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Peadiatric surgery emergencies

Peadiatric surgery emergencies. Yanal Abaza.MD. * Pyloric Stenosis * Congenital Diaphragmatic Hernia * Tracheoesophageal Fistula * Abdominal Wall Defects * Necrotizing Enterocolitis (NEC). Preoperative Evaluation. Maternal and perinatal history Recreational drug use

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Peadiatric surgery emergencies

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  1. Peadiatric surgery emergencies Yanal Abaza.MD

  2. *Pyloric Stenosis *Congenital Diaphragmatic Hernia *Tracheoesophageal Fistula *Abdominal Wall Defects *Necrotizing Enterocolitis (NEC)

  3. 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

  4. Pyloric Stenosis

  5. 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

  6. Etiology : unknown ? acquired condition with hereditary predisposition Symptoms are apparent between 2nd-6thwk of life Presents with nonbilious projectile vomiting, signs of dehydration, jaundice (2%) Pyloric Stenosis

  7. Physical Exam visible gastric peristalsis palpable “olive-shaped” mass to the right of the epigastric area signs of dehydration Labs: CBC serum electrolytes EKG ABG BUN Pyloric Stenosis

  8. 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

  9. Pyloric Stenosis • Metabolic Abnormalities • hyponatremia • hypochloremia • hypokalemia • 1° metabolic alkalosis • compensatory respiratory acidosis • paradoxical acidic urine

  10. Pyloric Stenosis Preoperative Preparation supportive treatment surgical management check labs

  11. Pyloric StenosisPreoperative Preparation Supportive therapy • Correction of fluid deficits maintenance: D5 0.2% NaCl + KCl 20 - 40 mEq/L replacement: albumin, normal saline • Correction of electrolyte imbalance • Prevention of aspiration : NGT

  12. Surgical Management Pyloromyotomy definitive treatment open or laparoscopic Lab indices for safe anesthesia serum Cl >100 mEq/L HCO3 < 28 mEq/L Pyloric Stenosis

  13. Pyloric Stenosis Concerns : • * pulmonary aspiration • * severe dehydration • * metabolic alkalosis

  14. Congenital Diaphragmatic Hernia

  15. 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

  16. 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

  17. Classification • Absent diaphragm : rare • Diaphragmatic hernia • 80% posterolateral L >R (Bochdalek) • 2% anterior (Morgagni) • 15 - 20% paraesophageal • Eventration (15 - 20%) Congenital Diaphragmatic Hernia

  18. Congenital Diaphragmatic Hernia • Associated anomalies (20-50%) • cardiovascular13 - 23% • CNS 28% • gastrointestinal 20% • genitourinary 15% • increase the mortality rate

  19. Congenital Diaphragmatic Hernia • Classic Triad • Dyspnea • Cyanosis • Apparent dextrocardia

  20. Congenital Diaphragmatic Hernia Physical Exam scaphoid abdomen and barrel chest bowel sounds in the chest displaced heart sounds Laboratory Studies CBC ABG electrolytes calcium glucose

  21. Congenital Diaphragmatic Hernia • Diagnosis: chest x-ray • loops of bowel in the chest • mediastinal shift • absent lung markings

  22. Congenital Diaphragmatic Hernia IMMEDIATE Intubation + Stomach Decompression

  23. Congenital Diaphragmatic Hernia Determinants of Survival • degree of pulmonary hypoplasia ipsilateral lung > contralateral lung • development pulmonary vasculature

  24. 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

  25. Congenital Diaphragmatic Hernia Standard Management Strategy Reduce pulmonary HTN Moderate alkalosis pCO2 < 40 mmHg PaO2 >100 mmHg

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. Congenital Diaphragmatic Hernia • Indications of Surgical Repair • Reversal of ductal shunting • O2 index of < 40 • Arterial pCO2 maintainable under • 40 mmHg • Hemodynamic stability

  32. Congenital Diaphragmatic HerniaPreoperative Preparation • Look for associated anomalies • Labs: CBC, electrolytes, ABG, glucose, blood type and crossmatch • CXR, Echo • Venous access: upper extremities preferred • Prevention of hypothermia

  33. Congenital Diaphragmatic HerniaIntraoperative Surgical repair primary closure staged procedure Transabdominal subcostal incision Thoracoscopic repair has been reported

  34. Congenital Diaphragmatic HerniaIntraoperative • Potential Problems • Hypoxemia • distension of stomach • 1° pulmonary hypoplasia / pulmonary HTN • Contralateral pneumothorax • Hypotension or IVC compression • Cardiac arrest

  35. 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

  36. Tracheoesophageal Fistula

  37. 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

  38. Tracheoesophageal Fistula Clinical Presentation choking on 1st feed coughing cyanosis excessive salivation aspiration pneumonia

  39. 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

  40. Tracheoesophageal Fistula Esophageal Atresia Tracheoesophageal Fistula Turnage RH, et al, Sabiston Textbook of Surgery,17th Ed. 2004

  41. TracheoEsophageal Fistula 5 Types (Gross and Vogt) 7.7% 0.8% 86% 0.7% 4.2% Gregory GA, ed, Pediatric Anesthesia, 3rd edition, 1996

  42. Tracheoesophageal Fistula 35-65% have associated anomalies VATER and VACTERL V vertebral anomalies or VSD A anorectal malformation C cardiac anomalies (common) T TEF E esophageal atresia R renal abnormalities L limb/radial malformation

  43. 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

  44. Tracheoesophageal Fistula Preoperative Preparation Laboratory studies CBC Electrolytes Glucose Calcium ABGs

  45. 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

  46. Tracheoesophageal Fistula Intraoperative Management Main Concern oxygenation and ventilation securing the airway Monitors ASA standard ± invasive : arterial line

  47. 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

  48. Tracheoesophageal Fistula Postoperative Management • Early extubation desirable • caution: disruption of surgical repair with • reintubation • Postop Pain Management • IV narcotics • epidural infusion: 0.1% bupivacaine + • fentanyl 0.5 mcg/ml at 01.-0.2 ml/kg/hr • 3. rectal Tylenol + LA infiltration of incision

  49. Tracheoesophageal Fistula Main Cause of Mortality associated anomalies survival rates 85-90% Long Term Complications GE reflux anastomotic stricture tracheomalacia

  50. Abdominal Wall Defects Gastroschisis Omphalocoele

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