Pediatric Surgical Themes: Pitfalls

and Pearls

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• 1. In infants with Bochdalek type congenital diaphragmatic hernia the
severity of pulmonary hypoplasia and the resultant pulmonary
hypertension are key determinants of survival.
• Barotrauma and hypoxia should be avoided.
• 2. During initial management of an infant with esophageal atresia
and distal tracheoesophageal fistula, every effort should be made to
avoid distending the gastrointestinal tract, especially when using
mechanical ventilation.
• The patient should be evaluated for components of the VACTERL
=7(vertebral, anorectal, cardiac, tracheoesophageal, renal, limb)
anomalies.
• Timing and extent of surgery is dictated by the stability of the patient.
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• 3. Although malrotation with midgut volvulus occurs most
commonly within the first few weeks of life, it should always be
considered in the differential diagnosis in a child with bilious
emesis.
• Volvulus is a surgical emergency; therefore in a critically ill
child, prompt surgical intervention should not be delayed for any
reason.
• 4. When evaluating a newborn infant for vomiting, it is critical to
distinguish between proximal and distal causes of intestinal
obstruction utilizing both prenatal and postnatal history, physical
examination and abdominal radiographs.
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• 5. Risk factors for necrotizing enterocolitis (NEC) include
• prematurity,
• formula feeding,
• bacterial infection, and
• intestinal ischemia.
• Critical to the management of infants with advanced (Bell stage III) or perforated NEC is timely and
adequate source control of peritoneal contamination.
• Early sequelae of NEC include
• perforation,
• sepsis, and
• death.
• Later sequelae include
• short-bowel syndrome and
• stricture.
• 6. In patients with intestinal obstruction secondary to Hirschsprung’s disease a leveling ostomy or
endorectal pull through should be performed using ganglionated bowel, proximal to the transition
zone between ganglionic and aganglionic intestine.

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• 7. Prognosis of infants with biliary atresia is directly related to age at
diagnosis and timing of portoenterostomy.
• Infants with advanced age at the time of diagnosis or infants who fail
to demonstrate evidence of bile drainage after portoenterostomy
usually require liver transplantation.
• 8. Infants with omphaloceles have greater associated morbidity and
mortality than infants with gastroschisis due to a higher incidence of
congenital anomalies and pulmonary hypoplasia.
• Gastroschisis can be associated with intestinal atresia, but not with
other congenital anomalies.
• An intact omphalocele can be repaired electively, while gastroschisis
requires urgent intervention to protect the exposed intestine.

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• 9. Prognosis for children with Wilms’ tumor is defined by the stage of
disease at the time of diagnosis and the histologic type (favorable vs.
unfavorable).
• Preoperative chemotherapy is indicated for
• bilateral involvement,
• a solitary kidney, or
• tumor in the inferior vena cava above the hepatic veins.
• Gross tumor rupture during surgery automatically changes the stage to 3
(at a minimum).
• 10. Injury is the leading cause of death in children older than 1 year of age.
• Blunt mechanisms account for the majority of pediatric injuries.
• The central nervous system is the most commonly injured organ system
and the leading cause of death in injured children.
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ANATOMY AND PHYSIOLOGY
• Anatomical differences between adults and children are important in
surgery.
• Infants and small children have a wider abdomen, a broader costal margin
and a shallower pelvis.
• Thus, the edge of the liver is more easily palpable below the costal margin
and the bladder is an intra-abdominal organ.
• The ribs are more horizontal and respiratory function is more dependent
on diaphragmatic movement.
• The umbilicus is relatively low lying.
• In the small child, transverse supraumbilical incisions are preferred to
vertical midline ones for laparotomy.
• Abdominal scars grow with the child and may migrate – a gastrostomy
sited in the epigastrium of the infant may end up as a scar over the costal
margin .
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• Thermoregulation is important in children undergoing surgery.
• The body surface area to weight ratio decreases with age and small
children therefore lose heat more rapidly.
• Babies have less subcutaneous fat and immature peripheral
vasomotor control mechanisms.
• The operating theatre must be warm and the infant’s head (which
may account for up to 20% of the body surface area compared with
9% in an adult) should be insulated.
• Infusions and respiratory gases may need to be warmed.
• The central temperature should be monitored and a warm air blanket
is advisable during lengthy operations.

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• Infants undergoing surgery are vulnerable in other ways.
• Impaired gluconeogenesis renders them more susceptible to
hypoglycaemia; blood glucose must be monitored and maintained above
2.6 mmol l–1.
• Newborns are at risk of clotting deficiencies and should be given
intramuscular vitamin K before major surgery.
• They are less able to concentrate urine or conserve sodium and have a
greater obligatory water loss to excrete a given solute load.
• Vitamin-K and blood clotting
• Vitamin-K is required for the synthesis of clotting factors:
• F-II, F-VII, F-IX and F-X
• Vitamin-K deficiency occurs in case of obstructive jaundice, chronic
diarrhoea, liver disease (hepatitis, cirrhosis, malignancy)
• Blood clotting factors are produced by
• Liver
• Platelets
• WBCs, Lymphocytes
• Endothelial cells
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• Fluid and sodium requirements are relatively high.
• Infants are prone to gastro-oesophageal reflux and have less
well-developed protective reflexes, rendering them more at risk
of pulmonary aspiration; adequate nasogastric aspiration is
essential in those with gastrointestinal obstruction.
• Immaturity of the immune system increases the risk of infection,
which can present with non-specific features such as poor
feeding, vomiting and listlessness.

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• Moderate (5–10%) dehydration is manifest by a decreased
urine output, dry mouth, and sunken eyes and fontanelle.
• Severe dehydration (> 10%) causes decreased skin turgor,
drowsiness, tachycardia and signs of hypovolaemia.
• Body weight is a critical measurement in children, not least
because this is a major determinant of drug doses and fluid
balance.
• Serial measures of weight and height provide a valuable index
of general growth and nutrition.

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• Post operatively, children often recover more quickly than adults.
• Postoperative analgesia must be adequate and appropriate,
recognising the potential for respiratory depression with opioids.
• Nursing care by appropriately trained staff involves monitoring the
airway and vital signs together with arterial oxygen saturation, fluid
balance, temperature, pain control and glucose homeostasis.
• Maintenance intravenous fluids, e.g. 0.45%saline with 2.5% dextrose
or isotonic saline, are being increasingly used instead of more
hypotonic saline solutions to reduce the risk of iatrogenic
hyponatraemia.
• Neonates require intravenous fluids with higher concentrations of
glucose. 290 17
• Stomas are necessary in some children.
• A gastrostomy may be required for nutritional support,
particularly in the neurologically disabled child.
• Temporary intestinal stomas are used in the management of
• anorectal malformations,
• necrotising enterocolitis and
• Hirschsprung’s disease;
• infants with a proximal colostomy or ileostomy frequently
require salt supplements to avoid sodium deficiency, which
causes poor weight gain.
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• The shorter neck and relatively larger tongue of the child mean that
respiratory obstruction will occur if the neck is overextended during
maintenance of the airway.
• The assessment of breathing includes respiratory rate, signs of
distress and the adequacy of chest expansion.
• The circulation is evaluated from vital signs, capillary refill time
(normally ≤ 2 s), skin colour and temperature, and mental status.
• Normal ranges for heart rate, systolic blood pressure and respiratory
rate are age-dependent (Table 6.2).
• Systolic blood pressure is often normal until at least 25% of the
circulating blood volume has been lost.

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GENERAL CONSIDERATIONS
• Fluid and Electrolyte Balance
• In management of the pediatric surgical patient, an
understanding of fluid and electrolyte balance is critical,
because the margin between dehydration and fluid overload is
rather small.
• This is particularly true in infants, who have little reserve.
• The infant's physiologic day is approximately 8 hours in
duration.
• Accordingly, careful assessment of the individual patient's fluid
balance, including fluid intake and output for the previous 8
hours, is essential to prevent dehydration
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• Clinical signs of dehydration include
• tachycardia,
• decreased urine output,
• reduced skin turgor,
• a depressed fontanelle,
• absent tears,
• lethargy, and
• poor feeding.
• Fluid overload is often manifested by a new requirement for oxygen
and the onset of respiratory distress, tachypnea, and tachycardia.
• The physical assessment of the fluid status of each child must
include a complete head-to-toe evaluation, with emphasis on
determining whether perturbations in normal physiology are present.

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• At 12 weeks' gestation, the total body water of a fetus is
approximately 94 mL/kg.
• By the time the fetus reaches full term, the total body water has
decreased to approximately 80 mL/kg.
• Total body water drops an additional 5% within the first week of
life, and by 1 year of life, total body water approaches adult
levels, 60 to 65 mL/kg.
• Parallel to the drop in total body water is the reduction in
extracellular fluid.

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• The volume of normal daily maintenance fluids for most children can be
estimated using the following formula:
• 100 mL/kg for the first 10 kg, plus 50 mL/kg for 11 to 20 kg, plus 20 mL/kg
for each additional kilogram of body weight thereafter.
• Because IV fluid orders are written as milliliters per hour, this can be
conveniently converted to 4 mL/kg per hour up to 10 kg, plus 2 mL/kg per
hour for 11 to 20 kg, and an additional 1 mL/kg per hour for each additional
kilogram of body weight thereafter.
• For example, a 26-kg child has an estimated maintenance fluid
requirement of (10 x 4) + (10 x 2) + (6 x 1) = 66 mL/h in the absence of
massive fluid losses or shock.
• A newborn infant with gastroschisis will manifest significant evaporative
losses from the exposed bowel, so that fluid requirements will be in the
range of 150 to 180 mL/kg per day.

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• Precise management of a neonate's fluid status requires an understanding
of changes in the glomerular filtration rate (GFR) and tubular function of
the kidney.
• The full-term newborn's GFR is approximately 21 mL/min per square
meter compared with 70 mL/min per square meter in an adult.
• Within the first year GFR increases steadily to the point that it essentially
reaches adult levels by the end of the first year of life.
• The capacity to concentrate urine is very limited in preterm and term
infants.
• In comparison with an adult who can concentrate urine to 1200 mOsm/kg,
infants can concentrate urine at best to 600 mOsm/kg.
• Although infants are capable of secreting antidiuretic hormone, the
aquaporin water channel–mediated osmotic water permeability of the
infant's collecting tubules is severely limited compared with that of an
adult, which leads to insensitivity to antidiuretic hormone.
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• Sodium requirements range from 2 mEq/kg per day in term
infants to 5 mEq/kg per day in critically ill preterm infants as a
consequence of salt wasting.
• Potassium requirements range from 1 to 2 mEq/kg per day.
• Calcium and magnesium supplementation of IV fluids is
essential to prevent laryngospasm, dysrhythmias, and tetany.

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Blood Volume and Blood Replacement
• A useful guideline for estimating blood volume for the newborn
infant is approximately 80 mL/kg of body weight.
• When PRBCs are required, the transfusion requirement is
usually administered in 10 mL/kg increments, which is roughly
equivalent to a 500-mL transfusion for a 70-kg adult.
• The following formula may be used to determine the volume (in
milliliters) of PRBCs to be transfused:

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• (65 represents the estimated hematocrit of a unit of PRBCs).
• One transfusion from one donor is preferable to many smaller-volume
transfusions.
• In the child, coagulation deficiencies may rapidly assume clinical
significance after extensive blood transfusion.
• It is advisable to have fresh-frozen plasma and platelets available if >30
mL/kg has been transfused.
• Plasma is given in a dose of 10 to 20 mL/kg and platelets are given in a
dose of 1 unit/5 kg.
• Each unit of platelets consists of 40 to 60 mL of fluid (plasma plus
platelets).
• After transfusion of PRBCs to neonates with tenuous fluid balance, a
single dose of a diuretic (such as furosemide 1 mg/kg) may help to
facilitate excretion of the extra fluid load.
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Enteral and Parenteral Nutrition
• The nutritional requirements of the surgical neonate must be
met for the child to grow and for surgical wounds to heal.
• If inadequate protein and carbohydrate calories are given, the
child may not only fail to recover from surgery but may also
exhibit growth failure and impaired development of the central
nervous system.
• In general, the adequacy of growth must be assessed
frequently by determining both total body weight and head
circumference.
• Neonates with gastroschisis, intestinal atresia, or intestinal
insufficiency from other causes, such as necrotizing
enterocolitis, are particularly predisposed to protein-calorie
malnutrition. 290 29
Thermoregulation
• Careful regulation of the ambient environment of infants and
children is crucial, because these patients are extremely
thermolabile.
• Premature infants are particularly susceptible to changes in
environmental temperature.
• Because they are unable to shiver and lack stores of fat, their
potential for thermogenesis is impaired.
• This is compounded by the administration of anesthetic and paralyzing
agents.
• Because these patients lack adaptive mechanisms to cope with
the environment, the environment must be regulated.
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• Attention to heat conservation during transport of the infant to and
from the operating room is essential.
• Transport systems incorporating heating units are necessary for
premature infants.
• In the operating room, the infant is kept warm by the use of overhead
heating lamps, a heating blanket, warming of inspired gases, and
coverage of the extremities and head with occlusive materials.
• During abdominal surgery, extreme care is taken to avoid wet and
cold drapes.
• All fluids used to irrigate the chest or abdomen must be warmed to
body temperature.

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• The use of laparoscopic approaches for abdominal operations
may result in more stable thermoregulation, due to decreased
heat loss from the smaller wound.
• Constant monitoring of the child's temperature is critical in a
lengthy procedure, and the surgeon should continuously
communicate with the anesthesiologist regarding the
temperature of the patient.
• The development of hypothermia in infants and children can
result in cardiac arrhythmias or coagulopathy.
• These potentially life-threatening complications can be avoided
by careful attention to thermoregulation.
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