General Pediatric Surgery

A

Maintenance Fluids

• 1.

  Neonates—fluid requirement is 65 mL/kg over 24 hours.

• 2.

  By the end of the first week of life—fluid requirements increase to 100 mL/kg over 24 hours.

• 3.

  To calculate based on weight:

  • a.

    [100 mL/kg per 24 hours (4 mL/kg per hour) for first 10 kg] + [50 mL/kg per 24 hours (2 mL/kg per hour) for each kg 11–20] + 25 mL/kg per 24 hours (1 mL/kg per hour) for each additional kilogram over 20]

• 4.

  Maintenance fluid—dextrose 5% in 1/4 normal saline

B

Resuscitation Fluids

• 1.

  Crystalloid: lactated Ringer or 0.9% normal saline

  • a.

    Ten to 20 mL/kg bolus

  • b.

    For ongoing fluid loss (high nasogastric output, protracted vomiting or diarrhea), replace 1 mL fluid loss with 1 mL replacement every 4 hours using D5 1/2 normal saline + 20 mEq KCl/L

• 2.

  Blood product replacement

  • a.

    Packed red blood cells (pRBCs): 10–15 mL/kg

  • b.

    Fresh frozen plasma (FFP): 10–15 mL/kg

  • c.

    Platelets: 1 unit/5 kg body weight

C

Fluid Balance

• 1.

  Clinical signs of dehydration

  • a.

    Lethargy, decreased feeding

  • b.

    Tachycardia, reduced urine output, depressed fontanelle

• 2.

  Clinical signs of fluid overload

  • a.

    New/increased oxygen requirement, respiratory distress

  • b.

    Tachypnea, tachycardia

D

Acid-Base Anomalies

• 1.

  Metabolic acidosis—inadequate tissue perfusion

  • a.

    Causes

    • (1)

      Intestinal ischemia (necrotizing enterocolitis, midgut volvulus, incarcerated hernia)

    • (2)

      Bicarbonate loss from gastrointestinal (GI) tract (diarrhea)

    • (3)

      Chronic renal failure with acid accumulation

    • (4)

      Diabetic ketoacidosis

    • (5)

      Ingestion (methanol, ethylene glycol, salicylates, paraldehyde, formaldehyde)

  • b.

    Treatment—treat underlying cause

    • (1)

      Sodium bicarbonate indicated if pH less than 7.1, bicarbonate less than 10

    • (2)

      Replacement = base deficit × weight (kg) × 0.3

    • (3)

      Administer half of calculated replacement amount over several hours then recheck pH

• 2.

  Metabolic alkalosis—gastric acid loss (pyloric stenosis: hypokalemic, hypochloremic), overaggressive diuresis

• 3.

  Respiratory acidosis—hypoventilation

• 4.

  Respiratory alkalosis—hyperventilation

E

Total Parenteral Nutrition

• 1.

  Indications: prolonged ileus, GI fistulas, gastroschisis/omphalocele, intestinal atresia, necrotizing enterocolitis, supplementation of enteral feeds in short bowel syndrome and malabsorption states, prematurity/very low birth weight

  • a.

    Enteral nutrition preferred whenever possible to promote growth and function of GI tract

• 2.

  Complications

  • a.

    Parenteral nutrition–associated liver disease (PNALD)

    • (1)

      Cholestasis, can progress to end-stage hepatic fibrosis and cirrhosis

    • (2)

      Treatment: decrease dose, modify/restrict lipids, or stop treatment; may require transplantation

  • b.

    Sepsis—central line–related infections; prevent with meticulous care and aggressive treatment of all infections

A

Thryoglossal Duct Cyst

• 1.

  Most common midline congenital cervical anomaly

• 2.

  Cause

  • a.

    Thyroglossal tract arises from base of tongue (foramen cecum); residual thyroid tissue from descent may persist in midline.

  • b.

    Pockets can fill with fluid and mucus, enlarging when infected, presenting as a nodule.

• 3.

  Symptoms

  • a.

    Most present in first 5 years of life.

  • b.

    Rounded, cystic mass of varying size in midline of neck; 60% adjacent to hyoid bone

  • c.

    Moves cephalad with swallowing and tongue protrusion

  • d.

    Often asymptomatic; may cause dysphagia, pain; drainage if infected

• 4.

  Work-up: thyroid-stimulating hormone (TSH) level, ultrasound; if hypothyroid or concern for lack of normal thyroid gland, obtain thyroid scan

• 5.

  Treatment

  • a.

    Resection to avoid recurrent infection and rule out underlying malignancy

    • (1)

      Sistrunk procedure: complete resection of cyst and its tract in continuity with the central hyoid bone

    • (2)

      Recurrence (10%) from incomplete excision or intraoperative rupture

  • b.

    Incision and drainage of abscess, antibiotic administration; definitive resection after resolution of inflammation

B

Branchial Cleft Anomalies

• 1.

  Most arise from second cleft/pouch

• 2.

  Cause: incomplete obliteration of paired branchial clefts and arches during development

• 3.

  Symptoms: usually discovered in first decade, present as fistulae, sinus tract, cartilaginous remnants

  • a.

    Second branchial cleft sinus presents with clear fluid draining from anterior border of lower 1/3 of sternocleidomastoid muscle (SCM).

  • b.

    Cysts are nontender soft tissue masses beneath SCM; may become infected; risk of in situ carcinoma in adults

• 4.

  Work-up: ultrasound to identify cystic nature of mass if not apparent on physical examination

• 5.

  Treatment

  • a.

    Complete excision of cyst and tract

    • (1)

      Use lacrimal probe to identify tract; may dip in methylene blue to stain tract

    • (2)

      Multiple small transverse “stepladder” incisions used if tract is long

  • b.

    Aspiration and systemic antibiotics if infected, resect when inflammation resolves

A

Pulmonary Sequestration

• 1.

  Nonfunctioning lung tissue, has anomalous arterial supply (systemic artery, not pulmonary artery) and absent or abnormal bronchial communication

• 2.

  Male predominance (3:1), left lower side more common

• 3.

  Associated with congenital diaphragmatic hernia (CDH), vertebral anomalies, and congenital heart disease

• 4.

  Two forms

  • a.

    Extralobar: completely separate from normal lung, separate pleural covering

    • (1)

      Often asymptomatic and found incidentally

    • (2)

      May become infected by hematogenous spread of bacteria

  • b.

    Intralobar: Incorporated into normal surrounding lung

    • (1)

      Present with recurrent pneumonia and abscess formation in same bronchopulmonary segment

• 5.

  Diagnosis:

  • a.

    Prenatal: ultrasound with Doppler flow, magnetic resonance imaging (MRI)

  • b.

    Chest radiograph, ultrasound with Doppler flow, computed tomography (CT) chest

• 6.

  Surgical treatment

  • a.

    Symptomatic sequestrations require resection

    • (1)

      Extralobar—simple excision

    • (2)

      Intralobar—lobectomy

    • (3)

      Must find and ligate feeding systemic arterial vessel, usually in inferior pulmonary ligament

B