Evaluation of the Pediatric Surgical Patient Flashcards
How are pediatric patients different from adults?
Childhood can be divided into different time periods:
neonatal, infant, toddler, child, and adolescent.
Each of these developmental periods impart different physiologic and psychosocial features.
Define the neonatal period.
The neonatal period (<30 days of life) is characterized by unique fluid, electrolyte, metabolic, and thermoregulatory requirements.
These factors are further influenced by gestational age, birth weight, prenatal factors, and co-morbid conditions.
Examples include high resting energy expenditure and glucose requirements, which not only change during the 1st week of life but are directly affected by size and gestation.
Clear understanding of these issues as well as unique neonatal conditions (e.g. duodenal atresia, necrotizing enterocolitis) is required by the surgeon.
Define the infancy period.
Infancy (30 days to 1 year of life) is characterized by a period of rapid growth and developmental change.
Children often double their birth weight by 6 months of life and see progressive development of motor and social skills.
This period is also characterized by unique surgical conditions (e.g. pyloric stenosis).
Define the toddler period.
Toddler (1–3 years) is one of the most challenging periods as communication with the child is difficult and fear of medical personnel often prevents a reliable physical exam.
Unique conditions such as intussusception may be seen in this period.
Define the childhood period.
Childhood (4–12 years) reflects continued development towards adulthood.
Psychosocial implications of surgery can be quite distressful and many children may experience anxiety and/or regression of developed skills.
Define the adolescent period.
Adolescents (>12 years) more commonly have adult type conditions but psychosocial aspects must be considered to develop healthy physician-patient relationships to foster trust, and treatment compliance.
What is the role of parents in the evaluation of pediatric surgery patients?
Parents and providers of children are critical in understanding the child’s history, presentation, and context of their condition.
Young children are non-verbal or often unable to effectively communicate their problems.
Older children may not share important information and be resistant to interacting with providers.
It is therefore, critical to develop a relationship with the parent not only to understand the clinical problem but to alleviate or address the concerns of the parents themselves.
Parental anxieties are known to exacerbate anxiety in the child.
Having a sick or injured child is stressful for caregivers and the surgeon must consider their needs in addition to the patient’s needs.
What do I need to know? What are the important aspects of the history?
In the young child an understanding of the prenatal period is critical.
It is important to understand details surrounding the pregnancy (prenatal care, known anomalies, maternal medication use, maternal infections, maternal co-morbid con- ditions), birth (gestational age, meconium present, rupture of membranes, APGAR scores), and early perinatal course.
Beyond the perinatal period much of the assessment is similar.
A complete evaluation of the history of present illness, past medical/surgical history, prior anesthesia history, a family history, social history and physical examination appropriate for the clinical scenario.
Children may present with rare or unusual conditions that may require multi- disciplinary discussion to fully understand the complete picture and to ensure adequate components of the history have been obtained.
Caveats: The family history may be more impactful in some patients and may clue the provider into disease process with known genetic or heritable components.
Example: A 2 y.o. girl with a cystic lung lesion. It is important to assess the family for other lesions such cystic nephroma, multinodular goiter, mesenchymal hamartoma of the liver, etc. to evaluate risk for DICER1 mutations.
If positive, one would be concerned that the cystic lung lesion could represent pleuropulmonary blastoma.
How do I examine a child? How is this different?
a. The assessment:
i. Child life resources with toys and electronics to distract young children may be helpful in performing an assessment.
ii. Garnering parental/caregiver support and involvement may not only be necessary but may also allow for a more complete physical examination.
iii. It is important to try to make the child feel comfortable and safe. This may include examining the child while a parent holds them and/or actively engages them in the assessment. It is also helpful to let the child know what you are going to do next.
iv. Occasionally, adequate assessment requires an evaluation in the operating room.
Examples include: the developmentally delayed child who is too large to safely restrain to adequately evaluate a perianal lesion or a teenage girl who may be too uncomfortable to relax for evaluation of a pelvic straddle injury.
b. The child’s size, age, and disease process may affect the exam. Example:
i. In young infants suspected inguinal hernias can be quite difficult to appreciate on exam. There are many cases where one cannot identify the hernia on exam but the history remains highly suspicious. In these cases of uncertainty, obtaining photos of the hernia can provide confidence before proceeding to surgical repair.
What are requirements/considerations for children undergoing surgical procedures?
Fasting recommendations?
Fasting recommendations:
i. Clear liquids 2 hours
ii. Breast milk 4 hours
iii. Infant formula 6 hours
iv. Full meal 8 hours.
If tasked with intubation how do I decide on the appropriate sized endotracheal tube?
Rule of thumb (Child > 2 years): ETT size = (Age +16)/4
Do children have different physiologic considerations important to surgery?
i. Yes, Cardiac output varies by age:
1. Neonate: 350 ml/kg/min, infant 150 ml/kg/min, Adult 75 ml/kg/min.
ii. Yes, they have increased oxygen consumption and alveolar ventilation
1. Preterm infants may have 3 fold increase in oxygen consumption and children have increased respiratory rates compared to adult counterparts.
iii. Yes, they have increased vagal sensitivity
1. More frequent bradycardic events with airway stimulation.
Premature infants can have apneic events. How long do they need to be observed?
i. Premature infants (<37 weeks) who are 60 weeks or less post menstrual age require overnight observation
ii. Term infants <44 weeks post menstrual age require observation in a monitored bed at least 4 hours
iii. Term infants>44weeks with no history of neonatal apnea can be discharged after meeting discharge criteria.
Is routine laboratory evaluation required?
The majority of healthy children undergoing routine outpatient procedures do not require pre-operative laboratory evaluation.
For children with medical co-morbid conditions, surgical judgement should be used to decide relevant laboratory values to guide management and limit procedures on children.
Examples include obtaining metabolic panels to evaluate the chloride, bicarbonate, and potassium levels on children prior to pyloromyotomy for pyloric stenosis, evaluation of hemoglobin S component on children with known sickle cell disease, and obtaining pregnancy tests in adolescent girls prior to surgery.
The parents are worried about anesthesia risk and surgery. How safe is it?
Overall mortality rates have been estimated at less than 1 in 45,000 and many of these occur in children with ASA scores of three or higher.
