Nicolae Testemitanu State Medical and Pharmaceutical University

Department of Pediatric Surgery, Orthopedics and Anesthesiology

Peculiarities of pediatric surgical patient

Alexandr Jalba, MD, PhD, associate professor

There is no standard pediatric patient that can be managed by set formulas or memorized rules of thumb. Each patient is unique and constantly changing !!! The surgeon faced with a sick infant or child must have a system or approach that permits flexibility and individualization. There are several essential ingredients to such a system.

First, the surgeon needs a basic knowledge of the factors that affect the surgical patient. Second, techniques must be available that can be used to evaluate the overall condition of the patient.

Then, utilizing the knowledge of surgical physiology and the data obtained from the evaluation techniques, the surgeon formulates a tentative therapeutic plan.

This plan is put into operation for a specific period of time. During that period, the responses of the patient to the therapy are continuously monitored, usually by the same techniques used in making the initial evaluation. Analysis of the feedback information from the monitoring allows reassessment of the therapeutic plan. Changes are made, and the revised plan is put in operation. Monitoring and readjustments are continuously made to meet the changing needs of the patient.

The system is dynamic and can be linked to a therapeutic poker

game with the surgeon and baby as opposing players (Fig. 1).

Figure 1. Therapeutic poker game. (Holder T.M. & Ashcraft K.W. Pediatric Surgery. W.B. Sounders Company, 1980, p.2.)

Factors in the care of the pediatric surgical patient

Five factors make the care of the critically ill pediatric surgery patient a complex and difficult task. There are: (1) the unique and constantly changing anatomic and physiologic characteristics of the neonate, the infant and the child;

(2) the variations in gestational age, physical development, and body size of individual patients of the same chronologic age;

(3) pathologic conditions common to the pediatric period that affect the management of the primary surgical disease;

(4) pathophysiologic changes produced by the primary surgical disease; and

(5) the side effects of surgical treatment itself.

(1) Unique physiologic characteristics

The neonate, infant, child, and adolescent all differ significantly from each other and from the adult.

It is during the neonatal period, however, that the pediatric patient possesses the most distinctive and rapidly changing physiologic characteristics.
This is due to the newborn infants adaptation to the extrauterine environment, the continued process of organ maturation, the demands of rapid growth and development, and the small physical size. For these reasons, we will place the emphasis on the neonatal period, especially on circulatory, blood volume, metabolic, host defense, and renal function characteristics.

Circulatory system before and after birth

Metabolic characteristics
The newborn baby is a metabolically active organism with a total energy expenditure well above that of the adult. The basal metabolic rate is high, varying between 32 and 48 kcal per kilogram per 24 hr (the adult rate is 24 kcal per kilogram in 24 hr). The infant requires approximately 38 kcal per kilogram per hour for growth and development. In spite of these high energy demands, energy reserves are low, and within a few hours of birth, fuel must be supplied from external sourses. Hepatic glycogen is depleted by 3 hours postnatally. Muscle glycogen falls less rapidly but is completely utilized by about 48 hours. Blood sugar rapidly decreases, reaching its nadir when the child is about 6 hours of age.

Host defense
The newborns host defenses against infection are generally sufficient to meet the challenge of most moderate bacterial insults, but may not be able to meet a major insult. Total complement activity is 50 per cent of adult levels. C3, C3,5,6 complex, factor B, and properdin concentrations are also low in comparison to the adult. Most studies suggest that white blood cell function and opsonization are equal to those of the more mature individual. IgG is presenting adult amounts, but IgM, since it does not pass through the placenta, is absent. The plasma cell of the newborn infant is immunologically competent to produce immunoglobulins but because of lack of experience with antigenic substances may lag in the production of antibodies in response to certain bacterial invaders.

Renal function

Neonatal renal function is adequate to meet the needs of the normal full-term infant but may be limited during period of stress. Glomerular filtration and tubular function is lower than in the adult. The concentrating ability of the kidney is reduced, and the urine osmolality seldom reach 500 mOsm per kilogram. Excretion of water, phosphate, hydrogen ion, and sodium is reduced.

(2) Variations in individual newborns

There are four different types of newborn infants:

(1) the full-term, full-size infant with gestational age of 38 weeks and a body weight greater than 2500 grams; (2) the preterm infant with a gestational age below 38 weeks and a birth weight appropriate for that age; (3) the small for gestational age infant with gestational age over 38 weeks and a body weight below 2500 grams; (4) a combination of (2) and (3), i.e. the preterm infant who is also small for gestational age.

The preterm baby

The characteristic that most significantly affects the survival of the preterm infant is the immature state of the respiratory system. For the baby to adapt successfully to the airbreathing state, the lungs must sufficiently develop anatomically and biochemically to allow for gas exchange. Between 27 and 28 weeks of gestation (when body weight is 900 to 1000 grams), anatomic lung development has progressed to the extent that extrauterine survival is possible. At this stage, gas exchange can take place in spite of the absence of recognizable alveoli. It is only after 30 to 33 weeks of gestation that true alveoli are present. Once there is adequate lung tissue, the critical factor that determines extrauterine adaptation and survival of the preterm infant is his capacity to produce the phospholipidrich material, surfactant, that lines the respiratory epithelium, lowers surface tension, and stabilizes the gas exchange surfaces of the lung. This complex detergent is secreted by Type 2 pneumatocytes. Synthesis and storage begins at about 16 weeks of gestation and increases by 20 weeks. However, surfactant does not reach the surface of the lung until between 28 and 38 weeks of gestation. The variation in the presence of surfactant in adequate amounts on the respiratory surfaces accounts, to a large extent, for the variation in pulmonary function between preterm infants of similar gestational age. Even when sufficient anatomic and biochemical development occurs, the premature infants work in breathing is greatly increased. He has proportionately smaller alveoli, respiratory ducts, and bronchial diameters than full-term infants. A greater force must, therefore, be generated to expand the alveoli and more positive end-expiratory pressure used to keep the alveoli from deflating. Nevertheless, because of the weak, compliant nature of the preterm infants thoracic cage, the chest wall cannot be fixed during inspiration, and a high negative intrathoracic pressure cannot be generated.

The preterm baby (continuation)

The handling of the breakdown products of hemoglobin is also a difficult task for the premature infant. The ability of the immature liver to conjugate bilirubin is reduced, the life span of the red blood cell is short, and the bilirubin load presented to the circulation via the enterohepatic route is increased. Physiologic jaundice is, therefore, higher in the preterm infant and persists for a longer period of time. Unfortunately, the immature brain has an increased susceptibility to the neurotoxic effects of high levels of unconjugated bilirubin, and kernicterus can develop in the preterm baby at a relatively low level of bilirubin. Among the many other problems associated with immaturity is the increased susceptibility of the retina to the damaging effects of high oxygen levels. Even brief exposures may results in retinolental fibroplasia. Feeding problems are common in the preterm infant and result from a weak suck reflex, a small gastric volume, and a relative decrease in disaccharide enzymes in the small intestine. Because of the preterm babys large surface area and thin skin with an increased permeability to water, evaporated water loss is as much as 6,5 times higher than in the adult. To maintain fluid balance, fluid volumes as high as 130 to 175 ml per kilogram per 24 hr may be required in the extremely premature infant. The preterm infant often has a reduction in the serum factors necessary for white blood cells to phagocytize and kill live bacteria. These deficits might, in part, account for the increased vulnerability of the preterm infant to overwhelming sepsis.

The small for gestational age baby

Babies born after 38 weeks of gestation and who weigh less than 2500 grams are thought to suffer from intrauterine growth retardation and are labeled as small for gestational age or small for date infants. Factors that lead to growth retardation may reside in the fetus (congenital abnormalities, sepsis or inherited factors) or result from placental or maternal abnormalities. The small for gestational age baby, compared with the preterm infant, tends to be hypermetabolic, increasing the basal metabolism rate rapidly in the first 10 days of life and then at a more gradual rate over a 6-week period. Because of their small size, these infants have a relatively large surface area and heat loss is increased. Body fat, because of intrauterine malnutrition, is frequently at levels below 1 per cent of the body weight. The lack of insulation increases the thermoregulatory problems of these babies. Hypoglycemia may develop early in the small for gestation age baby than in the normal full-term or preterm baby because of the high metabolic activity, the cost of the thermoregulation, and the reduced energy stores due to intrauterine malnutrition. The red blood cell volume and the total blood volume are much higher than in the preterm or full-term infant, the red cell volume frequently reaches levels of profound polycythemia and increased blood viscosity. Unlike the premature infant, because of adequate length of gestation, intrauterine development of the lungs of the small for gestational age baby usually results in function approaching that of the normal full-term infant.

(3) Associated pathologic conditions

There a host of complex pathologic conditions that occur during the newborn, infant, childhood and adolescent periods that profoundly alter the physiologic state of the surgical patient and have far-reaching effects on management and ultimate survival. Cystic fibrosis, juvenile diabetes, congenital heart disease, hemophilia, and allergies are obvious examples. Hyaline membrane disease is a classic example of the disease that pediatric surgeon must be aware of in the care of newborn surgical patient. It is the most common cause of death in premature infants and develops in 60 per cent of infants under 28 weeks of gestation and in 20 per cent of infants at 32 to 36 weeks of gestation. The hypoxia and low flow state that develop during the disease play a major role in the development of surgical lesions such as necrotizing enterocolitis and patent ductus arteriosus.

(4) Pathophysiologic effects of the primary surgical disease

Many of the surgical diseases that affect the pediatric patient are common to the adult age groups, but the majority are unique to infancy and childhood.

Their pathophysiologic effects are varied and range from

the minimal derangements produced by a hydrocele to the severe respiratory failure accompanying a diaphragmatic

hernia. Detailed descriptions of all these conditions are

contained in the later lections of this course.

(5) Side effects of therapy

In the effort to treat the primary surgical problem, the

surgeon profoundly alters the patients physiology and

produces pathophysiologic changes. Many of these alterations are of short duration, while others are permanent. The effects of anesthesia, blood loss, operative tissue damage, and the most drug are temporary, whereas the removal of organs and the changes in anatomic design are permanent.

In conclusion it is worth underlining once more that all these factors make the care of severely ill pediatric surgical patient a complex and difficult task.

Thanks for your attention!