Neonatal Emergency Surgery

Question 1

A 17-day-old baby requires an emergency laparotomy for necrotising enterocolitis.

What is a neonate?

Answer 1

• A neonate is a child aged from birth to 28 days of life.

Question 2

What are the indications for emergency abdominal surgery in neonates?

Answer 2

• Necrotising enterocolitis:
• Perforation.
• Failure to respond to non-surgical interventions.
• Small or large bowel perforation.
• Malrotation.
• Gastroschisis.
• Small or large bowel obstruction:
• Hirschsprung’s disease.
• Meckel’s diverticulum.

Question 3

How should the patient be assessed preoperatively?

Answer 3

*High-risk patient, needs review by experienced paediatric anaesthetist and neonatal MDT

HEI

History:
* Parental history: pregnancy, health conditions, medication and social history.

• Delivery: type, gestation and complications.
• Birth weight, current weight, and significant perinatal events.
• Any known medical conditions.
• Current physiological status (respiratory/cardiovascular support).
• Treatment so far (non-surgical/surgical) and current medication including whether the patient received IM vitamin K.

Question 4

How should the patient be assessed preoperatively?

Continued…

Answer 4

Examination:
* Airway: oxygen requirement, signs that may indicate a difficult intubation.

• Respiratory: oxygen requirement, work of breathing or ventilatory settings if appropriate.
• Cardiovascular: support, signs of compromise, fluid balance, lines in situ.

Investigations:
* Respiratory and cardiovascular observations.

• Arterial (or capillary) blood gas with recent trends.
• Bloods: full blood count, clotting, urea and electrolytes, glucose and cross match.
• Chest x-ray to check the endotracheal tube position if intubated and for signs of infant respiratory distress syndrome.
• Others relevant to the history and clinical findings such as echocardiogram or cranial USS.

Question 5

What is the normal value of haemoglobin at this age?

Answer 5

• Normal neonatal haemoglobin is 17–20g/dL due to the presence of foetal haemoglobin, which demonstrates an increased affinity for oxygen due to a reduced amount of 2,3-DPG.
• Blood volume for a term neonate is 90 mL/kg and small volumes of blood loss can be significant in terms of percentage blood volume lost. There is no consensus on appropriate transfusion triggers and this decision must be based upon the individual patient.
• By 6 months of age, the foetal haemoglobin will be largely replaced by adult haemoglobin, leading to a physiological anaemia.

Question 6

What are the priorities for anaesthetising this patient?

Answer 6

Preoperative:
* Personnel: Experienced paediatric anaesthetists, surgeons, neonatologists and trained theatre staff should be present due to the high-risk and specialist nature of this surgery. A preoperative multidisciplinary team brief is essential for careful planning and preparation of each stage.

• Equipment: Ensure appropriately sized paediatric airway equipment including a range of endotracheal tube sizes; the paediatric difficult airway trolley; correctly sized monitoring; devices used for warming both the patient and any infused fluids; and equipment required for transfer.
• Drugs: Both routine and emergency drug doses should be carefully calculated and drawn up prior to the patient being transferred to theatre to prevent any errors.
• Location: Surgery may need to be carried out on the neonatal unit if the patient is too unstable for transfer to theatre, which requires adequate planning.

Question 7

What are the priorities for anaesthetising this patient?

Continued…

Answer 7

Intraoperative:
* Four-quadrant aspiration of the nasogastric tube prior to induction.

• Preoxygenation followed by induction using an IV, inhalational or combined technique, muscle paralysis and tracheal intubation with
  controlled lung-protective ventilation.
• Consider invasive blood pressure monitoring and central venous access based upon risk/benefit for the individual patient.
• Fluids: continue dextrose-containing maintenance fluids and monitor and replace ongoing losses with isotonic solutions, guided clinically by cardiovascular status, and bedside investigations. A neonate can have up to 10 mL/kg/hour evaporative losses with an open abdomen. Blood products should be considered early.
• Regular monitoring and maintenance of blood glucose and temperature.
• Intraoperative and postoperative analgesia.

Question 8

What are the options for analgesia in this patient?

Answer 8

• A multimodal approach should be taken.
• Regular age/weight appropriate intravenous paracetamol.
• IV opioid boluses intraoperatively – dosing dependent on whether the
  patient will remain intubated postoperatively as there is a high risk of apnoeas in this patient.
• Local anaesthetic infiltration.
• Regional anaesthesia if appropriate (caudal/epidural) – rarely done
  in practice.
• Opioid infusion ± nurse controlled analgesia.