Presenter: Moises Auron, MD, and David Rappaport, MD
Summation: Pediatric hospitalist involvement in perioperative pediatric care covered six areas of consideration.
1) Preoperative risk. Patient-related factors, including prematurity, reflux, congenital diseases, and intercurrent illnesses increase operative risks. For many of these factors no specific remedies are available other than heightened attention to care, need, and timing of surgery.
2) Perioperative lab testing. Published data show that absent specific clinical indications there is no need for routine preop studies—including coagulation testing for T&A's. Certain circumstances: complex/prolonged surgeries or fertile females may merit limited testing.
3) Intravenous Fluids. Isotonic fluids carry lower risks of hyponatremia than hypotonic fluids.
4) VTE. VTE is the second most common hospital acquired complication. Risk factors included intubation, CVL, infection, cancer, immobility and dehydration. A graded approach to prophylaxis with more aggressive interventions for higher risk patients should be used.
5) GI stress ulcer prophylaxis. No published data are available to clearly demonstrate benefit outweighs potential risk for routine use of prophylactic antacid therapy. There is a weak recommendation for antacid prophylaxis in critically ill children. PPIs are probably equivalent to H2 blockers.
6) Pulmonary Complications. Atelectasis does not cause fever. Lots of strategies to try to prevent atelectasis—no clear data on what works. Most likely to be effective are positive pressure, either IPPV or CPAP and preoperative incentive spirometry.
Many areas of pediatric perioperative medicine lack high-quality, published data to guide care.
Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.