Care of Pediatric Surgical Patient

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Care of Pediatric Surgical Patient

Pediatric Otolaryngology
Author Credentials 

Yi-Chun Liu, MD
Pediatric Otolaryngology
Division of Pediatric Otolaryngology 
Department of - Head & Neck Surgery
Texas Children’s Hospital/Baylor College of Medicine
6701 Fannin Street, Suite 640
Houston, TX 77030

Module Summary

Postoperative vital sign monitoring routines for pediatric otolaryngology – head and neck surgery patients differ with respect to adult vital sign monitoring and involve special considerations, particularly with respect to airway procedures and tracheotomy. Different techniques for anesthesia have special advantages for different pediatric needs, particularly with respect to the postanesthetic care. Antibiotic dosing schedules are weight based. Certain antibiotics are to be avoided in children due to their side effects. Wound management in pediatric patients may require premedication with analgesics, anesthetics, or both. Each subset of pediatric patients (neonate, child, preteen, teenager and young adult) has its own set of nutritional requirements separate from adult needs. Although transfusions are preferentially avoided in children due to associated risks, they may be required earlier in care management and more frequently due to the patient’s smaller total blood volumes and/or due to the pediatric patient’s comorbidities (i.e., bone-marrow transplant patient for sinus surgery). Certain medications are commonly used in care of pediatric patients in the postoperative period. Uses and dosing strategies should be familiar.

Module Learning Objectives 
  1. Describe postoperative vital sign monitoring routines for pediatric otolaryngology – head and neck surgery patients, particularly with respect to airway procedures and tracheotomy.
  2. Explain different techniques for anesthesia, listing examples of their uses for pediatric cases and anticipated relationship to postoperative patient care.
  3. Discuss commonly used analgesics in pediatric patients, their dosing and their limitations.
  4. Name commonly used antibiotics, discuss their dosing and give examples of antibiotics to be avoided in children with their side effects.
  5. Discuss wound management issues in pediatric patients.
  6. Describe nutritional and fluid needs in pediatric patients; neonates versus children versus preteens versus teens versus young adults.
  7. Explain the roles, guidelines, and special circumstances for transfusions in pediatric patients.
  8. Give examples of commonly used medications (other than analgesics and antibiotics) in the care of pediatric patients in the postoperative period and explain dosing strategies.

Patient Evaluation

Learning Objectives 
  1. Describe postoperative vital sign monitoring routines for pediatric otolaryngology – head and neck surgery patients, particularly with respect to airway procedures and tracheotomy.
    1. Airway reconstruction patients (e.g. laryngotracheal reconstruction (LTR))
      1. Follow sedation algorithm to prevent potential morbidity associated with accidental decannulation or excessive endotracheal tube movement 
  2. Know the standard post anesthesia care unit (PACU), step-down unit and pediatric intensive care unit (PICU) monitoring regimens include careful vital sign monitoring for the first 1-4 hours after surgery.
    1. Most PACU routines involve monitoring with every 15 minutes.
    2. Most PICU routines involve recording vital signs at least every hour
    3. Step-down unit routines involve recording vital signs every 2 hours 
    4. Most floor units involve recording vital signs every 4 hours
    5. Careful records of fluid balance (I & O) need to be requested, especially in postoperative conditions wherein oral intake may be limited due to oropharyngeal discomfort.
  3. Understand that patients who are extubated after undergoing a non laryngotracheal reconstruction (LTR) airway procedure (e.g. supraglottoplasty, tonsillectomy and/or adenoidectomy) will require more intensive monitoring. 
    1. Oxygen-saturation monitoring is essential for inpatients after tonsillectomy and/or adenoidectomy for obstructive sleep apnea or sleep-disordered breathing.
    2. Patients under the age of 2 years who undergo these procedures often warrant PICU level observation, especially if there are comorbidities (e.g. Chromosome anomalies associated with OSA, craniofacial abnormality).
    3. At the age of 3 years or over, comorbidities such as severity of preoperative obstructive sleep apnea, asthma symptomatology, recent URI symptoms, and obesity will contribute to decision making with respect to the level of intensity of observation.
    4. PICU admission criteria - obstructive apnea-hypopnea index (AHI) > 24; age < 24 months; oxygen saturation < 90% on room air in the PACU; and intraoperative complications including bronchospasm or laryngospasm requiring treatment.
    5. Additional admission criteria for step-down unit or the floor include airway obstruction requiring nasal trumpet placement; oxygen requirement exceeding 40% fraction of inspired oxygen (FiO2) in the PACU; craniofacial abnormalities including Down syndrome and Pierre Robin sequence; and neuromuscular/neurodevelopmental disorders such as cerebral palsy and other conditions where patients require frequent suctioning to assist in management of secretions.
  4. Know that patients who have just undergone a tracheotomy are always at higher postoperative risk for serious sequelae, including pneumothorax, pneumomediastinum, and tracheotomy tube obstruction.
    1. Pediatric patients should be observed in a PICU until at least the first tracheotomy change (usually POD#5-7 depending on surgeon preference) performed by the surgical team to assess ease of tracheotomy tube change, degree of trach site healing and if there is any peripheral tissue breakdown.
    2. Most surgeons and/or PICU teams require that tracheotomy patients have a postoperative x-ray to confirm tracheotomy tube position and to rule out any pneumothorax.
    3. Oxygen monitoring is essential.
  5. Realize that blood pressure was thought for many years to be unimportant in pediatric patients.
    1. Recent evidence suggests that hypertension observed in a child will later become hypertension in that adult. However there are no accepted standards specifically for children.
    2. Many centers use serial blood pressure measurements to follow trends.
    3. An appropriately sized blood pressure cuff should be used.
  6. Know that tachycardia, bradycardia, and tachypnea are easily monitored physiological signs.
  7. Understand that neonatal temperatures can be very labile and hypothermia may be the result of florid sepsis.
  8. Know that although much of the above material is considered standard working routine in a dedicated pediatric facility, most surgical otolaryngologic procedures are not performed in dedicated pediatric facilities but in community settings that are trained and supplied for the care of the adult patient.
    1. Therefore the level of attention to these details remains the responsibility of the surgeon.
    2. If a facility cannot support the age-appropriate or acuity-appropriate monitoring or nursing support, then the surgical procedures should be deferred to a facility that can provide the appropriate level of care.
  9. Know that postoperative labs for routine procedures are not commonly required.
  10. Realize that in the setting of von Willebrand’s Factor deficiency (von Willebrand disease, vWD) and prophylactic administration of vasopressin/DDAVP in the prevention of postoperative bleeding, a serum sodium level should be checked the morning after surgery before administration of a second dose of DDAVP. (Note: Fluids are also relatively restricted in the setting of desmopressin/DDAVP administration with respect to typical postoperative routines.)
  11. Know that in the setting of an acute post-tonsillectomy bleed, obtaining a complete blood count for hemoglobin and hematocrit levels will help direct therapy for transfusion and provide baseline information for subsequent bleeding.
References 
  1. Baugh RF, Archer SM, Mitchell RB, Rosenfeld RM, Amin R, Burns JJ, Darrow DH, Giordano T, Litman RS, Li KK, Mannix ME, Schwartz RH, Setzen G, Wald ER, Wall E, Sandberg G, Patel MM; American Academy of Otolaryngology-Head and Neck Surgery Foundation. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011 Jan;144(1 Suppl):S1-30.
  2. Hill CA, Litvak A, Canapari C, Cummings B, Collins C, Keamy DG, Ferris TG, Hartnick CJ. A pilot study to identify pre- and peri-operative risk factors for airway complications following adenotonsillectomy for treatment of severe pediatric OSA. Int J Pediatr Otorhinolaryngol. 2011 Nov;75(11):1385-90.
  3. Peterson J, Losek JD. Post-tonsillectomy hemorrhage and pediatric emergency care. Clin Pediatr (Phila). 2004 Jun;43(5):445-8.
  4. Strychowsky, JE, Albert, D, Chan, K, Cheng, A, Daniel, SJ, De Alarcon, A, Garabedian, N, Hart, C, Hartnick, C, Inglis, A, Jacobs, I, Kleinman, ME, Mehta, NM, Nicollas, R, Nuss, R, Pransky, S, Russell, J, Rutter, M, Schilder, A, Thompson, D, Triglia, J, Volk, M, Ward, B, Watters, K, Wyatt, M, Zalzal, G, Zur, K, Rahbar, R. International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Routine peri-operative pediatric tracheotomy care. Int J Pediatr Otorhinolaryngol. 2016 Jul;86:250-5.

Medical Therapies

Learning Objectives 
  1. Describe nutritional and fluid needs of pediatric patients: neonates versus children versus preteens versus teens versus young adults.
  2. Know the caloric Intake needed:
    1. Infant (< 6 months) = 110-120 kcal/kg/day
    2. Infant (6-12 months) = 95-100 kcal/kg/day
    3. Boy (2-3 years) = 1000-1200 calories (not active), 1000-1400 calories (somewhat active) and 1000-1400 (very active).
    4. Boys (4-8 years) = 1200-1400 calories (not active), 1400-1600 calories (somewhat active) and 1600-2000 (very active).
    5. Male Preteen (9-13 years) = 1400-1600 calories (not active), 1600-2000 calories (somewhat active) and 2000-2600 (very active).
    6. Male Teen (14-18 years) = 2000-2400 calories (not active), 2400-2800 calories (somewhat active) and 2800-3200 (very active).
    7. Girl (2-3 years) = 1000 calories (not active), 1000-1200 calories (somewhat active) and 1000-1400 (very active).
    8. Girl (4-8 years) = 1200-1400 calories (not active), 1400-1600 calories (somewhat active) and 1400-1800 (very active).
    9. Female Preteen (9-13 years) = 1400-1600 calories (not active), 1600-2000 calories (somewhat active) and 1800-2200 (very active).
    10. Female Teen (14-18 years) = 1800 calories (not active), 2000 calories (somewhat active) and 2400 (very active).
  3. Know the protein requirements:
    1. Infants (7-12 months) = 1.5g/kg/day
    2. Children (1-3 years) = 1.1g/kg/day
    3. Children (4-13 years) = 0.95g/kg/day
    4. Teen (14-18 years) = 0.85g/kg/day
    5. Adults = 0.8g/kg/day
  4. Know that the essential amino acids for the pediatric diet are threonine, leucine, isoleucine, valine, lysine, methionine, phenylalanine, tryptophan, histidine,* tyrosine,** and cysteine,**
    • *essential only in infancy
    • **essential for the premature baby
  5. Understand that fats should comprise 2-4% of daily administered calories.
  6. Know that particularly important is the essential fatty acid linoleic acid (an 18-carbon chain with two double bonds).
  7. Know the following about fluids:
    1. Resuscitation – D5 NS (no K) 20-30mL/kg (LR patient is acidotic)
    2. Maintenance
      1. Infants need D5 NS + K
      2. Children need D5 NS + K
      3. 40 mL/kg for first 10 kg
      4. 20 mL/kg for next 10 kg
      5. 10 mL/kg for subsequent kgs
  8. Realize that breast milk and formula provide 20 kcal/oz (20 kcal/30mL).
  9. Know the following about vitamins:
    1. A, D, E, and K absorption may be affected by certain disease processes, such as cystic fibrosis, and that vitamin replacement may be necessary for perioperative safety. Similarly, pediatric diets may not be sufficiently well-rounded and therefore may result in a vitamin deficiency.
    2. Vitamins A, B2, and C are essential to wound healing.
      1. Vitamin A:
        1. Infants 0-6 months    =    400 mcg/day
        2. Infants 7-12 months    =    500mcg/day
        3. Children 1-3 years =    300 mcg/day
        4. Children 4-8 years =    400 mcg/day
        5. Children 9-13 years =    600 mcg/day
        6. Males 14 years and up    =    900 mcg/day
        7. Females 14 years and up = 700 mcg/day
      2. Vitamin B2:
        1. Infants 0-6 months = 0.3mg/day
        2. Infants 7-12 months = 0.4mg/day
        3. Children 1-3 years = 0.5mg/day
        4. Children 4-8 years = 0.6mg/day
        5. Children 9-13 years = 0.9mg/day
        6. Male 14 years and up – 1.3mg/day
        7. Female 13 – 18 years = 1.0mg/day
        8. Female 19-21 years = 1.1mg/day
      3. Vitamin C:
        1. Infants 0-6 months =    40mg/day
        2. Infants 7-12 months = 50mg/day
        3. Children 1-3 years =    15mg/day
        4. Children 4-8 years =    25mg/day
        5. Children 9-13 years = 45mg/day
        6. Males 14-18 years =    75mg/day
        7. Female 14-18 years = 65mg/day
        8. Male 19 years and up = 90mg/day 
        9. Females 19 years and up = 75 mg/day
References 
  1. Kliegman RM, Stanton BF, St Geme JW, Schor NF. Nelson textbook of pediatrics. Philadelphia: Elsevier, 2016. 
  2. Welch K, Randolph J, Ravitch M, O’Neill J Jr, Rowe M, eds. Pediatric surgery, 4th ed. Chicago: Year Book Medical Publishers; 1986, chapter 10.
  3. Parent Tips: Calories Needed Each Day. Accessed on 5/18/2018.
  4. Merck Manual: Nutrition in Infansts. Accessed on 5/18/2018.

Pharmacology

Learning Objectives 
  1. Give examples of commonly used medications (other than analgesics and antibiotics) in the care of pediatric patients in the postoperative period and explain dosing techniques.
  2. Know that medications administered to pediatric patients are administered using weight-based dosing until the patient’s weight reaches either an average adult weight or the weight-based dosing meets the maximum allowable daily dosage.
  3. Know that common medications include:
    1. Zantac (ranitidine): 
      1. For ulcers (acute and maintenance) = 2-4mg PO qHS
        1. Alt: 4mg/kg/day IM/IV divided q6-8h; 0.16mg/kg/h IV; Max: 300mg/24 hr PO; 200mg/24h IM/IV
      2. GERD: 5-10 mg/kg/day PO divided q12h
        1. Alt: 2-4mg/kg/day IM/IV divided q6-8h; 0.08-0.16 mg/kg/h IV; Max: 300mg/24h PO; 200mg/24h IM/IV
    2. Prevacid (lansoprazole):
      1. 1-11yo, <30kg = 15mg PO qd; Max: 30mg BID 
      2. 1-11yo, >30kg = 30mg PO qd; Max: 30mg BID
      3. 12–17yo = 15 mg PO qd
    3. Prilosec (omeprazole):
      1. 1-16yo, 5-10kg= 5mg PO/NG qd
      2. 1-16yo, 10-20kg = 10mg PO/NG qd
      3. 1-16yo, > 20kg = 20mg PO/NG dq
      4. Alt: start 1mg/kg/day PO/NG divided qd-BID, thes 0.2-3.5mg/kg/day divided qd - BID
    4. DDAVP (desmopressin) can be given:
      1. Intranasally (Stimate, high concentration spray 1.5mg/mL)
        1. infants ≥11 months, <50 kg = 1 spray (150mcg) given 2 hours before surgery
        2. infant ≥11 months; > 50kg = 1 spray per nostril (300mcg) given 2 hours before surgery.
      2. Intravenously
        1. infants ≥3 months = 0.3mcg/kg infused over 15-30 minutes given 30 minutes pre-operatively, then daily on postoperative days 1, 2, 6, and 7.
      3. Use of NSAIDs in patients receiving DDAVP may aggravate hyponatremia.
    5. Know that DDAVP/desmopressin is used for perioperative management of DDAVP-sensitive von Willebrand disease (vWD) type-1. (Response is variable with vWD type-2A, 2B, 2M and 2N)
      1. A single preoperative dose is sufficient for placement of tympanostomy tubes.
      2. All other procedures require the full regimen.
    6. vWF replacement therapy – for patients with type 3, more severe type 1 and those with types 2A, 2B and 2M disease
      1. Intermediate purity factor VIII concentrates containing vWF (HumateP, Alphanate, and Solvent Detergent/Heat Treated, Wilate).
    7. AMICAR (aminocaproic acid) - 250 mg/mL syrup or 500 mg tablets is used as adjunct therapy in vWD. Check with your pediatric hematologist for prescribing recommendations.
  4. Name commonly used antibiotics, discuss their dosing, and give examples of antibiotics to be avoided in children with their side effects.
  5. Know that intravenous antibiotics commonly used include:
    1. Ampicin (ampicillin) 
      1. Neonates – please check for weight-based dosing
      2. Infants/children:100-400mg/kg/day IM/IV divided q4-6h; Max: 12g/day IM/IV
    2. Ancef/Kefzol (cefazolin)
      1. Neonates – please check for weight-based dosing
      2. Infants/children – 25-100mg/kg/day IM/IV divided q6-8h; Max 6g/day.
    3. Cleocin (clindamycin)
      1. Neonates– please check for weight-based dosing
      2. Infants/children/adolescents - 25-40 mg/kg/day IM/IV divided q6-8h; Max 4.8g/day IM/IV
    4. Unasyn (ampicillin/sulbactam)
      1. 1-23 months old – 150-450 mg/kg/day divided q6h, duration varies with infection type/severity
      2. 2-12 yo – 300-600 mg/kg/day IV divided q4-6h; max: 12g/day.
      3. Renal dosing needed for renal failure
  6. Know that oral/tube administered antibiotics commonly used include:
    1. Amoxil (amoxicillin)
      1. 0-3 months – 20-30 mg/kg/day PO divided q12h; Max: 30 mg/kg/day, duration varies with infection type/severity
      2. > 3 months – 25-45 mg/kg/day PO divided q12h; Max: 875mg/dose, duration varies with infection type/severity 
    2. Augmentin (amoxicillin/clavulanic acid)
      1. 0-3 months – 30 mg/kg/day PO divided q12h
      2. > 3 months – 25-45 mg/kg/day PO divided q12h
    3. Cleocin (clindamycin)
      1. Infant/children – 10-25 mg/kg/day PO divided q6-8h; Max: 1.8 g/day PO
      2. adolescents - 150-300 mg PO q6h; Max: 1.8g/day PO
  7. Know that the antibiotics to be avoided in children include:
    1. Fluoroquinolones – tendon rupture in rats
    2. Tetracyclines – dental discolorations
    3. Combination therapy with vancomycin and loop diuretics -  due to synergistic effects of hearing loss (Pls. check changes)
  8. Discuss commonly used analgesics in pediatric patients, their dosing and their limitations:
    1. Codeine = The FDA announced on 4/20/2017 regarding restricting the use of codeine and tramadol medicines in children.
    2. Motrin (ibuprofen)*
      1. 6 mo-11yo – 5-10 mg/kg PO q6-8h PRN pain; Max: 40mg/kg/day.
      2. 12 yo and older – 400mg PO q4-6h PRN; Max: 2400 mg/day
    3. Hydrocodone - Peds dosing is currently unavailable
    4. Lortab (hydrocodone/acetaminophen)
      1. 12-15kg – 2.8mL PO q4-6h PRN
      2. 16-22kg - 3.75mL PO q4-6h PRN
      3. 23-31kg – 5.6mL PO q4-6h PRN
      4. 32-45kg – 7.5mL PO q4-6h PRN
      5. >46kg - 11.25mL PO q4-6 PRN
    5. oxycodone
      1. Children – 0.05mg-0/15mg/kg PO q4-6h PRN; Max: 5mg/dose
    6. Roxicet (oxycodone/APAP)
      1. 2 yo and older – 0.05mg-0.15mg/kg oxycodone PO q6h PRN; Max: 5mg/dose.
    7. Toradol (ketorolac)
      1. 6 mo and older – 0.5mg/kg IM/IV q6h up to 72h; Max: 30mg/dose IM and 15mg/dose IV
    8. Tylenol (acetaminophen/APAP)
      1. Neonates – 10-15 mg/kg PO q6-8h PRN; Max: 60mg/kg/day
      2. infants/children - 10-15 mg/kg PO q4-6h PRN; Max 75mg/kg/day up to 1g/4h and 4g/day 
      3. 12 yo and older – 325-650mg PO q4-6h PRN; Max: 1g/4h and 4g/day from all sources
    9. Tylenol w/codeine = The FDA announced on 4/20/2017 regarding restricting the use of codeine and tramadol medicines in children 
      • *essential only in infancy
      • **essential for the premature baby
  9. Know that oral/tube administered antiemetic commonly used include:
    1. Zofran (ondansetron) 
      1. 1 mo – 12 yo and <40 kg – 0.1mg/kg IV q8h PRN; Max:4 mg/dose
      2. >12 yo or > 40kg – 4mg IV q8h PRN
  10. = NSAIDS use for post-tonsillectomy patients – please provide Academy U Link.
  11. Realize that when dosing a combination narcotic/acetaminophen medication, you must be sure that you are not exceeding a safe allowable dosage of acetaminophen.
References 

 

  1. Committee on Infectious Diseases. The use of systemic fluoroquinolones. Pediatrics 2006 Sep;118(3):1287-92. 
  2. Dajani AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, Gewitz MH, Shulman ST, Nouri S, Newburger JW, Hutto C, Pallasch TJ, Gage TW, Levison ME, Peter G, Zuccaro G Jr.  Prevention of bacterial endocarditis: recommendations by the American Heart Association. Clin Infect Dis. 1997 Dec;25(6):1448-58. 
  3. Harley FH, Dattolo RA. Ibuprofen for tonsillectomy pain in children: efficacy and complications. Otolaryngol Head Neck Surg. 1998 Nov;119(5):492-6. 
  4. Krishna S, Hughes LF, Lin SY. Post-operative hemorrhage with nonsteroidal anti-inflammatory drug use after tonsillectomy: a meta-analysis. Arch Otolaryngol Head Neck Surg. 2003 Oct;129(10):1086-9.
  5. PDR Pharmacopoeia, 2007.  Physicians' Desk Reference Inc; 61 edition. 
  6. Physician’s Drug Handbook, 8th ed. (Add city and publisher, if possible)
  7. Rusy LM, Houck CS, Sullivan LJ, Ohlms LA, Jones DT, McGill TJ, Berde CB. A double-blind evaluation of ketorolac tromethamine versus acetaminophen in pediatric tonsillectomy: analgesia and bleeding. Anesth Analg. 1995 Feb;80(2):226-9.
  8. RxList.com.
  9. Seeran PW, Rose JB, Fazi LM, Chiavacci R, McCormick L. Rofecoxib administration to paediatric patients undergoing adenotonsillectomy. Paediatr Anaesth. 2004 Jul;14(7):579-83. 

Surgical Therapies

Learning Objectives 
  1. Explain different techniques for anesthesia, listing examples of their uses for pediatric cases and anticipated relationship to postoperative patient care.
  2. Know that conscious sedation techniques are very useful in the Emergency Department to control the movements of small children allowing for less traumatic ear or nasal foreign body extractions while simultaneously avoiding a general anesthetic and the risk, time, and expense of a trip to the operating room.
  3. Realize that Ketalar (ketamine) is often used in children (>3 months) for conscious sedation at a starting intravenous dose of 0.5-1.5mg/kg, Max: 2mg/kg/dose
    1. It can be administered as an intramuscular “dart” with a starting dose of 2-5 mg/kg; Max: 6mg/kg/dose. Onset of action after IM administration is 3-10 minutes and lasts 15-90 minutes.
    2. Concomitant use of narcotics may result in prolonged recovery time.
    3. Ketalar can prolong the neuromuscular effects of paralytic agents and it can result in significant hypotension and bradycardia when used with halothane or enflurane.
    4. Ketamine enhances the production of oral secretions and increases the likelihood of laryngospasm – should be use cautiously in children with asthma.
    5. Emergence reactions (i.e., delirium) occur in 12% of patients and can be counteracted with prior administration of benzodiazepine or propofol.
  4. Know that the general mask anesthesia (GMA) technique is frequently used for induction of a general anesthetic and, by itself, is used for placement of tympanostomy tubes, frenuloplasty, closed reduction of nasal fractures and nasal endoscopy with or without control of inactive epistaxis.
  5. Realize that nitrous oxide is usually mixed with another anesthetic gas, such as sevoflurane, for induction of anesthesia.
    1. The anesthetic gas alone may carry the remainder of the case.
    2. Emergence follows shortly after discontinuation of the gas administration.
    3. Patients are ambulatory fairly quickly thereafter.
  6. Understand that the general endotracheal anesthesia (GETA) technique is used for longer procedures and often is induced with GMA.
  7. Know that GETA may be maintained by intravenous anesthesia, gas anesthesia, or a combination of the two.
  8. Understand that narcotics are used to provide associated analgesia, and benzodiazepines or Diprivan (propofol) are frequently are used to augment the anesthetic.
  9. Realize that after GETA, pediatric patients are vulnerable to atelectasis and chest physiotherapy may be required by the more chronically ill patients to return to baseline.
  10. Know that it is generally believed that healthy children are not at risk for deep venous thrombosis (DVT) intraoperatively; therefore, TED hoses, systemic compression devices (SCDs), and subcutaneous heparin injections are not required.
  11. Know that the risk factors for DVT in pediatric patients include neoplastic diagnosis, trauma, indwelling catheters, osteomyelitis, long-bone surgery, and prolonged postoperative bed rest.
  12. Understand that each physician should asses the specific needs of the patient and should consider some form of DVT prophylaxis in menstruating females or females who are on contraceptives or who are known or suspected smokers.
References 
  1. Levy ML, Granville RC, Hart D, Meltzer H. Deep venous thrombosis in children and adolescents. J Neurosurg 2004. Aug;101(1 Suppl):32-7.

Rehabilitation

Learning Objectives 
  1. Discuss wound management issues in pediatric patients.
  2. Know that pediatric nursing involves management of the patient and the parent.
  3. Realize that wound care that is anticipated to be painful should be performed with the adjunctive use of age- and weight-appropriate doses of pain medications with sufficient time between administration and challenge for onset of action.
  4. Know that for more severe injuries or wound-management activities, sedatives, or ketamine may be additionally administered.
  5. Understand that it is of utmost importance to inform the patient’s nurse prior to beginning any wound management and explaining to the patient and family what needs to be done and the reasons for the technique.

Complications

Learning Objectives 
  1. Explain the roles, guidelines, and special circumstances for transfusions in pediatric patients:
    1. Red blood cells (RBCs) – the blood product of choice for replacement during surgery, red cell loss, and sporadic transfusion therapy.
    2. Transfusion of whole blood has limited use in pediatric patients, and in most areas of the US it is not readily available.
    3. The usual transfusion volume is 10-15mL/kg.
    4. Transfusions of 5mL/kg of PRBCs will result in a 5% increase in the hematocrit.
    5. Sickle cell disease (SCD) patients frequently require preoperative transfusions (increase the Hgb to 10g/dL) and hydration (dehydration and thus favoring sickling of the red blood cells).
  2. Know that platelet transfusions may be used for perioperative management of patients undergoing tonsillectomy or sinus surgery with acute or chronic thrombocythemia. The accepted life span of transfused platelets is 9-10 days, but should be expected to last less time in patients who are acutely bleeding.
  3. Understand that granulocyte transfusions (WBC transfusions) are occasionally used for management of invasive or acute life-threatening infections in patients with neutropenia/leukopenia, such as patients with aplastic anemia, post-chemoablative patients, or patients with newly transplanted bone marrow or stem cell donations.
References 
  1. Bailey BJ, Calhoun KH, eds. Head and neck surgery – Otolaryngology.  5thed.  Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams Wilkins.; 2014, chapter 15.
  2. Kliegman RM, Stanton BF, St Geme JW, Schor NF. Nelson textbook of pediatrics. Philadelphia: Elsevier, 2016.
  3. Potsic WP, Cotton RT, Handler SD, eds. Surgical pediatric otolaryngology,  New York: Thieme Medical Publishers; 1997.
  4. Welch K, Randolph J, Ravitch M, O’Neill J Jr, Rowe M, eds. Pediatric surgery.  4th ed. Chicago: Year Book Medical Publishers; 1986, chapters 6, 7A, 8, 9, 10, 11, and 13.
  5. Wetmore RF, Muntz HR, McGill TJI, eds. Pediatric otolaryngology: Principles and practice pathways. New York: Thieme Medical Publishers; 2000.
  6. Roseff SD, Luban NL, Manno CS. Guidelines for assessing appropriateness of pediatric transfusion. Transfusion. 2002 Nov;42(11):1398-413.

Review

Review Questions 
  1. What are vital sign monitoring routines for pediatric otolaryngology – head and neck surgery patients?
  2. What are special considerations with respect to airway procedures? Tracheotomy?
  3. For what case would you use conscious sedation? How?
  4. What is the benefit of general mask anesthesia for placement of ear tubes? For laryngoscopy?
  5. What limits acetaminophen dosing? What are current guidelines?
  6. Can narcotics be used for analgesia in children? What are special considerations?
  7. What are risk factors for wound breakdown? How should dressings for wound-breakdown be performed on an anxious 3-year-old?
  8. How are nutritional needs calculated? What are the different age groups for pediatric patients? How do their needs vary?
  9. A six-year-old sickle-cell patient presents with all signs and symptoms of obstructive sleep apnea. After the appropriate laboratory evaluation, what are preoperative considerations, with respect to fluids and hemoglobin? How do you calculate red blood cell transfusion volume?
  10. A six-year-old patient with vWD, type-1 presents with all signs and symptoms of severe obstructive sleep apnea. What is the significance of the vWD typing? After appropriate laboratory evaluation, what are preoperative considerations, with respect to fluids and hemoglobin?
  11. A 12-year-old cystic fibrosis patient presents with chronic sinusitis resulting in decline in respiratory function. What pre-operative laboratory data would you want to check and why?
  12. How is DDAVP used in perioperative management of bleeding disorders?
  13. What is the dosing and mechanism of action for anti-reflux medications:
    1. Prevacid?
    2. Zantac?
Resources 

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  1. Annual Meeting Webcast (AMW):