Postoperative Care in Pediatric Orthopedics

Postoperative Care in Pediatric OrthopedicsDuring the immediate postoperative period, the child is usually seen once or twice a day, depending upon the magnitude of the procedure. Fortunately, most children have few postoperative problems and recovery is rapid.

Postoperative Orders

General orders include positioning, activity, vital signs, circulation monitoring, and other special considerations.

Fluid management A common error during and after surgery is prescribing too much fluid—especially dextrose in water. Most patients require little or no potassium because of tissue damage. Limit intake the first 24 hours after usual maintenance doses.

Pain Management

IV analgesia Administer morphine 0.1–0.2 mg/kg as a loading dose and continuous infusion of 0.01-0.03 mg/kg/hr as necessary to maintain comfort. Reduce this by 10% every 12–24 hours.

Oral analgesia The patient is switched to oral analgesic when oral intake is allowed. Several agents are acceptable.

Patient-controlled analgesia (PCA) In children older than about 5–6 years of age, this method is useful. Administer a loading dose of about 0.2 mg/kg. Allow doses of 0.02–0.03 mg/kg be given every 5–10 minutes with a maximum of 0.75–0.1 mg/kg per hour.

Epidural anesthesia This neuraxis analgesia is administered by the caudal route in children under 6 years of age or by lumbar route. Higher-level administration may be necessary in selected cases.

Children with epidural pain management after surgery may be more comfortable, but be aware that epidural anesthesia may mask compartment syndromes.

Postoperative Problems

Fever Fever (temperature >38°C) is seen in most children following surgery. Be concerned if the fever is severe, the child looks more ill than expected, or if the child has positive physical findings suggesting a pulmonary or urinary problem.

Vomiting Nausea and vomiting following anesthesia are twice as common in children compared with adults. Causes of vomiting include such agents as nitrous oxide anesthesia and morphine. A history of motion sickness also increases the risk.

Special Needs

Continuous passive motion (CPM) is a valuable technique in restoring motion. The excursion is set at the range achieved by the interoperative releases. Continue the CPM for about 6 weeks.

Splints or braces may be fitted and completed during hospitalization.

Time for Discharge

Observing the child’s general appearance and behavior are valuable methods of monitoring recovery. Be concerned if the child is not becoming progressively better. As the child becomes comfortable and smiling, the parent’s concerns diminish. At this point, the child is ready for discharge.

Scheduling Follow-up Visits

Order the follow-up clinic visits thoughtfully. Make certain each visit has a specific purpose. Plan the postoperative visits to approximate the time when the child is at risk for a complication or when some change in management is anticipated. Most operative complications, such as infections, loss of reduction, or position or pressure sores will occur within the first week.

Time follow-up visits to coincide with timing for orthotic, physical therapy, or other postoperative visits. Being thoughtful about the family’s resources will be appreciated.

Activity Status

Compliance with orders to limit activity is poor. If necessary, ensure compliance by immobilization in a cast. Avoid burdening the family with the duty to enforce activity restriction; it is an impossible task and an unfair assignment.

Physical Therapy

Crutch training is best done preoperatively. Mobilize the child when possible before discharge. Therapy is necessary for special situations such as for children with muscular dystrophy following contracture release procedures. Physical therapy is not necessary for routine postoperative care.

Hardware Removal

Generally, smooth pins may be removed in the clinic. Threaded pins and fixation hardware often require removal under anesthesia. Most hardware removals are performed 3–9 months following surgery.

Indications In the past, removal of fixation devices was routine. Because removal of hardware requires an anesthetic, operative exposure, and sometimes added complications, routine removal is not appropriate. Indications for hardware removal include:

Prominent hardware Hardware that alters the body contour and may cause discomfort, such as proximal femoral fixation for varus osteotomies.

Fixation complicating known future procedures Large fixation devices that are buried in bone about the hip may complicate total hip replacement.

Fixation causing stress risers in the femur may require removal.

Hardware that extends into a joint.

Metal reaction or infections are relative indications.

Contraindications of hardware removal include:

Fixation that reduces the risk of pathologic fracture should be permanent. This includes IM fixation of benign tumors, or fractures through osteopenic bone. This permanent fixation strengthens the bone and usually prevents refracture.

Fixation that is likely to be very difficult to remove The difficulty of hardware removal is classically unappreciated. Complication rates can be significant. Make certain the benefit is worth the risks.

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