Paediatric Surgery

Question 1

What are the physiological differences between children and adults?

Answer 1

Weight (kg) = 2 x (age +4)
Blood volume (mls) = 80mls/kg
Urine output = 0.5-1ml/kg/day
Insensible fluid loss = 20ml/kg/day
Systolic BP (mmHg) = 80 + (2 x age)

Vital signs (change with age)
Don’t need to learn values
AGE | RR | HR | BP SYSTOLIC
Trends
- respiratory rate decrease as age increases
- heart rate decreases as age increases
- systolic bp increases as age increases

Biggest differences

• communication
• signs aren’t always what you expect, or are unique to children
• disease processes which occur differently or are unique to children
• physiological parameters
• expectations
• stress

Question 2

What are the principles of history taking and examination in paediatric surgery?

Answer 2

X

Question 3

How is pain managed in children?

Answer 3

WHO Pain ladder
Paracetamol (20mg/kg, 4-6hrly)
Ibruprofen (10mg/kg, 8hrly)
Weak opioid (no codeine!)
Strong opioid 

If a child is in pain, give them analgesia!

Question 4

What is the differential diagnosis, assessment and management of abdominal pain in children?

Answer 4

history: pain (location, colic v constant, movement), vomiting (bile?), diarrhoea, anorexia, previous episodes, menstrual history

Examination: distraction techniques essentials, general appearance important, temperature, “guarding and rebound” (don’t do rebound testing in children!)

Differential diagnosis: appendicitis, non specific abdominal pain, mesenteric adenitis, pneumonia (referred pain)

Investigations: urine, FBC if in diagnostic doubt, electrolytes if sick, very dry, rarely do xrays

Management:
- think: does this child need a surgical opinion?

Question 5

How is malrotation, pyloric stenosis, intussceptiom and inguinal hernia recognised and managed?

Answer 5

Malrotation

• bile vomiting
• young infant eg days
• investigation is an upper gi contrast study ASAP
• treatment is through laparotomy

Pyloric stenosis

• non bilious vomiting “projectile”, weight loss, cap gas
• investigate with test feed, give IV fluids, ultrasound
• treatment is periumbilical pyloromyotomy

Intussception (JUST children: bowel inside bowel

• 6-12mnth
• 3 day history of viral illness then intermittent colic and dying spells (floppy and white, vagal response)
• may or may not have bilious vomiting
• 4 sec cap refill
• can have bloody mucous PR (red currant jelly stool)
• investigate with USS abdomen, “target sign”
• manage with pneumostatic reduction (air enema), laparotomy

umbilical hernia

• spontaneous closure by 4yo
• complications rare
• repair if complications, relative eg >4y, large, anaesthetic
• distinguishe from paraumbilingual

Epigastric hernia

• defect in linea alba
• leave alone, may gradually enlarge

Gastroschisis
- abdominal wall defect, gut exposed, manage with primary / delayed closure, total parental nutrition

Exomphalos
- umbilical defect with covered viscera, manage with primary/delayed closure

Question 6

What are the principles of fluid managment?

Answer 6

Resuscitation (20ml/kg bolus 0.9% NaCl (crystalloid)

Maintenance

• 0.9% NaCl/5% dextrose +/- 0.15% KCl
• 4ml/kg 1st 10kg
• 2ml/kg 2nd 10 kg
• 1ml/kg every kg thereafter

eg 10yrs = 2 x (10+4) = 28kg = 40+20+8 = 68mls/hr

Question 7

What are red flag symptoms in infants?

Answer 7

Feed refusal
Bile vomits (green!) 
Colour of skin eg grey
Tone eg floppy baby 
Temperature eg too hot or too cold