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Management of Neonatal Surgery

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Management of Neonatal Surgery Management of Neonatal Surgery Dallas: Paul J. Samuels, MD Cincinnati Children’s Hospital Chicago: Shobha Malviya, MD University of Michigan 1 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Neonatal Surgery • GI • Diseases common in – Abdominal wall defects preemies • Omphalocele – NEC • Gastroschisis – HiHernia – Congenital defects • TEF • Duodenal atresia • Malrotation/Midgut • Diap hragmat ic HiHernia volvulus • Hirshsprung’s disease • Imperforate Anus and large bow el – Pyloric Stenosis obstruction • CCAM 2 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Neonatal Surgery • Closure of CV shunts • Neonatal pulmonary concerns • Temperature hihomeostasis • Glucose homeostasis • Immature renal function • Sensitivity to opioids and inhalational anesthesia 3 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Neonatal Surgery • Basic concepts: – Airway control – Maintenance of temperature – Fluid/electrolyte resuscitation – Nasogastric decompression – Antibiotic administration – Glucose homeostasis – Identification of associated congenital anomalies 4 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Pyloric Stenosis The most frequently encountered infant GI obstruction in most general hospitals A - Normal stomach in an infant 4 weeks of age B - Hypertrophic Pyloric Stenosis 5 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Pyloric Stenosis • 2‐6 weeks of age • Results in classic triad: • Non‐bilious, projectile – Hypochloremia vomiting, visible peristalsis – Hypokalemia • M:F=4:1, 1:500 – Metabolic alkalosis • Hypertrophy of muscularis • Renal response to vomiting layer of pylorus resulting in – Initial excretion of bicarb gastric outlet obstruction to maintain pH ° • Dx 1 made by U/S, occas – Eventual excretion of barium swallow acid “paradoxic • Infants exposed to EES? aciduria” 6 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Pyloric Stenosis • Further fluid loss may be • Postpone case if HCO3 > associated with prerenal 30 azotemia, hypovolemic shock, and metabolic • Some like to see Cl < acidosis 100 • Surgical intervention is NOT • Cimetidine has been EMERGENT used to rapidly • Tx of hypovolemia and normalize pH metabolic disturbances IS! 7 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Pyloric Stenosis • Anesthesia • Performed open or management laparoscopically – High risk for aspiration • Lap pyloric: faster – Gastric suction prior to progression of feeding, induction and quicker discharge – RSI common • Advanced to feeding – Awake extubation within 24 hours • Pyloromyotomy curative 8 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Neonatal Intestinal Obstruction: Duodenal, Ileal, and Colonic Atresias • Presumpt iv e ddagiagn ossosis in all infants with bilious emesis, and with or without gastric distention in first 24 hrs of life • Congenital anomalies – Duodenal atresia – Meconium ileus – Annular pancreas – Stenos is /Atres ia – Commonly associated with other anomalies 9 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Duodenal Atresia • Bilious vomiting within 48 hours of birth • “Double‐bubble sign” • No bowel gas beyond ddduodenum • 20‐30% also have Down syndrome • Other anomalies: prematurity, malrotation, CHD, esophlhageal atresia, anorectal anomalies 10 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Annular Pancreas • Rare condition in which the ddduodenum is surrounddded by a ring of pancreatic tissue • Complete or partial duodenal obstruction • May be asymptomatic • Associations: Down syndrome, Meckel’s diverticulum, imperfo r ate aausnus 11 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Meconium Ileus • Distal small bowel luminal • Diatrizoate meglumine (DM), obtbstruc tion water solblluble contttrast agent, • Almost exclusively found in as an enema, facilitates pts with Cystic Fibrosis, evacuation though only 10‐20% of CF • Surgical: DM, or pts have MI acetylcysteine, injected into • May result in meconium bowel lumen, and contents peritonitis, forming fibro‐ advanced into colon adhesive bands and • May require enterostomy widespread obstruction • Surgical and medical mgt 12 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Necrotizing Enterocolitis • 2 week old 28 week infant with abdominal free air, Hg 909.0. K+ 595.9, PLT 88K 13 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Necrotizing Enterocolitis (NEC) • Major source of • Occurs in 10% of infants perinatal M and M < 1500 gms • 90% infants with NEC • Mortality 10‐30%, premature highest in smallest • Primarily disease of infants premature infants, • Approx 1/3 of infants typically < 1500 gms or with NEC require 32 weekssurgical intervention 14 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Necrotizing Enterocolitis (NEC) • Systemic process • Only clear risk factor is primarily related to prematurity, and sepsis that accompanies intensity of disease is intestinal necrosis and inversely correlated increased mucosal with gestational age permeability • Despite it’s frequency, precise etiology is unknown 15 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Necrotizing Enterocolitis (NEC) • Three stages of NEC – 2: definite (surgical) disease • All of the above, AND (Bell, 1978) radiographic evidence of – 1: suspected (mild) disease pneumatosis or portal • Non‐specific symptoms venous air including vomiting, gastric ’ ’ residuals, A s and B s, – 3: advanced disease guaiac+, nl radiograp hs • Evidence of intestinal necrosis or perforation • Hemodynamic, resp, and hematologic instability 16 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Modified Bell’s Staging for NEC (Walsh and Kleigman) 17 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Necrotizing Enterocolitis (NEC) • Pathophysiology – Intestinal mucosal injury from – Occurs sporadically and in ischemia caused by clusters diminished mesenteric blood – When in FT infants, typically flow is commonly believed to in first 1‐3 DOL, with hx of contribute to NEC hypoxic or ischemic event – Risk factors include: birth such as perinatal asphyxia, asphyxia, hypotension, RDS, RDS, CHD PDA, recurrent app,nea, – When in preemies, tends to presence of UVC or UAC, occur after 2‐3 weeks after systemic infection, early enteral feeds initiated, enteral feeding without sentinel event 18 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Necrotizing Enterocolitis (NEC) • Most commonly occurs • Combination of bowel ischemia in ilio‐colic region, and btbacterem ia undliderlie NEC – Exaggerated inflammatory response though often in the setting of abnormal bacterial discontinuous and colonization, an inadequate patchy in both sm and epithelial barrier, immature intestinal immunity lg intestine – Character ize d by idinadequate • Primary pathology secretion of MUCIN, predisposing to increased permeability and – Coagul opath y bacterial adherence – Ischemic necrosis – Inflammatory 19 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Necrotizing Enterocolitis (NEC) • Preop Mgt • Laboratory findings – Typically preterm, <1000gms – Hyperg ly cemia – – Presentation Thrombocytopenia – Coagulopathy • Temp instability – Anemia • A’s and B’s – Hypotension • Poor feeding with gastric – residuals Metabolic acidosis – • Vomiting Pre‐renal azotemia • Malabsorption of feeds • Radiographic findings • Lethargy – Ileus • Hyperglycemia – Pneumatosis Intestinalis • Heme positive stool – Gas in biliary tract • Toxic, with distended and tender – Free air abdomen 20 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Necrotizing Enterocolitis (NEC) Clinical Management • Mild cases: • Absolute indications – GI decompression, – Pneumoperitoneum cessation of feeds, IV – Intestinal gangrene fluids, Abx, Inotropic • Relative indications support – Clinical deterioration • Metabolic acidosis • More severe cases: • Vent failure – Surgical exploration • Oliguria, hypovolemia • Thromobocytopenia – Peritoneal drain • Portal vein gas • Abd wall erythema • Fixed abdominal mass • Persistently dilated bowel loop 21 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Necrotizing Enterocolitis (NEC) • Intra‐op management • Post‐op Mgt – Availability of blood products – Mechanical ventilation – IV access and arterial line – Continued CV support – Potent inhal agents poorly tolerated – TPN – NM blockers – Inotropic support • Outcome – Glucose monitoring – Mortality 10‐30% (higher in ELBW) – Temp homeostasis – Short gut syndrome (20‐25%) – Preserve as much bowel as possible – Neurodevelopmental issues (2x incidence in those treated surgically vs medically) 22 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Perforated NEC 23 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Abdominal Wall Defects: Gastroschisis and Omphalocele • Two most common congenital abdominal anomalies – Impaired blood flow to herniated organs – Fluid shifts – Infifection rikisk – Associated anomalies • Approx 95% of defects are confirmed with U/S, allowing high‐risk delivery 24 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Omphalocele • Herniation of viscera into base of umbilical cord • Typically covered and midline • “Uh‐oh” omphalocele • 50‐75% of infants with omphalocele have other congenital anomalies • 45% have cardiac anomalies • 20‐30% have chromosomal anomalies 25 Intensive Review of Pediatric Anesthesiology Dallas - 2013 Omphalocele • Incidence 1:5000 • Male:Female 2:1 • Represents a failure of the gut to return from the yolk sac into the
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