Seminars in pediatric surgery
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Intraosseous infusion was used extensively for the parenteral administration of blood, fluids, and pharmacological agents in the 1940s. The technique was "discovered" and popularized again during the 1980s. Substances injected intraosseously are found rapidly in the central circulation. ⋯ After about 5 years of age, the distal tibia or femur are the preferred sites. Needles made specifically for resuscitative intraosseous infusion are available. Increased awareness of the role of intraosseous infusion, familiarity with the technique of insertion, and careful use of landmarks to guide insertion should minimize complications.
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Nutritional management of infants and children differs from that of adults because of the extra requirements for growth and the limitations of physiological immaturity. Although parenteral nutrition (PN) is an accepted practice and a potentially life-saving therapy for pediatric patients who cannot be fed through their gastrointestinal tract, it is associated with the risk of serious metabolic, mechanical, and infectious complications. Candidates for PN should be selected according to well-defined indications, with initial nutritional assessment and with careful attention given to fluid, electrolyte, vitamin, trace element, and caloric requirements. ⋯ PN should be initiated and monitored in accordance with well-established protocols. The lowest complication rate and highest cost-effectiveness are achieved by an interdisciplinary team that includes one or more nurses, dietitians, pharmacists, and physicians. The development of safe, reliable, and miniaturized intravenous pumps with built-in monitors has made home parenteral nutrition possible and desirable in selected patients.
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The fluid and electrolyte management of the surgical neonate must take into account the acute transition to extrauterine life superimposed on the gradual changes associated with fetal and neonatal maturation and growth. With this transition, there are acute changes in body water distribution, and a striking increase in evaporative losses from the skin and respiratory tract. These changes, as well as those in renal function and sodium balance in the preterm and full-term infant are discussed.
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Although biliary atresia is characterized by luminal obstruction of the extrahepatic bile ducts, the etiology and the pathophysiology of the liver are still controversial. The prognosis of biliary atresia has been improved after the introduction of Kasai's hepatic portoenterostomy, but there are still many problems to be solved in the treatment of this disease. Successful results of hepatic portoenterostomy depend on early diagnosis and operation, adequate operative technique, prevention of postoperative cholangitis, and precise postoperative management. However, we are on the verge of a new era in the therapy of biliary atresia combining portoenterostomy with liver transplantation.
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Recent research into the mechanisms of pain and pain management and the development of new pharmacological agents have greatly increased the possibilities for preventing and treating postoperative pain in the pediatric patient. This article briefly reviews the physiology of pain and the measurement and assessment of pain, and then discusses in some detail the various modalities useful in treating pain in the pediatric patient during the perioperative period.