3. PYLORIC STENOSIS
⢠Incidence:1 in 2000
⢠Male > female (first male child)
⢠Preterm = full term
⢠Etiology:Autonomic N system imbalance
& humeral disorder(?)
⢠Pathology : gross thickening of circular
smooth muscle of pylorus---gradual
obstruction of gastric outlet.
4. PYLORIC STENOSIS
⢠Diagnosis:
clinical: projectile vomits, mass in upper abd.
(âolive in abdomenâ)
upper G.I.series with barium
Ultrasound
⢠Anaesthetic concerns: - dehydration
- acid-base
abnormalities
-risk of aspiration
5. PYLORIC STENOSIS
⢠Pathophysiology:
Hypochloremia, hypokalemia, hyponatremia
& metabolic alkalosis.
⢠Preparation:
Medical emergency- parameters for surgery:
normal skin turgor,
Na>130mg/l
k at least 3meq/l,
Cl <85 meq/l
urine output 1-2ml/kg/hr
Resucitation c balanced salt soln, pot chlor after
urination.
6. PYLORIC STENOSIS
⢠Induction of Anesthesia:
-preoxygenation with 100% O2
- Ryles tube asspiraton
-Pentathol â 5 mg/kg.
-Suxa2mg/kgâŚintubation
-surgeon needs relaxation twice
a) at the time of delivery of pylorus
b)at the time of putting pylorus into abdomen
7. â Atracurium 0.5 mg/kg-best nondepolarizing
relaxant after induction followed by caudal
epidural 1.25ml/kg bupivacaine 0.25% with
1:200000 adrenaline.
â Reversal as usual
⢠Post-op care:respiratory depression is
common.
8. Tracheo - Esophageal Fistula,
with/without Esophageal Atresia
1. Incidence-1:3-4.5000 births
20-25% assoc. with
VSD,ASD,TOF,Coarctation of aorta.
another 20-25% with TEF are premature
wt<2kg
9. Tracheo Esophageal Fistula,
⢠Anatomy/Classification:
â Mostly TEF &EA occur together
â 90% lesions are typeâCâ â i.e. fistula between
trachea & lower esophagus above carina.upper
esophagus ends blindly.
10. Tracheo Esophageal Fistula,
⢠Associated anomalies:
â TEF with other anomalies in 30-50% pts.
â VATER association â 1973 by Quan & Smith
⢠V- vertebral defect / VSD
⢠A- anal defect
⢠T-TEF
⢠E- atresia
⢠R- radial dysplasia / renal dysplasia
11. Tracheo Esophageal Fistula
⢠Diagnosis:
â Early diagnosis is imp.to prevent pulmonary
complications- which determines prognosis.
â In utero-polyhydramnios-
â At delivery-pt.has excessive salivation,drooling,
cyanotic spells, cough-relieved by suction.
â Resp.depression
â Inability to pass a catheter(feeding tube#8)
â X-ray-radioopaque cath ending in proximal esophagus-
simple & diagnostic
12. Tracheo Esophageal Fistula,
⢠Pre-op management:
â âhas the baby suffered any pulmonary insultâ?
Aspiration pneumonia-more morbidity-delay the
procedure; stomach decompression by gastrostomy
â Avoid feeding
â Nurse in propped up position
â Intermittent suction
â Antibiotic therapy & physiotherapy
â Hydration
13. Tracheo Esophageal Fistula,
⢠Surgical management:
â Primary repair in 24-48 hrs.
â Gastrostomy under LA, delay thoracotomy for 48-72
hrs.,which allows proper hydration & assessment of
resp. & CVS.
⢠Anesthetic considerations:
â Pre-medication:inj.atropine IM.
â OT- AC off, warmers kept ready,(heat loss is more in
thoracotomy).
â Monitors:ECG,BP,FIO2,pulse oximetry,rectal
temp,arterial line,foley cath,precardial steth.
14. Tracheo Esophageal Fistula
â Induction /intubation.
⢠Decompression of stomach (gastrostomy tube allowed to vent,
& kept at head end of patient),
⢠Pre-oxygenation
⢠Awake/anesthetic intubation
⢠Correct position of ETT
⢠Induction with N2O+O2+ halothane
⢠IPPV cautiously attempted before NMJ blocker.
â ETT might enter fistula during intubation,or during
surgery difficulty in ventilation saturation and
ETCO2
15. Tracheo Esophageal Fistula,
⢠Maintenance:
â Continue inhalational agents.discontinue N2O if gastric
dilatation occurs
â Non depolarising muscle relaxant , conc of halothane
âless CVS depression
â O2 conc by ABG sampling. High FiO2 if pulmonary
pathology is present.
â Manual ventilation best- changes can be detected
easily. Airway obstruction can occur during surgery &
due to accumulation of blood & secretions in tube.
â Blood loss 20-30%. If Hct <30,and EBL >10-15%,vol.
replacement with blood.
â IV fluids for maintenance
17. CONGENITAL
DIAPHRAGMATIC HERNIA
⢠Incidence:
1:4000 live births
mortality with heroic post-op measures-30%
(earlier 40-50%)
⢠Def: herniation of abdominal contents into chest
through a defect in the diaphragm.
â Types: Lt.posterolateral defect in foramen of
Bochdalek(75-85%) - commonest
â anterior opening (foramen of Morgagni) -rarely
18. CONGENITAL DIAPHRAGMATIC HERNIAâŚ
⢠Associated anomalies:
still borns c CDH â 95% of other anomalies
live borns â20% CVS (esp. PDA) defects
⢠Clinical presentation:
variable
â Early hernia,pressure on lung bud small lung
â Hernia in late fetal life normal lung,but compressed
infants c severe hypoplasia symptoms in 1st hour
less severe forms symptoms in 24 hrs.
20. CONGENITAL DIAPHRAGMATIC HERNIAâŚ
⢠Diagnosis:
antenatal:1) 30% c polyhydramnios
2) ultrasound
after delivery: x-ray chest
⢠Anesthetic considerations:
delay surgery till infant stabilises
(24-48hrs.to 1week)âŚlevin 1987
21. 1. Pre-op care:
â Decompress c nasogastric tube
â Donât ventilate c mask
â Awake intubation paralyse, sedate, ventilate
c 100% O2
â Lowest possible inflation pressure (30cmH2O)
used (vs.-in pneumothorax)
â Tr.of acidosis-ventilation,soda bicarb,improve
circulation by fluids& inotropes
22. CONGENITAL DIAPHRAGMATIC HERNIAâŚ
2.anesthetic management:
â Intubation & paralyses before arrival to OT,or
preoxygenation-rapid sequence awake intubation-low
airway pressure & high resp.rate
â Frequent blood gas estimations,ET CO2 & pulse
oximetry-maintain effective ventilation
â Prevent hypothermia
â Low conc.of inhalational agent c high inspired O2 or
high doses of narcotics (fentanyl). Avoid N2O
â Primary closure of abdomen,or chimney prosthesis,or
silastic pouch
â Continue paralysis & controlled ventilation post-op,
except in infants c small defects & good gas exchange .
23. CONGENITAL DIAPHRAMATIC HERNIAâŚ
Options:
â in infants c severe lung dysplasia,tr. c ECMO
preop, wean then schedule for surgery
â Repair defect when on ECMO & maintain
ECMO post-op for 30 days
â Neonates c CDH have surfactant deficiency,
using ECMO will improve surfactant
24. CONGENITAL DIAPHRAGMATIC HERNIAâŚ
â Pts. given ECMO with NO before & after ECMO &
after surgery. NO was ineffective pre-ECMO. NO after
ECMO followed by surgery was able to increase
oxygenation. (Karamanaoukian et al.)
â UK study- pts. c CDH not treated c ECMO but c preop
stabilisation & supportive care had same results as c
ECMO therapy.
â âwhat is the best time to operate?
operation should be postponed till PVR is decreased as
revealed by Doppler EchoCardiography.
25. CONGENITAL DIAPHRAMATIC HERNIAâŚ
⢠Post-Op problems:
â Determination of outcome
⢠a) extent of Pulmonary Hypoplasia
⢠b) degree of pulmonary hypertension
Infants with post-op PaCo2 < 40mm.Hg. who could be
hyperventilated c airway pressure < 20 cm. H2O , & who had
a resp.rate < 60 /mt. survived well.(Bohn.,J.Paediatrics,1984)
Reducing PVR & prevention of Rt.to Lt. Shunt is accomplished
by ----- hyperventilation, ligation of PDA & drugs include
tolazoline, PGE1, & ECMO.
27. INTESTINAL OBSTRUCTION
⢠Upper GI obstruction:
â Persistent bilious or non-bilious vomiting
deficit of fluids & electrolytes.(Stomach contains
100-130 meq/l/Na.,& 5-10 meq/l of K.
â To prevent aspiration, awake / RSI.
⢠Anesthetic considerations:
â Pre-op preparation-
⢠Correction of dehydration
⢠Correction of electrolytes
⢠Ryles tube decompression
28. INTESTINAL OBSTRUCTION
⢠Anesthesia:
â Awake, rapid sequence intubation
â Repair of congenital defect & closure of abdominal
defect.
â N2O can be used.
⢠Extubation
â Possible only with good g.c.
â Patient debilitated,extensive surgery,big incision,
â Post-op ventilation c PEEP.
29. INTESTINAL OBSTRUCTION
⢠Lower GI obstruction:
â Problem develops between 2-7 days
â Incomplete anus can be evident after birth
â Vomiting secondary to obstruction
electrolyte or fluid disturbances.Large fluid
sequestration within GI tract, (ECF c high Na+
content)
â Na must be >130meq/l , & urine volume of
1.2ml/kg/hr.
30. INTESTINAL OBSTRUCTION
⢠Anesthetic considerations:
â Decompression of stomach
â Electrolyte & fluid management
â Awake, rapid sequence intubation
â N2O should not be used.
â Adequate relaxation
â If patients g.c. is good,reverse & extubated with post-
op O2 supplementation
â If patients g.c. is not good, post-op ventilation is
continued c PEEP.
31. OMPHALOCELE &
GASTROSCHISIS
Omphalocele:
⢠herniation of intestine into base of umbilical
cord.
Gastroschisis:
⢠defect of abdominal wall lateral to base of
umbilicus
⢠Incidence: omphalocele-1:10000 births
gastroschisis â 1: 30000 births
boys : girls 1:1
25-30% are premature or LBW
32. OMPHALOCELE & GASTROSCHISIS
Omphalocele:
⢠membrane covering peritoneum inside,
amniotic membrane outside.
⢠Sac may be small or large containing
liver,spleen etc.
⢠Prematurity 25-30%
⢠Associated anomalies:77%
33. OMPHALOCELE & GASTROSCHISIS
Gastroschisis:
⢠Eviscerated abdominal contents,involves small or
large lntestines
⢠Umbilical cord is to left of defect
⢠Prematurity is 58%
Anesthetic considerations:
⢠Pre-op management:
â Search for associated anomalies,
â Ruptured omphalocele is a surgical emergency.
34. ⢠Fluid resuscitation:
â Fluid loss is high,
â 3rd space loss,protein loss, increased fluid
requirements
â 150-300 ml / kg / day RL or 5% Albumin is
used.
â Correct acid â base status
â Insensible loss â wrapping the child in
polythene bag filled c warm saline.
35. OMPHALOCELE & GASTROSCHISIS
⢠Atropine
⢠Temperature regulation
⢠Hypoglycemia & hyperglycemia are
avoided.
⢠Nasogastric tube for decompression of
stomach.
36. OMPHALOCELE & GASTROSCHISIS
⢠Peri-operative management:
â Monitoring
â Induction c I.V. inhalation
â Awake intubation
⢠Maintenance:
â FiO2 to maintain saturation of 95-97%
â N2O should be avoided,
â Maintenance by balanced anesthesia,
â Airway pressure to be monitored
â Post-op ventilation for 24-48 hrs.
â Excellent skeletal muscle relaxation
â Repair is staged if primary closure is not possible
37. OMPHALOCELE & GASTROSCHISIS
⢠Post-op complications:
â Respiratory insufficiency
â Ileus,
â Venacaval compression due to tight closure.
â Sepsis is major cause of mortality & morbidity
â Temperature regulation
39. NECROTISING ENTEROCOLITIS
⢠Clinical Signs:
â Retained gastric secretions,
â Vomiting , bloody , mucoid diarrhea,
â Thermal instability,
â Abdominal distension c bloody, sticky stools
â Signs appear in first few days of life/2or 3 days after
feeding
â Lethargy & apnea, metabolic acidosis, jaundice,
â DIC c prolonged PT & APTT.
â X-ray abdomen: early â distended gas filled loops,
â Late gas in the bowel., (pneumatosis intestinalis ).
40. NECROTISING ENTEROCOLITISâŚ
⢠Non â surgical management:
â Decompression of stomach,
â Cessation of feeding, broad spectrum antibiotics,
â Fluid & electrolyte therapy
â Ionotropic agents, steroids in septic shock
⢠Indications for surgery:
â Peritonitis, air in portal system, ascitis,progressive
deteriotion.
46. CONGENITAL LOBAR EMPHYSEMAâŚ..
⢠Anesthesia:
â Crying, struggling amount of trapped air
â IPPV emphysema
â Halothane + O2 c mask , intubation c or c out
relaxation.
â IPPV postponed until thorax is opened.( cote,1978)
â Extubated at the end of lobectomy.
â Humidity, coughing mininises atelectasis in post-op
period,
â Results are good.
47. REFERENCES
⢠1. Wylie & Churchill Davidsons :
â âA practice of anesthesiaâ ; 6th Ed.,Chapter 30th
by James.M.Steven & John Downes.
⢠2. Physiology of the neonate of importance to
anesthesiologists , by Frederic.A.Berry, M.D., 42nd
anesthesiology review course lectures.
⢠3. Emergency neonatal surgery , by
Frederic.A.Berry, M.D., 42nd anesthesiology review
course lectures.
⢠4. Anesthetic management of neonatal
emergencies, by Anna Lucia Pappas, M.D.,
asst.prof. Loyola University Medical Centre.