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Pediatric Surgery (Pg 68-81)

I.

Periop. Management:

A.

Fluids & electrolytes

1.

Peds have: Incr. metabolism, rapid & major fluid shifts, Decr. concentrating & diluting ability (can’t compensate as well)

2.

Neonates: Highly incr. proportion of TBW (Incr. ECF)

3.

Fliud/electrolytes requirements:

a)

Maintenance: D5% in ¼ NS + 20 mEq/L KCl (Table 2-1)

b)

Pre-existing deficits: Rapid restore IV volume – usually isotonic losses in surgery (Table 2-2)

c)

Abnormal ongoing losses:

(1)

Measurable 3rd space loss (External: GI, drainage tubes)

(a)

Vol-to-vol replacement

(2)

Immeasurable: Pathologically sequestered in body

(a)

Estimated balanced salt soln. replacement

(b)

Adequacy of replacement based on response

(i)

UO > 1-2 in infants

(ii)

UO > 0.5 in teens

B.

Nutrition:

1.

Enteral: more physiologic, decr. complications, decr. cost

a)

W/o enteral, get mucosal atrophy, enterohepatic circulation stagnation, potential bacterial contamination & sepsis

b)

Baby who can’t suck: use NG tube

c)

Long term need for feedings in ped: G-tube

2.

Parernteral:

a)

Periph: preferred (easier cath insertion, decr. complications)

(1)

Up to 12.5% Glc + emulsified fat

b)

Central: via IVC

(1)

M.C. Complication = mechanical probs

(2)

Up to 25% Glc

c)

Liver damage: possible complication of TPN – usually reverses when TPN d/c’d

C.

Respiratory management (Table 2-6): common b/c peds have incr. needs, are obligate nasal breathers, rely on diaphragm >> chest wall muscles

1.

Endotracheal tube = most secure airway

2.

Pressure ventilators: preferred (over vol. ventilators) in infants b/c lungs are small & P vent. is easier to prevent over-inflation, etc.

a)

Use lowest O2 settings possible b/c of high risk of retinal damage & lung fibrosis

3.

High frequency vent: can get adequate gas exchange w/o high pressure

4.

ECMO (extracorporeal membrane oxygenation): prolonged cardiopulmonary bypass – overall survival = 80% in newborns

D.

Operative care/monitoring:

1.

General anesthesia almost always used

2.

Lab studies not routinely needed

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