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
• Cardiac and respiratory status
• Metabolic and electrolyte imbalance
• Hydration status
• Coagulation profile
• IV access
Pyloric Stenosis
Pyloric Stenosis
Most common GI obstructive anomaly in neonates
Hypertrophy of the muscular layer of the pylorus
A medical emergency but not a true surgical
emergency
Incidence: 1 – 3 :1,000 live births
2 - 5x more common in first born, M > F (4:1)
Pyloric Stenosis
Etiology : unknown
? acquired condition with hereditary
predisposition
Symptoms are apparent between 2nd-6th wk of life
Presents with nonbilious projectile vomiting, signs
of dehydration, jaundice (2%)
Pyloric Stenosis
Physical Exam
visible gastric peristalsis
palpable “olive-shaped” mass to the right
of the epigastric area
signs of dehydration
Labs: CBC
ABG
serum electrolytes
BUN
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
Pyloric Stenosis
Metabolic Abnormalities
• hyponatremia
• hypochloremia
• hypokalemia
• 1° metabolic alkalosis
• compensatory respiratory acidosis
• paradoxical acidic urine
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
• Correction of electrolyte imbalance
• Prevention of aspiration : NGT
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
Anesthetic Concerns
• pulmonary aspiration
• severe dehydration
• metabolic alkalosis
Pyloric Stenosis
Intraoperative Management
Monitors : ASA standard
Decompress the stomach
GA: Induction: controversial
awake intubation
rapid sequence IV induction and
intubation with cricoid pressure
inhalation induction with cricoid pressure
± muscle relaxant
Pyloric Stenosis
Intraoperative Management
Cook-Sather, 1998 (CHOP)
• prospective, nonrandomized study
• awake vs paralyzed intubation (RSI and MRSI)
• faster and more successful tracheal intubation
with muscle paralysis
• awake intubation does not protect from
bradycardia and desaturation
Pyloric Stenosis
Intraoperative Management
Maintenance
IV narcotics: rarely needed
inhalational agents
Postop pain relief
acetaminophen 30-40 mg/kg PR
caudal epidural
LA infiltration of surgical incision
Pyloric Stenosis
Extubate awake
Postoperative concerns
respiratory depression and apnea
hypoglycemia
Congenital Diaphragmatic
Hernia
a problem unresolved
Congenital Diaphragmatic Hernia
Herniation of abdominal viscera into the thorax
Result from failure of the pleuroperitoneal canal
to close at ~ 8th wk of gestation or early
return of midgut to the peritoneal cavity
Most challenging and frustrating of all neonatal
surgical emergencies
Congenital Diaphragmatic Hernia
50% mortality regardless of the method of
treatment
Incidence: 1:2,000-5,000 live births
M<F 1:1.8, frequently full term
Etiology: unknown
no genetic factors have been implicated
Antenatal history: polyhydramnios
Congenital Diaphragmatic Hernia
Classification
• Absent diaphragm : rare
• Diaphragmatic hernia
80% posterolateral L >R
(Bochdalek)
2% anterior (Morgagni)
15 - 20% paraesophageal
• Eventration (15 - 20%)
Congenital Diaphragmatic Hernia
Associated anomalies (20-50%)
cardiovascular
13 - 23%
CNS
28%
gastrointestinal
20%
genitourinary
15%
• increase the mortality rate
Congenital Diaphragmatic Hernia
Classic Triad
Dyspnea
Cyanosis
Apparent dextrocardia
Congenital Diaphragmatic Hernia
Physical Exam
scaphoid abdomen and barrel chest
bowel sounds in the chest
displaced heart sounds
Laboratory Studies
CBC
ABG
electrolytes
calcium
glucose
Congenital Diaphragmatic Hernia
Diagnosis: chest x-ray
• loops of bowel in the
chest
• mediastinal shift
• absent lung markings
Congenital Diaphragmatic Hernia
IMMEDIATE
Intubation
+
Stomach Decompression
Congenital Diaphragmatic Hernia
Determinants of Survival
• degree of pulmonary hypoplasia
ipsilateral lung > contralateral lung
• development pulmonary vasculature
Congenital Diaphragmatic Hernia
Goals of Management
• maximize arterial oxygenation
mechanical ventilation: use low inflating
pressures
increases pulmonary blood flow
• prevention of pain
fentanyl infusion 3-10 mcg/kg/hr
• correction of acidosis
Congenital Diaphragmatic Hernia
Standard Management Strategy
Reduce pulmonary HTN
Moderate alkalosis
pCO2 < 40 mmHg
PaO2 >100 mmHg
Congenital Diaphragmatic Hernia
Recent Strategy
• Permissive hypercapnia and hypoxemia
• Pressure-limited ventilation (<25 cmH2O)
• Postductal pCO2 40-65 mmHg
• Preductal SpO2 85-90%
• Postductal SpO2 ignored unless pH is
< 7.20 or pCO2 > 65
Congenital Diaphragmatic Hernia
Bohn (1986)
reevaluation of the traditional “mad dash”
surgical strategy
recommended 24 – 48 hrs medical stabilization
assessment of efficacy of delayed approach
infants unresponsive to initial therapy will fail to
survive with surgery or any other treatment
including ECMO
Congenital Diaphragmatic Hernia
The Relationship Between PaCO2 and Ventilation
Parameters in Predicting Survival in CHD
• Arterial CO2 accurately reflects the degree of
lung development
• Poor survival in the presence of severe
pulmonary hypoplasia
• CO2 retention and severe preductal shunting
have 90% mortality
Bohn, DJ, et al
J of Pedia Surg 19: 666-671, 1884
Congenital Diaphragmatic Hernia
nomogram:
to predict the degree of pulmonary hypoplasia in
the infants and chance of survival
used the preop PaCO2 and an index of ventilation (Vi)
If PaCO2 < 40 and Vi < 1000: survival almost universal
If PaCO2 > 40 and Vi > 1000: death virtually inevitable
‫ ٭‬Vi = mean airway pressure x respiratory rate
Congenital Diaphragmatic Hernia
Relationship of Alveolar-arterial Oxygen
Tension Difference in Diaphragmatic
Hernia in the Newborn
A-aDO2 on 100% O2
< 400 mmHg: usually survive
400 - 500 mmHg: intermediate chance
> 500 mmHg: unlikely to survive
Harrington J, et al
Anesthesiology 56: 473-476, 1982
Congenital Diaphragmatic Hernia
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
Congenital Diaphragmatic Hernia
Indications of Surgical Repair
• Reversal of ductal shunting
• O2 index of < 40
• Arterial pCO2 maintainable under
40 mmHg
• Hemodynamic stability
Congenital Diaphragmatic Hernia
Preoperative Preparation
• Look for associated anomalies
• Labs: CBC, electrolytes, ABG, glucose,
blood type and crossmatch
• Ancillary procedures: CXR, Echo
• Venous access: upper extremities
preferred
• Prevention of hypothermia
Congenital Diaphragmatic Hernia
Intraoperative Management
Monitors:
ASA standard
invasive : arterial line ± CVP
foley catheter
* 2 pulse oximeters: preductal and postductal
* precordial stethoscope on the right axilla
NGT to decompress the stomach
Adequate IV access
Congenital Diaphragmatic Hernia
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
Congenital Diaphragmatic Hernia
Intraoperative
Maintenance of anesthesia
volatile agents + IV narcotics + muscle relaxants
TIVA
avoid nitrous oxide
avoid increase in PVR leading to R→L shunting:
hypoxia, acidosis, hypothermia, pain
treat metabolic acidosis
replace significant blood loss
Congenital Diaphragmatic Hernia
Intraoperative
Mechanical Ventilation
adjust FiO2 to achieve
PaO2 80 -100 mmHg
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
Thoracoscopic repair has been reported
Congenital Diaphragmatic Hernia
Intraoperative
Potential Problems
• Hypoxemia
distension of stomach
1° pulmonary hypoplasia / pulmonary HTN
• Contralateral pneumothorax
• Hypotension or IVC compression
• Cardiac arrest
Congenital Diaphragmatic Hernia
Postoperative Care
Ventilatory support
Close fluid management
Hemodynamic monitoring
“Honeymoon Period” followed by deterioration
increase abdominal pressure
impaired peripheral and visceral perfusion
limited diaphragmatic excursion
worsening of pulmonary compliance
Congenital Diaphragmatic Hernia
Management of PPHN
• Minimize ETT suctioning
• Vasodilators : rarely effective
tolazoline
isoproterenol
nitroglycerin
SNP
PGE1
• Inhaled nitric oxide
endothelium - derived relaxing factor (EDRF)
selective pulmonary vasodilation
rapidly metabolized
has not been shown to improve survival
Congenital Diaphragmatic Hernia
Extracorporeal Membrane Oxygenation
(ECMO)
• Use: controversial
• Allows the lungs to develop & restructure
• Expensive
• improved survival in neonates with
> 80% mortality
Congenital Diaphragmatic Hernia
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
Congenital Diaphragmatic Hernia
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
(TEF)
Tracheoesophageal Fistula
Incidence: 1:4000 live births
M > F (25:3)
10-40% are preterm
Antenatal history: polyhydramnios (60%)
Etiology: failure in mesenchymal separation of
upper foregut
Tracheoesophageal Fistula
Clinical Presentation
choking on 1st feed
coughing
cyanosis
excessive salivation
aspiration pneumonia
Tracheoesophageal Fistula
Diagnosis
• inability to pass a suction catheter
into the stomach
• CXR: coiled orogastric tube in the
cervical pouch; air in the stomach
and intestine
Tracheoesophageal Fistula
Esophageal Atresia
Tracheoesophageal
Fistula
Turnage RH, et al, Sabiston Textbook of Surgery,17th Ed. 2004
TracheoEsophageal Fistula
5 Types (Gross and Vogt)
7.7%
0.8%
86%
0.7%
4.2%
Gregory GA, ed, Pediatric Anesthesia, 3rd edition, 1996
Tracheoesophageal Fistula
35-65% have associated anomalies
VATER and VACTERL
V
vertebral anomalies or VSD
A
anorectal malformation
C
cardiac anomalies (common)
T
TEF
E
esophageal atresia
R
renal abnormalities
L
limb/radial malformation
Tracheoesophageal Fistula
Preoperative Preparation
Minimize pulmonary complication
npo
head-up position
sump tube (repogle) on low continuous suction
± gastrostomy under local anesthesia
CXR, abdominal x-ray, renal ultrasound
12-L EKG and Echocardiogram : mandatory
IV access ± arterial line
Tracheoesophageal Fistula
Preoperative Preparation
Laboratory studies
CBC
Electrolytes
Glucose
Calcium
ABGs
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
oxygenation and ventilation
securing the airway
Monitors
ASA standard
± invasive : arterial line
* precordial stethoscope in the L axillary area
Tracheoesophageal Fistula
Intraoperative Management
Anesthetic Technique
• “classic approach”
GA without muscle paralysis
• combined light GA + epidural (Bosenberg)
• GA with muscle paralysis
Tracheoesophageal Fistula
Intraoperative Management
Induction
• awake intubation
• rapid sequence IV induction
• inhalation induction spontaneous
ventilation without muscle relaxant
Tracheoesophageal Fistula
Intraoperative Management
Assessment of ETT position
Goal: ETT just above the carina and just below
the fistula
• Right mainstem intubation and withdraw ETT
until bilateral breath sounds
• Left mainstem intubation: poorly tolerated
due to insufficient pulmonary reserve
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
Beware of gastric distention
gentle positive pressure ventilation
gastrostomy: open if present
TEF + RDS combination
now what???!!
gastrostomy under local anesthesia
fogarty embolectomy catheter
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
Intraoperative problems
• Endobronchial intubation
• Intubation of fistula
• Obstruction of ETT
• V/Q mismatch
lateral decubitus position
nondependent lung retraction
• Vagal response to tracheal manipulation
• Return to transitional circulation and shunting
Tracheoesophageal Fistula
Postoperative Management
Early extubation desirable
caution: disruption of surgical repair with
reintubation
Postop Pain Management
1. IV narcotics
2. epidural infusion: 0.1% bupivacaine +
fentanyl 0.5 mcg/ml at 01.-0.2 ml/kg/hr
3. rectal Tylenol + LA infiltration of incision
Tracheoesophageal Fistula
Main Cause of Mortality
associated anomalies
survival rates 85-90%
Long Term Complications
GE reflux
anastomotic stricture
tracheomalacia
Abdominal Wall Defects
Gastroschisis
Omphalocoele
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
Absence of covering or sac
chemical peritonitis
infection
ECF loss
heat loss
Incidence: 1:15,000-30,000 live births
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
• rupture of umbilical cord at the site
of the resorbed right umbilical vein
• ? Maternal: smoking, ETOH,
recreational drugs, medications
(NSAIDS, pseudoephredrine)
• associated anomalies - rare
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
Cranial Fold : Pentalogy of Cantrell
Epigastric omphalocoele
Sternum cleft
Diaphragmatic defect
Ectopia cordis
Cardiac anomaly
Omphalocoele
Lateral Fold
omphalocoele with cord coming of the
center of the sac
Caudal Fold
Hypogastric omphalocoele
Extrophy of the bladder
Imperforate anus
Colonic agenesis
Vesicointestinal fistula
Omphalocoele
Associated Congenital Anomalies: 75-80%
chromosomal: trisomy 13, 15, 21
cardiac anomalies: 20%
craniofacial
gastrointestinal
Beckwith-Wiedeman Syndrome
omphalocoele
microcephaly
visceromegaly
hypoglycemia
macroglossia
hyperviscosity
Pentalogy of Cantrell
Omphalocoele
Survival: 20% with heart disease
70% without heart disease
Major cause of mortality
cardiac defects
prematurity
Definitive Treatment: surgical repair
Incidence
Peritoneal
covering/sac
Location of
defect
Herniated
bowel
Associated
anomalies
Gastroschisis
Omphalocoele
1:15,000-30,000
1:6,000
absent
present
periumbilical
matted, edematous
low (10-15%)
intestinal atresia
(15%)
within the umbilical
cord
normal
high (40-60%)
congenital heart dis.
Beckwith-Weidman
syndrome
Gastroschisis
Omphalocoele
Abdominal Wall Defects
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
Abdominal Wall Defects
Preoperative Management
• Infection and postop nutrition
• Postoperative ventilation
• Airway
• Metabolic status
• Aspiration precautions
• Direct trauma to herniated organ
Abdominal Wall Defects
Preoperative Management
Lab workup
CBC
Electrolytes and Glucose
ABG
Ancillary Procedures
CXR
Echocardiography
Abdominal Wall Defects
Intraoperative Management
Premedication: ± atropine
IV access: 2 large bore IVs preferably above
the diaphragm
Monitors:
ASA standard : 2 pulse oximeters
invasive: arterial line
± CVP
foley catheter
intraop airway pressures
Abdominal Wall Defects
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
Abdominal Wall Defects
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
Abdominal Wall Defects
Intraoperative Management
Prevent hypothermia
full access body hugger
heating blanket
increase room temp
plastic wrap
fluid warmer
Fluid requirement
maintenance: D5 0.2% NS
3rd space loss replacement
isotonic fluid 10 -15 ml/kg/hr
blood loss from adhesions
Abdominal Wall Defects
Intraoperative Management
Surgical Closure
• optimal method remains controversial
1) primary fascial closure : 80%
± intraop and postop muscle paralysis
2) staged repair
silicone elastometer pouch
primary skin closure
Abdominal Wall Defects
Intraoperative Management
• Closure dependent on the
1) size of the defect
2) development of abdominal wall
3) presence of associated anomalies
Abdominal Wall Defects
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
3) aortocaval compression → bowel ischemia, ↓ CO,
renal and hepatic dysfunction, wound
dehiscence
Abdominal Wall Defects
Intraoperative Management
Unsafe for Primary Abdominal Closure
• Intragastric pressure > 20 cmH2O
• Intravesical pressure > 20 cmH2O
• Change in CVP 4 ≥ mmHg
• ETCO2 ≥ 50 mmHg
• Peak inspiratory pressure ≥ 35 cmH2O
Abdominal Wall Defects
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
Abdominal Wall Defects
Intraoperative Management
Silo closure
Abdominal Wall Defects
Intraoperative Management
To extubate or not to extubate?
• Size of patient
• Intraoperative events
• Prematurity
• Associated pathology
• Hemodynamic status
• Magnitude of the abdominal defect
• Type of repair
Abdominal Wall Defects
Postoperative Management
NICU
Postop ventilation in most neonates for 24-48 hrs
Fluid requirements may remain high
Prolonged postop ileus: TPN or PPN
Prevent infection: higher with silo
Watch for circulatory compromise
cyanotic lower limbs
Postop HTN due to ↓ renal perfusion and
activation of renin-angiotensin-aldosterone
Abdominal Wall Defects
Early Postoperative Complications
• Necrotizing enterocolitis
• Renal insufficiency
• Pneumonia
• Abdominal wall breakdown
• PDA
• GE reflux
Necrotizing Enterocolitis
(NEC)
Necrotizing Enterocolitis (NEC)
Life-threatening intestinal inflammation
or injury
Caused by bacterial invasion of previously
injured or ischemic bowel wall
Incidence: 5 -10% in infants <1500g birth
weight
Mortality rate: 10 - 30%
Necrotizing Enterocolitis (NEC)
Single most important factor
PREMATURITY
Can occur in:
premature infants
LBW infants
Full term infants
fed and unfed infants
Necrotizing Enterocolitis (NEC)
Other factors
ischemia
bacterial infection
GI endotoxemia
enteral feeding
use of hyperosmolar formula
congenital heart disease
hx of umbilical arterial catheterization
hx of exchange transfusion
Necrotizing Enterocolitis (NEC)
Early signs
↑ gastric residuals with feedings
temperature instability
poor feeding
bilious vomiting
lethargy
mucoid or bloody stool
apnea and bradycardia
Necrotizing Enterocolitis
Late Signs
Hemodynamic instability
Anemia
Thrombocytopenia
Coagulopathy, DIC
Prerenal azotemia
Metabolic acidosis
Necrotizing Enterocolitis (NEC)
Physical Exam
distended and tender abdomen
Labs:
CBC
electrolytes and glucose
platelets and coagulation profile
DIC profile
ABG
Necrotizing Enterocolitis (NEC)
Abdominal X-ray
• signs of bowel obstruction
• ileus with edematous
bowel
• Pneumatosis intestinalis
or intramural air (arrow)
• portal vein air
• pneumoperitoneum
Necrotizing Enterocolitis (NEC)
Medical Management
initial treatment, for 7-10 days
75% successful
Surgical Treatment
10 - 50% mortality
Necrotizing Enterocolitis (NEC)
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
Necrotizing Enterocolitis (NEC)
Surgical Indications
• Absolute Indications
1) bowel perforation
new mx: peritoneal drains under
local anesthesia
2) intestinal gangrene
Necrotizing Enterocolitis (NEC)
• Relative Indications
• clinical condition
metabolic acidosis
respiratory failure
oliguria, hypovolemia
thrombocytopenia
leucopenia, leukocytosis
• air in the portal vein
• bowel wall edema
• persistent dilated bowel loops
Necrotizing Enterocolitis
• Non-Surgical Indications
severe GI hemorrhage
abdominal tenderness
intestinal obstruction
gasless abdomen with ascites
Necrotizing Enterocolitis (NEC)
Preoperative Management
Anesthetic Concerns
• Fluid/volume status
• Significant 3rd space loss
• Full stomach / pulmonary aspiration
• Metabolic abnormalities
acidosis, hyperglycemia
Necrotizing Enterocolitis (NEC)
Preoperative Management
• Electrolyte imbalance: hyperkalemia
• Coagulopathy: thrombocytopenia
• Respiratory failure
• Sepsis / hemodynamic instability
inotropic support
dopamine infusion
Necrotizing Enterocolitis (NEC)
Intraoperative Management
Adequate IV access
Monitors:
ASA standard
invasive: arterial line, ± CVP
foley catheter
Induction
rapid sequence if not intubated
Necrotizing Enterocolitis (NEC)
Intraoperative Management
Maintenance of Anesthesia
• Narcotic based technique
• Avoid nitrous oxide
• Inhalational agents poorly tolerated
• Massive fluid requirements
• PRBC, FFP and platelets transfusion
Necrotizing Enterocolitis (NEC)
• Avoid hypothermia
• Give blood early when indicated
Postop Management
• NICU
• Postop ventilation required
• Continue resuscitation
• Parenteral Nutrition
Summary
• Almost all neonatal surgical “emergencies”
are really “urgencies”
• Immaturity of organ system in neonates
alters pharmacology and physiology
• Thorough preop assessment is required in
all neonates
• One anomaly mandates a search for others
• Murmurs necessitate a cardiology consult
• 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