Surgery: pediatrics

Question 1

consent is a legal issue: what specific situations can kids seek care without parental consent? what type of intervention NEEDS an adults signature

Answer 1

substance abuse, contraception and pregnancy, psychiatric problems
BUT Operative intervention needs an adult’s signature

Question 2

what is “assent”?

Answer 2

Consideration of child’s input
considers…
Child’s developmental state
Child’s understanding of disease process

Question 3

what are the most common conditions that warrant pediatric surgery?

Answer 3

Pyloric Stenosis
Meckel Diverticulum
Intussusception
Appendicitis
Splenic injury

Question 4

Resuscitation for kids includes what? what might you need for severe hypovolemia?

Answer 4

20 mL/kg bolus of isotonic fluid
Normal saline or lactated ringer’s (rare)
*May need additional boluses for severe hypovolemia

Question 5

two ways we remove intravascular fluid?

Answer 5

Diuresis and Dialysis

Question 6

goal of mgmt for fluid management

Answer 6

make the pt euvolemic

not hypo or hypervolemic or fluid in the wrong place

Question 7

fluid management: maintenance

Answer 7

Often 5% dextrose in 0.45% saline with 20 miliequivalents of potassium
“D5 ½ NS w/ 20 mEq K+”
4-2-1 rule

Question 8

fluid mgmt: 4-2-1 rule

Answer 8

4 mL/kg/hr for each of the first 10 kg weight
2 mL/kg/hr for each kg from 10-20 kg
example: A 12.5 kg infant would need 40 + 5 = 45 mL/hr
1 mL/kg/hr for each kg above 20 kg
example: A 45 kg child would need 40 + 20 + 25 = 85 mL/hr

Question 9

Most common cause of emesis (projectile vomiting) in infancy

Answer 9

pyloric stenosis

Question 10

on physical exam: you palpate an olive shaped- mass in the abdomen (with projectile vomitting)

Answer 10

pyloric stenosis

Question 11

what is the major danger with pyloric stenosis?

Answer 11

metabolic alkalosis (barfing all acid of the stomach)
- you have basic blood and acidic urine
so balance them!

Question 12

what is the basic pathophys of pyloric stenosis?

Answer 12

Delayed hypertrophy, hyperplasia of pyloric circular muscles

Not present at birth, it develops

Question 13

extensive PE of pyloric stenosis may show what signs ? (4)

Answer 13

1. Progressive non-billious emesis : Undigested milk ( coffee-ground with gastritis) , diarrhea
2. Dehydrated/malnourished : Increased appetite/thirst , Jaundice
3. sunken fontanelles (if its progressed)
4. “olive” felt in abdomen

Question 14

txt of pyloric stenosis?

Answer 14

resuscitation

• can’t do surgery until they are electrodynamically stable
• need bicarb < 30

Question 15

what procedure can help pyloric stenosis?

Answer 15

NG decompression

Question 16

surgery for pyloric stenosis?

Answer 16

Pyloromyotomy
Open or laparoscopic
Divide hypertrophic muscular layer but not mucosa

Question 17

presentation of meckel’s diverticulum ?

Answer 17

often asymptomatic- incidental finding

- PE usually shows normal

Question 18

Most common congential GI abnormality

Answer 18

meckel’s diverticulum

Question 19

what is the “rule of 2s “ for meckel’s diverticulum?

Answer 19

“Rule of 2”

~2% population, 2 inches long, 2 cm in diameter, 2 feet from IC valve, can have 2 types of heterotopic mucosa, often presents by 2 years old

Question 20

txt for meckel’s diverticulum

Answer 20

Resect if symptomatic or causing pathology

–> Open and laparoscopic approaches (resection)

Question 21

Leading cause of obstruction before 2 years old

Answer 21

Intussusception

Question 22

Dx of Meckel’s Divertculum

Answer 22

Technetium-99 pertechnetate scan (aka a Meckel’s Scan)

- Ectopic gastric parietal cells

Question 23

what is intussusception? what is the usual cause?

Answer 23

Usually idiopathic

Bowel “telescopes” in on itself

Question 24

presentation of intussusception ?

Answer 24

Severe intermittent pain with periods of complete relief
Blood and mucus in stool
May or may not have vomiting
Pain is cramping
* some infants demonstrate no signs of pain

Question 25

what is the “dance sign” on Xray indicative of?

Answer 25

intussusception

Question 26

2 ways to Dx of intussusception?

Answer 26

Ultrasound: Target or “Donut” sign

Air or Contrast enema (can Dx and Txt with this)

Question 27

intussusception txt (3)

Answer 27

1. Fluid resuscitation: Multiple attempts at reduction with enema if stable
2. Small bowel – small bowel will often spontaneously resolve
3. Operate for peritonitis or persistent obstruction
   Manually reduce intussusception

Question 28

appendicitis presentation

Answer 28

Decreased appetite
Periumbilical pain that migrates to the RLQ
Laying very still, Felt every bump on the ride to hospital

Question 29

appendicitis: often will rupture in ___ - ___ hrs after onset of symptoms

Answer 29

24-36 hrs

Question 30

what are these indicative of?
Rovsing Sign – referred pain to RLQ
Psoas and obturator signs

Answer 30

appendicitis

Question 31

Dx of appendicitis ?

Answer 31

MOSTLY a clinical Dx but CT is helpful to confirm

Question 32

appendicitis txt

Answer 32

Laparoscopic appendectomy

Question 33

what is stump appendicitis?

Answer 33

the interval repeated inflammation of remaining residual appendiceal tissue after an appendectomy.

Question 34

PE of splenic injury

Answer 34

• abd pain/discomfort
• pale
• tachy
• hypotension (late finding)

Question 35

Dx of splenic injury

Answer 35

CT scan

Question 36

txt of splenic injury

Answer 36

• MOST can be done with supportive care
• if operation is needed you can try to repair spleen with angioembolization
• splenectomy and provide vaccines to avoid OPSI

Question 37

(OPSI)

Answer 37

Overwhelming Post-splenectomy Sepsis
-Fairly rare, but more common in children
-Very severe once developed
Sepsis, meningitis 
Encapsulated organisms