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Flashcards in Pediatric Surgery Deck (41):
1

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

2

What are clinical signs of pediatric dehydration?

Lethargy
Decreased feeding
Tachycardia
Reduced UOP
Depressed fontanelle

3

What are clinical signs of pediatric fluid overload

New/increased oxygen requirement
Respiratory distress
Tachypnea
Tachycardia

4

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

5

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

6

What are some causes of pediatric metabolic alkalosis?

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

7

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

8

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

9

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)

10

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

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

11

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,

12

How much water is lost insensibly through skin of PRETERM infants

<1500g
45-60 mL/kg/day

13

How much water is lost insensibly through skin of TERM infants

30-35 mL/kg/day

14

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

140-150 mL/kg/day

15

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

16

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

17

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

18

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

19

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

isotonic lactated Ringer solution

20

How is hypovolemia due to acute hemorrhage corrected?

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

21

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

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

22

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

23

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

24

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

25

How is pulmonary sequestration Dx'd?
Tx?

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

26

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

27

what is a posterolateral diaphragmatic hernia called

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

28

what is an anterior diaphragmatic hernia called

morgagni hernia - rare, more common on R

29

what is the embryology of a congenital diaphragmatic hernia?

Failure for the Transverse septum and pleuroperitoneal fold to fuse.

30

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

Ultrasound
-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

31

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

32

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%)

33

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

34

What are lab findings of hypertrophic pyloric stenosis?

Gastric outlet obstruction = nonbilious postprandial projectile vomting

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

35

How is hypertrophic pyloric stenosis dx'd?
Tx?

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

Tx = Ramstedt pyloromyotomy

36

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

37

What is a essential nutritional fatty acid? deficiency sx?

Linoleic acid

deficiency = dryness, rash, desquamation of skin

38

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.

39

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

Fixed, nontender, progressively enlarging nodes
+ B symptoms

40

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

41

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