Evaluation of the Pediatric Surgical Patient

Comprehensive care of the pediatric surgical patient is multifaceted and requires a thorough understanding of the surgical diseases encountered, a detailed knowledge of the physiology of the pediatric population, and an awareness of the unique issues inherent in providing medical care for children. ^{[1, 2, 3, 4]} Establishing a healthy and trusting relationship with the child, as well as the child’s parents or guardian, is essential.

This article describes the general approach to treating the pediatric surgical patient. Care must be individualized; the approach may differ for newborns, infants, children, and adolescents and depends on the overall health of the patient.

Parental considerations

Complete care of the pediatric surgical patient includes establishing a good rapport not only with the child but also with the child’s parents or guardian. Parents and guardians are often anxious about the treatment of their child, and the responsibility to allay their fears lies with the pediatric surgeon. Fostering a good relationship with the family can be accomplished with skilled communication.

The surgeon should always thoroughly explain the child’s problem. Reviewing the results of imaging studies with the parents and patient is helpful. Freehand drawings and diagrams from books can also be used to aid the surgeon in illustrating the anatomy and explaining the problem.

Parents often gain a better understanding of their child’s problem if the surgeon takes the time to explain how or why the problem arose. Be prepared to explain embryology in layperson’s terms when talking to parents of patients with congenital lesions or defects. Also, be familiar with basic genetics and modes of inheritance when counseling parents of a child with a genetic defect.

Knowledge of oncology is useful for discussing management of tumors; be prepared to answer general questions regarding chemotherapy and radiation regimens for tumors commonly encountered in pediatric surgery. Notify parents that the oncology staff is part of the team involved in their child’s care.

The explanation of the proposed surgical procedure in layperson’s terms includes describing where the incision will be made, the steps of the operation, how the incision will be closed, and the size of the scar. At this time, basic postoperative issues can also be addressed, including the anticipated length of hospital stay, the activity and dietary restrictions in the postoperative period, and the time the child will likely be away from school.

Of particular importance is explicitly explaining why the surgical procedure should be performed and what it should accomplish. This is also the time to discuss the risks of surgery. In addition, discussing options and alternative treatment plans is important. The consequences of not performing surgery should be addressed as well.

Pause after providing important information so that parents have the opportunity to take it all in. Leave time for questions at the end of the encounter, and give parents a means by which to contact you with questions. Refer parents to other resources (eg, support groups, the hospital’s family resource center, and reliable sources on the Internet). Caution parents about the information they find on the Internet; the accuracy of online information varies widely. ^[5]

The surgeon must obtain a complete and detailed history from the patient and parents. The history, in concert with a well-performed physical examination, is the basis for a diagnosis and treatment plan. ^[6] In an academic setting, the attending surgeon often sees the patient after a resident or medical student performs the initial evaluation. At this time, the surgeon must verify important points in the reported history and findings. This initial encounter with the surgeon also provides him or her with an opportunity to get to know the child and family.

The chief complaint (CC) is the reason why the child presents to the pediatric surgery service. Statement of the CC should always include the duration of symptoms. The history of present illness (HPI) should detail the course of the symptoms, including its acuity of onset, progression, and severity. Also include symptoms associated with the child’s CC. Document pertinent negative findings. Aggravating or relieving factors are important and must be noted, as should any treatment the child has received.

Any medical or surgical history relevant to the CC should be stated in the HPI. Birth history, medical conditions, and previous surgeries should be listed separately in the past medical history (PMH) and past surgical history (PSH). Of importance, a history of bleeding disorder or unusual bleeding should be noted, as well as any history of receiving anesthetics.

Note the names, doses, and frequency of all medications that the child is currently taking. Include both medications taken on a schedule and those taken as needed. Use of herbal supplements is increasingly popular, even in the pediatric population, and these supplements should be included in the list of medications. Note drug allergies and reactions, along with symptoms that occur when the patient is given the drug. Food and environmental allergens may also be listed.

Document the family history and the social history. For many pediatric surgical patients, the family history is noncontributory. However, it is clinically significant in children with congenital malformations, genetic diseases, or malignancies. A child’s social history should address issues regarding the family and home environment and the child’s academic and social development.

Conduct a thorough review of systems (ROS); list pertinent positives and negatives already stated in the HPI.

The goal of the physical examination is to identify the current surgical issues and to ensure that the organ systems other than the one being treated are healthy. Unlike the adult physical examination, in which one can often follow the same routine every time, the pediatric examination must be modified for each patient. Interacting with children of different ages and temperaments in different settings can be challenging. ^[7]

Hand washing before and after performing the physical examination is essential. This serves purposes beyond infection control. On a psychological level, it conveys a reassuring message to the parent that hygiene is important to the surgeon. On a practical level, it warms the surgeon’s hands before he or she touches the child.

In an older and cooperative child, physical examination can be performed according to a standard routine. However, this routine may have to be modified in young children or infants who do not cooperate.

Infants should be positioned on the examination table for the entire examination. Toddlers and small children may sit in their parent’s lap for the initial part of the examination, and they may be moved to the examination table and positioned for the abdominal, inguinal, genital, and rectal examinations when necessary. Having the parent by the examination table reduces the child’s anxiety and should be encouraged.

Skin and integument

Always ask the patient to undress completely. The pediatric surgeon is often consulted for evaluation of lesions or lumps and bumps. The lesion in question should be inspected for its size, shape, consistency, circumscription, and mobility. Thoroughly search for other, similar lesions on the body. Also inspect the skin for rashes, which may indicate an infectious process or vasculitis. Scars indicating previous surgery should be noted.

Cellulitis may arise after any trauma that interrupts the skin barrier (eg, a scratch, laceration, foreign body, or surgical wound). Erythema and warmth with induration and fluctuance indicates an abscess. Inspect the skin for birthmarks, noting any changes in their character. Bruises and burn scars, especially those resembling cigarette burns or burns that have a well-defined shape, should be suspected as signs of child abuse.

Lymph nodes

Lymphadenopathy can occur in many locations and often involves the cervical, axillary, epitrochlear, or inguinal chains. In children, lymphadenopathy most commonly has an infectious etiology, and a source of infection should be sought throughout the examination. The infection may be bacterial, viral, fungal, or protozoal. Enlarged lymph nodes may represent metastatic disease, or they may be the presenting sign of malignancies, such as acute lymphoblastic leukemia (ALL), Hodgkin disease, and non-Hodgkin lymphoma.

Head, ears, eyes, nose, and throat

On head, ears, eyes, nose, and throat (HEENT) examination, note the size and shape of the patient’s head. Children with abnormal fusion of the coronal sutures are not normocephalic. Microcephaly or macrocephaly may indicate a neurologic or intracranial process. An icteric sclera suggests hepatic or biliary dysfunction.

Otitis media can be excluded if tympanic membranes that are clear and if visible landmarks are found. Finding an erythematous oropharynx or inflamed nasal turbinates with associated rhinorrhea is common in upper respiratory tract infections. A quick dental examination to identify loose teeth is important in children scheduled to undergo surgery.

Chest wall

Breast tissue is commonly observed in infant boys and girls. This is normal and due to a slow decline in maternal hormones in the infant’s bloodstream. On a similar note, the pediatric surgeon may be asked to evaluate a male adolescent for gynecomastia, which is often due to the changing hormonal environment associated with puberty.

Evaluation of breast masses in girls requires particular attention. In preadolescent girls, one must distinguish a mass from a breast bud, keeping in mind that breast development does not occur at the same rate in both breasts. Normal breast tissue must be differentiated from a breast mass in female adolescents.

The pediatric surgeon may also encounter deformities in the chest wall, such as pectus excavatum and pectus carinatum. Apart from discerning the degree of deformity, performing cardiac and pulmonary examinations is important in children with these deformities.

Cardiovascular system

Heart rate and rhythm should be noted on the cardiovascular examination. Many children have an audible murmur at some point between infancy and adolescence. Most murmurs, fortunately, occur in normal hearts and are benign. Murmurs that have a structural cause may indicate a need for preoperative antibiotic prophylaxis. Consult a cardiologist if a new-onset murmur is in question.

Check proximal and distal pulses. Expect strong pulses throughout. Suspect coarctation of the aorta if pulses in the upper extremity are strong but pulses in the lower extremity are weak or absent. ^[8]

Lungs

Good respiratory effort in a cooperative child is critical in the pulmonary examination. No layers of clothing should be present between the stethoscope and skin. Breath sounds should be clear on both sides. Abnormal breath sounds, such as rhonchi, wheezes, and crackles, indicate an underlying pulmonary process.

Abdomen

The abdominal examination should be performed systematically and gently.

First, observe the patient’s abdomen. If scars are present, their length and location can give the surgeon an idea of the previous surgical procedures performed. The shape of the abdomen may also be a clue to guide diagnosis. A scaphoid abdomen in a neonate or infant may suggest a diaphragmatic hernia but may be normal in a thin child. Intestinal obstruction, an abdominal mass, or ascitic fluid may cause abdominal distention.

Second, listen for bowel sounds. Be patient, because up to 2 minutes may pass before bowel sounds are heard. The absence of bowel sounds may suggest peritonitis. The character of the bowel sounds is also important; high-pitched sounds are consistent with bowel obstruction.

While listening for bowel sounds in a young child, the clinician may use a stethoscope to palpate the abdomen, systematically covering the entire abdomen. Begin the palpation in an area away from the area of reported pain, leaving that area for last. Diffuse tenderness may suggest peritonitis or a generalized process. Focal points of tenderness often reflect the underlying pathology. Determine whether the pain is superficial, musculoskeletal, or visceral.

Gently evaluate the patient for peritoneal signs, such as rebound and guarding. Overly aggressive examination creates unnecessary pain and fear in the child. In young children, facial expressions and behavior are often more reliable indicators of pain than verbal reports are. Palpation can also give the surgeon an idea of the size, shape, and consistency of an abdominal mass. The size of the liver and spleen can be determined by percussion and palpation of their edges.

Inguinal region

The inguinal region is most commonly examined in the evaluation of a hernia or hydrocele. If an inguinal hernia is not visible on examination, the child should be coaxed to perform a Valsalva maneuver (eg, coughing or straining as during a bowel movement). Intra-abdominal pressure is increased in crying infants. Hernias should be easily reducible and not incarcerated or strangulated; an incarcerated or strangulated hernia is a surgical emergency.

Genitalia

Children as young as 2 years understand the concept of modesty, and special attention must be given to modesty during the genital examination. In addition, always ensure that a staff person of the same sex as the patient is present in the room during the examination.

Genital examination in boys is necessary in the evaluation of a number of conditions, including hydroceles and undescended testes. The genital examination is one of the least comfortable parts of the physical examination; boys can assume the position most comfortable for them—lying down, sitting frog-legged, or standing.

Transillumination may be a useful technique to visualize the contents of an enlarged scrotum but cannot be relied on for a diagnosis, especially in infants. Note the size and shape of the testicle in the scrotal sac and the character of any fluid. Part of the male genital examination includes checking for the presence of both testes in the scrotal sac.

The testis, epididymis, and spermatic cord should be appreciated as separate structures. Retractile testes can masquerade as undescended testes; always check to determine whether a testicle that is not in the scrotum can be brought down into the scrotum.

Performing a female genital examination to evaluate for fused labia, imperforate hymen, vaginal or perineal bleeding, and an assortment of other issues is not uncommon. Note that a pelvic examination performed by the surgeon is likely to be the first for a girl and has lasting psychological consequences. Always suspect sexual abuse when vaginal tears are present. Vaginal discharge can be a sign of a sexually transmitted disease and should raise the surgeon’s index of suspicion for abuse.

Rectum

The rectal examination may be traumatic to the child and their parents and should be performed quickly but thoroughly. Explaining the process to the child is useful to assure them that nothing will be done to them without first letting them know.

First, inspect the anus. Fissures, fistulas, skin tags, and other lesions can be seen by gently separating the anal opening.

Next, inform the child that he or she will feel a finger on the outside. Gentle external pressure often causes the anal sphincter to relax and facilitates passage into the anal canal. Condylomata acuminata, caused by human papillomavirus, are consistent with sexual abuse. Always use water-soluble lubricant on a gloved finger and obtain a stool sample for a guaiac test whenever feasible. The little finger may be used in infants and toddlers, and the index finger may be used in larger children.

Sphincter tone may be decreased in patients who have previously undergone anoplasty or have sustained traumatic injury to the sphincter muscle. Decreased sphincter tone is more alarming in the trauma setting because it indicates spinal cord injury (SCI).

Palpate the entire circumferences of the anal canal and rectum. Note the location, size, and texture of a palpated mass. Presacral tumors may be the cause of a child presenting with constipation. The examiner must differentiate discomfort due to the examination itself from tenderness due to an underlying process. Many children can make this differentiation if asked.

Pain on examination may be caused by anal fissures externally, appendicitis in a low-lying appendix, or pelvic inflammatory disease (PID). The surgeon may also detect a fecal impaction during the rectal examination of a child with constipation.

Back and spine

Scoliosis and other spinal deformities are obvious during examinations of the back. Vertebral tenderness to palpation may be a sign of trauma. Costovertebral angle tenderness may be indicative of pyelonephritis or appendicitis in a patient with a retrocecal appendix.

Extremities

Clubbing is observed in many patients with chronic illness, especially patients who have pulmonary disease. Cyanosis is an indicator of poor oxygenation or perfusion, and efforts should be made to determine whether the cyanosis is chronic or acute. Edema may be a sign of impaired renal or cardiac function. Suspect abuse in patients with extremity deformities secondary to long-bone fractures.

Nervous system

Much can be gained from observing a child’s behavior. An interactive and playful child is likely to have no focal neurologic findings on examination. However, a basic neurologic examination, which only takes a minute with practice, should be performed regardless. This comprises assessment of cranial nerve function, motor and sensory examination, reflex evaluation, and cognitive assessment.

Patients who have an isolated surgical problem and who are otherwise healthy do not require routine laboratory tests before surgery. ^{[9, 10, 11, 12]}

In patients with other medical problems and those undergoing major operations, order a complete blood count (CBC), electrolyte tests, and coagulation studies; other studies may be ordered if indicated. ^{[13, 14]} If clinically significant blood loss is anticipated, the patient’s blood should be typed and screened or crossmatched so that blood can be immediately available if needed in the operating room.

A number of pediatric surgical problems are found on routine physical examination by a pediatrician or family physician. Children are then referred to the pediatric surgeon. Evaluation of an otherwise healthy child should still include a discussion of the child’s health issues and a complete history and physical examination.

Perform only the tests that are to be used for diagnostic purposes. Routine preoperative laboratory tests and chest radiography are not indicated for most children. Explain outpatient surgery and details of nothing-by-mouth (nil per os; NPO) status to parents. Advising parents that surgery may be canceled in the event of upper respiratory tract symptoms or infection is wise. Postponing hernia surgery in an infant with a severe diaper rash is reasonable.

A repeat history and a thorough physical examination on the day of surgery are crucial; close attention should be paid to the respiratory system and the surgical area. Clearly mark the surgical site on the day of surgery.

History

The history of a patient with trauma is often brief and aimed at identifying the mechanism and circumstances surrounding the injury. Trauma can be divided into two categories on the basis of the mechanism of injury: blunt and penetrating.

For blunt trauma, determining the mechanism and force of impact is important. Head ^[15] and extremity injuries are extremely common in children. Acceleration-deceleration injuries commonly occur in motor vehicle accidents and falls from heights. Abdominal organs most susceptible to injury include the liver, spleen, and fluid-filled loops of the small bowel.

Blunt trauma at low velocities causes compression injuries to the area of trauma. These are often injuries to the liver or spleen in blunt abdominal trauma, fractures to the ribs, and crush injuries to the extremities. Pulmonary contusions are also common.

Penetrating trauma may be accidental or nonaccidental. Knowledge of the impaling object or weapon used is a crucial piece of information. For stab wounds and impalement injuries, the size and length of the object should be documented. In gunshot wounds, the amount of damage caused is related to the amount of energy the bullet dissipated to the tissue in its trajectory. Therefore, the extent of injury can be gauged by the caliber of the firearm used.

Other important information that may aid in assessment of the patient with trauma includes the time of injury, the treatment received before arrival, the patient’s other symptoms, the character of pain, and the amount of blood loss. In addition, information on past medical and surgical history, medications, allergies, and immunization status, if available, may influence management decisions. Also, note the time when the child last ate or drank.

Always keep the possibility of child abuse in mind. Have a high index of suspicion for nonaccidental injury if the pattern of injuries is inconsistent with the described mechanism or if several injuries of various chronicities are found.

Physical examination

Initial evaluation of the pediatric trauma patient should follow the well-known ABCDE mnemonic recommended by the American College of Surgeons (ACS): Airway (with cervical-spine control), Breathing, Circulation, Disability, and Exposure. ^[16] The secondary survey follows this initial assessment. Imaging studies may be indicated.

Remember that pediatric patients with trauma are anatomically and physiologically different from adult patients with trauma. ^[17]

Airway

Airway obstruction is the most rapidly lethal problem in the patient with trauma. Situations in which airway protection are needed include the following:

• Maintaining an airway in an unresponsive patient
• Protecting against aspiration
• Preventing or reversing hypoxia
• Providing hyperventilation to decrease intracranial pressure

Provide supplemental oxygen to all patients with trauma. If the patient has any signs of respiratory distress or inadequate ventilation, immediately secure and maintain the airway. An intubated patient should also receive an orogastric or nasogastric tube for decompression and to minimize risk of aspiration. Protect the cervical spine at all times.

Breathing

When securing the airway, check to see that both lungs are ventilated. Ensure that chest expansion is symmetric and that breath sounds can be auscultated over both lung fields. If an endotracheal tube was placed, listen over the stomach to ensure that esophageal intubation has not occurred. Examine the chest for sucking wounds, flail chest, and subcutaneous emphysema.

Circulation

Assess the presence and strength of pulses, skin color, capillary refill, and blood pressure. Apply direct pressure to any visible hemorrhage.

Whenever possible, place two intravenous (IV) lines by using large-bore catheters. If peripheral access is not possible, consider placing a central line or an intraosseous line (in children < 6 y). Heart rate is a better indicator of impending circulatory collapse than blood pressure because hypotension does not occur until 25-30% of the child’s blood volume is lost.

Warmed isotonic crystalloids (eg, isotonic sodium chloride solution and lactated Ringer solution) are the mainstays of fluid resuscitation. Give an initial bolus of 20 mL/kg to treat shock. If the response is inadequate, this bolus may be repeated for a total of three boluses. If the child is still hemodynamically unstable, use 10 mL/kg of packed red blood cells (RBCs) for resuscitation. If type-specific blood is not available, O-negative blood may be given. If fluid resuscitation cannot keep up with hemorrhage, the patient may have signs of hypovolemic shock.

Age-appropriate parameters are as follows:

• Age 0-6 months - Weight 3-6 kg, heart rate 160-180 beats/min, systolic blood pressure 60-80 mm Hg, respiratory rate 60 breaths/min
• Infant - Weight 12 kg, heart rate 160 beats/min, systolic blood pressure 80 mm Hg, respiratory rate 40 breaths/min
• Preschool age - Weight 16 kg, heart rate 120 beats/min, systolic blood pressure 90 mm Hg, respiratory rate 30 breaths/min
• Adolescent - Weight 35 kg, heart rate 100 beats/min, systolic blood pressure 100 mm Hg, respiratory rate 20 breaths/min

Disability

Rapid neurologic examination should be performed in any child with trauma. The Glasgow Coma Scale (GCS; see the Glasgow Coma Scale calculator) may be used in children; however, the verbal component must be modified for children younger than 4 years, as follows:

• Appropriate words, social smile, fixes and follows - Verbal score of 5
• Cries but is consolable - Verbal score of 4
• Persistently irritable - Verbal score of 3
• Restless, agitated - Verbal score of 2
• None - Verbal score of 1

Assess the patient for movement of extremities. If the patient is comatose, check for movement in response to noxious stimuli. Seek a sensory level if the patient is cooperative. Determine whether the Babinski reflex is present. Do not sedate or paralyze the patient until a good neurologic examination is performed (usually during the secondary survey).

Exposure

The patient’s clothing should be completely removed and the entire body exposed. The body surface area (BSA)-to-weight ratio is higher in children than in adults. Blankets and additional warming measures should be used to maintain the patient’s body temperature. Examine the patient for occult injuries, making sure that a log roll is performed and the back is inspected for entry and exit wounds, vertebral deformities, and tenderness.

At this time, perform a rectal examination to evaluate for sphincter tone and gross blood. Spinal precautions should be maintained, and movement of the patient should be minimized until the cervical spine, chest, and pelvis are cleared.

Secondary survey

The secondary survey, proceeding from head to toe, should follow initial assessment. The HEENT examination focuses on facial lacerations and fractures, hemotympanum, tympanic membrane rupture, cerebrospinal fluid (CSF) otorrhea, CSF rhinorrhea, epistaxis, septal hematoma, loose teeth, and maxillary-mandibular malocclusion.

A quick cranial-nerve examination should include pupillary reactivity, extraocular movements, and facial symmetry (eg, raising eyebrows). The neck examination is performed to identify areas of tenderness, spinous process deformities, jugular venous distension, and tracheal deviation.

The chest should be palpated and rib fractures identified. Evaluate for signs of blunt or penetrating trauma. If not already identified in the primary survey, pneumothorax, hemothorax, sucking wounds, and flail chest should be recognized at this time. The abdominal examination includes auscultation of bowel sounds and palpation to detect tenderness.

Always look for signs of blunt or penetrating trauma. Evaluate the pelvis for tenderness and instability. Neurovascular assessment of the extremities and identification of fractures, dislocations, and contusions should follow.

Tertiary survey

Despite careful primary and secondary surveys, 2-50% of injuries are still missed. Missed injuries are more common in patients with blunt trauma than in those with penetrating trauma. A tertiary survey is therefore necessary and instrumental in identifying all injuries.

The tertiary survey identifies and catalogs all injuries and is performed after the initial trauma resuscitation and operative intervention, typically within 24 hours of injury. A repeat survey should be performed when the patient is awake, responsive, and able to communicate at an age-appropriate level. ^[18]

The tertiary survey involves the following:

• Comprehensive review of the medical record (mechanism, pertinent comorbidities)
• Repeat of primary and secondary surveys
• Review of all laboratory data
• Review of all radiographic studies with an attending radiologist

Workup

Focused abdominal sonography for trauma

Efforts to further define the role of focused abdominal sonography for trauma (FAST) in pediatric trauma patients are ongoing. At present, FAST appears to be most useful in hemodynamically unstable patients who have sustained blunt abdominal trauma. In this group of patients, FAST can potentially demonstrate the presence or absence of free intraperitoneal fluid. ^[19]  As with any test, however, the quality of the study and interpretation of the images is technician-dependent, and the results should be considered in this context.

Radiography

Radiographically assess the cervical spine by obtaining anteroposterior (AP) and lateral views. Also obtain a chest AP view and pelvic images. Obtain these images as early in the evaluation as possible, but do not delay attempts at resuscitation.

Computed tomography (CT) of the head is required if the patient has a history of loss of consciousness or has evidence of head injury on physical examination. Magnetic resonance imaging (MRI) of the spine may be needed to assess vertebral injury or SCI. ^[20] Abdominal and pelvic CT is indicated if abdominal tenderness or distention is present on examination, if the chest radiograph depicts free air, or if intra-abdominal injury is a concern.

Imaging of extremities and other studies can be delayed until all potentially life-threatening conditions are excluded or addressed.

Laboratory tests

In every patient with clinically significant trauma, order a CBC and urinalysis. Additional tests (eg, an electrolyte panel, a coagulation panel, and typing and crossmatching) may be indicated in selected patients. Serum transaminase, amylase, and lipase levels may be helpful in evaluating abdominal injury. Hematuria can be detected on urinalysis.

Surgical evaluation and treatment of the child with acute illness is one of the most challenging aspects of pediatric surgery. Patients with intra-abdominal catastrophes, patients who have ingested foreign objects, and patients with trauma (see above) are in this category.

Physical examination of the child with acute illness is similar to that of the patient with trauma. The child’s airway must be secured and maintained, breathing must provide adequate ventilation, and oxygenation, and circulation must adequately perfuse the end organs.

Children with signs of hypovolemic shock are most commonly those with ongoing hemorrhage, peritonitis, intestinal obstruction, burns, vomiting, or diarrhea. A patient in hypovolemic shock should be resuscitated with a 20 mL/kg bolus of warm lactated Ringer solution administered via a peripheral or central venous line.

If the child’s condition responds inadequately and if further resuscitation is necessary, the choice of fluid (eg, crystalloid, colloid, blood) depends on the type of fluid that the child has lost. In general, fluid lost because of burns, peritonitis, and bowel obstruction may be replaced by lactated Ringer solution, which has an electrolyte composition similar to that of the fluid lost from the intravascular space.

Acid-base imbalances and electrolyte disturbances must be corrected before surgery. Electrolytes and arterial blood gases must be monitored serially until corrected and stabilized.

Adequate volume resuscitation is crucial because anesthetic agents cause vasodilation. Therefore, patients with hypovolemia can have sudden hypotension with possible end-organ damage if they undergo anesthesia before receiving sufficient resuscitation. The endpoint for volume resuscitation includes improvement in skin color and capillary refill and adequate urine output (1 mL/kg/hr measured via a urinary catheter).

Treating a child with chronic illness creates a unique set of challenges for the pediatric surgeon. These children tend to be deconditioned, and they often have several medical problems that require careful attention before surgery. Depression, malnutrition, anemia, and growth retardation are all characteristic findings in these children. In addition, some children are immunocompromised or have coagulopathies as a result of their illness or medical therapy.

Whenever possible, children with chronic illnesses should be brought to their individual optimum level of health before undergoing a surgical procedure. Malnourished children can be fed a high-calorie diet, or their tube feedings can be increased. The target plasma protein concentration is 5 g/dL.

Children with chronic disorders or renal disease often have associated anemia with usual hemoglobin concentrations of 6-9 g/dL. Target preoperative hemoglobin values should be individualized to the type of procedure planned and to the outcomes of a discussion with the anesthesiologist. Coagulopathies and electrolyte derangements must be corrected before surgery. Features of various chronic illnesses that require special attention are elaborated in the following subsections.

Diabetes mellitus

Before surgery, blood glucose levels should be closely monitored in patients with diabetes mellitus, especially during fasting. Hyperglycemia and hypoglycemia can be corrected with insulin and with the addition of dextrose to IV fluids, respectively.

Patients taking regimens of short- and intermediate-acting insulin should continue this regimen until the morning of surgery. Patients who take long-acting insulin may receive intermediate-acting insulin the evening before surgery. If a patient is taking a complicated insulin regimen or if he or she has an insulin pump, consulting an endocrinologist regarding preoperative and postoperative care is prudent.

Obesity

With rates of obesity steadily on the rise and reaching epidemic proportions, pediatric surgeons are encountering obese patients with increasing frequency. ^{[21, 22, 23]} Such patients have an increased incidence of medical comorbidities, including glucose intolerance, diabetes mellitus, hypertension, hyperlipidemia, nonalcoholic steatohepatitis, obstructive sleep apnea (OSA), deep vein thrombosis (DVT), and pulmonary embolism (PE). These conditions must be taken into account in the preoperative workup.

Additional concerns are limitations regarding radiographic evaluation in obese patients. Weight limits for tables used to perform CT, MRI, and angiography are 250-450 lb (114-205 kg) and vary from one manufacturer to another. Sizes of gantries and patient compartments also vary. Alternative methods of evaluation must be sought if the patient’s size exceeds the capacity of the machine.

Cardiac disease

To minimize the risk of bacterial endocarditis, children with congenital heart disease, prosthetic valves or patches, valvular prolapse, and valvular insufficiency should be given antibiotic prophylaxis before surgery of the gastrointestinal (GI), genitourinary (GU), or respiratory tract. ^[24]

In GI and GU surgery, ampicillin and gentamicin are the recommended regimen unless the patient has a penicillin allergy, in which case vancomycin and gentamicin are recommended. Patients undergoing respiratory tract surgery require ampicillin prophylaxis. Cephalosporins, clindamycin, azithromycin, or clarithromycin may be used in patients with a penicillin allergy.

For patients who have a complicated heart condition, the pediatric surgeon should communicate with the pediatric cardiologist before surgery. Close electrolyte monitoring is required for patients taking diuretics. Patients taking digitalis must be carefully observed for digitalis toxicity. The patient’s intake and output must be strictly recorded, and the surgeon should watch for signs of heart failure.

Pulmonary disease

Common pulmonary diseases encountered by the pediatric surgeon include asthma and cystic fibrosis. Patients with asthma should be preoperatively asymptomatic; to resolve symptoms, pharmacologic, environmental, and/or dietary control may be needed. Patients should continue their medications during the preoperative period. Patients with cystic fibrosis are often deconditioned, and the pediatric surgeon should work in concert with the pulmonologist to optimize the patient’s health before surgery to minimize the surgical risk.

Hyaline membrane disease is a common problem in the neonatal population, and patients with this disease may develop bronchopulmonary dysplasia, which increases the risk of atelectasis and carbon dioxide retention. Chest radiography is routine for all patients with pulmonary disease.

Hepatic disease

Chronic liver disease can result from biliary atresia, cystic fibrosis, hepatitis of any etiology, or liver injury. If edema or ascites is present, the patient should be given diuretics and be on a sodium-restricted diet. In children with a history of any of these conditions, determine liver enzyme levels and perform coagulation tests before surgery. If a coagulopathy is present, administer vitamin K and fresh frozen plasma (FFP) preoperatively and ensure that FFP is available in the operating room.

Be careful when prescribing drugs that are metabolized and excreted by the liver; monitoring of serum drug levels is essential.

Renal disease

Renal function can be easily assessed by performing urinalysis and obtaining serum blood urea nitrogen (BUN) and creatinine levels. The fluid and electrolyte balance is often tenuous in patients with renal disease.

Pay careful attention to the patient’s intake and output. Patients with difficulty concentrating urine often have increased fluid and salt intake to compensate for increased urine output. Closely monitor these patients during the fasting period before surgery because they can become dehydrated quickly. In such patients, securing peripheral IV access is always sensible, even before surgery. Electrolyte monitoring is important in the preoperative period, and any acid-base imbalances and electrolyte disturbances must be corrected before surgery.

In its advanced stage, renal failure is manifested by hyperkalemia, hyperphosphatemia, and acidosis. Patients with renal failure require immediate attention. Be careful when prescribing drugs that are metabolized and excreted by the kidney; monitoring of serum drug levels is essential.

HIV infection

HIV infection in pediatric patients is often associated with medical manifestations such as failure to thrive, persistent lymphadenopathy, oral candidiasis, chronic parotitis, chronic cough, and generalized dermatitis. ^[25]

The surgical manifestations in pediatric patients with HIV infection or AIDS are less often discussed. ^[26] Patients with HIV who come to the attention of surgeons often have infections and may be severely septic with opportunistic pathogens. Prompt recognition and treatment of the surgical problem is essential. Outcomes are improved when antiretroviral medications are used. Close consultation with pediatric immunodeficiency specialists is warranted in the management of pediatric patients with HIV who have a surgical problem.

Establishing NPO status

Anesthesia carries an inherent risk of the patient’s vomiting and aspirating the stomach contents. NPO status should be discussed with the anesthesia team and assigned according to the guidelines and policies of the individual institution.

General guidelines are as follows:

• Solids or formula - Newborns and infants younger than 6 months should be assigned to NPO status for 4 hours before surgery; patients older than 6 months should be NPO for 6 hours before surgery
• Clear liquids - All patients should be NPO for 3 hours before surgery

Gastric ultrasonography (US) has been suggested as a potential preoperative bedside test for residual gastric volume in pediatric surgical patients. ^[27]  

Anesthetic evaluation

Always consult the anesthesia team before complicated and unusual operations. These include procedures that involve repositioning the patient during the operation or manipulation of the great vessels or lungs. Notify the anesthesia team if the patient has a history of complications with previous anesthetics, malignant hyperthermia, or a coagulation disorder.

Alert the anesthesia team if the patient has symptoms of an upper respiratory tract illness because this increases the risk of postintubation laryngotracheal edema. Preoperatively notify the anesthesia team about patients who might benefit from a caudal injection or an epidural catheter insertion for postoperative pain control.

Preoperative pain consultation is appropriate if clinically significant postoperative pain is anticipated. The pain-management team can then proactively discuss postoperative pain treatment options with the family. In deciding whether to proceed with or cancel an operation, deferring to the anesthesiologists is always prudent.

Medication

Condition the patient’s current medications. ^[28] Patients who have been taking corticosteroids for extended periods may not be able to mount a natural stress response because of chronic suppression of the hypothalamic-pituitary-adrenal axis. During the perioperative period, these patients should receive stress dosing of corticosteroids proportional to the stress of surgery. ^{[29, 30, 31]}

Patients who are taking antihypertensive drugs should continue to do so but must be closely monitored for intraoperative hypotension.

Other drugs that should be continued in the perioperative period include antiepileptics, drugs for asthma, and immunosuppressants. Drugs that should be discontinued before surgery include anticoagulants, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and diuretics.

Regarding preoperative medications, bowel-preparation guidelines are as follows:

• Administer polyethylene glycol – electrolyte solution 50 mL/kg by mouth (PO) or via a nasogastric or gastrostomy tube; if the bowel is not clear after 4 hours, administer an additional 25 mL/kg
• Administer 5% dextrose in 0.2% sodium chloride solution plus potassium chloride (KCl) 20 mEq/L IV as a maintenance fluid
• After the polyethylene glycol-electrolyte solution is given, administer neomycin and erythromycin base, each at a dose of 15 mg/kg PO every 90 minutes for three doses
• If necessary, administer two doses of 1% neomycin enema per rectum or through a stoma or mucous fistula when the polyethylene glycol – electrolyte solution clears the bowel; for the neomycin enema, administer 10 mL/kg in infants, 100-150 mL in small children, 150-200 mL in large children, and 200-300 mL in adolescents

Consider sedation. Patients who are unusually anxious in the immediate preoperative period may be given sedation with midazolam.

Obtaining consent

Obtaining consent from a parent or guardian for a procedure requires the clinician to discuss the indication for the procedure, describe the procedure, explain alternatives to the procedure, and declare the potential risks and complications. ^{[32, 33, 34]} Bleeding and infection must always be mentioned, along with any other risks inherent in the surgery being performed.

When appropriate, involve the child in the discussion of the surgery and the consent process. Be sure that the child has an age-appropriate understanding of why the surgery must be done and what participation it involves on his or her part. Children are often curious and may have questions and concerns, which should be addressed seriously.

Pain management

Pain is a common issue in the evaluation of the postoperative patient. ^{[35, 36, 37, 38]}  One must attempt to differentiate between anxiety and pain.

Pain in patients who have undergone minor procedures (eg, hernia repair) is generally controllable with oral analgesics such as acetaminophen, ibuprofen, or oxycodone/acetaminophen. In a randomized controlled trial comparing oral morphine 0.5 mg/kg (n = 65) with oral ibuprofen 10 mg/kg (n = 67) in children (age range, 5-17 y) undergoing minor outpatient orthopedic procedures, Poonai et al found the two regimens to be equivalent in analgesic efficacy. ^[39]  Morphine had significantly more adverse effects, suggesting that ibuprofen is a safer first-line analgesic in this setting. 

Pain control after major surgery (eg, laparotomy, thoracotomy) is more complex. Consider the use of IV patient-controlled analgesia (PCA) or parent- or nurse-controlled analgesia (PNCA). In select patients, epidural analgesia can be used and is sometimes preferred. The transition to oral pain medication should be made when the patient is tolerating a diet.

Control of postoperative nausea and vomiting

Postoperative nausea and vomiting (PONV) is a common problem encountered in the postoperative period. ^[40] The physiologic pathways and triggers surrounding PONV are complex. Four classes of drugs can be used to manage this problem: anticholinergics, antihistamines, dopamine D2 receptor antagonists, and 5-HT₃ receptor antagonists.

Gastric distention can also cause nausea, and the index of suspicion should be high for this condition, especially if the patient was bagged without gastric decompression. Patients who have undergone abdominal surgery may also have a distended stomach as a result of GI ileus. In many cases, gastric decompression can alleviate nausea if this is the cause.

Resuscitation

Hemodynamic status and urine output are useful indicators of how well a child is resuscitated. A normotensive child who is not tachycardic is likely to be well resuscitated; a child with tachycardia or hypotension may be hypovolemic. It is also important to try to account for the influence of anxiety and pain, which can raise the heart rate and blood pressure.

Patients who third-space fluid may do so over a period of days and will require particularly careful monitoring of their fluid status during this time. Urine output is an objective measure of volume status. Urine output of 2 mL/kg/hr is acceptable in neonates and infants, whereas 1 mL/kg/hr is acceptable in older children.

A hypovolemic patient should be resuscitated with 10 mL/kg boluses of isotonic fluid, such as normal saline or lactated Ringer solution. Once the patient is intravascularly euvolemic, he or she should be placed on maintenance IV fluid. If repeated attempts at resuscitation fail, other reasons for hypotension should be considered, including ongoing bleeding and sepsis.

In a Cochrane review comparing isotonic and hypotonic solutions for maintenance fluid therapy on the basis of data from 10 studies that included 1106 children (primarily surgical or intensive care unit patients, or both), McNab et al found that the isotonic solutions were associated with a lower risk of hyponatremia. ^[41] It was not clear whether the isotonic solutions were associated with a higher risk of hypernatremia.

Laboratory studies

Most patients do not need laboratory studies in the postoperative period. A CBC, platelet count, and coagulation panel should be checked if ongoing blood loss is a concern. Electrolytes should be checked when there are significant fluid shifts or losses. Concern for infection should prompt an evaluation for leukocytosis, as well as culture studies.