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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
Gastroschisis can be associated with ______ \_\_\_\_\_\_\_ but not __________ abnormalities.
intestinal atresia (abnormally closed) chromosomal
26
What is depicted in utero?
gastroschisis
27
What is the % of associated abnormalities in neonates with: Omphalocele Gastroschisis
75% Rare with gastroschisis.
28
What is the most common cause of omphalocele and gastroschisis?
Prematurity ## Footnote 33% in omphalocele 62% in gastroschisis
29
What are preoperative evaluation considerations for omphalocele and gastroschisis? (3)
Cardiac disease Less developed lungs from prematurity Less developed kidneys from prematurity
30
What are perioperative concerns for omphalocele and gastroschisis? (3)
Heat/fluid loss from large exposed surface Volume depletion Risk for hypoglycemia/hypocalcemia
31
What monitors are needed for omphalocele/gastroschisis? (5)
Art line IV access in UPPER extremities Urinary catheter **Intra-abdominal pressure monitor** Clear drape over legs (to monitor lower ext. perfusion)
32
Why is lower extremity perfusion at risk for omphalocele/gastroschisis surgery?
Lower veins may be compressed when putting bowel back into the body.
33
What is the induction plan for omphalocele/gastroschisis surgery? (3)
Awake intubation if hypovolemic RSI after IV atropine and O2 (increased risk of bradycardia) ETT leak at 30-40 cm H2O
34
Why is ETT leak at 30-40 cmH2O rather than usual levels?
Higher than usual due to increased intrabdominal pressures.
35
What drugs are needed during maintenance of omphalocele/gastroschisis? (2)
Fentanyl, **5-20 mcg/kg ** Maximum muscle relaxation
36
What are important to monitor intraoperatively for omphalocele/gastroschisis? (8)
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
What values are desired for omphalocele/gastroschisis surgeries? SaO2 (term) SaO2 (preterm) Hematocrit
Term: 94 - 97 % Preterm: 90 - 94 Hematocrit \> 30 % Note: Keep SaO2 lower to prevent retinopathy with increased pressures.
38
What is a primary closure for omphalocele/gastroschisis? What is the risk?
Pushing bowel back in. Increased intra-abdominal pressure leading to respiratory, circulatory, renal, and GI dysfunction.
39
What can occur as a result of increased intra-abdominal pressure due to a primary closure for omphalocele/gastroschisis? (5)
Cyanotic legs Decreased urine ouput Increased AW pressure Hypotension Poor venous return chipd
40
What is a secondary closure for omphalocele/gastroschisis? What is the risk?
Staged closure where bowel stays exposed. Higher risk of infection, but less compromise to other organs.
41
In a secondary closure for omphalocele/gastroschisis, how long does closure take?
7 - 10 days with daily cinching of silo (which requires no anesthesia)
42
What action is taken if the defect is too large to close primarily? (4)
* 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
What is depicted?
Silo reduction of omphalocele/gastroschisis.
44
What is depicted? Where is this surgery performed?
staged closure ICU especially when \< 1kg
45
What is the postop management for omphalocele/gastroschisis? (4)
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
BOARDS What are the complications of omphalocele/gastroschisis? (7)
Peritonitis (from exposure) Pneumothorax (from high pressures) Respiratory failure Renal failure Hypothermia Bowel/hepatic ischemia Sepsis/Metabolic acidosis
47
What is the most common cause of neonatal GI obstruction?
Hirschsprung's disease | (congenital aganglionic megacolon)
48
Hirschsprung's disease is the failure of embryonic neuroganglion cells to migrate to ______ and ________ plexuses of the colon.
Auerbach Meissner
49
Where is Hirschsprung's disease usually confined to? What % of Hirschsprung's involves the entire colon?
rectosigmoid 10%
50
What is the congenital absence of the ganglion cells needed to allow relaxation of the internal sphincter?
Hirschsprung's disease
51
How does Hirschsprung's disease present?
Failure to pass meconium within the first 24 hours of life.
52
What is depicted? What is used to demonstrate the condition pictured below?
Hirschsprung's disease Barium enema Note: Anus constriction is cause of bowel obstruction.
53
How is Hirschsprung's disease diagnosed? What is the treatment?
Rectal biopsy ## Footnote "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
What is the definitive repair for Hirschsprung's disease?
abdominoperineal resection with colon pull-through Child must be **\> 10 KG**
55
The incidence of tracheoesophageal fistula is rare. True or false? Males:Females?
True. 1:1
56
What is the most common type of esophageal atresia?
Esophageal atresia (abnormally closed) with distant fistula (abnormal connection)
57
What are associated abnormalities with tracheoesophageal fistula?
VACTERL ## Footnote Verterbral Anal Congenital heart disease TEF Esophageal atresia Renal or radius anomalies Limb abnormalities
58
What is the anesthetic management for transesophageal fistula? (6)
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
How is induction of a TEF managed? (3)
Atropine 10-20 mcg/kg Awake or RSI ETT position is important!! Past fistula, above carina
60
What are monitors needed for transesophageal fistula? (4)
* 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
What is the position for a TEF?
Lateral decubitus position with thoracotomy incision on side opposite aortic arch. Laparoscopic is being more common.
62
What is the postop management of a TEF? (3)
Extubation preferable to minimize stress on tracheal anastomosis Place in humidified O2 Mark suction catheters/NG for nursing
63
What are post-op risks of a TEF repair? (5)
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
Mortality of TEF \_\_-\_\_% due to prematurity and associated anomalies.
1 - 15%
65
What are long-term risks with TEF repair? (3)
Mild dysphagia (90%) Abnormal esophageal motility Increased bronchial activity 18 years after repair
66
What condition is noted when no gas noted distal to esophagus and failure to pass orogastric tube into the stomach?
esophageal atresia
67
How is esophageal atresia corrected?
Gastrostomy and later anastomosis
68
How does TE fistula present? (3)
Polyhydramnios Excessive oral secretions Cyanosis with feedings
69
If neonate has esophageal atresia with air in the stomach, then \_\_\_\_\_\_. However, if no air in bowel, then _____ alone.
TE fistula Esophageal atresia
70
What is depicted?
* Double fistula * Fistula without esophageal atresia * Esophageal atresia without fistula * Aplasia of trachea, lethal
71
What TEF represents the majority of cases? (2) What is it also known as?
Blind esophageal pouch Fistula off distal trachea Type 3B (most common)
72
What is depicted?
TE fistula
73
What are anomalies associated with TEF? (8)
Prematurity (40%) Cardiac anomalies Musculoskeletal GI atresia GU Craniofacial (4%) VATER VACTERL
74
What is VATER? What is VATER and VACTERYL associated with?
Verterbral Anal TE fistula Esophageal atresia Renal or radius anomalies Transesophageal Fistula

AP Summer Final (7 decks)

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