Paeds Surgery 2

appendix, vascularity, and relationship of vessels to the intestines
can be visualised
􀂙 CT scan — Not commonly required. Obese patients, masses.
Postoperative evaluation. All major trauma
􀂙 Barium studies — Swallow/meal to rule out volvulus, otherwise
not in a patient who is nil by mouth. Enema for reduction of
intussusception if air is not available (3ft height, three attempts, each
three minutes, ensure a good seal at the anus)
􀂙 Air enema — Therapeutic in intussusception (gas pressure not >
100mm, three attempts, three minutes each, ensure a very good seal,
and accompany your patient to the Radiology Department; ensure
a well-functioning IV line before sending down, and have the baby
prepped for eventual surgery in case of failure of reduction)
􀂙 Meckel’s Scan — Isotope scan; usually not done on an emergency
basis, as the child requires pre-scan preparation with H2 antagonists
MANAGEMENT
􀂙 Fluid resuscitation — According to hydration status, urea/
electrolytes levels and estimated third space losses. Consider saline
10ml/kg boluses in addition to maintenance fl uids. Replace specifi c
losses, and correct electrolyte imbalance. Monitor pulse, BP and urine
output to assess response
􀂙 Rest intestine — Nil by mouth, nasogastric tube of suffi cient caliber,
hourly aspiration and passive drainage in-between, until intestinal
function is ascertained or re-established. Replace losses using saline
with KCL
􀂙 Surgery — Inform nursing staff to prepare child for surgery, obtain
consent from parent or legal guardian, fi ll in and fax OT chit to
OT reception and inform anaesthetist on-call. Trace all pending
investigations; ensure blood or blood products are available if
required. Inform surgeon of estimated time of surgery, especially if
any delay is anticipated and the surgeon is not stationed in-house
􀂙 Laparoscopy — Investigation when other investigations fail to
give a diagnosis; it is also therapeutic for many conditions. Open vs
minimally invasive surgery must be discussed with the parents by
the surgeon
􀂙 Pain management
􀂊 While under observation, limit analgesia until the diagnosis has
been established
􀂊 Treat as appropriate e.g. give
Post-operative morphine infusion: 1mg/kg body weight in
50ml of dextrose 5% to run at 1–2ml/hr. Use half this dose if at
all required in infants and neonates. Use a pulse oximeter for
all cases, and tail down the morphine as soon as the child is
comfortable
􀂊 Consider regional analgesia, suppository paracetamol 15mg/kg,
or epidural analgesia. If on an epidural catheter, the child should
be nursed in the High Dependency Area
􀂙 Review/observation — Some conditions presenting acutely are
not of a surgical nature, and all that is required is intestinal rest, IV
fl uids, and regular review and observation. It is important to explain
to parents what is happening to the child, and what the plan of
treatment is, as otherwise they will invariable think that they spent
days in the hospital ‘and nothing was done’. In general, children
should not be sent home with persistent pain, but some judgment is
allowed. In a stable child with normal intestinal function and minimal
pain, home recovery may be allowed, with the proviso that parents
bring the child back in case of persistence or worsening of symptoms
COMMON CONDITIONS
Included below are the most common conditions seen, accounting
for 95% of cases here. Some, although not common, require mention
as a high index of suspicion is required for diagnosis, and immediate
treatment is required. Trauma is not covered here. Some conditions
are seen more commonly in certain age groups, and the conditions are
arranged in increasing frequency seen from infancy onwards.
Incarcerated Inguinal Hernia
􀂙 Clinical examination should make the diagnosis immediately evident
􀂙 Diff erential may include an encysted hydrocoele of the cord
􀂙 Try to reduce the hernia by gentle traction and pressure. Sedation
and analgesia may be helpful, but ensure adequate hydration and
monitoring of the child
􀂙 Immediate surgery if irreducible or on the next elective list. In infants
and neonates, bilateral herniotomies should be done
Malrotation and Volvulus
􀂙 Typically occurs about Day 3 to Day 5 in an otherwise well child
􀂙 50% of patients who become symptomatic do so in the fi rst month
of life. In older children, the presentation is that of chronic abdominal
pain and FTT. Incidence at autopsy is about 0.5–1% of the total
population.

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appendix, vascularity, and relationship of vessels to the intestines

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