Paediatrics: Post-operative care: fluids

Post-operative care: fluids

Day case children

Children admitted for day case surgery will return to the day care ward from the theatre recovery area once they are alert, able to maintain their airway, haemodynamically stable, and comfortable. The presence of a par-ent in the recovery room is usually beneficial. Oral fluids can be offered in most cases on return to the ward and, if tolerated without nausea, followed by food. Within a few hours most children can be discharged home.

Major surgery

Following major surgery children will return to the ward or intensive care unit. The operation note should include specifi c instructions regarding an-tibiotics, catheters, IV fluids, etc.

•   Post-operative IV fluids: will depend on the nature of the surgery. There is now a general directive to use 0.45% sodium chloride with 5% dextrose or 0.9% sodium chloride for post-operative fluid because the risk of hyponatraemia is minimized. The rate of infusion should be adjusted according to the weight of the child. Potassium chloride 20mmol/L should be added to fluids after the first day.

•   Nasogastric aspirates: should be replaced mL for mL with 0.9% sodium chloride with 20mmol KCI/L. It is easy to underestimate ‘third space losses’ (i.e. fluid translocating into the peritoneum, bowel, or chest) after major surgery and this volume of fluid should be added to the maintenance requirements and fluid given to replace continuing losses (e.g. NG aspirates). If the child has cool peripheries and a prolonged capillary refill time the situation will almost always improve after infusion of 20mL/kg of additional fluid (0.45% sodium chloride with 5% dextrose, 0.9% saline, 4.5% albumin, and plasma substitutes are all used in practice).

•   Haemoglobin: check the haemoglobin on the first post-operative day. Blood transfusion is to be avoided whenever possible and, with the exception of oxygen dependent children, a moderate post-operative anaemia is well tolerated. If transfusion is necessary (i.e. haemoglobin <7.0g/dL) every effort should be made to ensure that the child is only exposed to blood from one donor even if this means that the volume of blood transfused is less than originally calculated. Routine co-administration of diuretics is not necessary in the surgical patient.

•   Biochemistry: children with high urinary or high stoma losses receiving IV fluids should have blood U&E measured daily. Frequent adjustments to the electrolyte content and rate of infusion may be necessary.

Oral fluids: following abdominal surgery most children will have a paralytic ileus for 36–48hr. After this period, oral intake will resume and IV fluids can be discontinued. If more prolonged IV fluid therapy is necessary consideration should be given to parenteral nutrition

Nasogastric tubes

NGTs usually inserted to keep the stomach empty. In the pre-operative period this is useful in a child with an intestinal obstruction. A bile-stained aspirate signifies an intestinal obstruction and emptying the stomach will prevent the child from vomiting. Unless otherwise instructed, the NGT should be aspirated every hour and the aspirate replaced intravenously mL for mL with 0.9% saline containing KCI 20mmol/L.

• Common practice to insert a NGT in theatre in a child undergoing abdominal surgery that is likely to result in a paralytic ileus.

• Post-operative management is the same as pre-operative. As the ileus resolves after 24–36hr the volume of the NGT aspirate will decrease and it will become clear. At this stage the NGT can usually be removed and oral fluids resumed. In most cases prescription of the volume of oral fluid is not necessary, but restricting the child to water only for the first 24hr effectively limits the amount they ingest.

Transanastomotic tubes

Following repair of OA in the newborn the surgeon will commonly place a ‘transanastomotic tube’ (TAT). The purpose of the TAT is to allow early resumption of enteral nutrition.

• Do not attempt to repass a TAT that has been removed inadvertently without seeking advice from the surgeon.

• Perforating an anastomosis is likely to land both you and the baby in trouble!

Newborns and infants

Newborns and infants <44wks post-conception should be transferred to a neonatal or special care baby unit post-operatively. The risk of post-operative apnoea after general anaesthesia is relatively high. Monitoring for a minimum of 24hr post-anaesthetic should include routine nursing observations of:

·temperature;

• pulse;

• respirations;

• pulse oximetry;

apnoea monitoring.