جراحة عملي الاولى

• Preterm

  Less than 37 completed weeks' gestation
• Full term


  Between 37 and 42 completed weeks of gestation
• Neonate


  Newborn baby up to 28 days of age
• Infant


  Up to 1 year of age
• Child


  All ages up to 16 years, but often divided into: preschool child (usually <5 years), child and adolescent (puberty up to 16 years)
• Infants and small children

  • Wide abdomen, broad costal margin and a shallow pelvis
  • The edge of the liver comes below the costal margin
  • The bladder is largely intra-abdominal
  • The ribs are more horizontal and are flexible
  • The umbilicus is relatively low lying

  
• Transverse supraumbilical incisions


  • Give greater access than vertical midline ones for open surgery
• Trauma (including surgical access)

  Can easily damage the liver or bladder
• The geometry of the ribs


  • Means that ventilation requires greater diaphragmatic movement
  • Their flexibility means that rib fractures are rare and often a sign of abuse
• A stoma in the lower abdomen of a neonate


  • Must be carefully sited for its bag not to interfere with the umbilicus
• Infants


  • Have less subcutaneous fat
  • Immature vasomotor control
  • Greater heat loss from pulmonary evaporation
  • Higher surface area to weight ratio
• These factors need to be considered when managing sick children in the accident and emergency department, anaesthetic room or operating theatre
• The environments must be warm, infusions are warmed, and respiratory gases both warmed and humidified
• The core temperature is monitored and safe direct warming is needed for lengthy operations
• The infant's large head and short neck


  • Predispose to flexion
• The large tongue


  • Can obstruct the airway when unconscious
• The epiglottis


  • Projects posteriorly and the larynx is high
• A bladed laryngoscope is needed
• Before prescribing fluids (or drugs), the child's weight must be known, their vital signs and their fluid and electrolyte requirements should be considered in relation to normal values and ranges
• Dehydration

  Moderate (5% loss of total body water) manifests in poor urine output, dry mouth, and sunken eyes and fontanelle; severe (>10%) in decreased skin turgor, drowsiness, tachycardia and poor capillary refill (>2 s) and signs of hypovolaemia
• Fluids are given intravenously for four reasons


  1. Circulatory support in resuscitating vascular collapse

  2. Replacement of previous fluid and electrolyte deficits

  3. Replacement of ongoing losses

  4. Maintenance
• Fluids used for circulatory support


  • 0.9% saline
  • Blood
  • 4.5% albumin
  • Colloid
• Fluids used for replacement of previous fluid and electrolyte deficits


  • 0.9% saline + 0.15% KCl
  • Hartmann's solution
• 4.5% albumin if protein loss is great, replace losses mL for mL
• Fluids used for maintenance outside neonatal period


  • 0.45% saline + 0.15% KCl in 2.5–5% glucose
  • Hartmann's ± glucose
  • 0.9% saline + 0.15% KCl ± glucose
• Fluids used for maintenance in the neonate

  • 10% glucose at 60 mL/kg per day in first 48 hours
  • From day 3, around 4–5mL/kg per hour or 100–120 mL/kg per day
  • Preterm babies or those <2 kg may require 180 mL/kg/day of fluid
• Consider impaired gluconeogenesis: monitor and keep glucose above 2.6 mmol/L
• Operative surgery

  • Well-prepared patient who has not been excessively starved
  • Appropriate consent
  • Gentle technique
  • Strict haemostasis
  • Fine suture materials
• Wound dehiscence is rare and usually the result of poor technique
• Clean skin incisions are best closed with absorbable subcuticular sutures
• Analgesia


  • Must be adequate and appropriate, recognising the potential for respiratory depression with opioids
• Appropriately trained staff monitor the airway, vital signs, oxygen saturation, fluid balance, temperature, pain control and glucose levels during recovery