Postoperative Management of Children

This chapter will take approximately 11 minutes to read.

By Kyle O. Rove, MD ^{1, 2}

Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA
Department of Surgery, Division of Urology, University of Colorado, School of Medicine, Aurora, CO, USA

Introduction

Pediatric postoperative care is a critical aspect of any surgical procedure, and it plays a significant role in the child's recovery. The postoperative management of the pediatric patient is essential to prevent complications and ensure optimal healing. This chapter will discuss the postoperative management of the pediatric patient, including intravenous fluids, electrolyte balance, TPN, and pain management.

Intravenous Fluids

Intravenous (IV) fluids are an essential component of postoperative management for pediatric patients. Children who undergo surgical procedures may experience fluid loss due to anesthesia and surgery, which can lead to dehydration, electrolyte imbalance, and hypovolemia. Therefore, it is crucial to maintain adequate fluid volume to ensure proper organ function and to prevent postoperative complications.

There are various types of IV fluids used in postoperative management, including isotonic, hypotonic, and (rarely) hypertonic solutions (Table 1). Isotonic solutions, such as 0.9% saline and lactated Ringer's solution, are commonly used in pediatric patients as they have the same osmolarity as the body's extracellular fluid. These solutions help to maintain fluid balance and prevent dehydration. Dextrose (most commonly 5%) may be added for caloric support in patients who are not taking enteral support.

Hypotonic solutions, such as 0.45% saline, are used when there is a need for hydration but no significant fluid loss. These solutions have a lower osmolarity than the body's extracellular fluid and can lead to hyponatremia and cerebral edema in excess.

Hypertonic solutions, such as 3% saline, are only used to treat severe hyponatremia or hypovolemia. However, these solutions must be used cautiously in pediatric patients, as they can lead to electrolyte imbalances and dehydration.

The choice of IV fluid and the rate of administration depends on the child's age, weight, medical history, and the type of surgery performed. It is essential to monitor the child's fluid intake and output to prevent fluid overload or dehydration.

The suggested maintenance rate and type of intravenous fluids (IVF) in a postoperative pediatric urology patient can depend on various factors such as the patient's age, weight, underlying medical conditions, type and duration of surgery, and fluid and electrolyte balance. In general, the maintenance fluid requirements for pediatric patients can be calculated using the Holliday-Segar method, which recommends a daily fluid intake of 100 mL/kg for the first 10 kg of body weight, plus 50 mL/kg for the next 10 kg, and 20 mL/kg for each additional kilogram.1

The 4-2-1 rule is a simplified method to estimate the maintenance fluid requirements for pediatric patients.2 It suggests that the daily maintenance fluid requirement for a child who weighs less than 10 kg is 4 mL/kg/hour, for a child who weighs between 10–20 kg is 2 mL/kg/hour, and for a child who weighs over 20 kg is 1 mL/kg/hour. This rule can be used as a quick estimate for the initial fluid rate in a stable pediatric patient who does not have significant fluid losses or electrolyte imbalances.

Table 1 Common postoperative intravenous fluid compositions, including indications, pros and cons.

IVF Composition	Composition (per liter)	Indications	Advantages	Disadvantages
Normal saline (0.9% NaCl)	154 mEq Na⁺ 154 mEq Cl^-	Used for isotonic volume resuscitation in patients with hypovolemia, dehydration, or shock.	Low cost, readily available	Can cause hyperchloremic metabolic acidosis, especially with large volumes or prolonged administration
Lactated Ringer’s (LR)	130 mEq Na⁺ 109 mEq Cl^- 28 mEq lactate 4 mEq K⁺ 3 mEq Ca²⁺	Used for isotonic volume resuscitation in patients with hypovolemia, dehydration, or shock.	Contains additional electrolytes, mimicking plasma composition	May cause hyperkalemia, especially with renal insufficiency.
0.45% normal saline (NS)	77 mEq Na⁺ 77 mEq Cl^-	Used for maintenance IVF when fluid restriction is needed.	Less likely to cause fluid overload or electrolyte imbalances than isotonic solutions.	May not provide adequate volume expansion in patients with significant dehydration or fluid losses.
D₅W	50 g dextrose 278 mOsm/L	Used for maintenance IVF when fluid restriction is not needed.	Provides free water and calories, can help maintain euglycemia.	Provides no electrolytes or other nutrients, can lead to hyponatremia, hyperglycemia, or fluid overload if given in excess.
D₅LR	50 g dextrose 130 mEq Na⁺ 109 mEq Cl^- 28 mEq lactate 4 mEq K⁺ 3 mEq Ca²⁺	Used for maintenance IVF when additional electrolytes are needed.	Combines the advantages of D₅W and LR solutions.	May cause hyperkalemia, especially with renal insufficiency.
D₅½NS (0.45% NaCl with 5% dextrose)	77 mEq Na⁺ 77 mEq Cl^- 50 g dextrose 495 mOsm/L	Used for maintenance IVF when fluid restriction is not needed and additional electrolytes are needed.	Provides free water, calories, and some electrolytes.	May cause hyponatremia, hyperglycemia, or fluid overload if given in excess.

Electrolyte Balance

Electrolyte balance is critical in the postoperative management of the pediatric patient. Surgery and anesthesia can lead to electrolyte imbalances due to fluid loss and changes in organ function. Electrolyte imbalances can lead to complications such as cardiac arrhythmias, muscle weakness, and seizures.

Common electrolytes monitored in postoperative pediatric patients include sodium, potassium, calcium, and magnesium. The normal range for sodium is 135–145 mEq/L, potassium is 3.5–5.0 mEq/L, calcium is 8.5–10.5 mg/dL, and magnesium is 1.5–2.5 mEq/L.

In the postoperative period, electrolyte imbalances can occur due to various factors, such as inadequate fluid intake, excessive fluid loss, medication use, and changes in organ function. In short-stay, healthy patients who are supporting themselves postoperatively with enteral nutrition, laboratory testing is probably not routinely indicated. Even for complex operations like creation of catheterizable channel or bladder augmentation or nephrectomy, we advocate for checking a basic metabolic panel on postoperative day 1. If that is normal and hospital course is otherwise normal, no further testing is done.

Correction of electrolyte imbalances can be achieved through various methods, including oral or IV replacement. Oral replacement is preferred when the child is alert and can tolerate oral intake. IV replacement is used when the child is unable to tolerate oral intake or when rapid correction is necessary.

Total Parenteral Nutrition

Total parenteral nutrition (TPN) is a form of specialized nutrition composed of carbohydrates, proteins, lipids, vitamins, and minerals used in pediatric patients who cannot tolerate oral or enteral feeding. TPN provides complete nutrition through an intravenous line, which allows nutrients to be directly absorbed by the body.

Indications for TPN use in pediatric patients include short bowel syndrome, malabsorption syndromes, severe inflammatory bowel disease, and congenital anomalies. TPN is also used in the postoperative period when oral intake is contraindicated for prolonged periods (ileus, small bowel obstruction, critical illness requiring intubation and sedation).

There is limited evidence regarding the use of prophylactic total parenteral nutrition (TPN) in pediatric patients undergoing complex lower urinary tract reconstruction. Some studies have suggested that TPN may be beneficial in this population by improving nutritional status, but this can also be associated with more postoperative complications and longer hospital stays.3 The decision to use TPN should be individualized and based on the patient's clinical status, nutritional needs, and potential risks and benefits. At our center, TPN is rarely used or needed outside of postoperative complications limiting enteral nutrition.

Pediatric Postoperative Pain Management

Effective postoperative pain management is crucial for minimizing patient discomfort, reducing complications, and improving recovery outcomes. However, managing pain in pediatric patients can be challenging, as children may have difficulty communicating their pain and may require different approaches to pain management than adults.

The use of opioids for postoperative pain management in children has been associated with adverse events, including respiratory depression, nausea, vomiting, and sedation. Therefore, multimodal analgesia techniques are often employed to minimize opioid use and improve pain control.

Common Regional Blocks in Pediatric Patients

Regional anesthesia techniques, such as nerve blocks, have been shown to be effective in reducing postoperative pain and opioid use in pediatric patients. Here are some common regional blocks used in pediatric patients:

Caudal block: This block involves injecting local anesthetic into the caudal epidural space to provide analgesia for lower abdominal, pelvic, and lower extremity surgeries.
Epidural block: This block involves injecting local anesthetic into the epidural space to provide analgesia for thoracic, abdominal, and lower extremity surgeries.
Transversus abdominis plane (TAP) block: This block involves injecting local anesthetic into the plane between the internal oblique and transversus abdominis muscles to provide analgesia for abdominal surgeries.

Strategies for Minimizing Opioid Use

In addition to regional anesthesia techniques, there are several strategies for minimizing opioid use in pediatric patients:

Preemptive analgesia: Providing analgesia prior to the start of surgery can reduce the amount of pain experienced postoperatively. The gate control theory of pain proposes that the perception of pain can be modulated by the spinal cord's "gate," which can be opened or closed by various inputs, including sensory signals from nerve fibers, as well as emotional and cognitive factors.4 Preemptive analgesia aims to close the gate by providing analgesic treatment before the onset of painful stimuli, which can reduce the overall pain experience and the need for postoperative pain control.5 For this reason, we encourage preoperative analgesia (oral medications in preoperative area and locoregional analgesia prior to incision) whenever possible.

Figure 1 The gate control theory of pain proposes that modulation of sensory tracts prior to painful insult can reduce the overall pain experience and the need for postoperative pain control. We maximize this effect by providing preoperative analgesics orally or by applying logoregional blocks prior to incision.

Non-opioid analgesics: Using non-opioid analgesics, such as acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs), can reduce the need for opioids and improve pain control. We schedule these postoperatively for all appropriate patients.

Patient-controlled analgesia (PCA): PCA allows the patient to self-administer small doses of opioids as needed, reducing the risk of oversedation and respiratory depression.6 After the introduction of ERAS at our institution, PCA usage in pediatric urology is quite rare.

Regional anesthesia techniques: As mentioned earlier, regional anesthesia techniques can reduce opioid use and improve pain control.7

Multimodal analgesia: Combining multiple analgesic techniques, such as opioids, non-opioids, and regional anesthesia, can improve pain control and reduce the need for opioids.8

Effective postoperative pain management is essential for improving recovery outcomes in pediatric patients. Regional anesthesia techniques, such as nerve blocks, are effective in reducing postoperative pain and opioid use. Additionally, strategies for minimizing opioid use, such as preemptive analgesia, non-opioid analgesics, PCA, regional anesthesia techniques, and multimodal analgesia, can improve pain control and reduce the need for opioids.

Pediatric Enhanced Recovery After Surgery

Enhanced Recovery after Surgery (ERAS) is a multimodal approach to perioperative care that aims to optimize patient outcomes by reducing surgical stress, promoting early recovery, and minimizing complications. ERAS protocols typically include interventions such as preoperative carbohydrate loading, minimally invasive surgery, opioid-sparing analgesia, early mobilization, and early oral intake.

ERAS protocols have been successfully implemented in adult surgical patients, and over the past few years, there has been increasing interest in applying this approach to the pediatric population. Several studies have shown that ERAS protocols can reduce length of stay, improve pain management, and decrease complications in children undergoing surgery.

ERAS can be applied to a variety of pediatric surgeries, including but not limited to:

Orthopedic surgery (e.g., spinal fusion)
General surgery (e.g., appendectomy)
Urologic surgery (e.g., nephrectomy, pyeloplasty, complex lower urinary tract reconstruction)9,10,11
Colorectal surgery (e.g., cecostomy/Malone procedures)
Cardiac surgery (e.g., repair of congenital heart defects)

Several specialties have also implemented ERAS protocols in pediatric patients. For example, the Pediatric Colorectal and Pelvic Learning Consortium has developed an ERAS protocol for children undergoing surgery for anorectal malformations.12 Pediatric Urology Recovery after SUrgery Endeavor (PURSUE) is a multicenter working group aiming to demonstrate the value of ERAS care for patients undergoing complex lower urinary tract reconstruction.13

In summary, pediatric ERAS protocols are a promising approach to improving postoperative outcomes in children undergoing surgery. They can be applied to a variety of surgical specialties and procedures and have the potential to reduce length of stay, improve pain management, and decrease complications.

Standardizing Care

Electronic medical records (EMRs) have become an integral part of modern healthcare and can improve the efficiency and safety of postoperative care. EMRs can be used to facilitate the ordering of medications, laboratory tests, and imaging studies, as well as to document the patient's progress and response to treatment. In addition, EMRs can be used to develop order sets that standardize postoperative care and reduce variability in practice.14

For postoperative care of a pediatric urology patient, order sets may include orders for intravenous fluids, pain management medications, antibiotics, and key nursing communication points. EMRs can also incorporate clinical decision support tools to help guide the clinician in selecting the appropriate medications and dosages for the patient based on their age, weight, and medical history.

We have developed and maintained three order sets at our institution for all patients undergoing pediatric urology operations. These order sets help our team standardize care. In 2018, we added ERAS elements for both admission order sets shown below. In 2019, we removed routine opioids for postoperative pain control for outpatient surgery.

Pediatric Urology Outpatient Surgery Discharge (Figure 2)
Pediatric Urology Short-Stay Admission
Pediatric Urology Reconstruction Admission

Figure 2 Listing of orders within the Pediatric Urology Outpatient Surgery Discharge order set at Children’s Hospital Colorado. Most sections have additional areas for documenting non-standard details that may be unique to the case, but these are rarely needed.

With the help of our antibiotic stewardship team, we opted to remove antibiotic options from postoperative admission and discharge order sets given the lack of supporting evidence for continuing antibiotics in most elective postoperative scenarios. The default selections and options available within the order set are deliberate choices on the part of our team to minimize variation, avoid therapeutic duplication, and enable standard care all while streamlining communication with nursing, avoiding overdiagnosis with unneeded scheduled testing (e.g., daily labs) and thus minimizing cost and potential harm to patients.

Conclusions

Postoperative management of the pediatric patient requires a multifaceted approach that includes careful monitoring of fluid and electrolyte balance, pain management, and nutritional support. Intravenous fluids are a crucial aspect of postoperative care, and the choice of IVF composition should be tailored to the individual patient's needs. TPN may be indicated in select patients, but its routine use in complex lower urinary tract reconstruction remains controversial. Regional blocks and multimodal analgesia can help reduce the need for opioid medications and improve pain control in the postoperative period. Enhanced recovery after surgery protocols have been shown to be quite beneficial for improving outcomes and reducing hospital length of stay. Overall, effective postoperative management requires a coordinated effort among the surgical team, nursing staff, and other healthcare professionals to optimize the patient's recovery and prevent complications.

Key Points

Effective postoperative care is essential for minimizing complications, reducing discomfort, and improving recovery outcomes in pediatric patients.
Multimodal analgesia techniques, including regional blocks, preemptive analgesia, non-opioid analgesics, and patient-controlled analgesia, can help minimize opioid use and improve pain control in pediatric patients.
Enhanced recovery after surgery (ERAS) protocols can improve outcomes in pediatric patients undergoing a variety of surgeries by implementing evidence-based practices to reduce complications, decrease pain, and accelerate recovery.
Careful monitoring of fluid and electrolyte balance, including appropriate use of intravenous fluids and total parenteral nutrition, is important in postoperative management of pediatric patients to maintain proper hydration and prevent complications.

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Last updated: 2024-02-16 20:59

10: Postoperative Management of Children