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Anesthetics Management for Neonates with Gastroschisis Repair

Anesthetics Management for Neonates with Gastroschisis Repair. Claire Yang, SRNA Duke University Class of 2013 . Objectives. Differentiate between gastroschisis and omphalocele Temperature regulation of the neonate Identify correct strategies for fluid management

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Anesthetics Management for Neonates with Gastroschisis Repair

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  1. Anesthetics Management for Neonates with Gastroschisis Repair Claire Yang, SRNA Duke University Class of 2013

  2. Objectives • Differentiate between gastroschisis and omphalocele • Temperature regulation of the neonate • Identify correct strategies for fluid management • List the preop considerations, possible intraop complications, and postop anesthetic care

  3. Gastroschisis & Omphalacoele

  4. Gastroshisis • 1 birth per 10,000, male > female • Young maternal age <20, cigarette smoking, preterm, and low birth weight • Often diagnosed with routine ultrasound • When? Where? How to deliver?

  5. Hypothermia • Large surface area to body weight ratio • Less SQ fat to insulate • Infants less than 3 months cannot shiver • Immature SNS, can’t control vasoconstriction • Greater skin permeability to water Exaggerated by the exposed bowel

  6. Non-shivering Thermogenesis • Infants respond to cold by increasing the production of norepinephrine • This increases the metabolism of brown fat

  7. Thermoregulation Brown Adipose Tissue (Brown Fat) • Found in newborn and hibernating mammals • Develops at 26 to 30 weeks of gestation • 5% of total weight • Midscapular, back of the neck, clavicles, axillae, mediastinum, kidneys, and adrenal glands • Abundance of mitochondria, glycogen stores, blood supply to generate body heat

  8. Review Four Mechanism of Heat Loss

  9. How to Warm? • Warm OR to 75-80*F • Heat lamps • Bair Hugger blanket • Plastic • Fluid warmer

  10. Post-Delivery Management • Begin in delivery room before coming to the OR • Assess V/S and early stabilization (oxygenation, intubation*, ventilation, IV access*) • Place gastric tube to decompress the stomach • Cover bowels with warm, moist, sterile dressing • Cover the entire lower body with a sterile plastic bag • Transfer to OR or other facilities in the incubator • Avoid further trauma to bowel during transport (twisted bowel can result in ischemia)

  11. Preop Assessment • Gestational age? Term or preterm? Weight? • Vitamin K? Surfactant? • If intubated already, check the ETT size and position • If not intubated, continue respiratory assessment (SaO2 on routine handling, tachypnea, tachycardia, nasal flaring) • Signs of circulatory insufficiency: tachypnea, tachycardia, cold peripheries, pale or mottled skin, delayed capillary refill; low BP is a late sign. • Continue fluid resuscitation, reassess and repeat

  12. Intraop Monitoring Standard ASA Monitoring (EKG,BP, SaO2, ETCO2, Temp) • If the neonate is able to maintain respiratory homeostasis and whose hernia size is < 4cm Invasive Pressure Monitoring • If the neonate is unstable, hypotensive, hypoxic, using accessory muscle to maintain saturation, and with hernia size > 4cm • Central venous line, arterial line

  13. Anesthetic Technique • Susceptible to aspiration • Awake intubation or RSI • RSI with Propofol; +/- muscle relaxant • Mask induction with Sevoflurane & oxygen • Preemie: 2.5 ETT Term: 3.0-3.5 ETT • A slight leak pressure of 20-25 cmH2O to prevent compression damage to the tracheal mucosa • Bradycardia b/c PNS is dominant

  14. Maintenance of Anesthesia • Anesthesia requirement for maintenance in neonates (Sevo 2.1%) is less than infants (3.2%) • Oxygen, air, and Sevoflurane • Maintain O2 saturation mid-90’s% to avoid the risk for retinopathy of prematurity • No Nitrous oxide • Keep them on muscle relaxant* • Opioids*

  15. Intraop Fluid Management • Maintenance • Third space losses • Estimated blood volume • Maximum allowable blood loss • How to give blood and albumin

  16. Maintenance Fluid • D5 0.2%NS • Via syringe pump or 250ml bag on IV pump or buratrol drip chamber tubing • No air bubbles • May double the MIVF

  17. 3rd Space Losses • LR is used • Albumin 5% maybe used if rapid volume expansion is needed • 6-10-15 ml/kg/hr

  18. Estimated Blood Volume

  19. Allowable Blood Lost ABL = EBV x (starting Hct – allowable Hct) starting Hct

  20. How to Give Blood and Albumin • Warm blood with hotline • Use a pediatric blood set + stopcock • Push blood with a syringe for accurate measurement • Give 10-20ml/kg at a time • Watch BP!!!

  21. Surgical Repair • Goal: to return the bowel to the abdomen and close the fascia in one operation • Primary closure • Staged closure: silo pouch first  complete closure Gastroschisis.net

  22. Hemodynamic Effects of Primary Closure Intra-abdominal Pressure • A NG/OG can be placed in the stomach with a column of saline; or bladder pressure • Goal: < 20 mmHg when closing the defect • Increased intra-abdominal pressure results in:  preload: hypotension  pulmonary compliance:  PIP,  Vt, ETCO2,SaO2  urine output

  23. Yaster et al • Intragastric pressure > 20 mmHg or CVP > 4mmHg • Higher mortality rate caused by ischemia of the bowel or the lower extremities Morgan & Mikhail • Suggested criteria for a staged closure include: • Intragastric pressure >20 mmHg • PIP > 35 cmH2O • ETCO2 > 50mmHg

  24. Emergence • If the neonate tolerated the primary closure or the defect is very small, may try extubate at the end of the surgery. • In these patients, give reversal and extubate when fully awake, with regular spontaneous breathing, grimacing, moving all limbs vigorously • However, the majority of babies will returned to NICU intubated b/c the increased intra-abd pressure with compromised respiratory function

  25. The Sux Dart • If laryngospasm does occur post extubation, remember to give atropine and succinycholine together • If IV access is not present, atropine and succinycholine can be given IM or sublingually • Atropine 0.02mg/kg IM • Succ 4mg/kg IM

  26. Postop Management • Neonatal ICU • If remains intubated, continue sedation with morphine (10-20 mcq/kg/hr) • Some may require muscle relaxation for 24 hrs; cisatracurium (3 mcq/kg/min) • The duration of sedation and paralysis is governed by the ease and speed of return of bowel to the abdominal cavity ~ 10 days

  27. #1 Postop Complication Abdominal Compartment Syndrome • Upward shift in the diaphragm interfering with ventilation • Renal and hepatic perfusion • Perfusion to lower limbs, ✓SaO2 on big toes • Re-open the abdomen and place the silo pouch • Reduce the tension on the pouch and allow a portion of the bowel to re-herniate

  28. Other Postop Complications

  29. Prognosis • In the 1960’s, up to 70% of these neonates failed to survive • With improved preoperative and postop resuscitation, 90% survival rate • Majority of the neonates have no associated cardiac or respiratory abnormalities, survive to normal adult lives

  30. Summary • Neonates with gastroschisis require emergent surgical repair • Susceptible to heat/fluid loss, infection, electrolyte imbalance, and trauma • Goals: secure the airway, obtain I.V. access, begin fluid resuscitation as early as possible, prevent hypothermia, continue ventilatory support intraop and postop Questions?

  31. Reference • Cauchi, J., Parikh, D. H., Samuel, M., & Gornall, P. (2006). Does gastroschisis reduction require general anesthesia? A comparative analysis. Journal of Pediatric Surgery, 41, 1294-1297 • Hartley, L., & Poddar, R. (2009). Exomphalos and gastroschisis. Continuing Education in Anaesthesia, Critical Care & Pain. doi: 10.1093/bjaceaccp/mkp001 • Jaffe RA, Samuels SL. (2004). Anesthesiologist’s Manual of Surgical Procedures. 3rd ed. Philadelphia PA: Lippincott Williams & Wilkins • Leabetter, D. (2006). Gastroschisis and omphalocele. Surgical Clinics of North America, 86, 249-260

  32. Reference • Macksey, L. F. (2009). Pediatric Anesthetics and Emergency Drug Guide. Sudbury, Massachusetts: Jones and Bartlett Publishers • Morgan, G. E., Mikhail, M. S., & Murray, M. J. (2006). Clinical Anesthesiology. 4th ed. New York, NY: McGraw-Hill • Myo, C.C. (2007). Preanesthetic assessment of the newborn with an abdominal wall defect. Retrieved from http://www.amcresidents.com • Wielar, A. (2011). Anesthetic Considerstions for Patients Smaller Than a Box. [PowerPoint slides]. Retrieved from Duke University Advanced Principles of Anesthesia II Blackboard: http://blackboard.duke.edu

  33. Reference • Wouters, K., & Walker, I. (2007). Anaesthesia for neonates with abdominal wall defects. Retrieved from: http://www.frca.co.uk/article.aspx?articleid=100983

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