This document discusses surgical problems in newborns. It covers neonatal physiologic characteristics like water metabolism and renal function. It describes variations in individual newborns based on gestational age and weight. Fluid and electrolyte requirements are provided for terms. Urine output requirements are given for different surgical conditions. Metabolic issues like hypocalcemia and hypothermia are risks. The surgical stress response in newborns is characterized by catabolism with increases in cathecolamines, cortisol, and glucagon.
This document discusses surgical problems in newborns. It covers neonatal physiologic characteristics like water metabolism and renal function. It describes variations in individual newborns based on gestational age and weight. Fluid and electrolyte requirements are provided for terms. Urine output requirements are given for different surgical conditions. Metabolic issues like hypocalcemia and hypothermia are risks. The surgical stress response in newborns is characterized by catabolism with increases in cathecolamines, cortisol, and glucagon.
This document discusses surgical problems in newborns. It covers neonatal physiologic characteristics like water metabolism and renal function. It describes variations in individual newborns based on gestational age and weight. Fluid and electrolyte requirements are provided for terms. Urine output requirements are given for different surgical conditions. Metabolic issues like hypocalcemia and hypothermia are risks. The surgical stress response in newborns is characterized by catabolism with increases in cathecolamines, cortisol, and glucagon.
This document discusses surgical problems in newborns. It covers neonatal physiologic characteristics like water metabolism and renal function. It describes variations in individual newborns based on gestational age and weight. Fluid and electrolyte requirements are provided for terms. Urine output requirements are given for different surgical conditions. Metabolic issues like hypocalcemia and hypothermia are risks. The surgical stress response in newborns is characterized by catabolism with increases in cathecolamines, cortisol, and glucagon.
SURGICAL PROBLEMS IN THE concentration ability (limited urea in
NEWBORN medullary interstitium) which makes
Dr. Noel Binayas them less tolerant to dehydration. June 26, 2013 The neonate is metabolically active and Group 9 v2.0 production of solute to excrete in the urine is high. The kidney in the newborn SURGICAL NEONATE can only concentrate to about 400 A. Neonatal Physiologic Characteristics mOsm/L initially (500-600 mOsm/L the 1. Water metabolism full term compared to 1200 mOsm/L for 2. Fluid and electrolytes concepts an adult), and therefore requires 2- B. Variations in Individual Newborns 4cc/kg/hr urine production to clear the 1. Types of Newborn Infants renal solute load. 2. Metabolic and Host Defense 3. Surgical Response of Newborn Fluid and Electrolyte Concepts Electrolyte requirements of the full- VARIATIONS IN INDIVIDUAL NEWBORNS term neonates are: 1. Types of newborn Infants Sodium 2-3 meq/kg/day a. The full term, full-size infant with a gestational Potassium 1-2 meq/kg/day age of 38 weeks and a body weight greater than Chloride 3-5 meq/kg/day 2500 grams (TAGA) - they received adequate At a fluid rate of 100cc/kg/24 hrs for intrauterine nutrition, passed all fetal tasks and the first 10 kg of weight their physiologic functions are predictable. As a rule of thumb, the daily fluid b. The preterm infant with a gestational age below requirement can be approximated too: 38 weeks and a birth weight appropriate for that age ( PreTAGA) Prematures 120-150cc /kg/24 hrs c. The small-for-gestational-age infant (SGA) with a gestational age over 38 weeks and a body Neonates (term) weight below 2500 grams-has suffered growth 100cc/kg/24 hrs retardation in utero. Infants >10kg d. A combination of (b) and (c), i.e., the preterm 1000cc +50 cc/kg/24hrs infant who is also small for gestational age. Impaired ability to excrete a sodium load can be amplified with surgical NEONATAL PHYSIOLOGIC CHARACTERISTICS stress (progressive renal retention of Water Metabolism sodium). Estimations of daily fluid Water represents 70-80% of the body requirements should take into weight of the normal neonate and consideration: premature baby respectively. 1. Urinary water losses There is a gradual decrease in body 2. Gastrointestinal losses water and the extracellular fluid 3. Insensible water losses and compartment with a concomitant 4. Surgical losses (drains) increase in the intracellular fluid compartment. This shift is interrupted NEWBORN FLUID VOLUME REQUIREMENTS (ML/KG/24HRS) FOR VARIOUS SURGICAL CONDITIONS with a premature birth. The newborns body surface area is Group Day 1 Day 2 Day 3 relatively much greater than the adult Mod. surgical conditions 80+25 80+30 80+30 and heat loss is a major factor. (e.g. colostomies, laparo- Insensible water loss are from the lung tomies for intestinal (1/3) and skin (2/3) atresia, Hirschsprung's Neonatal renal function is generally disease adequate to meet the needs of the Severe surgical condition 140+45 90+20 80+15 normal full-term infant but may be (gastrochisis, mid gut limited during periods of stress. Renal volvulus, meconium peritonitis) characteristics of newborns are low Necrotizing enterocolitis 145+70 135+50 130+40 with perforation glomerular filtration rate and The degree of dehydration can be measured by clinical Hypocalcemia parameters such as: The preterm and surgical neonate is more Body weight prone to hypocalcemia due to reduced stores, Tissue turgor renal immaturity, and relative State of peripheral circulation hypoparathyroidism (high fetal calcium levels). Depression of fontanelle Symptoms are jitteriness and seizures with Dryness of the mouth and increased muscle tone. Urine output Calcium maintenance is 50mg/kg/day
MINIMUM NEWBORN IDEAL URINE OUTPUT Hypothermia
(ML/KG/HR) FOR VARIOUS SURGICAL CONDITIONS There is an association between the hypothermia and mortality in the NICU's Group Day 1 Day 2 Day 3 The surgical neonate is prone to hypothermia Mod. surgical 2+0.96 2.63+1.71 2.38+0.92 Infants produce heat by increasing metabolic conditions activity and using brown fat. Below 35oC the (e.g. colostomies, newborn experiences lassitude, depressed laparotomies respiration, bradycardia, metabolic acidosis, for intestinal hypoglycemia, hyperkalemia, elevated BUN and atresia, Hirschsprung's oliguria (neonatal cold injury syndrome) disease) Factors that further precipitate these problems Severe surgical condi- 2.67+0.92 2.96+0.54 2.96+1.0 are: prematurity, prolonged surgery, and tion (gastrochisis, mid gut eviscerated bowel (gastroschisis) volvulus, meconium peritonitis) SURGICAL RESPONSE OF NEWBORN Necrotizing 2.58+1.04 3.17+1.67 3.46+1.46 The endocrine and metabolic response to enterocolitis with perforation surgical stress in newborns (NB) is characterized by catabolic metabolism. An initial elevation in The newborn infants require 100-200 cathecolamines, cortisol and endorphins upon calories/kg/day for normal growth. This is increased stimulation by noxious stimuli occurs; a defense during stress, cold, infection, surgery and trauma. mechanism of the organism to mobilize stored Minimum daily requirements are 2-3 gm/kg of energy reserves, form new ones and start protein, 10-15 gm/kg of carbohydrate and small cellular catabolism amount of essential fatty acids. Cortisol is responsible for protein breakdown, release of gluconeogenic aminoacids from METABOLIC AND HOST DEFENSES ‘ADAPTATIONS' muscle, and fat lipolysis with release of fatty Jaundice acids. "physiological Jaundice" Glucagon secretion is increased. Plasma insulin ability of the immature liver to conjugate increase is a reflex to the hypoglycemic effect, bilirubin is reduced, the life span of the red although a resistance to its anabolic function is blood cell is short, and the bilirubin load present. presented to the circulation via the During surgical stress NB release glucose, fatty enterohepatic route is increased. acids, ketone bodies, and amino acids; *other problems affecting the baby include the rapid necessary to meet body energy needs in time of development of "HYPOGLYCEMIA' (35mg%) increase metabolic demands. * Newborns have a poorly developed gluconeogenesis system, and depends on glycolysis from liver glycogen Factors correlating with a prolonged catabolic response stores (depleted 2-3 hrs after birth) and central during surgery are: nutrition. The degree of neuroendocrinological maturation Duration of operation Amount of blood loss Type of surgical procedure, extent of surgical trauma Associated conditions (hypothermia, 9. Esophageal atresia with or without TE fistula prematurity, etc.) (TEF) They could be detrimental due to the NB's 10. Gastroesophageal reflux and hiatal hernia limited reserves of nutrients, the high metabolic 11. Hirschsprung's disease (megacolon) demands impose by growth, organ maturation 12. Hydrometrocolpos and imperforate hymen and adaptation after birth. Anesthetics such as 13. Imperforate anus including persistent cloaca halothane and fentanyl can suppress such 14. Inguinal hernias response in NB. 15. Intestinal obstruction including duodenal atresia, annular pancreas, malrotation,midgut ESTIMATION OF BLOOD VOLUME volvulus, intestinal atresia, meconium ileus and meconium peritonitis Group Blood volume (ml/kg) 16. Necrotizing enterocolitis Premature infants 85-100 17. Ovarian cysts Term newborns 85 18. Pyloric stenosis 1mo 75 19. Rib cage and sternal deformities 3 mos -adult 70 20. Teratoma (sacrococcygeal) and other tumors of the newborn Obstructive and GI problems 21. Umbilical anomalies including hernia, patent Obstructions urachus, patent omphalo-mesenteric duct Bleeding (NEC) 22. Undescended testes Thoracic (respiratory distress) problems Hernias, diaphragmatic, etc. Many of these neonatal surgical problems are very Lung bud anomalies rare, occurring in 1 in 5,000 to 1 in 25,000 live Abdominal wall defects births. Pediatric surgeons have specialized training Umbilical hernias and granulomas in treating these conditions. Omphalocele and gastroschisis Cloacal extrophy "The Neonate has innate disadvantages in the Epigastric hernias immediate period of extra-uterine existence." Recurrent inguinal hernias " The Child is not a small adult neither is the neonate Acute scrotum & epididymis just a small child! " Pancreatic, biliary, splenic, hepatic conditions (biliary atresia, choledochal cyst) "the neonate is not just a small child" Tumors (wilms tumor, neuroblastomas, germ cell tumors) Gynecological intersex conditions SURGICAL PECULIARITIES Twinning and deformities (mostrosity) Miscellaneous (trauma, etc) Anatomic Disadvantages (Peculiarities) -Small Size (parts, orifices, vessels) -Small weight to BSA ratio INTESTINAL OBSTRUCTION IN THE NEONATE -Pliable and Delicate tissues, vessels -Head and Neck peculiar Neonatal surgical conditions which are best managed by -Thoracic wall/Lungs peculiar pediatric surgeons include -CVS peculiar 1. Abdominal wall defects including gastroschisis, -Abdomen peculiar… omphalocele, and Pentalogy of Cantrell 2. Biliary atresia and choledochal cyst Functional Disadvantages (Peculiarities) 3. Cloacal exstrophy -Poor thermo-regulation 4. Conjoined twins -Glucose source is limited 5. Cystic adenomatoid malformation of the lung -Obligate nose-breather and other types of bronchogenic cysts -Diaphragmatic breather 6. Cystic hygroma and other neck masses -Easily fatigued 7. Diaphragmatic hernia -Respiratory failure 8. Duplication cysts and mesenteric cysts -Poor renal handling of fluid volume - Small blood volume; inadequate sympathetic response * manifestations : whole midgut rotaton OR ischemic * "These peculiarities must be considered in any midgut surgical neonate… in addition to the specific effects and *amount of distention is determined by the distance of consequence of any persistent congenital anomaly… obstruction. The farther, the better. and dealt with appropriately!" - Anal Fissures 6. Masses or tumors; - Wilm's Tumor - Neuroblastoma 7. Jaundice - Biliary Atresia - Choledochal Cyst
**BROWN FAT is located in the interscapular areas
and around the big vessels of the neck, chest and abdomen.
NEONATAL SURGICAL EMERGENCIES
LOGICAL APPROACH TO NEONATAL INTESTINAL Manifested AFTER Birth! OBSTRUCTION
1. Breathing problems: Signs and Symptoms:
-apnea, respiratory distress, dyspnea, cyanosis, 1. Bilious vomiting is always abnormal. - Congenital Diaphragmatic Hernia; 2. Abdominal distention - Esophageal Atresia (scaphoid abdomen possible). 2. Feeding Problems: 3. Delayed, scanty or no passage of meconium. -vomiting (bilious), regurgitation 4. Polyhydramnios in mother - Malrotation 5. Down's syndrome - Intestinal Atresias 6. Family history -Hypertrophic Pyloric Stenosis a. Hirschsprung's disease 3. Delay, Failure in passage of meconium; b. Diabetic mother - Hirschsprung Disease c. Jejunal atresia - Anorectal Malformation 4. Abdominal Defects * "The surgeon must have a high index of suspicion" - Omphalocele - Gastroschisis 5. GI Bleeding - Volvulus Neonatorum Dr. C.E. Coop's "2-minute test" 1. High Index of suspicion in the delivery room. 2. Within two minutes of birth, 1. Inspection 2. Palpation 3. Rectal probing / digital examination 4. OGT-NGT insertion / gastric aspiration
*While in the Delivery Room: you should be able to
rule-out or consider the following (as yet) unapparent anomalies: 1. Choanal atresia 2. Esophageal Atresia 3. Gastric Outlet/ Duodenal Obstruction -congenital pyloric obstruction -duodenal or jejunal atresia/stenosis -congenital bands/malrotation 4. Anorectal Anomalies/ Imperforate Anus 5. Anal stenosis
WORK-UP (LOGICAL APPROACH)
"double bubble" - pathognomonic of duodenal atresia 1. While the infant is being studied, it must be kept in mind that the problem may be "non-surgical". a. Sepsis of the newborn with associated ileus is the most important cause of non-surgical bilious vomiting and abdominal distention. b. Intracranial lesions 2. Plain roentgenograms of the abdomen. a. Diagnostic in complete high intestinal obstruction- no gas in distal small bowel. b. Many gas filled loops (requires 24 hours) indicates some form of low intestinal obstruction. c. May be nonspecific in instances of malrotation of the intestines. This diagnosis must always be considered in neonates with unexplained bilious vomiting. d. Calcifications - at some time during fetal life meconium is present in the abdomen. 3. Contrast enema will differentiate the various types Roentgenogram (X-Ray) of person with duodenal of low intestinal obstruction. atresia a. Microcolon - complete obstruction of the small bowel. b. Meconium plug syndrome - colon dilated proximal to an intraluminal mass. c. Hirschsprung's disease - although it may appear to be diagnostic, not reliable in the newborn. d. Small left colon syndrome - colon dilated to the splenic flexure, then becomes narrow.
4. Upper G.I. series - the procedure of choice in
diagnosing malrotation of the intestines. *In the past a contrast enema was thought to be the diagnostic test of choice in instances of malrotation but the cecum and ascending colon can be in normal position in an infant or child with malrotation of the intestines. 5. Rectal biopsy- a pathologist competent in reading the * Barium enema has known limitations in slides is essential and should not be taken for granted diagnosis of malrotation. a. Suction biopsy of the rectal mucosa and *In cecum malrotation- bilious emesis is a submucosa surgical emergency until proven otherwise b. Full thickness biopsy of the rectal wall may be *If the history and physical findings are highly necessary if the suction biopsy is non-diagnostic or suspicious for acute mid-gut volvulus in the newborn, if the pathologist is unwilling or unable to make the urgent operative intervention is indicated without diagnosis of aganglionosis on a suction biopsy confirmatory radiographic studies. specimen. c. All newborns who have delayed passage of This is justified due to the disastrous meconium associated with a suspicious contrast consequences related to delayed treatment of this enema should have a suction biopsy of the rectal potentially correctable process. " - paul stockmann mucosa and submucosa. d. Suction biopsy of the rectum is probably NEONATAL HIRSCHPRUNG DISEASE indicated in all cases of so called meconium plug Signs and Symptoms syndrome or small left colon syndrome. • Delayed passage of meconium MALROTATION • Sudden/acute abdominal distention frank -refers to a group of congenital anomalies resulting obstruction from aberrant intestinal rotation and fixation during the • Progressive abdominal Distension acute first 3 months of gestation. obstruction • Intermittent Abdominal Distension relieved by "Bilious emesis in the newborn is a surgical emergency passage of stool and gas until proven otherwise." • Constipation from newborn and early infancy • Due to the risk of significant adverse outcome, • Large abdomen, meconium with rectal malrotation should be the first consideration. stimulation, whitish OGT drainage • The anomalies of intestinal rotation and fixation • Visible bowel loops consist of a spectrum of anatomic defects and a • Gush of stool and gas (diarrhea) with rectal wide range of clinical findings. stimulation/examination Acute mid-gut Volvulus - Duodenal Obstruction * most common distal obstruction which involves: • Asymptomatic or present during infancy and - post prandial vomiting early childhood -non bilious • Nonrotation - Incomplete rotation (70%) - hypertrophic Pyloric Stenosis • Mixed rotational and fixation anomalies • Mesocolic hernias Surgical procedure: cut the muscle in pylorus but do not include the mucosa Keys to Diagnosis • High Index of Suspicion In summary • Radiographic Studies : * Malrotation of the intestines and Hirschsprung's - Plain x-ray (Obstructive series) disease must be ruled out before a newborn with - Upper GI series unexplained bilious vomiting and/or abdominal 1. Incomplete duodenal obstruction, usually in the third distention is sent home. It can be unsafe to rely on portion. parents to observe their infant for problems 2. The ligament of Treitz not to the left of midline or at the resulting from the above conditions. level of the gastric antrum. 3. Abnormal position of the proximal jejunal loops to the right * If diagnosed late, malrotation of the intestines or of the midline. Hirschsprung's disease can become life threatening 4. Deformity of the duodenum, "bird's beak", "corkscrew" or or result in life long problems. "coiled" configuration. 5. Delayed films show intestine-cecum junction not in the RLQ.