I. WHO IS THE PEDIATRIC SURGEON?

§ INSENSIBLE WATER LOSS: continuous evaporative loss of water

§ At least 4 years of medical school through the respiratory tract and the skin
§ Five additional years of general surgery
§ Two additional years of residency training in pediatric surgery Daily Fluid Requirements for Neonates and Infants
§ Certification: Weight Fluid Requirements*
- Philippine Board of Surgery Premature <1.5 kg 150 ml/kg
- Philippine Board of Pediatric Surgery Neonates and infants 1.5-10 kg 100 ml/kg
Infants and children 10-20 kg 1,000 ml + 50 ml/kg over 10 kg
II. WHAT IS THE SCOPE OF PEDIATRIC SURGERY? Children >20 kg 1,500 ml + 20 ml/kg over 20 kg
*Maintenance Na+ and K+ requirements range from 2 to 3 mEq/kg; solution can
§ From newborn to late adolescence generally be given as 0.2% saline, with 5% or 10% dextrose and K+ added
§ Zero age to 18 years old
§ Pediatric surgery provides the opportunity to intervene positively in C. ACID BASE STATUS
a wide array of diseases and to exert a long-lasting impact on the lives
§ METABOLIC ALKALOSIS
of children and their grateful parents
- Caused by loss of electrolytes (specifically, chloride)
- Corrected by replacing the lost electrolytes
III. THE PEDIATRIC SURGICAL PATIENT
§ METABOLIC ACIDOSIS
§ Children are not little adults, but they are little people - Result of poor tissue perfusion and lactic acidosis
- Children are very sensitive to changes in their normal physiology - Corrected by treating the underlying cause of the poor perfusion
- May easily suffer from volume overload or dehydration and by temporarily administering buffers (e.g., sodium
§ Sick children whisper before they shout bicarbonate)
- “whispers”
- Tachycardia, bradycardia, hypothermia, fever, recurrent emesis, D. TEMPERATURE
feeding intolerance
§ Infants have a higher ratio of body surface area to weight
§ Always listen to the mother and the father
§ Less subcutaneous fat (and therefore poorer thermal insulation)
§ Family dynamics
§ Less lean body mass (which is required for generating and retaining
§ Children suffer pain after surgery
heat)
§ Pediatric tissue must be handled delicately and with profound respect
E. MEASURES TO PREVENT HYPOTHERMIA
A. PHYSIOLOGIC CONSIDERATIONS
§ Incubator
§ HOMEOSTASIS
§ Radiant heaters/warmers
§ NUTRITION
§ Warm air blankets
§ Wrap head and extremities with plastic
B. FLUID AND ELECTROLYTES
§ Lower glomerular filtration rates and reduced renal concentrating F. NUTRITION
ability
§ Low caloric reserves à protein-calorie malnutrition à impaired host
§ Tolerate dehydration poorly
resistance à infection à poor wound healing à MORBIDITY &
§ Cannot excrete a water load as effectively as older persons with
MORTALITY
mature kidneys can
NUTRITIONAL REQUIREMENTS
Total body water (TBW) and
extracellular fluid (ECF) decrease § WELL-BALANCE DIET: 50% carbohydrate, 35% fat, and 15% protein
between fetal life and adulthood, § ESSENTIAL AMINO ACIDS:
and intracellular fluid (ICF) increases - Histidine is essential in infants
- Cysteine and tyrosine in premature infants

Daily Kilocalorie and Protein Requirements for Infants and Children

Age (yr) Kilocalorie Requirements* Protein Requirements
(kcal/kg) (g/kg)
0-1 90-120 2.0-3.5
1-7 75-90 2.0-2.5
§ Maintenance fluid requirement of a neonate is considered to be 70 7-12 60-75 2.0
ml/kg/24 hr initially – this figure rises to 100 ml/kg/24 hr after a few 12-18 30-60 1.5
days of life
18+ 25-30 1.0
§ The sodium requirement of a full-term infant is, on average, 2
*These numbers represent volume administered when 1 kcal/ml solutions are used.
mEq/kg/24 hr Growth can be maintained with 10% to 20% fewer calories if parenteral nutrition is
§ Potassium requirement is 2 mEq/kg/24 hr after the first 2 to 3 days of employed
life
ENTERAL NUTRITION
URINE OUTPUT § Enteral nutrition is preferable and is the first choice for patients
§ Useful guide to fluid management whose GI tract is functioning adequately
§ Appropriate urine output is 1 to 2 mg/kg/hr - BREASTMILK

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 - ENTERAL FORMULA
- BLENDERIZED FEEDING
- ELEMENTAL DIET

PARENTERAL NUTRITION
§ TPN is reserved for infants and children who are threatened by
catabolic or nutritional deficits because feeding via the GI tract is
hazardous, inadequate, or impossible
§ TPN should not be employed when enteral nutrition is feasible

COMPLICATIONS OF TPN
§ Catheter based problems
§ Electrolyte abnormalities
§ Hepatic cholestasis

G. MANIFESTATIONS OF SHOCK IN INFANTS OR NB

§ BRADYCARDIA instead of tachycardia 3. CONGENITAL LOBAR EMPHYSEMA:
§ POOR CAPILLARY REFILL instead of hypotension
§ Support normal oxygenation
§ Minimize mean airway pressure
IV. 7 EMERGENCY SURGICAL PROBLEMS IN NEONATES AND WHAT YOU
§ Marked overdistention of all
SHOULD DO
alveoli
1. CONGENITAL DIAPHRAGMATIC HERNIA (CDH): § Progressive respiratory distress
§ Insert a nasogastric or orogastric
tube
§ Ventilation by face mask is
contraindicated
§ If ventilation is required, intubate

4. INTESTINAL OBSTRUCTION
§ Use nasogastric or orogastric
suction
§ Confirm placement and function
CHD – Laparoscopic view of I.V. lines

5. OMPHALOCELE OR GASTROSCHISIS:
§ Use nasogastric or orogastric
2. ESOPHAGEAL ATRESIA:
suction
§ Insert a tube to aspirate secretions § Cover the sac with nonadherent
from pouch gauze, and take care not to rupture
§ If possible, avoid mechanical the membrane (if present)
ventilation § Cover the intestine with saline-
§ If intubation is required, use his soaked gauze and a see-through
frequency, low-pressure bowel bag
ventilation to prevent distention § Place the I.V. line in the upper
and possible perforation of the extremity or the neck, if possible
stomach § Maintain hydration by increasing
fluid administration to replace fluid
lost from the exposed bowel.
Support the bowel with dressings.
Maintain body temperature

GASTROSCHISIS
§ HIGHER RATE OF INTESTINAL ATRESIA
§ IMMEDIATE MANAGEMENT: THERMOREGULATION AND FLUID
RESUSCITATION
§ SURGICAL OPTIONS

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 - Primary repair of the defect, if
the abdominal cavity
accommodates the exposed
organs easily
- Gradual reduction of the
intestines by means of a silo
technique
6. EXSTROPHY OF THE BLADDER:
§ Cover the exposed bladder with a
nonadherent dressing
A. PATHOPHYSIOLOGIC CONSEQUENCE
§ Loss of domain à lung hypoplasia à severe pulmonary hypertension
- Respiratory acidosis
- Barotrauma
B. MANAGEMENT
§ Fluid resuscitation
§ Correction of acidosis
§ Endotracheal intubation
§ Insert OGT
§ Delayed surgical intervention
§ Permissive hypercapnia
§ ECMO (extra corporeal membrane oxygenation)

7. MENINGOMYELOCELE:
§ Cover the sac with a nonadherent
dressing

V. CONGENITAL DIAPHRAGMATIC HERNIA

§ Embryopathy that results from
abnormal development of the
diaphragm and the lungs
§ Defect in the diaphragm allows
herniation of abdominal contents

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VI. INTESTINAL ATRESIA VIII. INTESTINAL BANDS
§ Discontinuity of the GI tract § Congenital adhesive band
§ CAUSATION causing complete high grade intestinal
- Results from errors in this obstruction
recanalization of the intestinal
lumen during the 9th week of
gestation
- Related to ischemic episodes
occurring after organogenesis

§ PRIMARY REPAIR OF INTESTINAL

ATRESIA – END-TO-END IX. MECKEL’S DIVERTICULUM
ANASTOMOSIS

VII. HIRSCHSPRUNG’S DISEASE

§ Results from the failure of migration of
neural crest cells to the distal large
intestine
§ Resulting absence of ganglion cells in
the distal colon results in a failure of
relaxation and causes a functional
obstruction
§ Proximal, healthy bowel becomes
progressively dilated

§ TRANSITION ZONE COMMONLY AT

THE RECTOSIGMOID

§ Designated true diverticula

because their walls contain all of the
layers found in normal small intestine
§ 60% of Meckel’s diverticula
contain heterotopic gastric mucosa

§ DEFINITIVE DIAGNOSIS: RECTAL

BIOPSY § COMPLICATIONS:
- The absence of ganglion cells in - BLEEDING
the myenteric plexuses - INTESTINAL OBSTRUCTION
- Increased acetylcholinesterase
staining A. BLEEDING MECKEL’S DIVERTICULUM
- Presence of hypertrophied nerve § The result of ileal mucosal ulceration that occurs adjacent to acid-
bundles producing, heterotopic gastric mucosa located within the
diverticulum
A. TREATMENT
§ Surgical in all cases B. MECHANISM OF INTESTINAL OBSTRUCTION IN MECKEL’S
§ Classic approach: MULTIPLE staged DIVERTICULUM
procedure § Entrapment of intestine by a
- Colostomy in NB period mesodiverticular band
- Pull through procedure § Intussusception with the
- Closure of colostomy diverticulum acting as a lead point
§ New method: primary pullthrough § Stricture secondary to chronic
procedure diverticulitis

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§ Volvulus of the intestine around the - Undescended testis
fibrous band attaching the - Testicular tumor
diverticulum to the umbilicus - “bell-clapper” deformity – poor
§ MIDGUT VOLVULUS gubernacular fixation of the testicles to the
scortal wall

A. TESTICULAR TORSION
§ The blood supply to the testicle is
X. INTUSSUSCEPTION compromised due to twisting of the spermatic
§ One segment of the intestine becomes cord within the tunica vaginalis, resulting in
drawn in to the lumen of the proximal ischemia to the epididymis and the testis
segment of the bowel
§ CAUSES:
- Adhesive band
- Tumor
- Enlarged mesenteric lymph nodes

XI. APPENDICITIS
§ The diagnosis of appendicitis is based
on the presence of localizing physical
findings in the right lower quadrant of
the abdomen

XII. ANORECTAL MALFORMATIONS

§ IMPERFORATE ANUS
- The rectum fails to descend
through the external sphincter
complex
- The rectal pouch ends “blindly” in
the pelvis, above or below the
levator ani muscle
§ PERSISTENT CLOACA

XIII. CIRCUMCISION
§ Urinary tract infections, sexually
transmitted diseases, and genital
cancer occur less frequently in
circumcised males

XIV. PEDIATRIC UROLOGICAL EMERGENCY

§ TESTICULAR TORSION
§ Risk factors

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