Seminar presentation by 5th year Medical Student under the supervision of a pediatric specialist from HRPZ II. Reference as mentioned in the slide.

1. P R E A N D P O S T O P E R A T I V E C A R E
P R E S E N T E D B Y
N U R U L H I D A Y U I B R A H I M
N I K N O R L I Y A N A
A F F A N S Y A F I Q I
I N S U R G I C A L PA E D I AT R I C S

2. 1 . I n t r o d u c t i o n
2 . S p e c i a l c o n s i d e r a t i o n i n s u r g i c a l
3 . P r e - o p e r a t i v e c a r e
4 . P o s t - o p e r a t i v e c a r e
R E F E R E N C E S
B a i l e y a n d L o v e 2 6 t h E d i t i o n
C u r r e n t D i a g n o s i s a n d T r e a t m e n t S u r g e r y 1 4 t h E d i t i o n
O U T L I N E
 T e m p e r a t u r e
 V e n t i l a t i o n
 F l u i d s
 B l o o d l o s s
 N u t r i t i o n
 H i s t o r y , p h y s i c a l e x a m i n a t i o n a n d i n v e s t i g a t i o n s
 C o n s e n t
 S p e c i f i c p r e - o p e r a t i v e p r o c e d u r e s
 G e n e r a l m a n a g e m e n t
 C o m p l i c a t i o n
 D i s c h a r g e a n d f o l l o w - u p

3. INTRODUCTION
 Premature and term neonates differ in their
anatomy, physiology, neurology, psychology,
pathology and pharmacology just as infants differ
from school-age children and adolescents from
adults.
 Infants and children also suffer from congenital
abnormalities and diseases not seen in adults, and
their management requires an intimate
understanding of the relevant embryology and
pathogenesis.

4. P R E S E N T E D B Y
N U R U L H I D A Y U
S P E C I A L C O N S I D E R AT I O N
I N P A E D I AT R I C S U R G E R Y

5. A. TEMPERATURE
In comparison with older children, infants have less
subcutaneous fat, immature vasomotor control,
greater heat loss from pulmonary evaporation, and
their surface area to weight ratio is higher.
These need to be considered when managing sick
children in the accident and emergency department,
anaesthetic room or operating theatre. These
environments must be warm and the infant’s head
(20% of surface area compared with 9% in an adult)
should be insulated).
Infusions are warmed, and
respiratory gases both
warmed and humidified.
The core temperature is
monitored and safe direct
warming is needed for
lengthy operations.

6. A. TEMPERATURE
Exposure to cold environments increases metabolic
work and caloric consumption.
Due to limited energy reserves and thin skin,
prolonged exposure may rapidly cause hypothermia.
Resultant catecholamine secretion increases the
metabolic rate (particularly in the myocardium) and
produces vasoconstriction with impaired tissue
perfusion and increased lactic acid production.
To attain optimal
environment, the gradient
between the skin surface
and the environmental
temperature must be less
than 1.5°C.
As the skin surface
temperature averages
35.5°C, the optimal
environmental
temperature is 34°C
(slightly higher for premature
infants).

7. A. TEMPERATURE
The neonate’s environmental temperature is best
controlled by placing the infant in an enclosed
incubator.
An open radiant warmer is used when the infant is
sick and frequent access is necessary.
In the OT room, the temperature
must be continuously recorded by
placing a thermistor in the rectum
or esophagus.
Body heat may be conserved by a
heating pad, circulated warm air
around the child (bearhugger),
infrared lamp, and warm irrigation
fluids.
The operating room should be
prewarmed and the temperature
kept at 20-27°C.

8. B. FLUID
D E F I C I T T H E R A P Y
M A I N T E N A N C E T H E R A P Y
R E P L A C E M E N T T H E R A P Y
Fluid management is divided into 3 phases :
PA R A D I G M F O R F L U I D M A N A G E M E N T

9. COMPOSI T I ON OF B ODY F LUI DS
 Total Body Water (TBW) as a
percentage of the body weight varies
according to age.
 Fetus has a very high TBW, which
gradually decreases to about 75% of
birth weight for a term infant.
 TBW of Premature infants > term
infants
 The high fat content in overweight
children leads to decrease in TBW as a
% of body weight
 During dehydration  TBW decrease

10. F I G U R E : T O TA L B O D Y W E I G H T A C C O R D I N G T O A G E

11. 1. DEFICIT THERAPY
PA R A D I G M F O R F L U I D M A N A G E M E N T
Deficit therapy based on 3 components :
a. Estimation of the severity of dehydration
b. Determination of the type of fluid deficit
c. Repair of the deficit.
Dehydration is simply the excessive loss of body water resulting a decrease in total
body water
Total Fluid Loss > Total Fluid Intake

12. 1. DEFICIT THERAPY
C L I N I C A L E VA L U AT I O N O F D E H Y D R AT I O N

13. 1. DEFICIT THERAPY
S E V E R I T Y O F D E H Y D R AT I O N

14. 1. DEFICIT THERAPY
D E T E R M I N AT I O N T Y P E O F F L U I D D E F I C I T
Calculation of deficits:
 Water deficit : % of
dehydration x weight
 Sodium deficit :
Water deficit x 80
mEq/L
 Potassium Deficit :
Water deficit x 30
mEq/L

15. 2. MAINTENANCE
 Prevent dehydration
 Prevent electrolyte disorders
 Prevent ketoacidosis
 Prevent protein degradation
GOAL OF MAI NTAI NENCE F LUI DS
I NFANTS ARE MORE SUSCEPT I B L E FOR WAT ER LOSS DUE TO
 Physiological inability of their renal tubules to concentrate
 Higher metabolic rate
 Larger body surface area
 Poorly developed thirst mechanism
 Larger turnover water exchange

16. 2. MAINTENANCE
F L U I D M A I N T E N A N C E
 Maintenance fluid requirements may need to be increased in
children with pyrexia, excess sweating, hypermetabolic states
such as burns or when radiant heaters or phototherapy is
used.
 Maintenance fluid volume is calculated according to body
weight:
BODY WEIGHT FLUID PER DAY
0 – 10 kg 100 ml/kg
11 – 20 kg 50 ml/kg
> 20 kg 20 ml/kg

17. 2. MAINTENANCE

18. 2. MAINTENANCE
E L E C T R O LY T E S M A I N T E N A N C E
 Sodium, Potassium & Chloride are given in maintenance fluids to replace
losses from urine and stool.
 Maintenance requirements:
Electrolytes Requirement
Sodium 2 -3 mEq/kg/24 hour
Potassium 1 -2 mEq/kg/24 hour
Chloride Adequate chloride is provided as long as
at least half of the sodium and
potassium are given as chloride salts.
Glucose Maintenance fluids usually contain 5%
dextrose (D5), which provide 17 cal per
100 mL & close to 20% of the daily
caloric needs

19. 3. REPLACEMENT
PA R A D I G M F O R F L U I D M A N A G E M E N T
 Replacement fluid therapy is designed to replace
ongoing abnormal fluid and electrolyte losses.
e.g. drains, ileostomy
 Best measured and replaced: any fluid losses
>0.5ml/kg/h needs to be replaced
 Replaced with NS / HM, or 5% human albumin if
fluid loss with high protein content (burns)

20. C. BLOOD LOSS
PRE OPERATIVE PREPARATION AND EVALUATION FOR RED BLOOD CELL TRANSFUSION
 Complete blood count must be done in infants < 12 months of age to evaluate
haemoglobin levels, haematocrit, and the reticulocyte.
 Trigger threshold for blood transfusion vary according to age, haemoglobin level,
and other factors such as :
Infants < 4 months require blood transfusion if:
 Haemoglobin < 12 g/dL in first 24 hour of life
 Haematocrit < 20% with symptoms of anaemia with low reticulocyte count,
 Haematocrit < 30% on oxygen therapy with continuous positive airway pressure with
clinical signs like apnoea, bradycardia, tachycardia and low weight gain.
 Haematocrit > 45% in presence of cyanotic congenital heart disease
 Blood loses >10%

21. C. BLOOD LOSS
PRE OPERATIVE PREPARATION AND EVALUATION FOR RED BLOOD CELL TRANSFUSION
Infants >4 months require blood
transfusion if :
 Acute loss of > 15% of estimated
blood volume
 Hypervolemia (not responding to
treatment)
 Post operative anaemia
(heaemoglobin < 10 g/dl)
 Pre operative haemoglobin <
12g/dl in presence of
cardiopulmonary disease
 Severe chronic anaemia with
haemoglobin < 7g/dl

22. C. BLOOD LOSS
M A X I M U M A L LOWA B L E B LO O D LO S S ( M A B L )
This formula is indicated as the volume of red packed cells is transfused, in
accordance with the desired haematocrit

23. C. BLOOD LOSS
I N T R A O P E R AT I V E M O N I TO R I N G A N D M A N A G E M E N T
 The need for intraoperative transfusion depend on the rapidity
and amount of blood loss, assessment of patient's blood
volume, pre-operative haematocrit, general medical condition
(presence of cardiac/lung disease, nature of surgery and the
risk : benefit ratio of transfusion in that situation)
 Adequate and appropriate replacement of blood losses is
essential to reduce mortality and morbidity in paediatric
surgical patient

24. C. BLOOD LOSS
C A LC U L AT I O N O F B LO O D VO LU M E TO B E T R A N S F U S E D
 The volume of blood to be transfused must be estimated to
achieve the target hematocrit:
Once the estimated blood loss reaches the target, transfusion
should be initiated
Estimated blood volume x (ideal haematocrit – actual haematocrit)
Haematocrit of the transfused blood

25. C. BLOOD LOSS
C O M P L I C AT I O N S O F M A S S I V E B LO O D T R A N S F U S I O N
Metabolic consequences of massive blood transfusion occur more
frequent in children due to the relationship between blood
component administered and their circulating blood volume.
 Hypocalcemia
 Hyperkalemia
 Hypomagnesemia
 Acid base disorder
 Hypothermia

26. D. NUTRITION
P R E - S U R G I C A L E AT I N G A N D D R I N K I N G G U I D E L I N E S
• It is very important that you follow these guidelines. If these guidelines are not
followed, the child's surgery will be delayed until the end of the day or re-
scheduled.
• The fasting guidelines are:
• After midnight: Stop non-clear liquids and solids (this includes any food and
also hard candy or gum)
• 6 hours before arrival: Stop infant formula
• 4 hours before arrival: Stop breast milk
• 2 hours before arrival: Stop clear liquids (water, clear apple juice)

27. D. NUTRITION
Source : Pediatric
Anesthesia Digital
Handbook
We follow
the "2, 4, 6, 8
rule" for
fasting
guidelines in
children.

28. P R E S E N T E D B Y
N I K N O R L I Y A N A
P R E - O P E R T I V E C A R E

29. INTRODUCTION
Pre-op care is important in assessing whether patient is fit for surgery
and to prepare them for surgery.
Also to evaluate whether surgery is truly necessary for the patient:
 Eliminate preventable causes of cancellation of surgery
 Familiarize patient and child to hospital
 Reduce % of cancellation of surgery

30. 6 MAIN TASKS
1. To explain to the patient / relative the nature of the illness,
implications of the surgery and prognosis.
2. Identification of potential operative mortality and post
operative morbidity
3. To assess the fitness for operation
4. Identification of the risks of potential postoperative
complications and prophylactic measures
5. Planning of operation and consent

31. MEDICAL HISTORY
 Birth history: full-term, pre-term
 Determine post-conceptual age
 History of previous hospitalization and surgical
procedure
 Concurrent medical illness
 Respiratory history
Recent URTI, noisy breathing, history of intubation, sleep apnea,
feeding problems, rapid breathing, productive cough, purulent nasal
discharge
 Allergies
PAT I E N T I S C O U G H I N G ?
 It is difficult to secure airway in pediatric patient with ongoing URTI
 URTI can cause:
Laryngospasm, bronchospasm, breath holding, oxygen desaturation
 In severe URTI, surgery should be postponed for at least 4-6 weeks
Possible problems
 Pulmonary: lung immaturity,
bronchopulmonary dysplasia,
elevated pulmonary vascular
resistance
 Airway: tracheomalacia,
subglottic stenosis
 Multiple medication
 Apnea, bradycardia
FOR FORMER PRETERM PATIENTS

32. MEDICAL HISTORY

33. FAMILY HISTORY
 Parental history: diabetes mellitus, preeclampsia, alcohol abuse
 Unusual reaction to surgery or anesthesia
 Malignant hyperthermia
 Sickle cell anemia
 Thalassemia
 Atypical pseudo cholinesterase
 Neuromuscular disorder

34. PHYSICAL EXAMINATION
Done to assess difficulty of intubation
 Any inspiratory/expiratory stridor?
 Signs of respiratory distress?
 Is mouth accessible?
 Macroglossia?
 Hypoplastic mandible?
 Neck mobility
 Purulent discharge from nose??
Auscultate for bronchial breath sounds, wheeze, crackles
A I R W AY A S S E S S M E N T
L U N G S

35. PHYSICAL EXAMINATION
 To avoid unnecessary dental damage and traumatic intubation
 Poor dentition (crowded teeth, tooth decay)
 Age 5-12 more susceptible to teeth avulsion
 Intraoral appliances, difficult intubation due to reduced space
D E N T I T I O N

36. PHYSICAL EXAMINATION
H E A R T M U R M U R S
 Must differentiate between an innocent murmur and a pathological
murmur (HOCM)
 Any congenital cardiac problems poses a 2 folds increase in mortality
rate if it is a non-cardiac surgery
 High suspicion if associated down syndrome, VACTERL, CHARGE,
Turner, DiGeorge syndromes.

37. PHYSICAL EXAMINATION
Irritability, sudden mood change, ataxia, nuchal rigidity, photophobia,
opisthostonos, Kernig sign, Brudzinski etc
N E U R O L O G I C S TAT U S A N D D E F I C I T
S K I N R A S H E S
May be having active viral infection, poses threat to other patient,
hospital staffs

38. NIL-PER-ORAL STATUS
 Rules for no eating or drinking before surgery.
 These guidelines must be followed to prevent
complications (aspiration pneumonia) during surgery.
 Surgery might be delayed if rules are not obeyed.
 NPO times are based on your time upon arrival to the
surgery center and not actual surgery time.

39. NPO
 This recommendation applies to healthy patients who are
undergoing elective procedures.
 Guidelines does not guarantee complete gastric emptying.
 Fasting periods stated above applies to patient of all ages.
 Ex of clear fluid include water, fruit juices, carbonated drink,
tea and black coffee.
 Non human milk has gastric emptying time similar to solid
food. Therefore the amount ingested must be considered in
determining the appropriate fasting period.
 Light meal consist of toast and clear fluid.
 Heavy meal may need additional fasting time. (8hrs) or more

40. INVESTIGATIONS
 Preoperative evaluation and preparation of the child for
surgery forms a major consideration in paediatric
anaesthesia practice.
 Special considerations include evaluation of the medical
condition, assessing the psychological status of the child,
allaying anxiety of the child as well as the parent and
understanding the special needs of the surgical procedure
planned.

41. ROUTINE INVESTIGATIONS
F U L L B L O O D C O U N T
Children with known or suspected anaemia and all patients undergoing major surgery or with
suspected or known low (hemoglobin < 12) should have a full blood count and ferritin.
B L O O D U R E A & S E R U M E L E C T R O LY T E
Check electrolyte balance for hydrational status.
C O A G U L AT I O N P R O F I L E
B L O O D G R O U P A N D C R O S S M AT C H I N G
 Blood should be taken for grouping and screen at pre-assessment clinic for all those
undergoing major surgery and other listed operations .
 A further sample will need to be taken on the day of admission if it is predicted that blood
may need to be ordered for surgery.
U R I N E I N P U T A N D O U T P U T C H A R T

42. RADIOLOGICAL IX
E C H O C A R D I O G R A M
Echocardiography should be considered if:
New murmur
Poor functional capacity
Syncope or dizzy spells
C H E S T X - R AY
 To check if there is any abnormality in the lungs and to access if the lung is clear cause
children are more prone to URTI.

43. P R E S E N T E D B Y
A F F A N S Y A F I Q I
P O S T- O P E R T I V E C A R E

44. PURPOSES
1. To enable a faster and successful recovery of the
patient posteratively.
2. To reduce post operative mortality rate.
3. To reduce length of the hospital stay.
4. To provide quality care service.

45. The immediate postoperative period: recovery room
• The theatre team should formally hand over the care of the
patient to the recovery staff. The information provided should
include the patient’s name, age, the surgical procedure,
existing medical problems, allergies, the anaesthetic and
analgesics given, fluid replacement, blood loss, urine output,
any surgical and anaesthetic problems encountered or
expected.
• Patient’s vital parameters, consciousness, pain and hydration
status are monitored in the recovery room and supportive
treatment is given.
GENERAL MANAGEMENT

46. The patient can be discharged from the recovery
room when they fulfil the following criteria:
 Patient is fully conscious.
 Respiration and oxygenation are satisfactory.
 Patient is normothermic, not in pain nor nauseous.
 Cardiovascular parameters are stable.
 Oxygen, fluids and analgesics have been prescribed.
 There are no concerns related to the surgical procedure
GENERAL MANAGEMENT

47.  Respiratory complications are the second most common postoperative complication for
all pediatric surgeries, after infection
 The most common respiratory complications in the recovery room are hypoxaemia,
hypercapnia and aspiration. Pneumonia tend to appear later in the postoperative
period.
 Postoperative hypoxia
 Hypoxia is defined as an oxygen saturation of less than 90%. Hypoxia may present as
shortness of breath or agitation or as upper airway obstruction or cyanosis or as a
combination of any of the above. Hypoxia in the postoperative period may occur due to
a variety of reasons, for example:
 Upper airway obstruction due to the residual effect of general anaesthesia, secretions or wound
haematoma after neck surgery.
 Laryngeal oedema from traumatic tracheal intubation, recurrent laryngeal nerve palsy and tracheal
collapse after thyroid surgery.
 Hypoventilation related to anaesthesia or surgery.
 Atelectasis and pneumonia especially after upper abdominal and thoracic surgery
 Pulmonary oedema of cardiac origin or related to fluid overload.
COMPLICATIONS
R E S P I R AT O R Y C O M P L I C AT I O N S

48. COMPLICATIONS
M A N A G E M E N T O F R E S P I R AT O R Y C O M P L I C AT I O N S
 Patients with hypoxia should be treated urgently.
 If the patient is breathing spontaneously, adminester oxygen at
15L/min, using a non breathing mask.
 A head tilt, chin lift or jaw thrust should relieve obstruction
related to reduced muscle tone.
 Suctioning of any blood or secretions may be needed.
 Inform the anaesthetist if tracheal intubation or manual
ventilation may be needed.

49.  Hypotension in the immediate postoperative period may be due
to inadequate fluid replacement, vasodilatation from
subarachnoid and epidural anaesthesia or rewarming of the
patient.
 However, other causes of hypotension such as surgical bleeding,
sepsis, arrhythmias, myocardial infarction, cardiac failure, tension
pneumothorax, pulmonary embolism, pericardial tamponade and
anaphylaxis should be also sought
 Patients with hypotension are likely to have cold clammy
extremities, tachycardia and a low urine output ≤0.5 mL/kg per
hour and low CVP. Hypovolaemia should be corrected with
intravenous crystalloid or colloid infusions.
COMPLICATIONS
C A R D I O VA S C U L A R C O M P L I C AT I O N S

50.  Pain is one of the most common surgical complications,
with undertreatment associated with adverse
 Adequate postoperative pain control for all is required
to ensure safety and efficacy in pain management, and
maintain maximum physical function, psychological
well-being, and quality living.
 Pain assessment is required for effective delivery of pain
control but relies heavily on self-report of pain.
COMPLICATIONS
PA I N

51.  Anaesthesia induces loss of thermoregulatory control. Exposure
of skin and organs to a cold operating environment, volatile skin
preparation (which cool by evaporation), and the infusion of cold
i.v. fluids all lead to hypothermia.
 This, in turn, leads to increased cardiac morbidity, a
hypocoagulable state, shivering with imbalance of oxygen supply
and demand, and immune function impairment with the
possibility of wound infection. Active warming devices should be
used to treat hypothermia as appropriate.
COMPLICATIONS
H Y P O T H E R M I A A N D S H I V E R I N G

52. About 40 per cent of patients develop pyrexia after major surgery; however, in
most cases no cause is found. The inflammatory response to surgical trauma may
manifest itself as fever, and so pyrexia does not necessarily imply sepsis.
However, in all patients with a pyrexia, a focus of infection should be sought. The
causes of a raised temperature postoperatively include:
• Days 2–5: atelectasis of the lung
• Days 3–5: superficial and deep wound infection
• Day 5: chest infection, urinary tract infection and thrombophlebitis
• >5 days: wound infection, anastomotic leakage, intracavitary collections and
abscesses
• DVTs, transfusion reactions, wound haematomas, atelectasis and drug reactions,
may also cause pyrexia of non-infective origin.
Patients with a persistent pyrexia need a thorough review. Relevant
investigations include full blood count, urine culture, sputum microscopy and
blood cultures
COMPLICATIONS
F E V E R

53.  Within hours of the wound being closed, the dead space fills up with an
inflammatory exudate. Within 48 hours of closure, a layer of epidermal cells
from the wound edge bridges the gap. So, sterile dressings applied in theatre
should not be removed before this time.
 Wounds should be inspected only if there is any concern about their condition
or the dressing needs changing. Inspection of the wound should be performed
under sterile conditions. If the wound looks inflamed, a wound swab may need
to be taken and sent for Gram staining and culture.
 Infected wounds and hematoma may need treatment with antibiotics or even
a wound washout.
COMPLICATIONS
W O U N D C A R E

54.  Wound dehiscence is disruption of any or all of the layers in a wound.
Dehiscence may occur in up to 3 per cent of abdominal wounds and is very
distressing to the patient.
 Wound dehiscence most commonly occurs from the 5th to the 8th
postoperative day when the strength of the wound is at its weakest. It may
herald an underlying abscess and usually presents with a serosanguinous
discharge. The patient may have felt a popping sensation during straining or
coughing. Most patients will need to return to the operating theatre for
resuturing. In some patients, it may be appropriate to leave the wound open
and treat with dressings.
COMPLICATIONS
W O U N D D E H I S C E N C E

55.  Patients discharged home need a ‘discharge
letter’ which includes the diagnosis, treatment,
lab results, complications, discharge plan and
follow ups.
 They should be adviced regarding referring
patients back to hospital if specific problem
occurs.
DISCHAGE OF PATIENTS

56. THANK YOU