Neonatal Emergencies
ALYSSA BRZENSKI
Overview
 Tracheoesphageal Fistulas
 Congenital Diaphragmatic Hernias
 Omphaloceles and Gastroschisis
 Necrotizing Enterocolitis
 Myelomeningocele
TEF
Background
 TEF/EA associated with
 1:2,500-4,000 live births
 30% of the neonate are premature
 Few cases diagnosed prenatally
 May present after birth with inability to pass an OGT
Background
Co-morbidities
Waterson Classification
Spitz Classification
Pre-repair Bronchoscopy
The Evidence behind the pre-repair Bronch
 May change the operative management (changed
operative approach in 57% with 31% being crucial
changes)
 Bronchoscopy can
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Define the fistula location
Determine unusual characteristics of the fistula(double fistula
or trifurcation)
Determine presence of tracheobronchitis (surgery
contraindicated)
Locate the aortic arch
Influence anesthetic management
Thorascopic vs. Open Repair
 Reduces Musculocutaneous sequelae
 32% of patients have significant musculocutaeous sequelae
 24% with winged scapula
 20% asymmetry of chest wall 2/2 atrophic serratus anterior
 18% developed thoracic scoliosis
 Better visualization
 Reduced Pain Post-operatively
Anesthesia for Thorascopic
 Rarely need lung isolation as operative lung
compressed by CO2 insufflation (5mmHg)
 Can be associated with mild desaturation requiring
100% O2 or mild hand ventilation.
 Some centers using HFOV for these repairs to
minimize the movement of the operative side
(MAP 14-24, Hz=10-14, delta P=20-27, FiO2
adjusted to Sat of 92%)
 EtCO2 will be falsely low due to compression of the
lung and CO2 insufflation.
Patient Position
Anesthetic Considerations
 Routine ASA monitors +/- A-line
 Maintence of spontaneous ventilation during
induction
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Classic teaching that paralysis can be given after fistula ligated
 Balanced anesthetic +/- epidural for post-op pain
management
 May have difficulty with hypercapnia or difficulty
ventilating
Fistula Management
Extubate or Not?
 Must consider pre-op lung disease and other
comorbidities
 Spontaneous ventilation decreases the stress placed
on the suture line
 Risk of injury to the repaired fistula with reintubation
Congenital Diaphragmatic Hernia
Background
 1 in 2,500 births
 Location of the defect
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80% left sided
20% right sided
1-2% bilateral
 Etiology unknown
 50-70% post-natal
survival
Co-morbidities
Co-morbidities
 Trisomy 13, 18, 21
 Goldenhar syndrome
 Beckwith-Wiedemann syndrome
 Survival in patients with co-morbidities 15%
Diagnosis
 Prenatal diagnosis
 Ultrasound can detect 50-60%
 Fetal MRI can further delineate
 Postnatal diagnosis
 Respiratory distress
 Scaphoid abdomen
 Distended Chest
 NGT coiled in the chest
Pathophysiology
 Impaired lung development bilaterally with
hypoplastic ipsilateral lung
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Decreased bronchial branches and alveoli
Increased muscularization into the intraacinar alveoli
Decreased type II pneumocytes
 Pulmonary Hypertension and persistent fetal
circulation
 Hypoxemia, Hypercapnea, and Acidosis
Prenatal Management
Balloon Tracheal Occlusion
Postnatal Management
 Not a surgical emergency!!!!
 Definitive airway control
 Minimize airway pressures to avoid pneumothorax
 NGT to decompress the stomach
 Cardiac Echocardiogram to assess pulmonary HTN
Postnatal Ventilatory Strategy
 Gentle ventilation- PIP less than 25cm H20
 pH> 7.25
 paCO2<65
 Preductal Sat>90%
 Rescue Ventilatory Strategies
 iNO
 HFOV
 ECMO
When can we operate?
 Delay surgery for
 Physiologic stabilization
 Improvement in pHTN
 Hemodynamically stable
 Minimal vent support
 Exact criteria is insitution-dependent
 Surgery can occur on the HFOV or on ECMO
Anesthesia for CDH Repiars
 Standard ASA monitors and A-line
 Have adequate access, blood, iNO and inotropes
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available
Minimize peak inspiratory pressures
Avoid nitrous oxide
Peak airway pressures may increase from increased
abdominal pressure following repair
DO NOT try to expand the contralateral lung after
the repair
Intraoperative Complications
 Exacerbation of Pulmonary HTN
 PTX on contralateral lung
 Hemorrhage
 Hypothermia
Abdominal Wall DefectsOmphalocele and Gastroschisis
Background Omphalocele
 1 in 4000 live births
 Gender: Males > females
 Location: Umbilical
 Membranous Sac: Present
 Size of defect: > 4 cm (Giant > 5 cm)
 Liver involvement: 30-50%
Co-morbidities- Omphalocele
 50-75% of patients will have other anomalies
 Cardiovascular (30-50%)- tetralogy of fallot
 Gastrointestinal(25%) Genitourinary (25%)- cloacal extrophy
 Beckwith-Wiedemann syndrome (10%)
 Chromosomal abnormalities- Trisomy 13, 18, 21
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Multiple anomalies more common in minor omphaloceles
Background- Gastroschisis
 1 in 4000 births
 Genders: Male = Female
 Location: Right of the umbilicus
 Membranous Sac: Absent
 Size of defect: 2-5 cm
 Liver involvement: Rare
Co-morbidities-- Gastroschisis
 Low association with other anomalies (10-20%)
 Gastrointestinal– bowel atresia
 Genitourinary– cyrptorchidism
 Chromosomal anomalies: Rare
 Prematurity common
Prenatal Care
 All children with omphalocele or gastroschisis
should be born at a hospital with a NICU
 Vaginal or C-Section are both acceptable birth plans
Surgical Closure
 Omphalocele has a membranous covering–
emergent surgery not necessary
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Unless the membranous covering is ruptured
 Gastroschisis does not have a membranous covering Primary Closure vs
 Staged Closure
Staged Closure– Spring Loaded Silo
Preoperative Considerations
 Optimize the fluid status–
 Correct hypoglycemia
 Maintain euthermia
 Cover mucosal surfaces with plastic wrap
 NGT decompression
 Labs
 Type and Cross
 +/- ECHO
Anesthetic Considerations
 Standard ASA monitors
 Adequate IV access
 Avoid nitrous oxide
 Balanced anesthetic technique– most babies will
remain intubated
 Fluid, fluid, fluid
Abdominal Compartment Syndrome
 Impaired ventilation
 Decreased preload and hypotension
 Lower limb venous congestion
 Arterial compression
 Decreased renal perfusion and oliguria
 Decreased perfusion to the lower extremities and bowels
 Monitor the peak airway pressures during closure of
the fascia!!!!
Necrotizing Entercolitis
Background
 Occurs in 1-5 of every 1000 live births
 Most common in premature and ELBW neonates
 11.5% of neonates weighing 401-750g will develop
 High mortality (15-30%)
Term babies
 Unusual in term neonates
 First 1-3 days of life
 Occurs before feedings begin
 Associations
 Perinatal asphyxia
 Congenital Heart Disease
 Respiratory Distress
Risk Factors
 Prematurity
 Enteral Feeds
 Hyperosmolar formula
 Bacterial infections
 Umbilical arterial catheters
Pathophysiology
Reduced Mesenteric
Blood Flow
Mucosal Ischemia
Intestinal Mucosal
Injury
Pathophysiology
What else is affected?
 Cardiovascular
 Hypotension
 Metabolic
 Hyperglycemia
 Metabolic Acidosis
 Hematologic
 Thrombocytopenia
 Coagulopathy
 Anemia
 Renal
Treatment
 Prevention
 Feed with breast milk
 Medical management
 Stop feeds
 Optimize hemodynamics and treat with antibiotics
 Peritoneal drain
 Surgical exploration
Intraoperative Management
 Standard ASA monitors plus A-line
 Adequate IV access
 Narcotic based anesthetic
 Large volume fluid resuscitation
 Have pRBC, FFP and Platelets available
 Glucose source
 Keep the baby warm
Myelomeningocele
What is Spina Bifida?
Varying Neural Tube Defects
Spina Bifida
Basics of MMC
 3.4:10,000 births
 Related to low folate levels, anticonvulsants
(carbamazepine, valproic acid)
 Previous child with same partner is a risk factor
Co-morbidities
 Sensory motor deficits
 Bowel and Bladder Incontinence
 Arnold Chiari Type II
 Caudal displacement of cerebellar vermis, fourth ventricle, and
lower brainstem
 Hydrocephalus
 Cognitive delay
 Lower risk if no VP Shunt needed
Co-morbidities
Latex Allergies
 All patients with MMC are labeled as latex allergic
 High rates due to recurrent procedures including
urinary catheterization
 Cross reaction to avocados, banana, passion fruit,
kiwi, tomato
Management of Myelomeningocele Study
Post-natal MMC Repair
 Infants repaired early after birth
 Must be cautious to not injury the neural tissue
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during moving or intubation
Routine ASA monitors
Prone position for repair
May or may not receive VP Shunt at the same time
Typically remain intubated as infant should not lie
supine for the first day
VP Shunts have Complications