet similar
challenges
Cardiovascular system
Pulmonary system
Metabolic system
Renal system
Trauma
Ethics
Cardiovascular System
Fetal circulation: FO: PDA
CO-rate dependent
Cardiac volume decreased
Restrictive/uncompensated
Starlings curve to left
Compliant vessels
Homeostenosis
Apoptosis
CO-volume dependent
Cardiac volume increased
Restrictive/Decompensated
Starlings curve to right
Stiff vessels
Pediatric Elderly
Myocardial Oxygen Balance
Demand (TTI) Supply (DPTI)
Myocardial contractility Myocardial O
2
uptake
(dp/dt & v. max.) Coronary flow
Heart rate Diastolic B.P.
L.V. wall tension Coronary resistance
( LA PLACE LAW T = P x R) L.V. Intramural Pressure
h
2
The Precipice
Physiologic reserves
available
Physiologic reserve
already in use
Increasing age
Figure 15.5
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.
Decline pulmonary
functional 2
0
changes
in the thoracic cage
and lung
Mechanics of breathing

Loss of elasticity:
Alveolar collapse
Pulmonary System
Air/tissue interface = 3-
4 meter
2
(75M
2
adult)
Trachea funnel
shaped
Immature Alveoli = less
surfactant (type II
pneumocytes)
Nose breather
Decreased anti-trypsin
protease leads to
alveolar hydrolysis.
Type I pneumocytes do
not replicate
Loss of small airway
support
Mouth breather
Metabolic System
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
Decreased hepatocytes
but LFT remains
Immune competence
declines
Increase autoantibodies;
Monoclonal IgM and
tumorigenesis
Thymus involution
Comorbid disease
Pre-op assessment
Functional status
Cognitive status
Nutritional status albumin
Pediatrics
Elderly
3
0
2
4
6
8
10
12
14
< 34 35-54 55-74 > 75
0
1
2
> 3
Age in years
Figure 15-6
Box 15.1. Simple Preoperative
Assessment Tools
Function
ASA classification
Activities of daily living (ADLS)
Exercise capacity in metabolic equivalent
(METs)
Cognition
Three-item recall
Folstein Mini mental Status exam if three-item
recall is positive
Nutrition
Risk factor assessment
Subjective global assessment
Multi-nutritional assessment
Serum albumin
Estimated energy requirements for various
activities
1 MET* Can you take care of yourself?
Eat, dress, or use the toilet?
Walk indoors around the house?
2-3 mph or 3.2-4.8 km/h?
Do light work around the house like
dusting or washing dishes?
4 METs
*MET, metabolic equivalent
4 METs Climb a flight of stairs or walk up hill?
Walk on level ground at 4 mph or
6.4 km/h?
Run a short distance?
Do heavy work around the house like
scrubbing floors or lifting or moving
heavy furniture?
Participate in moderate recreational
activities like golf, bowling, dancing,
doubles tennis, or throwing a baseball
or football?
Participate in strenuous sports like
swimming, singles tennis, football,
basketball, or skiing?
10 METs
Figure 15-7
Box 15-2. Historical Findings Associated
with an Increased Risk of Nutritional
Deficiency
Recent weight loss
Restricted dietary intake (limited variety)
Limited variety, food avoidances
Psychosocial situation
Depression, cognitive impairment, isolation, economic difficulties
Problems with eating, chewing, swallowing
Previous surgery
Increased losses due to gastrointestinal disorders such as
malabsorption and diarrhea
Systemic disease interfering with appetite or eating (chronic lung,
liver, heart and renal disease, abdominal angina, cancer)
Excessive alcohol use
Medications that interfere with appetite and/or nutrient metabolism
4
Renal System
Increased insensible water
loss
Fluid requirement
substantial
Urine output and
osmolarity are indicators of
adequate fluid intake
Urine output=1-2ml/kg/hr.
Can concentrate urine to a
maximum 700 mosm/kg
(adult = 1200mosm/kg)
Decrease in renal cortex
40% nephrons sclerotic
Renal blood flow 50%
GFR 45%
Renal tubular function
Lower urinary tract
anatomical changes
Bacteriuria:host defense
Pediatrics
Elderly
Decrease in renal cortex
40% nephrons sclerotic
Renal blood flow 50%
GFR 45%
Renal tubular function
Lower urinary tract
anatomical changes
Bacteriuria:host defense
Pediatrics
Trauma
Leading cause of
death 1-15 yr. old
Prevention is key
ABCs unique, narrow
margin
5
th
leading cause of
death
Aging process: Brittle
Prevention is key
ABCs unique, narrow
margin
Pediatrics
Elderly
Ethics
Extracorporeal life
support (ECLS) ECMO
Interact: respect
Patient self-
determination
ACT
- advance directives
- DNR
Predicting futility
Interact: respect
Pediatrics
Elderly
Baby in OR
Adult Patient in RR On Happiness and Aging
At age 5 ......... Happiness is not wetting pants
At age 10 Happiness is having friends
At age 17 Happiness is driving a car
At age 20 Happiness is having sex
At age 35 Happiness is having money
At age 50 Happiness is having more money
At age 60 Happiness is having sex
At age 70 Happiness is driving a car
At age 80 Happiness is having friends
At age 85 Happiness is not wetting pants