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Pediatric Surgery (Pg 68-81) - page 2 / 33

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3.

Pre-op intake: Older kids - no food or milk 8hrs & NPO hrs, Infants – 6 & 4 hrs, respectively

4.

Intraoperative:

a)

Monitor O2 sat -  if below 95%, needs immediate investigation

b)

If indwelling cath needed (BP instability), umbilical artery is safe easy access (Central venous caths not often used)

c)

Must prevent hypothermia in peds

5.

Outpatient: starting at 3 mo for term babies & 52 wks if premature

E.

Emotional support & Pain management:

1.

Face-mask anesthesia induction in little kids

2.

Post-op:

a)

Long-acting local n. block during surgery helps for hours afterward & epidural cath can be left in place several days

b)

Avoid IM (administration hurts)

c)

Careful w/ narcotics b/c of apnea (patient-controlled dosing in kids over 5 actually works best)

d)

NSAIDs can be also used

II.

Neonatal surgical conditions - Birth defects = MMC of perinatal mortality in US

A.

Congenital diaphragmatic hernia – prototype of surgical cause of resp distress

1.

Types:

a)

Bockdalek: defect of posterolateral diaphragm – most common

b)

Morgagni: retrosternal – not often emergencies

2.

Embryology: pleuroperitoneal canal stays open, viscera pass thru, pulmonary hyperplasia

3.

Pathophys: compression of lung by herniated viscera, pulmonary hyperplasia, pulmonary hypertension (can cause R to L shunting)

4.

Presentation: dypnea & cyanosis, decr. breath sounds on side of herniation; confirmed by CXR

5.

Tx: Resuscitate first then sgx: supplemental O2 & ET intubation w/ mech vent & place NG tube

a)

Pos P vent thru face mask is CI

b)

Sgx: Viscera reduced, diaphragm closed, ECMO used in peds who don’t respond well to vent support

6.

Px: Mortality = 50%

B.

Neonatal thoracic mass lesions: congenital lobar emphysema, cystic adenomatoid malformation, pulmonary sequestration, foregut duplication cysts

1.

Can be Sx or a-Sx; Seen on CXR

2.

Tx: Surgical excision if possible

3.

Good Px except cystic adenomatoid malformation w/ hydrops

C.

Esophageal atresia & Tracheoesophageal fistula - Usually occur in combo:

1.

EA=interruption in continuity of upper & lower parts of esoph.

2.

TEF=abnormal communication btw esophagus & trachea

3.

Most common combo= upper esoph ends blindly & lower portion communicates w/ trachea (type C)

4.

Pathophys: Often have “VACTER association” abnormalities

a)

Vertebral, Anal, Cardiac, Tracheal, Esophageal, Radial or Renal

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