Pediatric Perioperative

Preoperative care

Consultation
Physical Examination
Diagnostic studies and Laboratory Investigations
Pain Management
Blood Donation
Presurgical Visitation

Puri P, Sweed Y. Preoperative assessment. In: Puri P, ed. Newborn Surgery. Oxford:
Butterworth-Heineman 1996; 4151
 Fluids and Electrolytes
Paramount to successful treatment
Special attention estimating and correcting
pre-existing dehydration
Most neonates are born with 10% fluid excess
secondary to high levels of ADH that limit excretion
of fluid during the first 24 hours of life.

Nelson WE, Behrman RE, Kliegman RM et al. Fluid and Electrolyte Therapy. In: Joe Editor et al
eds. Textbook of Pediatrics. Philadelphia: WB Saunders Co. 1996; 206-222
 Other Sources of Fluid Imbalance
(Sensible Water Loss)

Third space (e.g., NEC burns)

Diarrhea
Diabetes insipidis
SIADH
Renal failure
Congestive heart failure (e.g., from PDA)
Hyperglycemia (osmotic diuresis)

Nelson WE, Behrman RE, Kliegman RM et al. Fluid and Electrolyte Therapy. In: Joe Editor et al
eds. Textbook of Pediatrics. Philadelphia: WB Saunders Co. 1996; 206-222
Bell EF, Oh W. Fluid and electrolyte balance in very low birth weight infants. Clin
Perinatol 1979; 6:139150
 Maintenance Fluid Requirements for Term Infants
and Older Children

Weight Daily Fluid requirements

0-10 kg 100 cc/kg/day or 4 cc/kg/hr

10-20 kg 1000 cc + 50 cc/kg/day >10 kg or

40 cc + 2 cc/kg/hr >10 kg

> 20 kg 1500 cc + 20 cc/kg/day > 20 kg or

60 cc + 1 cc/kg/hr > 20 kg

Rowe MI. Fluid and electrolyte management. In: Welch KJ et al, ed. Pediatric Surgery, 4th Edition. Chicago :
Year Book Medical Publishers 1986; 2227.
 Maintenance Electrolytes for Infants:

Sodium
Maintenance: 2-4 mEq/kg/d for infants > 30
weeks gestation; 3-5 for infants < 30 weeks
gestation
Generally not given in the first 24 hours
Bicarbonate is a sodium salt: 1 mEq NaHCO3 =
1 mEq Na

Wesley JR, Khalidi N. Faubion WC et al. The University of Michigan Medical Center Parenteral and Enteral
Nutrition Manual, Sixth Edition. North Chicago: Abbott Laboratories, 1990.
 Potassium
Maintenance: 2 mEq/kg/d
Generally not in first 24 hours of age, or until
infant has urinated
Decrease need with renal compromise or
extensive tissue breakdown (e.g., NEC, burns)
Increase need with diuretics and certain drugs
(e.g., Amphotericin B)
Wesley JR, Khalidi N. Faubion WC et al. The University of Michigan Medical Center Parenteral and Enteral
Nutrition Manual, Sixth Edition. North Chicago: Abbott Laboratories, 1990.
Maintenance electrolytes for term infants and children
up to 20 kg
Component Supplied As Amount Required

Na NaCl; Na acetate 2-4 mEq/kg/day

K KCl; K phosphate 2-4 mEq/kg/day

Ca Ca Gluconate 10% 0.5-3.0 mEq/kg/day

PO4 K phosphate 0.5-1.5 mM/kg/day

Mg MgSO4 0.5-1.0 mEq/kg/day

Nelson WE, Behrman RE, Kliegman RM et al. Fluid and Electrolyte Therapy. In: Joe Editor et al eds. Textbook of
Pediatrics. Philadelphia: WB Saunders Co. 1996; 206-222.
 Dehydration
Add to maintenance fluids any losses from dehydration:

% Weight H2Occ/kg Na mEq/kg Cl mEq/kg K mEq/kg

loss

5 50 4 3 3

10 100 8 6 6

15 150 12 9 9
For practical purposes, mild to moderate dehydration should be corrected with
IV D5-1/2 NS + 20 mEq KCl/L; and severe dehydration should be corrected with
Ringers Lactate or normal saline (NS) + 20 mEq/KCl/L.

John R. Wesley, RM, Alensman, Fluid and Electrolite management in pediatric perioperative.
Pediatric Surgery 2000, pg 19 -24
 Metabolic and nutrient

Inadequate nutritional support may result in :

weakening of respiratory muscles,
depression of central nervous system function,
apnea,
increased difficulty
in weaning from mechanical ventilation
increased susceptibility to infection.

In: Suskind RM ed. Textbook of Pediatric Nutrition, Second edition. New York:
Raven Press 1993
 Administering Parenteral Nutrition Solutions

started on half-strength solutions (4-8 mg/kg/min of

dextrose)
advanced to 3/4 and full-strength (10-14 mg/kg/min
maximum) over the ensuing 24-48 hours
Lipids can be advanced at a rate of 0.5 g/kg/day to a
maximum of 3 g/kg/day

Wesley JR, Khalidi N, Faubion WC et al. The University of Michigan Medical Center
Parenteral and Enteral Nutrition Manual, Sixth Edition. North Chicago: Abbott
Laboratories, 1990: 54-69
 Transition from Parenteral to Enteral Nutrition

Select an appropriate formula

Design a feeding regimen,
Taper the parenteral support appropriately
Designed to allow for adaptive
Start Low Go Slow

Braunschweig CL, Wesley JR, Clark SF et al. Rationale and guidelines for transitional
feeding in the 3-30 kg child. J Amer Diet Assoc 1988; 88:479-482.
 Pediatric PN: Macronutrients

In: Suskind RM ed. Textbook of Pediatric Nutrition, Second edition. New York:
Raven Press 1993
 Respiratory Failure and Support
in Children
Most Common: Persistent Pulmonary Hypertension &
Fetal Circulation
Shunt between them, named PDA and Patent foramen ovale
End physiology ARDS
Principal treatment Adequate oxygenation and ventilatory
support

Arensman RM, Statter MB, Bastawrous AL et al. Modern treatment modalities for
neonatal and pediatric respiratory failure. Am J Surg 1996; 172:41-47.
 Consideration of treatment
Airways of the child are smaller airway conductance
is less
Stress : increase respiratory rate > tidal volume in
times of stress
Inspiratory time is much shorter (as low as 0.4-0.5
seconds).
Tidal volumes as low as 20 ml
Hirschl RB. Respiratory failure: Current status of experimental therapies. Sem
Pediatr Surg 1999; 8:155-170.
 Hypovolemic Shock and Resuscitation

Shock:
evidence of multisystem organ hypoperfusion
(supported by laboratory tests and monitoring
systemic acid-base balance)
On a cellular imbalance between oxygen delivery
and oxygen consumption.

Walley KR, Wood LDH. Shock. In: Hall JB, Schmidt GA, Wood JDH eds. Principles
of Critical Care, 2nd Edition. New York: McGraw Hill 1992; 277301.
 Differences from adults
Cardiac output can fall without exhibiting systemic
hypotension
Loss of 40-45% of the intravascular volume before
systemic blood pressure can no longer be maintained

American Heart Association. Pediatric Advanced Life Support. Dallas, TX: American
Heart Association, 1988
 Clinical Indicators of Inadequate Tissue
Perfusion
Tachycardia
Altered Mental Status
Decreased Diastolic Pressure ( N: 2/3 Sistole )
Mottled Cool Extremities
Urine Output ( 1cc/kg/hr and sp.gr 1,010 1.030 )
Decreased Systolic Blood Pressure (N: 80 + 2n )

Walley KR, Wood LDH. Shock. In: Hall JB, Schmidt GA, Wood JDH eds. Principles
of Critical Care, 2nd Edition. New York: McGraw Hill 1992; 277301.
 Treatment
Secure airway ensuring adequate
ventilation and oxygenation
Intravenous Access
Fluid Resuscitation 20cc/kg crystalloid,I,II,
10cc/kg III PRC
Thermoregulation

Walley KR, Wood LDH. Shock. In: Hall JB, Schmidt GA, Wood JDH eds. Principles
of Critical Care, 2nd Edition. New York: McGraw Hill 1992; 277301.
 Disorders of AcidBase Homeostasis:
Metabolic Acidosis

Defined as a net gain in H+ ions or a net loss of bicarbonate

HCO3- ions in the ECF
pH is usually below normal (less than 7.37)
Grouped into two major categories: normal and increased
anion gap (N: 164mEq/L)

Anion gap = serum [Na]mEq/L [CI- + HCO3-]mEq/L

FleisherR. G et al textbook of Pediatric Emergency Medicine 5th edition pg 829

Kathleen M Cronan MD; Susanne I Kost MD, Renal and Electrolyte Emergencies
Pediatric Emergency Medicine. Chpt: 86 pg 891-92
 Pathophysiology

Basic Mechanisms
1. increased H+ ion delivery into the ECF
2. increased HCO3- loss from the ECF (GI or renal),
3. decreased renal H+ ion excretion.

Kathleen M Cronan MD; Susanne I Kost MD, Renal and Electrolyte Emergencies
Pediatric Emergency Medicine. Chpt: 86 pg 893
 Buffering Mechanisms in Metabolic Acidosis

1. Extracellular buffering (instantaneous)

H+ + HCO3- H2CO3
2. Respiratory buffering (1015 min)
H+ + HCO3 H2CO3 H2O + CO2
3. Intracellular buffering (24 hrs)
Diffusion of H+ into cells

Kathleen M Cronan MD; Susanne I Kost MD, Renal and Electrolyte Emergencies
Pediatric Emergency Medicine. Chpt: 86 pg 893
 Clinical Manifestations

Kathleen M Cronan MD; Susanne I Kost MD, Renal and Electrolyte Emergencies
Pediatric Emergency Medicine. Chpt: 86 pg 894
 Factors that mandate rapid diagnosis (therapy)
include
1. severely depressed blood pH (less than 7.20)
2. MODS especially pulmonary and/or renal disease
3. inability to treat the underlying disease
4. combination of hypoxia and acidemia myocardial
depression

Kathleen M Cronan MD; Susanne I Kost MD, Renal and Electrolyte Emergencies
Pediatric Emergency Medicine. Chpt: 86 pg 894
Laboratory Evaluation of Metabolic
Acidosis

I. Blood
A. Electrolytes (Na, K, Cl, HCO3-)a
B. Arterial blood gases
C. Blood urea nitrogen, creatinine
D. Glucose
E. Toxic screenb
F. Lactate, pyruvatec

II. Urine
A. Dipstick (pH, glucose, protein)
Kathleen M Cronan MD; Susanne I Kost MD, Renal and Electrolyte Emergencies
Pediatric Emergency Medicine. Chpt: 86 pg 894
 Management

Treat underlying disorder

require treatment if the serum HCO3- is less than 15 mEq per L
and/or the pH is less than 7.20
The choice of therapy is alkali, and the preferred agent is
almost always NaHCO3
Sodium lactate = lactated Ringer's solution
(if liver function is normal and lactic acidosis is ruled out)

Kathleen M Cronan MD; Susanne I Kost MD, Renal and Electrolyte Emergencies
Pediatric Emergency Medicine. Chpt: 86 pg 895
 amount of bicarbonate to use and the rate of
repair?
Mild/moderate acidosis (pH 7.20 to 7.37):
Defisit HCO3- mEq = [HCO3-] 20% of total body weight

Severe acidosis (pH less than 7.20):

Defisit HCO3- mEq = [HCO3-] 50% of total body weight

Goal serum HCO3- in increments of 5 to 10 mEq per L until a

level of 15 to 18 mEq per L is achieved or a pH of 7.25 or greater

therapy can be continued at roughly 2 mEq per kg per day

Kathleen M Cronan MD; Susanne I Kost MD, Renal and Electrolyte Emergencies
Pediatric Emergency Medicine. Chpt: 86 pg 895
 HYPOTHERMIA

Defined as core temperature at or less than 35C (95F), is

often overlooked
May be a consequence or cause of many disorders
Mortality rates, reported from 30% to 80%

Michael BurnsE, Environtmental Emergencies, Pediatric Emergency Medicine Chp. 89.

pg 1021-22.
 < 37oC (98oF)

Cold Blood

Hypothalamus

Oxidative Phosporillation
> Muscle tone >

Non shivering 50% Heat

thermogenesis production
Critical level

2-4 times basal

shivering thermogenesis
level

Michael Burns E, Environtmental Emergencies, Pediatric Emergency Medicine Chp. 89 pg 1021-

22.
 Thermogenesis failed oxygen consumption and carbon
dioxide production decline reaching 50% of normal at 28C
(82.4F). Hypoxemia, metabolic acidosis, hypoglycemia, and
hypocalcemia

Michael Burns E, Environtmental Emergencies, Pediatric Emergency Medicine Chp. 89 pg 1021-

22.
 Tractus respiratorius
Cold-induced bronchorrhea airway obstruction and aspiration

Cardiovasculair
- fall in cardiac output.
- Peripheral vasoconstriction and an early increase in central
vascular volume cause a transient rise in BP
- cardiac conduction abnormalities arise

Welton D, Mattox K, Miller R, et al. Treatment of profound hypothermia. JAMA 1978;240:2291

 Cold-induced vasoconstriction and elevated central blood
volume and pressure diuresis, diminishes intravascular
volume
Splenic sequestration plasma loss fall in white blood cell
and platelet countsDIC

Michael BurnsE, Environtmental Emergencies, Clinical manifestation of hypothermia. Pediatric

Emergency Medicine Chp. 89 pg 1023
 CNS
Each fall of 1C produces a 6% to 7% decline in cerebral blood
flow impaired cerebral microcirculation and mentation

Peripheral nerve
conduction slows, and deep tendon reflexes decrease. Pupils
dilate and react sluggishly,

Michael BurnsE, Environtmental Emergencies, Clinical manifestation of hypothermia. Pediatric

Emergency Medicine Chp. 89 pg 1023
Table 89.9. Management of Hypothermia
Initial Management
Provide supplemental oxygen
Cardiopulmonary resuscitation for asystole, ventricular fibrillation

Laboratory Determinations
Arterial blood gas analysis corrected for temperature
Complete blood count, platelet count
Prothrombin time, partial thromboplastin time
Electrolytes, blood urea nitrogen, creatinine
Glucose, amylase
Urine drug screen

Monitor
Heart rate, electrocardiogram, respiratory rate, blood pressure
Temperature
Consider central venous pressure

Treatment
Correct hypoxemia, hypercarbia
Correct hypokalemia
Correct hypoglycemia, 25% dextrose 1 g/kg IV
Tolerate hyperglycemia
Temperature:
32C (89.6F): passive rewarming or simple external rewarming
<32C (89.6F) (acute): external or core rewarming
<32C (89.6F) (chronic): core rewarming
Fluid replacement:
(acute) 5% dextrose in 0.2% saline at maintenance rates
(chronic) Normal saline, 5% albumin, fresh-frozen plasma to maintain blood pressure
 Active rewarming is divided into external and core rewarming
techniques.

External rewarming techniques:

- Electric blankets, hot-water bottles, overhead warmers, and
thermal mattresses

Core rewarming techniques:

- Pleural lavage : 6C /hrs/m2
- Peritoneal dialysis with dialysate warmed to
43C (109.4F)
- Gastric or colonic irrigation

Michael Burns E, Environtmental Emergencies, Pediatric Emergency Medicine Chp. 89 pg 1022 -

24.
Thanks