Pre and Post operative in Paediatric Surgery

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

1. PRE AND POST OPERATIVE CARE PRESENTED BY NURUL HIDAYU IBRAHIM NIK NOR LIYANA AFFAN SYAFIQI IN SURGICAL PAEDIATRICS

2. Introduction Special consideration in surgical 3. Pre-operative care 4. Post-operative care REFERENCES Bailey and Love 26 th Edition Current Diagnosis and Treatment Surgery 14 th Edition OUTLINE Temperature Ventilation Fluids Blood loss Nutrition History, physical examination and investigations Consent Specific pre-operative procedures General management Complication Discharge and follow-up

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. PRESENTED BY NURUL HIDAYU SPECIAL CONSIDERATION IN PAEDIATRIC SURGERY

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, t he 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 DEFICIT THERAPY MAINTENANCE THERAPY REPLACEMENT THERAPY Fluid management is divided into 3 phases : PARADIGM FOR FLUID MANAGEMENT

9. COMPOSITION OF BODY FLUIDS 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. FIGURE : TOTAL BODY WEIGHT ACCORDING TO AGE

11. 1. DEFICIT THERAPY PARADIGM FOR FLUID MANAGEMENT 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 CLINICAL EVALUATION OF DEHYDRATION

13. 1. DEFICIT THERAPY SEVERITY OF DEHYDRATION

14. 1. DEFICIT THERAPY DETERMINATION TYPE OF FLUID DEFICIT 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 MAINTAINENCE FLUIDS INFANTS ARE MORE SUSCEPTIBLE FOR WATER 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 FLUID MAINTENANCE 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 ELECTROLYTES MAINTENANCE 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 PARADIGM FOR FLUID MANAGEMENT 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 : I nfants < 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 B lood loses >10%

21. C. BLOOD LOSS PRE OPERATIVE PREPARATION AND EVALUATION FOR RED BLOOD CELL TRANSFUSION I nfants >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 MAXIMUM ALLOWABLE BLOOD LOSS (MABL) T his formula is indicated as the volume of red packed cells is transfused, in accordance with the desired haematocrit

23. C. BLOOD LOSS INTRAOPERATIVE MONITORING AND MANAGEMENT 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 CALCULATION OF BLOOD VOLUME TO BE TRANSFUSED 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) H aematocrit of the transfused blood

25. C. BLOOD LOSS COMPLICATIONS OF MASSIVE BLOOD TRANSFUSION 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 PRE-SURGICAL EATING AND DRINKING GUIDELINES 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. PRESENTED BY NIK NOR LIYANA PRE-OPERTIVE CARE

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 To explain to the patient / relative the nature of the illness, implications of the surgery and prognosis. Identification of potential operative mortality and post operative morbidity To assess the fitness for operation Identification of the risks of potential postoperative complications and prophylactic measures 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 PATIENT IS COUGHING? 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 AIRWAY ASSESSMENT LUNGS

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 DENTITION

36. PHYSICAL EXAMINATION HEART MURMURS 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 NEUROLOGIC STATUS AND DEFICIT SKIN RASHES 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 FULL BLOOD COUNT 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. BLOOD UREA & SERUM ELECTROLYTE Check electrolyte balance for hydrational status. COAGULATION PROFILE BLOOD GROUP AND CROSS MATCHING 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. URINE INPUT AND OUTPUT CHART

42. RADIOLOGICAL IX ECHOCARDIOGRAM Echocardiography should be considered if: New murmur Poor functional capacity Syncope or dizzy spells CHEST X-RAY 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. PRESENTED BY AFFAN SYAFIQI POST-OPERTIVE CARE

44. PURPOSES To enable a faster and successful recovery of the patient posteratively. To reduce post operative mortality rate. To reduce length of the hospital stay. 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 RESPIRATORY COMPLICATIONS

48. COMPLICATIONS MANAGEMENT OF RESPIRATORY COMPLICATIONS 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 CARDIOVASCULAR COMPLICATIONS

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 PAIN

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 HYPOTHERMIA AND SHIVERING

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 FEVER

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 WOUND CARE

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 5 th 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 WOUND DEHISCENCE

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

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