ALYSSA BRZENSKI

Neonatal Emergencies

Overview

Tracheoesphageal FistulasCongenital Diaphragmatic HerniasOmphaloceles and GastroschisisNecrotizing EnterocolitisMyelomeningocele

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 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 visualizationReduced 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-lineMaintence of spontaneous ventilation during

induction Classic teaching that paralysis can be given after

fistula ligatedBalanced anesthetic +/- epidural for post-op

pain managementMay 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 re-intubation

Congenital Diaphragmatic Hernia

Background

1 in 2,500 birthsLocation of the defect

80% left sided 20% right sided 1-2% bilateral

Etiology unknown50-70% post-natal

survival

Co-morbidities

Co-morbidities

Trisomy 13, 18, 21Goldenhar syndromeBeckwith-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 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 ManagementBalloon Tracheal Occlusion

Postnatal Management

Not a surgical emergency!!!!Definitive airway control

Minimize airway pressures to avoid pneumothoraxNGT to decompress the stomachCardiac Echocardiogram to assess pulmonary

HTN

Postnatal Ventilatory Strategy

Gentle ventilation- PIP less than 25cm H20pH> 7.25paCO2<65Preductal 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-dependentSurgery can occur on the HFOV or on ECMO

Anesthesia for CDH Repiars

Standard ASA monitors and A-lineHave adequate access, blood, iNO and

inotropes availableMinimize peak inspiratory pressuresAvoid nitrous oxidePeak 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 HTNPTX on contralateral lungHemorrhageHypothermia

Abdominal Wall Defects-Omphalocele and Gastroschisis

Background Omphalocele

1 in 4000 live birthsGender: Males > femalesLocation: UmbilicalMembranous Sac: PresentSize 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

Multiple anomalies more common in minor omphaloceles

Background- Gastroschisis

1 in 4000 birthsGenders: Male = FemaleLocation: Right of the umbilicusMembranous Sac: AbsentSize of defect: 2-5 cmLiver 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 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 hypoglycemiaMaintain euthermiaCover mucosal surfaces with plastic wrapNGT decompressionLabsType and Cross+/- ECHO

Anesthetic Considerations

Standard ASA monitorsAdequate IV accessAvoid nitrous oxideBalanced anesthetic technique– most babies

will remain intubatedFluid, fluid, fluid

Abdominal Compartment Syndrome

Impaired ventilationDecreased preload and hypotensionLower limb venous congestionArterial compression

Decreased renal perfusion and oliguria Decreased perfusion to the lower extremities and

bowelsMonitor the peak airway pressures during

closure of the fascia!!!!

Necrotizing Entercolitis

Background

Occurs in 1-5 of every 1000 live birthsMost common in premature and ELBW

neonates 11.5% of neonates weighing 401-750g will develop

High mortality (15-30%)

Term babies

Unusual in term neonatesFirst 1-3 days of lifeOccurs before feedings beginAssociations

Perinatal asphyxia Congenital Heart Disease Respiratory Distress

Risk Factors

PrematurityEnteral FeedsHyperosmolar formulaBacterial infectionsUmbilical 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 drainSurgical exploration

Intraoperative Management

Standard ASA monitors plus A-line Adequate IV accessNarcotic based anestheticLarge volume fluid resuscitation Have pRBC, FFP and Platelets availableGlucose sourceKeep the baby warm

Myelomeningocele

What is Spina Bifida?

Varying Neural Tube Defects

Spina Bifida

Basics of MMC

3.4:10,000 birthsRelated to low folate levels, anticonvulsants

(carbamazepine, valproic acid)Previous child with same partner is a risk

factor

Co-morbidities

Sensory motor deficitsBowel and Bladder IncontinenceArnold Chiari Type II

Caudal displacement of cerebellar vermis, fourth ventricle, and lower brainstem

HydrocephalusCognitive 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 birthMust be cautious to not injury the neural

tissue during moving or intubationRoutine ASA monitorsProne position for repairMay or may not receive VP Shunt at the same

timeTypically remain intubated as infant should

not lie supine for the first day

VP Shunts have Complications