(BQ) Part 2 book General surgery prepare for the MRCS key articles from the surgery journal presentation of content: Anatomy of the caecum, appendix and colon, anatomy of the rectum and anal canal, the pathology of colorectal polyps and cancers, chemotherapy andradiotherapy for colorectal cancers,... and other contents.
Surgery is an authoritative, comprehensive collection of educational reviews that present the current knowledge and practice of surgery Surgery also indicates recent advances that improve the understanding of disease and the safe and effective treatment of patients It comprises concise and systematically updated contributions that are produced over a three-year cycle Surgery is an excellent didactic tool to help consultant surgeons train their junior staff to become safe and competent surgeons Series editor W E G Thomas MS FRCS FSACS(Hon) Consultant Surgeon, Honorary Senior Lecturer, Sheffield University, Member of Council and past Vice President of the Royal College of Surgeons of England Clinical editor Michael G Wyatt MSc MD FRCS FRCSEd (ad hom) Consultant Surgeon, Freeman Hospital, Newcastle upon Tyne; Honorary Reader, Newcastle University; Clinical Editor, SURGERY; Honorary Secretary, The Vascular Society of Great Britain and Ireland, and Member of the Court of Examiners for the Intercollegiate MRCS Editorial adviser Harold Ellis CBE DM FRCS FRCOG Emeritus Professor of Surgery, London University Clinical Anatomist, Guy’s, King’s and St Thomas’s School of Biomedical Science, London, UK Editorial Board Ian Nesbitt MBBS FRCA DICM (UK) Consultant in Anaesthesia and Critical Care Freeman Hospital, Newcastle-upon-Tyne, UK Joseph Shalhoub BSc MBBS MRCS (Eng) FHEA PhD Specialty Registrar in General Surgery, London Deanery and Joint Vice President, Association of Surgeons in Training Jon Anderson FRCS (CTh) Consultant Cardiothoracic Surgeon Hammersmith Hospital NHS Trust, London, UK Frank CT Smith BSc MD FRCS Consultant Senior Lecturer in Surgery Bristol Royal Infirmary, Bristol, UK Emily Jane Baird MBChB MRCS (Glasgow) Trauma and Orthopaedic Specialty Registrar, West of Scotland Rotation; and President of the British Orthopaedic Trainees Association Helen Sweetland MD FRCS (Ed) Reader in Surgery and Honorary Consultant Surgeon Cardiff and Vale NHS Trust, UK Frank Carey FRCPath Professor and Consultant Histopathologist Ninewells Hospital, Dundee, UK Christopher R Chapple MD FRCS(Urol) FEBU Visiting Professor, Sheffield Hallam University Consultant Urological Surgeon, Royal Hallamshire Hospital, UK Ben Cresswell MBChB FRCS (Gen Surg) Consultant Hepatopancreatobiliary Surgeon The Basingstoke Hepatobiliary Unit North Hampshire Hospital, UK William Wallace MBChB(Hon) PhD FRCPE FRCPath Consultant Pathologist and Honorary Senior Lecturer Royal Infirmary of Edinburgh, UK Robert Wilkins MA DPhil (Oxon) Lecturer in Physiology Department of Physiology, Anatomy & Genetics St Edmund Hall, University of Oxford, UK Mark Wilkinson PhD FRCS (Orth) Professor of Orthopaedic Surgery University of Sheffield, UK Consultant Orthopaedic Surgeon Northern General Hospital, Sheffield, UK Michael J Kelly MChir FRCS MRCP (UK) Consultant Colorectal Surgeon, Leicester, UK and National Advisor Colorectal Cancer, NHS Improvement Court of Examiners RCSEng Peter Lamb MBBS FRCS(Eng) MD FRCS (Gen) Consultant Upper GI and General Surgeon Royal Infirmary of Edinburgh, UK Surgical and Clinical Anatomy for the MRCS exam Anthony Lander PhD DCH FRCS (Paed) Senior Lecturer in Paediatric Surgery and Consultant Paediatric Surgeon, Birmingham Children’s Hospital, UK Series editors Mary Murphy MB BCh, BAO, FRCS (SN) Consultant Neurosurgeon Royal Free Hospital, London, UK This series is available only on the website: www.surgeryjournal.co.uk Harold Ellis CBE DM MCh FRCS FRCOG London Vishy Mahadevan MB BS PhD FRCS London Founder editors John S P Lumley MS FRCS London John L Craven MD FRCS York Paediatric Surgery II Volume 31:12 December 2013 A great revision guide for the MRCS and beyond 622 Paediatric fluid and electrolyte therapy guidelines Anthony Lander 599 The vomiting infant: pyloric stenosis Brian W Davies 626 Pathology of common childhood tumours Lesley Christie Steve Lang 603 Intussusception Joana Lopes Simon N Huddart 631 Appendicitis and non-specific abdominal pain in children Aly Shalaby Niyi Ade‑Ajayi 608 Anorectal anomalies and Hirschsprung disease (including stomas) Jonathan Sutcliffe Ian Sugarman Marc Levitt Abdominal and pelvic tumours in children Emma Sidebotham 639 Gastro-oesophageal reflux in children: surgical management Dhanya Mullassery Matthew O Jones 614 Disorders of sex development Mark Woodward Andrew Neilson 646 Oesophageal atresia Gareth P Hosie Elizabeth Gavens 618 BASIC SCIENCE PAEDIATRIC SURGERY II TEST YOURSELF Test yourself: MCQ and extended matching 652 Based entirely on the Intercollegiate Surgical Curriculum Issue Editor Anthony Lander frcs (paed) Consultant Paediatric Surgeon Birmingham Children’s Hospital, Birmingham, UK www.surgeryjournal.co.uk ONLINE, IN PRINT, IN PRACTICE © 2013 Elsevier Ltd ISSN 0263-9319 BASIC SCIENCE Paediatric fluid and electrolyte therapy guidelines Importantly the NPSA wanted all stocks of 4% glucose with 0.18% saline removed from non-specialized areas and this should now have happened (Table 2) Postoperative fluid prescriptions e new regulations The NPSA say that postoperative fluid prescriptions should never include 4% glucose with 0.18% saline or 0.45% saline with 5% glucose and outside the neonatal period can only be chosen from: 0.9% saline 0.9% saline with 5% glucose Ringer’s lactate/Hartmann’s solution 4.5% albumin For neonates 10% glucose with 0.18% saline and 0.45% saline with 5% glucose remain options Anthony Lander Abstract The advice in this article is based on a multidisciplinary consensus opinion generated by the Association of Paediatric Anaesthetists and on a National Patient Safety Agency (NPSA) recommendation of March 2007 entitled ‘Reducing the risk of hyponatraemia when administering intravenous infusions to children’ To this has been added advice from our specialist hospital fluid policy Prescribing intravenous (IV) fluids IV fluids should be prescribed with the same care and attention as given to other drugs No one prescribes analgesics when antibiotics are needed and no one should prescribe maintenance fluids when replacement fluids are intended Fluids are given intravenously for the following four reasons: circulatory support in resuscitating vascular collapse replacement of previous fluid and electrolyte deficits maintenance replacement of ongoing losses Keywords Hyponatraemia; intravenous fluids; paediatrics The National Patient Safety Agency (NPSA) Alert of 2007 was expected to bring about a widespread change in postoperative maintenance fluid administration such that children would receive solutions containing 0.9% saline or Hartmann’s solution rather than solutions containing 0.18% or 0.45% saline in glucose Telephone surveys show that practice has changed such that 0.18% saline has mostly been removed from wards but that the preferred postoperative fluid is often 0.45% saline with 5% dextrose The potential benefit of the recommendations is that the chances of serious error from bad prescribing will be reduced However, hypernatraemia or hyperchloraemia should be looked for in those children having 0.9% saline or Hartmann’s solution for protracted periods and instances reported appropriately IV fluid prescriptions Practice should be determined locally and ideally IV fluids should be prescribed daily by the team involved in the child’s care either at the morning round or in the early evening before handover Fluids should not be being prescribed by the night team who will not be as familiar with the patient unless the fluid management requires fine-tuning in response to the clinical situation or as a result of investigations Such a patient would then have had a detailed and specific handover NPSA: The dangers of 4% glucose 0.18% saline Potassium Potassium 20 mmol/litre (0.15%) (10 mmol in each 500-ml bag) should be included in maintenance fluids and in replacement fluids unless there are specific contraindications If there are special reasons not to give potassium these should be detailed in the notes Potassium is not included in the first 24 hours of life nor traditionally in the first 24 hours after surgery However, it will be given if Hartmann’s solution is prescribed Remember that most potassium is intracellular and so a slightly lower serum level than normal may indicate marked potassium depletion The NPSA reminded clinicians of the dangers of the use of lowsodium-containing fluids such as 0.18% saline with 4% glucose This fluid has always been inappropriate when used for resuscitation or when used to replace most fluid and electrolyte deficits or when given at excessive rates when maintenance fluids were intended The risk is one of precipitating hyponatraemia which can be fatal Sadly even in university and tertiary centres local audits have shown that inappropriate prescriptions like this are not rare Many surgeons have traditionally used 4% glucose with 0.18% saline as a maintenance fluid when given at appropriate rates in well children based on their weight This or 0.45% saline with 5% glucose has been traditionally given at reduced rates in the postoperative period The term isotonic is now to be considered in relation to the tonicity of the electrolyte components of fluids Thus 0.18% saline with 4% glucose and 0.45% saline with 5% glucose are now to be considered hypotonic since the glucose is ignored Monitoring Monitoring of the patient’s weight is important and particularly helpful in managing rehydration Urine specific gravity is also a good guide to rehydration Daily electrolytes are mandatory in those solely on IV fluids for more than a day The electrolytes should be looked at in the context of previous results and not simply in relation to the normal values Typically when the serum sodium falls fluid restriction is appropriate and when it rises fluid rates can be increased This is particularly relevant in managing fluids in the postoperative period A falling sodium is usually a sign of over administration of fluid and not of giving too little sodium Anthony Lander PhD FRCS (Paed) DCH is a Consultant Surgeon at Birmingham Children’s Hospital, Birmingham, UK Conflicts of interest: none declared SURGERY 31:12 599 Ó 2013 Elsevier Ltd All rights reserved BASIC SCIENCE Normal water, electrolyte, energy and protein requirements Body weight Water (ml/kg/day) Sodium (mmol/kg/day) Potassium (mmol/kg/day) Energy (kcal/kg/day) Protein (g/kg/day) First 10 kg Second 10 kg Subsequent kg 100 50 20 2e4 1e2 0.5e1 1.5e2.5 0.5e1.5 0.2e0.7 75 75 30 3.00 1.50 0.75 Table Circulatory support in shock necessary followed by a slower correction of residual dehydration with an isotonic fluid, taking into account ongoing losses, serum electrolytes and urine output The following fluids are appropriate for bolus administration at 10 or 20 ml/kg given over periods of up to 20 minutes: 0.9% saline Ringer’s lactate or Hartmann’s solution blood 4.5% albumin colloid or blood It is inappropriate to use low-sodium-containing fluids in these situations 0.18% saline or 0.45% saline in glucose is not to be used for circulatory resuscitation Hyponatraemia can result and this can be fatal Monitoring is typically based on the clinical response, blood pressure, capillary refill, blood gasses, etc Serum electrolytes should be checked in anyone needing circulatory resuscitation Maintenance fluid requirements in children Maintenance fluid requirements are still to be calculated according to the recommendations of Holliday and Segar (Table 1) Table is a starting point only and the individual child’s response to fluid therapy should always be monitored and appropriate adjustments made In children outside the neonatal period 0.45% saline in glucose or Hartmann’s solution or 0.9% saline are options supported by the NPSA However, in the postoperative period it recommends not using 0.45% saline These fluids give more than the daily requirements of sodium, but the risks of this are considered to be less than the risks of hyponatraemia if 0.18% saline is administered Our preferred fluid is Hartmann’s solution since this gives less chloride In term neonates during the first 48 hours of life 10% glucose should be given at a rate of 60 ml/kg/day unless there is a clinical indication for increased or decreased fluid administration Sodium would be added to IV fluids on day 2e3 depending on renal function, serum sodium and weight From day of life maintenance fluid should be 0.18% saline with 10% glucose given at a rate of ml/kg/hour or 100e120 ml/kg/day Preterm babies or those under kg may require higher rates of administration and should be assessed at least daily by assessment of weight and electrolytes Correcting previous fluid and electrolyte deficits However estimated, previous losses are typically between and 15% of body weight Sometimes the weight loss is accurately known The fluid used to replace this deficit should be isotonic 0.9% sodium chloride or Ringer’s lactate/Hartmann’s solution A 15-kg child who is 5% dehydrated has a water deficit of 750 ml Audits have shown that it is not an uncommon misconception that 10% dehydration can be corrected by increasing maintenance fluid rates by 10%! This is clearly incorrect Hypovolaemia, should be corrected with an initial fluid bolus of 10e20 ml/kg of an isotonic fluid or colloid, repeated as Commonly available crystalloid fluids Fluid Saline 0.9% (normal saline) Saline 0.9% þ 0.15% KCl Saline 0.9% þ 0.15% KCl þ 5% glucose Hartmann’s solution Saline 0.45%, glucose 2.5% Saline 0.45%, glucose 5% Saline 0.18%, glucose 4% Saline 0.18%, glucose 4%, 10 mmol KCl/500 ml (0.15%) Glucose 5% Glucose 10% Saline 0.18%, glucose 10% Glucose 20% Isotonic Isotonic Isotonic Isotonic Hypotonic Hypotonic Hypotonic Hypotonic Hypotonic Hypotonic Hypotonic Hypotonic NaD (mmol/litre) KD (mmol/litre) ClL (mmol/litre) Energy (kcal/litre) Other 150 150 150 131 75 75 30 30 0 30 0 20 20 0 20 0 0 150 170 170 111 75 75 30 50 0 30 0 200 100 200 160 160 200 400 400 800 Lactate 0 0 0 0 Note: The tonicity ignores the glucose component This is the view of the National Patient Safety Agency (NPSA) Table SURGERY 31:12 600 Ó 2013 Elsevier Ltd All rights reserved BASIC SCIENCE Maintenance fluid requirements may need to be increased in children with pyrexia, excess sweating, hypermetabolic states such as burns or when radiant heaters or phototherapy is used There is no consensus on whether maintenance fluid requirements should be reduced in children on a paediatric intensive care unit (PICU) who are sedated and ventilated with humidified gases Simple calculations will show that the electrolyte requirements are met if 0.18% NaCl, 0.15% KCl is administered at the prescribed rates But the dangers of hyponatraemia are considered to outweigh the benefits of restricting the sodium and chloride content of the fluid Fluid rates in the postoperative period are still to be calculated using Holliday and Segar’s formula, and may be restricted to 70% of full maintenance if required Ongoing losses from drains or nasogastric tubes should be replaced with an isotonic fluid such as 0.9% sodium chloride It is possible that this change in practice may lead to high serum chlorides and these should be monitored Hyperchloraemia can give rise to headaches, but it is less dangerous than hyponatraemia Oral fluids should be started and increased after surgery whilst IV fluids are reduced and then discontinued The rate at which this happens depends upon the child and the surgery Monitoring of fluid therapy Fluids given during operations Serum electrolytes not need to be measured in all preoperatively healthy children prior to elective surgery where IV fluids are to be given for the duration of surgery and for a short period thereafter If there has been bowel preparation or there is unshunted hydrocephalus, electrolytes should be checked preoperatively Serum electrolytes need to be measured preoperatively in all children presenting for elective or emergency surgery who require IV fluid to be administered prior to surgery Children should be weighed prior to fluids being prescribed Serum electrolytes should be measured every 24 hours in all children on IV fluids or more frequently if abnormal Children should be weighed daily while on IV fluids unless this is difficult A fluid input/output chart must be carefully maintained and checked by the prescribing doctor During surgery the majority of children may be given fluids without glucose Blood glucose should be monitored Maintenance fluid used during surgery should be isotonic such as 0.9% sodium chloride or Ringer’s lactate/Hartmann’s solution Neonates in the first 48 hours of life should be given glucose during surgery Preterm and term infants already receiving glucose-containing solutions should continue with them during surgery Infants and children on parenteral nutrition preoperatively should continue to receive parenteral nutrition during surgery or change to a glucose-containing maintenance fluid and blood glucose monitored Children of low body weight (less than third centile) or having prolonged surgery should receive a glucosecontaining maintenance fluid (1e2.5% glucose) or have their blood glucose monitored during surgery Children having extensive regional anaesthesia with a reduced stress response should receive a glucosecontaining maintenance fluid (1e2.5% glucose) or have their blood glucose monitored All losses during surgery should be replaced with an isotonic fluid such as 0.9% sodium chloride, Ringer’s lactate/Hartmann’s solution, a colloid or blood, depending on the child’s haematocrit In children over months of age the haematocrit may be allowed to fall to 25% Children with cyanotic congenital heart disease may need a higher haematocrit to maintain oxygenation Common electrolyte derangements Hyponatraemia Hyponatraemia (serum Na