Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
Fundamentals of Surgical Practice
The Surgical Patient
Approach to the surgical patient
The paediatric patient
Surgical Techniques
Tissue Handling
Suture and suture technique
Prophylaxis
Basic Surgical Procedures
Wound management
Specific lacerations and wounds
Burns
Foreign bodies
Cellulitis and abscess
Excision and biopsies
The Paediatric Patient
 


> PHYSIOLOGICAL CONSIDERATIONS
> SURGICAL PROBLEMS IN NEONATES
> SURGICAL PROBLEMS IN YOUNG CHILDREN



PHYSIOLOGICAL CONSIDERATIONS

Vital signs
Infants and children have a more rapid metabolic rate than adults. This is reflected in their normal vital signs.

Chart

Temperature regulation
Children lose heat more rapidly than adults because they have a greater relative surface area and are poorly insulated. Hypothermia can affect drug metabolism, anaesthesia and blood coagulation. Children are especially prone to hypothermia in the operating room.

Prevent hypothermia by:

:: Turning off any air conditioning in the operating room (aim for a room temperature of >28°C)
:: Using warmed intravenous fluids
:: Avoiding long procedures
:: Monitoring the child’s temperature at least every 30 minutes and at the completion of the case.

It is easier to keep children warm than to warm them up when cold. Encourage the mother to keep the child warm.

Compensatory mechanisms for shock
Children compensate for shock differently from adults, mainly by increasing their heart rate. A rapid heart rate in a child may be a sign of impending circulatory collapse. Do not ignore a decreased blood pressure. A slow heart rate in a child is hypoxia until proven otherwise.

Blood volume

Children have smaller blood volumes than adults

:: Even small amounts of blood loss can be life threatening
:: Intravenous fluid replacement is needed when blood loss exceeds 10% of the total blood volume
:: Chronic anaemia should be slowly corrected before elective operations with iron, folic acid or other supplements, as appropriate
:: Make sure that safe blood will be available in the operating room if blood loss is anticipated during surgical procedures.


See The Clinical Use of Blood (WHO, 2000) for additional information on the use of blood in paediatrics and neonatology.

Chart

Nutrition and hypoglycaemia

Infants and children are at special risk for nutritional problems because of their higher caloric needs for growth. Poor nutrition affects response to injury and ability to heal wounds. Many surgical conditions, such as burns, increase caloric needs or prevent adequate intake of needed nutrition.

Good nutrition helps healing. Poor nutrition prevents it.

Infants are at risk for developing hypoglycaemia because of a limited ability to utilize fat and protein to synthesize glucose. If prolonged periods of fasting are anticipated (>6 hours), give intravenous fluids that contain glucose.

Fluid and electrolytes


Baseline fluid and electrolyte requirements are related to the child’s weight. However, the actual fluid requirements may vary markedly, depending on the surgical condition.

Chart

Hourly maintenance fluid requirements can be calculated using the 4:2:1 rule.

Chart

Fluid requirements in surgical patients commonly exceed maintenance requirements.
Children with abdominal operations typically require up to 50% more than baseline requirements and even larger amounts if peritonitis is present. Special care is needed with fluid therapy in children; pay close attention to ongoing losses (e.g. nasogastric drainage) and monitor urine output. In the case of fever, add 12% to total maintenance requirements per 1°C rise above 37.5°C temperature measured rectally.

The most sensitive indicator of fluid status in a child is urine output. If urinary retention is suspected, pass a Foley catheter. A catheter also allows hourly measurements of urine output that can prove invaluable in the severely ill patient.

Normal urine output: Infants 1–2 ml/kg/hour
Children 1 ml/kg/hour


Infants are unable to concentrate urine as well as adults, making them more susceptible to electrolyte abnormalities.

Establishing intravenous access in paediatric patients can be challenging. See pages 13–11 to 13–16 for IV access techniques.

Anaesthesia and pain control


Anaesthesia in children poses special problems. The smaller diameter airway makes children especially susceptible to airway obstruction. Children often need intubation to protect their airway during surgical procedures. Ketamine anaesthesia is widely used for children in rural centres (see pages 14–14 to 14–21), but is also good for pain control.

Children suffer from pain as much as adults, but may show it in different ways. Make surgical procedures as painless as possible:

:: Oral paracetamol can be given several hours prior to operation
:: Local anaesthetics (bupivacaine 0.25%, not to exceed 1 ml/kg) administered in the operating room can decrease incisional pain
:: Paracetamol (10–15 mg/kg every 4–6 hours) administered by mouth or rectally is a safe and effective method for controlling postoperative pain
:: For more severe pain, use intravenous narcotics (morphine sulfate 0.05–0.1 mg/kg IV) every 2–4 hours
:: Ibuprofen 10 mg/kg can be administered by mouth every 6–8 hours
:: Codeine suspension 0.5–1 mg/kg can be administered by mouth every 6 hours, as needed.
Pre- and postoperative care


The pre- and postoperative care of children with surgical problems is often as important as the procedure itself. For this reason, surgical care of children does not begin or end in the operating room. Good care requires teamwork, with doctors, nurses and parents all having important roles to play:

:: Prepare the patient and family for the procedure
:: Ensure that the needed paediatric supplies (such as intravenous catheters, endotracheal tubes and Foley catheters) are available in the operating room to complete the procedure
:: Monitor the patient’s vital signs during the critical period of recovery
:: Encourage a parent to stay with the child in the hospital and to be involved in his/her care.

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> PHYSIOLOGICAL CONSIDERATIONS
> SURGICAL PROBLEMS IN NEONATES
> SURGICAL PROBLEMS IN YOUNG CHILDREN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
  Kep Points  
Infants and young children, especially those with little subcutaneous fat, are unable to maintain a normal body temperature when there are wide variations in the ambient temperature or when they have been anaesthetized.


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 
Kep Points
 
Malnutrition can impair the response of children to injury and their ability to heal and recover
 
When completing a preoperative assessment on a child, consider nutritional status and anaemia; treat chronic anaemia as part of the preparation for surgery.

 
 

 

 

 

 

 

 
 
Kep Points
 
Whenever possible, give fluids by mouth

 
Use the intravenous route for rapid resuscitation (20 ml/kg bolus of normal saline) and for cases where the oral route is not available or inadequate

 
Intraosseous puncture can provide the quickest access to the circulation in a shocked child in whom venous cannulation is impossible (see page 13–15).