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AP Summer Final > Neonatal Surgical Emergencies > Flashcards

Neonatal Surgical Emergencies Flashcards

1
Q

What do you need to consider relating to neonatal physiology? (6)

A

Cardiopulmonary function differences
Increased O2 consumption
Apnea
Atelectasis
More compliant chest
Cardiac output relies on HR

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2
Q

What factors place neonates at increased risk of hypothermia? (3)

A

Thin skin
Less fat
Large surface area

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3
Q

What are renal/hepatic considerations for neonates? (4)

A
  • Kidneys not fully developed until late in gestation
  • 25% GFR of an adult
  • Sodium retaining ability at 32 weeks gest.
  • Renal blood flow decreased
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4
Q

What is the total body water for a premie?

For a term baby?

A

75-85%

70%

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5
Q

What is special to know about glucose and calcium metabolism in neonates?

A

Neonates are not able to regulate these well.

Note: Neonates muscle mass–> less Ca results in slower drug distribution–> LONGER EFFECT.

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6
Q

Where can we obtain IV access in a neonate? (4)

A

Femoral
IJ or EJ
Umbilical
Intraosseous

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7
Q

The management of omphalocele and gastroschisis is similar to manage despite embrological/anatomical differences. True or false?

A

True, even though the physiology is different.

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8
Q

Omphalocele occurs in females more than males. True or false?

A

False.

Males to females = 2:1

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9
Q

What is the failure of the gut to migrate from the yolk sac into the abdomen during gestation?

A

Omphalocele

Note: The bowel is covered by sac and protected from amniotic fluid in utero also.

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10
Q

What is the % mortality of omphalocele?

What is the cause of mortality?

A

30%

Prematurity and other associated defects

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11
Q

What is a larger abdominal defect?

Omphalocele or gastroschisis?

A

Omphalocele

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12
Q

Where is the defect normally located in an omphalocele?

A

base of umbilicus

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13
Q

What other conginital abnormalities is omphalocele usually associated with? (4)

A

Cardiac
Genetic
Metabolic
Urologic

Note: Prematurity is COMMON in omphalocele.

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14
Q

What occurs in omphalocele/gastroschisis to the neonate’s physiological state? (3)

A

Impaired blood supply to visceral organs

Bowel obstruction

Extreme fluid shifts/deficits

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15
Q

What is depicted?

A

Omphalocele

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16
Q

What can you expect to occur with this situation? (2)

How is bowel function altered?

A

Evaporative losses

Fluid shifts

Usually normal bowel function besides bowel obstruction.

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17
Q

The incidence of gastroschisis is more prevalent in males than females. True or false?

A

False

1:1

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18
Q

What develops as a result of occlusion of the omphalomesenteric artery during gestation?

A

Gastroschisis

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19
Q

What other congenital abnormalities is gastroschisis associated with?

A

None, it is not usually associated with other conditions.

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20
Q

What is the mortality rate from gastroschisis?

A

15%

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21
Q

Where is the opening usually located in gastroschisis?

A

To the right of the umbilicus

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22
Q

What is depicted?

A

gastroschisis

“Red, angry bowel”

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23
Q

What is the cause of the tissue reaction in gastroschisis?

A

Exposure to amniotic fluid.

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24
Q

What are other considerations relating to the bowel in gastroschisis? (3)

A

Dilated

Shortened

Functionally ABNORMAL

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25
Q

Gastroschisis can be associated with ______ _______ but not __________ abnormalities.

A

intestinal atresia (abnormally closed)

chromosomal

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26
Q

What is depicted in utero?

A

gastroschisis

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27
Q

What is the % of associated abnormalities in neonates with:

Omphalocele
Gastroschisis

A

75%

Rare with gastroschisis.

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28
Q

What is the most common cause of omphalocele and gastroschisis?

A

Prematurity

33% in omphalocele
62% in gastroschisis

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29
Q

What are preoperative evaluation considerations for omphalocele and gastroschisis? (3)

A

Cardiac disease

Less developed lungs from prematurity

Less developed kidneys from prematurity

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30
Q

What are perioperative concerns for omphalocele and gastroschisis? (3)

A

Heat/fluid loss from large exposed surface

Volume depletion

Risk for hypoglycemia/hypocalcemia

31
Q

What monitors are needed for omphalocele/gastroschisis? (5)

A

Art line
IV access in UPPER extremities
Urinary catheter
Intra-abdominal pressure monitor
Clear drape over legs (to monitor lower ext. perfusion)

32
Q

Why is lower extremity perfusion at risk for omphalocele/gastroschisis surgery?

A

Lower veins may be compressed when putting bowel back into the body.

33
Q

What is the induction plan for omphalocele/gastroschisis surgery? (3)

A

Awake intubation if hypovolemic

RSI after IV atropine and O2 (increased risk of bradycardia)

ETT leak at 30-40 cm H2O

34
Q

Why is ETT leak at 30-40 cmH2O rather than usual levels?

A

Higher than usual due to increased intrabdominal pressures.

35
Q

What drugs are needed during maintenance of omphalocele/gastroschisis? (2)

A

Fentanyl, **5-20 mcg/kg **

Maximum muscle relaxation

36
Q

What are important to monitor intraoperatively for omphalocele/gastroschisis? (8)

A

Glucose
Calcium
ABG
Urine output: 1cc/kg/hr
D10
NS, 0.25 (10-15 cc/kg/hr)

WARM OR to 80ºF
Decompress stomach

dugcan

37
Q

What values are desired for omphalocele/gastroschisis surgeries?

SaO2 (term)
SaO2 (preterm)
Hematocrit

A

Term: 94 - 97 %

Preterm: 90 - 94

Hematocrit > 30 %

Note: Keep SaO2 lower to prevent retinopathy with increased pressures.

38
Q

What is a primary closure for omphalocele/gastroschisis?

What is the risk?

A

Pushing bowel back in.

Increased intra-abdominal pressure leading to respiratory, circulatory, renal, and GI dysfunction.

39
Q

What can occur as a result of increased intra-abdominal pressure due to a primary closure for omphalocele/gastroschisis? (5)

A

Cyanotic legs
Decreased urine ouput
Increased AW pressure
Hypotension
Poor venous return

chipd

40
Q

What is a secondary closure for omphalocele/gastroschisis?

What is the risk?

A

Staged closure where bowel stays exposed.

Higher risk of infection, but less compromise to other organs.

41
Q

In a secondary closure for omphalocele/gastroschisis, how long does closure take?

A

7 - 10 days with daily cinching of silo (which requires no anesthesia)

42
Q

What action is taken if the defect is too large to close primarily? (4)

A
  • Temporize with a spring-loaded silo.
  • In NICU with NO transport, NO anesthesia
  • Silo reduced in NICU
  • Elective repair after bowel back in abdomen
43
Q

What is depicted?

A

Silo reduction of omphalocele/gastroschisis.

44
Q

What is depicted?

Where is this surgery performed?

A

staged closure

ICU especially when < 1kg

45
Q

What is the postop management for omphalocele/gastroschisis? (4)

A

May extubate IF no lung disease and IF small defect.

Maintain PPV until intra-abdominal pressure decreases.

PEEP to improve FRC.

Third space loss and fluid requirements remain high until venous pressure normalizes.

46
Q

BOARDS

What are the complications of omphalocele/gastroschisis? (7)

A

Peritonitis (from exposure)
Pneumothorax (from high pressures)
Respiratory failure
Renal failure
Hypothermia
Bowel/hepatic ischemia
Sepsis/Metabolic acidosis

47
Q

What is the most common cause of neonatal GI obstruction?

A

Hirschsprung’s disease

(congenital aganglionic megacolon)

48
Q

Hirschsprung’s disease is the failure of embryonic neuroganglion cells to migrate to ______ and ________ plexuses of the colon.

A

Auerbach

Meissner

49
Q

Where is Hirschsprung’s disease usually confined to?

What % of Hirschsprung’s involves the entire colon?

A

rectosigmoid

10%

50
Q

What is the congenital absence of the ganglion cells needed to allow relaxation of the internal sphincter?

A

Hirschsprung’s disease

51
Q

How does Hirschsprung’s disease present?

A

Failure to pass meconium within the first 24 hours of life.

52
Q

What is depicted?

What is used to demonstrate the condition pictured below?

A

Hirschsprung’s disease

Barium enema

Note: Anus constriction is cause of bowel obstruction.

53
Q

How is Hirschsprung’s disease diagnosed?

What is the treatment?

A

Rectal biopsy

“Leveling” colostomy where multiple colon biopsies are sent to pathology to determine the level at which ganglia are present.

This determines how much colon to remove.

54
Q

What is the definitive repair for Hirschsprung’s disease?

A

abdominoperineal resection with colon pull-through

Child must be > 10 KG

55
Q

The incidence of tracheoesophageal fistula is rare. True or false?

Males:Females?

A

True.

1:1

56
Q

What is the most common type of esophageal atresia?

A

Esophageal atresia (abnormally closed) with distant fistula (abnormal connection)

57
Q

What are associated abnormalities with tracheoesophageal fistula?

A

VACTERL

Verterbral
Anal
Congenital heart disease
TEF
Esophageal atresia
Renal or radius anomalies
Limb abnormalities

58
Q

What is the anesthetic management for transesophageal fistula? (6)

A

Head up position to prevent aspiration
NG in esophagus to continuous suction
Check other anomalies (CHD, GI, renal)
Warm room/fluids
Good IV access
Type and crossmatch

59
Q

How is induction of a TEF managed? (3)

A

Atropine 10-20 mcg/kg
Awake or RSI
ETT position is important!! Past fistula, above carina

60
Q

What are monitors needed for transesophageal fistula? (4)

A
  • Art line
  • Pre-post ductal pulse oximeters (pre- right hand, post foot)
  • Axillary precordial stethoscope to detect AW obstruction

Note: Nothing in the esophagus except suction catheter or dilator.

61
Q

What is the position for a TEF?

A

Lateral decubitus position with thoracotomy incision on side opposite aortic arch.

Laparoscopic is being more common.

62
Q

What is the postop management of a TEF? (3)

A

Extubation preferable to minimize stress on tracheal anastomosis

Place in humidified O2

Mark suction catheters/NG for nursing

63
Q

What are post-op risks of a TEF repair? (5)

A

High incidence of upper/lower respiratory infection (75%)

Aspiration (68%)–reflux issues in 2nd decade of life

Strictures (35%)–later in life

Anastomotic leaks (15%)

Tracheomalacia/atelectasis

64
Q

Mortality of TEF __-__% due to prematurity and associated anomalies.

A

1 - 15%

65
Q

What are long-term risks with TEF repair? (3)

A

Mild dysphagia (90%)

Abnormal esophageal motility

Increased bronchial activity 18 years after repair

66
Q

What condition is noted when no gas noted distal to esophagus and failure to pass orogastric tube into the stomach?

A

esophageal atresia

67
Q

How is esophageal atresia corrected?

A

Gastrostomy and later anastomosis

68
Q

How does TE fistula present? (3)

A

Polyhydramnios
Excessive oral secretions
Cyanosis with feedings

69
Q

If neonate has esophageal atresia with air in the stomach, then ______.

However, if no air in bowel, then _____ alone.

A

TE fistula

Esophageal atresia

70
Q

What is depicted?

A
  • Double fistula
  • Fistula without esophageal atresia
  • Esophageal atresia without fistula
  • Aplasia of trachea, lethal
71
Q

What TEF represents the majority of cases? (2)

What is it also known as?

A

Blind esophageal pouch

Fistula off distal trachea

Type 3B (most common)

72
Q

What is depicted?

A

TE fistula

73
Q

What are anomalies associated with TEF? (8)

A

Prematurity (40%)
Cardiac anomalies
Musculoskeletal
GI atresia
GU
Craniofacial (4%)
VATER
VACTERL

74
Q

What is VATER?

What is VATER and VACTERYL associated with?

A

Verterbral
Anal
TE fistula
Esophageal atresia
Renal or radius anomalies

Transesophageal Fistula

AP Summer Final (7 decks)

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