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Flashcards in Pediatric Surgery Deck (41):

What is the resuscitation fluid amount for pediatric pts? (fluid, blood products)

1. Crystalloid (LR, 0.9% NS): 10-20 mL/kg bolus
--ongoing fluid loss (high NG output, protracted vomiting/diarrhea) = 1mL loss replaced w 1mL every 4 hrs using D5 1/2 normal saline + 20 mEq KCl/L

2. Blood products
-pRBC: 10-15 mL/kg
-FFP: 10-15 mL/kg
-platelets: 1 unit/5kg


What are clinical signs of pediatric dehydration?

Decreased feeding
Reduced UOP
Depressed fontanelle


What are clinical signs of pediatric fluid overload

New/increased oxygen requirement
Respiratory distress


What are some causes of pediatric metabolic acidosis?

1. Intestinal ischemia (Necrotizing enterocolitis, midgut volvulus, incarcerated hernia)
2. Bicarb loss from GI tract (diarrhea)
3. Chronic renal failure w acid accumulation
4. DKA
5. Ingestion of Methanol, ethylene glycol, salicylates, paraldehyde, formaldehyde


How do you treat pediatric metabolic acidosis?

Sodium bicarb if:
1. pH <7.1
2. Bicarb <10

Replacement = Base deficit x weight(kg) x 0.3
--administer half amount over several hours and recheck pH


What are some causes of pediatric metabolic alkalosis?

1. Gastric acid loss (pyloric stenosis)
2. Overaggressive diuresis


What are complications of Parenteral nutrition?

1. Parenteral nutrition- associated liver disease (PNALD)
--CHOLESTASIS (>2.5 mg/dL Conj bili)- progress to end stage hepatic fibrosis/cirrhosis
--Tx: Decrease TPN dose, modify/restrict lipids, stop tx, may require transplantation

2. Sepsis from central line related infection


What are reasons for higher risk for cold stress/hypothermia in newborns?

1. relatively large body surface area
2. lack of hair and subcutaneous tissue
3 greater insensible loss
4. *Nonshivering thermogenesis - increase metabolism and oxygen consumption


What is the important factor in infant Cardiac output? Sensitive indicator?

Cardiac Output is largely heart rate dependent
-infant has limited capacity to increase stroke volume
-bradycardia can significantly diminish cardiac output

**Capillary refill is a sensitive indicator of adequate cardiac perfusion = (>1-2 seconds may represent substantial shunting of blood for peripheral to central organs)


What is the normal RR and tidal volume of a normal newborn?

RR: 40-60 breaths/min
Tidal Vol: 6-10 mL/kg


What is the work up for sepsis evaluation in an infant?

CBC with platelet count
Differential smear
Plain radiography
Surveillance cultures of blood, urine, CSF,


How much water is lost insensibly through skin of PRETERM infants

45-60 mL/kg/day


How much water is lost insensibly through skin of TERM infants

30-35 mL/kg/day


What is the daily fluid requirement for premature infants <2kg

140-150 mL/kg/day


What is the fluid requirment for children?

100mL/kg/day for first 10 kg
50mL/kg/day for second 10 kg
20mL/kg/day for weight > 20 kg


What are the best indicators for sufficient fluid intake in children?

UOP: minimum is 1-2 mL/kg/day
Urine Osmolarity: Infant is only able to concentrate to 700 mOsm/kg (adults up to 1200 mOsm/kg)

--if UOP low or Osm is that high = higher fluid intake is necessary to to excrete solute load


What is generally the daily requirement for sodium in children?

2-4 mEq/kg
usually met with 5% dextrose in 0.45% NS w 20 mEq/L KCL at calculated maintenance rate


What is generally the daily requirement for potassium in children?

1-2 mEq/kg
usually met with 5% dextrose in 0.45% NS w 20 mEq/L KCL at calculated maintenance rate


How are Diarrheal, pancreatic, biliary losses replaced in children?

isotonic lactated Ringer solution


How is hypovolemia due to acute hemorrhage corrected?

Rapid transfusion of:
10-20 mL/kg
pRBCs, plasma, or 5% albumin


What is a general guideline for enteral calorie requirement of infants?

120 calories/kg/day - to achieve 1% body weight gain/day


What is the minimum glucose infusion rate for neonates?

4-6 mg/kg/min

for TPN, glucose infusion is increased in daily increments of 1-2 mg/kg/min to max of 10-12 mg/kg/min


What is typical amount of protein administration in infants receiving parenteral nutrition?

start at 0.5 g/kg/day
increase by 0.5/kg/day to goal of ~3.5 g/kg/day
--reduced in half by age 12 and approaches adult goal of 1g/kg/day


what are two types of pulmonary sequestration?
How do they differ in presentation?

1. Extralobar (separate pleural lining) - usually ASx, may become infected from hematogenous bacterial spread
2. Intralobar - Recurrent pneumonia/abscess formation in the same bronchopulmonary segment


How is pulmonary sequestration Dx'd?

Diagnosis: CXR, Doppler US, CT Chest,
1. Extralobar - simple excision
2. Intralobar - lobectomy
--systemic vessel must be ligated (usually in inferior pulmonary ligament)


What is a Congential Cystic Adenomatoid Malformation?

Mucus producing respiratory epithelium cyst
-increase in smooth muscle, elastic tissue, no overlying cartilage
--nonfunctional gas exchange, but connects to the tracheobronchial tree = GAS TRAPPING


what is a posterolateral diaphragmatic hernia called

bochdalek hernia - most common (90-95%) more common on L


what is an anterior diaphragmatic hernia called

morgagni hernia - rare, more common on R


what is the embryology of a congenital diaphragmatic hernia?

Failure for the Transverse septum and pleuroperitoneal fold to fuse.


How is a congenital diaphragmatic hernia diagnosed prenatally? How is the prognosis evaluated?

-To evaluate at L CDH: measure R Lobe width at cardiac atria, multiply by height and divide by circumference of head
---Ratio <1 - poor prognosis
---Ratio >1 - good prognosis


What is the management of congenital diaphragmatic hernia?

CDH = physiologic emergency (not surgical emergency)
1. Cardiopulmonary stabilization
-intubation/mech ventilation w permissive hypercapnea
-Nitric Oxide, Tolazoline, sildenapfil
-ECHO to assess pulm hypertension
-may require ECOM until pulm htn improves

2. Decompress bowels w NG tube
3. temp regulation, glucose homeostasis, volume monitoring
4. Surgical intervention


What are the different types of TEF?

A: just esophageal atresia (EA)
B: EA w prox TEF (5%)
C: EA w distal TEF (84%)
D: EA w prox TEF + distal TEF
E: TEF w/o EA (H-type) (4%)


What are congenital anomalies a/w Tracheoesophageal fistulas?

VATER or VACTERL syndrome
1. Vertebral (missing vertebrae)
2. Anorectal (imperforate anus)
3. Cardiac (congenital dz)
4. TEF
5. Renal agenesis
6. Radial limb hyperplasia


What are lab findings of hypertrophic pyloric stenosis?

Gastric outlet obstruction = nonbilious postprandial projectile vomting

-Metabolic alkalosis
-Paradoxical aciduria (from kidneys trying to preserve K)


How is hypertrophic pyloric stenosis dx'd?

Abd U/S
>3mm thick
>14mm long

Tx = Ramstedt pyloromyotomy


What is the preoperative management of hypertrophic pyloric stenosis?

1. NPO, possible NG decompression
2. fluid resuscitation (20mL/kg crystalloid) + electrolyte repletion (potassium + HCO3 to <30)
3. D5 1/2 NS at 125%-150% maintenance fluids


What is a essential nutritional fatty acid? deficiency sx?

Linoleic acid

deficiency = dryness, rash, desquamation of skin


What is the fat requirements of pediatric patients on parenteral nutrition?

what is a special consideration to make when calculating fat administration?

start at 0.5g/kg/day advance to 2-3.5 g/kg/day

fats are administered with caution in infants with unconjugated hyperbilirubinemia - fats may displace bilirubin from albumin.


What findings of supraclavicular lymphadenopathy hsould raise suspicion for more serious underlying conditions

Fixed, nontender, progressively enlarging nodes
+ B symptoms


What is a DDX of cervical lymphadenitis?

1. respiratory viral infectious causes
2. Bacterial (S.aureus. GA Strep) - acute pyogenic
3. Cat-scratch (B. henslae) - usually self limiting
4. Nontuberculous mycobacterial infection


What are cystic hygromas?

multiloculated cystic space lined by epithelial cells occurring from lymphatic malformation

-most involve lymphatic jugular sacs
-present in Posterior neck region
--other sites: axillary, mediastinal, inguinal, retroperitoneal