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Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Joy Loy MD
March 2009
Objectives
Participants will be able to
1. discuss the underlying pathophysiology of selected neonatal emergencies, 2. explain the anesthetic implications and 3. describe safe anesthetic plans for each.
Preoperative Evaluation
Maternal and perinatal history
Recreational drug use
Birth history
Minimum labs: glucose and CBC Look for associated anomalies
Pyloric Stenosis
Pyloric Stenosis
Most common GI obstructive anomaly in neonates
Pyloric Stenosis
Etiology : unknown
Pyloric Stenosis
Physical Exam visible gastric peristalsis palpable olive-shaped mass to the right of the epigastric area signs of dehydration
EKG
Pyloric Stenosis
Diagnosis
history and physical exam abdominal ultrasound upper GI series with barium contrast not recommended pathological pyloric wall thickness 4 mm pyloric length of > 16 cm
hypochloremia
hypokalemia
1 metabolic alkalosis
Pyloric Stenosis
Preoperative Preparation supportive treatment
surgical management
check lab indices for safe anesthesia
Pyloric Stenosis
Preoperative Preparation
Supportive therapy
Correction of fluid deficits
maintenance: D5 0.2% NaCl + KCl
20 - 40 mEq/L
replacement: LR, albumin, normal saline
Pyloric Stenosis
Surgical Management Pyloromyotomy definitive treatment open or laparoscopic Lab indices for safe anesthesia serum Cl >100 mEq/L HCO3 < 28 mEq/L
Pyloric Stenosis
metabolic alkalosis
Pyloric Stenosis
Intraoperative Management
Monitors : ASA standard
Pyloric Stenosis
Intraoperative Management
Maintenance
IV narcotics: rarely needed inhalational agents
Pyloric Stenosis
Extubate awake Postoperative concerns respiratory depression and apnea hypoglycemia
Congenital Diaphragmatic Hernia 50% mortality regardless of the method of treatment Incidence: 1:2,000-5,000 live births
15 - 20% paraesophageal
Eventration (15 - 20%)
cardiovascular
CNS
13 - 23%
28%
gastrointestinal
genitourinary
increase the mortality rate
20%
15%
Cyanosis
Apparent dextrocardia
Physical Exam scaphoid abdomen and barrel chest bowel sounds in the chest displaced heart sounds Laboratory Studies CBC ABG
electrolytes
glucose
calcium
prevention of pain
fentanyl infusion 3-10 mcg/kg/hr
correction of acidosis
Recent Strategy
Permissive hypercapnia and hypoxemia Pressure-limited ventilation (<25 cmH2O) Postductal pCO2 40-65 mmHg Preductal SpO2 85-90%
Congenital Diaphragmatic Hernia Bohn (1986) reevaluation of the traditional mad dash surgical strategy
infants unresponsive to initial therapy will fail to survive with surgery or any other treatment including ECMO
The Relationship Between PaCO2 and Ventilation Parameters in Predicting Survival in CHD Arterial CO2 accurately reflects the degree of lung development
Acid Base Balance and Blood Gases in Prognosis and Therapy of CHD High Mortality pH < 7.0 pCO2 >60 mmHg pO2 < 50 mmHg
Boix-Ochoa J, et al J Pediatric Surg 9:49-57, 1974
Indications of Surgical Repair Reversal of ductal shunting O2 index of < 40 Arterial pCO2 maintainable under 40 mmHg Hemodynamic stability
Preoperative Preparation
Intraoperative Management Monitors: ASA standard invasive : arterial line CVP foley catheter * 2 pulse oximeters: preductal and postductal
* precordial stethoscope on the right axilla
Intraoperative Management Induction awake intubation rapid sequence IV induction and intubation with assisted or controlled ventilation * avoid mask ventilation or PPV before intubation Supine position, left subcostal incision
Intraoperative
Maintenance of anesthesia
volatile agents + IV narcotics + muscle relaxants
TIVA avoid nitrous oxide avoid increase in PVR leading to RL shunting: hypoxia, acidosis, hypothermia, pain
SpO2 95 - 98%
small tidal volume to keep airway pressure < 20-30 cm H2O high respiratory rate 60-120 /min to PaCO2 25-30 mm Hg
Congenital Diaphragmatic Hernia Intraoperative Surgical repair primary closure staged procedure Transabdominal subcostal incision
Intraoperative
Potential Problems
Hypoxemia
distension of stomach
Contralateral pneumothorax
Postoperative Care
Ventilatory support Close fluid management Hemodynamic monitoring
Management of PPHN
Minimize ETT suctioning Vasodilators : rarely effective
tolazoline nitroglycerin isoproterenol SNP PGE1
Extracorporeal Membrane Oxygenation (ECMO) Use: controversial Allows the lungs to develop & restructure Expensive improved survival in neonates with > 80% mortality
Criteria for ECMO Gestational age 34 wks Reversible disease process present Weight 2000 grams Predicted mortality 80% estimated by oxygenation index of > 40
FiO2 x mean airway pressure x 100
PaO2
Contraindications
Gestational age < 34 wks Weight < 2000 grams Preexisting intracranial hemorrhage ( grade II) Aggressive respiratory treatment > 1 wk Congenital heart disease Congenital or neurological abnormality incompatible with good outcome
Tracheoesophageal Fistula
Incidence: 1:4000 live births
M > F (25:3) 10-40% are preterm
Tracheoesophageal Fistula
Clinical Presentation
choking on 1st feed
coughing cyanosis excessive salivation aspiration pneumonia
Tracheoesophageal Fistula
Diagnosis
Tracheoesophageal Fistula
Esophageal Atresia
Tracheoesophageal Fistula
TracheoEsophageal Fistula
5 Types (Gross and Vogt)
7.7%
0.8%
86%
0.7%
4.2%
Tracheoesophageal Fistula
35-65% have associated anomalies VATER and VACTERL V A vertebral anomalies or VSD anorectal malformation
C
T E R L
Tracheoesophageal Fistula
Preoperative Preparation
Tracheoesophageal Fistula
Preoperative Preparation 24-48 hr medical stabilization Antibiotics: ampicillin and gentamicin Ensure availability of blood in the OR Optimize volume status and metabolic state Intubation preferably in the operating room under controlled situation
Tracheoesophageal Fistula
Intraoperative Management
Main Concern
Monitors
ASA standard
Tracheoesophageal Fistula
Intraoperative Management
Tracheoesophageal Fistula
Intraoperative Management
Induction awake intubation rapid sequence IV induction inhalation induction spontaneous ventilation without muscle relaxant
Tracheoesophageal Fistula
Intraoperative Management
Tracheoesophageal Fistula Intraoperative Management If g-tube present, place end of g-tube under water seal: ETT above fistula (+) bubbles
Connect capnograph to
g-tube: (+) ETCO2 if ETT above the fistula ? rigid bronchoscopy - not proven
Tracheoesophageal Fistula
Intraoperative Management
Berry FA, Anesthetic Management of Difficult and Routine Pediatric Patients, 2nd Ed. 1990
Tracheoesophageal Fistula
Intraoperative Management
Tracheoesophageal Fistula
Intraoperative Management
Lateral decubitus position Posterolateral thoracotomy Maintenance of Anesthesia Narcotic technique Inhalation technique + regional anesthesia ? Use of nitrous oxide
Tracheoesophageal Fistula
Intraoperative Management
Surgical repair
ligation of fistula
check air leak in suture line esophageal repair identify the pouch placement of feeding tube chest tube placement and closure of thoracic cavity
Tracheoesophageal Fistula
Intraoperative Management
V/Q mismatch
lateral decubitus position
Tracheoesophageal Fistula
Postoperative Management
Early extubation desirable
Tracheoesophageal Fistula
anastomotic stricture
tracheomalacia
Gastroschisis Greek word for belly cleft Evisceration of gut through a 2-3 cm defect in the anterior abdominal wall lateral to the umbilicus, usually on the right
ECF loss
heat loss
Gastroschisis
Gastroschisis
Etiology
exact cause unknown Theories intrauterine occlusion of omphalomesenteric artery ischemia and atrophy of abdominal muscles early fetal rupture of an omphalocoele
Gastroschisis
Omphalocoele
Omphalocoele
External herniation of abdominal viscera into the base of the umbilical cord through a central defect Defect: small or large Umbilical cord is inserted into the apex of the lesion Presence of covering or sac (amnion and peritoneum) Incidence: 1-5,000-10,000 live births
Omphalocoele
Omphalocoele
Etiology
incomplete return of the gut to the abdominal cavity due to an abdominal lateral fold defect Failure of migration and fusion of cranial, caudal and/or lateral folds of the embryonic disc at ~ 3rd wk of gestation
Omphalocoele
Diaphragmatic defect
Ectopia cordis Cardiac anomaly
Omphalocoele
Pentalogy of Cantrell
Omphalocoele
Gastroschisis Incidence Peritoneal covering/sac Location of defect Herniated bowel 1:15,000-30,000 absent periumbilical matted, edematous
Associated anomalies
low (10-15%)
intestinal atresia (15%)
high (40-60%)
congenital heart dis. Beckwith-Weidman syndrome
Gastroschisis
Omphalocoele
Preoperative Management
Anesthetic Concerns
Hydration / fluid status
warm moist sterile saline-soaked gauze plastic bowel bag
initial fluid requirement 10 -15 ml/kg/hr; higher with gastroschisis 100-200 ml/kg/hr
Heat loss : neutral thermal environment Difficulties of surgical closure Associated congenital anomalies & prematurity
Preoperative Management
Aspiration precautions
Direct trauma to herniated organ
Preoperative Management
Ancillary Procedures
CXR
Echocardiography
Intraoperative Management Premedication: atropine IV access: 2 large bore IVs preferably above the diaphragm Monitors: ASA standard : 2 pulse oximeters
Intraoperative Management
Choice of Anesthesia
general anesthesia spinal (reported) in selected patients
Induction
decompress the stomach rapid sequence IV induction with cricoid pressure or inhalation induction and intubation or awake intubation
Intraoperative Management
Maintenance of Anesthesia
Opiate technique or judicious use of
inhalational agents Avoid nitrous oxide Adjust FiO2: PaO2 50-70 mmHg SpO2 97-98% term
87-92% preterm
Muscle relaxant facilitates abdominal closure
Intraoperative Management
Prevent hypothermia
full access body hugger
increase room temp fluid warmer
heating blanket
plastic wrap
Fluid requirement
maintenance: D5 0.2% NS
Intraoperative Management
Surgical Closure
optimal method remains controversial
1) primary fascial closure : 80% intraop and postop muscle paralysis 2) staged repair
Intraoperative Management
Closure dependent on the 1) size of the defect 2) development of abdominal wall 3) presence of associated anomalies
Intraoperative Management
Primary Closure monitor: airway pressure, O2 saturation and ABG tight abdominal closure
1) impairs diaphragmatic excursion ventilatory compromise 2) impedes venous return profound hypotension
Intraoperative Management
Staged Reduction
Dacron reinforced silastic silo
Gradual reduction over 1- 2 weeks Ketamine or opioid muscle relaxant in intubated patients or Titration of ketamine 0.5 -1 mg/kg IV with spontaneous breathing unintubated infants Final closure in the OR
Silo closure
Intraoperative Management
Postoperative Management
NICU Postop ventilation in most neonates for 24-48 hrs Fluid requirements may remain high Prolonged postop ileus: TPN or PPN
Necrotizing enterocolitis
Renal insufficiency
Pneumonia
Abdominal wall breakdown
PDA
GE reflux
weight
Mortality rate: 10 - 30%
PREMATURITY
Can occur in:
premature infants
LBW infants
enteral feeding
use of hyperosmolar formula congenital heart disease hx of umbilical arterial catheterization hx of exchange transfusion
Early signs
gastric residuals with feedings temperature instability poor feeding bilious vomiting lethargy
Necrotizing Enterocolitis
Thrombocytopenia
Coagulopathy, DIC
Prerenal azotemia
Metabolic acidosis
Physical Exam distended and tender abdomen Labs: CBC electrolytes and glucose platelets and coagulation profile
DIC profile
ABG
Abdominal X-ray
signs of bowel obstruction ileus with edematous bowel
Pneumatosis intestinalis
or intramural air (arrow)
Medical Management
10 - 50% mortality
Medical Management
No enteral feedings for 10-14 days NGT on intermittent suction Hydration and correction of electrolytes Ventilatory support Antibiotics Blood and platelet transfusion if needed
Surgical Indications
Absolute Indications
1) bowel perforation
2) intestinal gangrene
Relative Indications
clinical condition
metabolic acidosis
respiratory failure oliguria, hypovolemia thrombocytopenia leucopenia, leukocytosis
Necrotizing Enterocolitis
Non-Surgical Indications severe GI hemorrhage abdominal tenderness intestinal obstruction gasless abdomen with ascites
Anesthetic Concerns
Fluid/volume status
Significant 3rd space loss Full stomach / pulmonary aspiration Metabolic abnormalities acidosis, hyperglycemia
Coagulopathy: thrombocytopenia
Respiratory failure Sepsis / hemodynamic instability
inotropic support dopamine infusion
Intraoperative Management
Adequate IV access
Monitors:
ASA standard
Induction
rapid sequence if not intubated
Intraoperative Management
Maintenance of Anesthesia
Narcotic based technique Avoid nitrous oxide Inhalational agents poorly tolerated
Avoid hypothermia
Postop Management
NICU Postop ventilation required Continue resuscitation Parenteral Nutrition
Summary
Almost all neonatal surgical emergencies are really urgencies
Successful perioperative outcome depends on open communication and teamwork between neonatologist, anesthesiologist and surgeon Initial resuscitation of neonatal surgical candidates includes:
airway protection adequate IV access fluid resuscitation temperature stabilization gastric decompression administration of antibiotics identify associated anomalies
Omphalocoele
Embryology Failure of the midgut to return to the abdominal cavity by the 10th wk of gestation