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

• 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
CNS

13 - 23%
28%

gastrointestinal
genitourinary
• increase the mortality rate

20%
15%

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
glucose

calcium

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 nitroglycerin isoproterenol 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 A vertebral anomalies or VSD anorectal malformation

C
T E R L

cardiac anomalies (common)
TEF esophageal atresia renal abnormalities 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 visceromegaly macroglossia microcephaly hypoglycemia 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

Gastroschisis Incidence Peritoneal covering/sac Location of defect Herniated bowel 1:15,000-30,000 absent periumbilical matted, edematous

Omphalocoele 1:6,000 present within the umbilical cord normal

Associated anomalies

low (10-15%)
intestinal atresia (15%)

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
increase room temp fluid warmer

heating blanket
plastic wrap

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