peds wk3 GI surgeries Flashcards
gastroschisis and omphalocele incidence
rare 0.3-2:10,000 live births,
etiology unclear
what is gastroschisis
defect of anterior abdominal wall to the right of the umbilical cord.
no sac-bowel is exposed to the intrauterine environment,
bowel is matted, thickened, covered with an inflammatory coating,
usually involves only large and small intestines
what does gastroschisis result in?
malabsorption issues,
results in peritonitis, extracellular fluid loss,, significant heat loss,
fascial defect is 2-5cm
what artery or vein cause vascular event resulting abnormality for gastroschisis
right omphalomesenteric artery or right umbilical artery
In gastroschisis, abnormality of _____ ________ artery or _____ ______ vein, results in ischemia to ______ _______ area and _______ abdominal wall growth and weakened area ruptures as abdominal organs grow
right omphalomesenteric artery,
right umbilical vein,
right paraumbilical area,
dysplastic
OmphaloCele
“central”
what is omphalocele?
Central defect of umbilical ring/base of umbilical cord.
Abdominal contents are within a sac.
Umbilical cord embedded in sac.
Fascial defect >4cm.
in Omphalocele what does the sac contain at what percentage of time?
stomach, large and small intestine, liver (30-50%)
If sac in omphalocele is less than 4cm?
Considered umbilical hernia, (can be as big as 10-12cm)
risk factors for gastroschisis?
young maternal age, tobacco and alcohol exposure during development
Embryology of omphalocele?
week 7-12 midgut herniates into umbilical cord,
week 12 abdominal cavity is large enough, gut re-enters abdomen. (in omphalocele, gut fails to return)
Associated anomalies with gastroschisis?
usually isolated lesion
Associated anomalies with omphalocele?
50-70% incidence of other anomalies,
20-30% incidence of chromosomal abnormalities,
Beckwith-wiedemann syndrome, reiger syndrome, prune belly syndrome,
Trisomy 13, 15, 18, 21,
cardiac 20%
associated anomalies with beckwith-wiedemann syndrome
(macrosomia) omphalocele, visceromegaly, macroglossia, mild microcephaly hypoglycemia
Omphalocele survival rates
isolated defect 95-97%,
without congenital heart defect 70%,
with congenital heart defect 20%,
prematurity also contributes to increased mortality
comparison of gastroschisis
1:10,000 isolated lesion, lateral defect(usually right), umbical cord normal, bowel exposed, thickened, edematous
comparison omphalocele
1:4,000-7,000
assoc. anomalies common,
central defect,
umbilical cord within defect,
sac covers organs, bowel normal
surgical management of omphalocele and gastroschisis
replacing the viscera and repairing the defect,
primary vs staged repair with soli/mesh chimney,
staged-organs gradually returned to the abdominal cavity over 3-14 days
negative effects of tight abdominal closure
impairs diaphragmatic excursion-inadequate vent, increased airway pressure,
impedes venous return-profound hypotension,
aortacaval compression- bowel ischemia, decreased CO, renal and hepatic dysfunction,
Abdominal compartment syndrome
Unsafe for primary closure
intragastric pressure >20mmHg, Change in CVP >4mmHg above baseline, ETCO2 >50mmHg, Peak inspiratory pressure >35cmH2O, CVP change >4 above baseline can indicate reductions in venous return and CI
Fluid resuscitation
massive fluid losses from peritonitis, edema. Ischemia, protein loss, third space loss results in dehydration metabolic acidosis, hypovolemic shock.
maintenance fluid- D5 or D10 in 0.2 NS,
Replacment fluid-isotonic solution at 2-4 times main rate,
Urine output 1-2mL/kg/hr
Monitor glucose electrolytes, acid/base.
NS or LR as replacement (8-15mL/kg/min
how to prevent heat loss from exposed viscera
cover abd. contents with warm, saline soaked gauze,
or plastic bowel bag
preoperative management
treat sepsis with broad spectrum antibiotics,
avoid trauma to organs,
prevent aspiration-decompression of stomach with orogastric tube
chest xray, echo, ABG, CBC
anesthetic management
ASA standard,
2 pulse ox-pre ductal (right arm) and post ductal (left foot),
2 large bore IVs above diaphragm(d/t aortacaval compression, 24g large)
a-line,
foley,
airway pressure,
CVP-changes in blood volume, magnitude of visceral compression
Induction
preoxygenate, atropine, decompress stomach,
IV RSI w/ cricoid pressure,
IH induction and ETI,
Awake intubation
Maintenance
Avoid N2O, Oxygen/air/IH agent, muscle relaxation, opioids-fentynal boluses, remi infusion, FIO2 to maintain SPO2 95-97%, PaO2 50-70 mmHg (full-term)
Fluids
D5 .2 NS,
Third space isotonic 8-15mL/kg/hr,
replace blood loss with washed PRBCs (decreased K in Washed)
How to prevent hypothermia
Room temp 80,
full access bair hugger blanket,
fluid warmer,
plastic wrap for extremities, head, leave the babies hat on
extubation multiple factors
size of patient/prematurity, associated anomalies, size of defect(small defect-easier to extubate), type of repair, intraop events, hemodynamic status
postop management
mechanical vent 24-48hrs-great improvement in resp compliance,
fluid requirements closely monitored,
circulatory compromise-cyanotic lower limbs, owel sichemia,
prolonged postop ileus-TPN required for days to week,
prevent infection,
bowel distention
postop complications
pneumonia, necrotizing enterocolitis, renal insufficiency, abdominal wall breakdown, gastroesophageal reflux, need for further surgeries related to bowel obstruction or adhesions causing issues
what is congenital diaphragmatic hernia and incidence
defect in that diaphragm allows herniation of abdominal organs into the thoracic cavity through a diaphragm that fails to full develop early in gestation.
1:2,500-3,000 live births
CDH associated anomalies
malrotation of the gut-40%,
CV 20%
CNS, GI, GU 15-30%
CDH classification
Posterolateral 80-90% left 75%,
Anteromedial 2%,
Para esophageal 15-20%
