1 / 35

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

hume
Télécharger la présentation

Anesthetics Management for Neonates with Gastroschisis Repair

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

More Related