Surgical Emergencies Flashcards
What is the most common GI emergency in Neonates?
NEC
Name the clinical findings a/w NEC
Abdominal Distension
GI bleeding
Pneumatosis intestinales
Can NEC be reversed?
No, not even if you intervene early.
Have to ride it out.
Name 4 risk factors for NEC
- Prematurity
- CHD
- Neonatal Distress
- Enteral Feeding
Mortality is ___-___% higher for pan-intestinal necrosis
20-40% higher
Name the Absolute indications for OR intervention for NEC
-Pneumoperitoneum
-Peritonitis (diffuse)
-Clinical deterioration
-Sepsis refractory to medical therapy
-Intestinal obstruction or stricture
(happens w/healing from primary NEC epsiode/scarring ~3-4 wks after repair w/increased fdg vols-can’t advance)
Name Relative indications for OR intervention for NEC
- Abdominal wall erythema
- Fixed loop of intestine
- Portal venous gas
- Positive paracentesis
- Thrombocytopenia
Bilious emesis + toleration of initial feedings = ? -until proven otherwise
Malrotation + Midgut Volvulus (twisting)
When Malrotation & Midgut Volvulus is suspected on x-ray, what test is ordered?
Why?
Upper GI (limited series) It looks at rotational anatomy
If a Malrotation & Midgut Volvulus is not caught early, it can be ?
Catastrophic
What might be seen on Upper GI w/Malrotation & Midgut Volvulus?
What should the Duodenum look like?
A corkscrew appearance to the contrast passing through the intestines.
A “C” shape
Besides Upper GI series, what else is likely needed w/Malrotation and Midgut Volvulus?
Emergency Surgery
What does Normal Rotational Anatomy do to the Mesentery?
Broadens the base of the mesentery preventing twisting
The mesentery takes blood vessels from the ______ out into the _________.
Aorta
Intestine
Failure of Rotation—>
Failure of broad base of mesentery. It will look like a tree trunk w/top heavy tree that can twist.
Malrotation w/Midgut Volvulus compromises what?
The entire Midgut
-intestines supplied by Superior Mesenteric Artery from Duodenal-Jejunal junction to mid-transferse colon
In surgical repair of Malrotation w/Midgut Volvulus, what do they do?
360 degree Counterclockwise Detorsion followed by a second 360 degree Counter clockwise Detorsion
What congenital attachments are noted during surgical correction of Malrotation w/Midgut Volvulus?
What do they do with them?
LADS bands
They try to remove them and broaden the base of the mesentery so the Duodenum is on the Rt & Cecum is in Left, upper quadrant, appendix removed.
Does the anatomy remain abnormal after surgery?
Is there chance of re-vovlulization?
Yes
5-15% chance re-volvulization
7 out of 10 times, bilious emesis is ?
Nothing, but check anyway.
Name the Nursing considerations for Malrotation w/Midgut Volvulus.
-GI decompression
-Prepare for transport (radiology, OR, transfer)
-Post-op (resumption of bowel activity-could take a week)
they tend to get an ileus and have bilious residuals (are TPN dependent for a little while)
What Dx do you suspect in an infant who begins vomiting bile stained fluid in first few hrs of life?
Duodenal Atresia
What might be noted on prenatal US with Duodenal Atresia?
Polyhydramnios
What other anomalies is Duodenal Atresia A/W?
50% a/w: Cardiac, GU, Anorectal, or esophageal abnormalities
40% have Trisomy 21
30% have Malrotation
Is repair of Duodenal Atresia a surgical emergency?
No, not usually-there’s time to do heart ECHO and Renal US first.
**unless a/w malrotation (15-30%)
85% of Duodenal Atresia occur where?
Post-Ampullary (after common bile duct drains into the Duodenum)
What is Duodenal Atresia thought to be caused from?
Failure of recannalization of the lumen of the intestine during development (wks 8-10).
What is the surgical treatment of Duodenal Atresia?
Web excision or Duodenoduodenostomy with or w/o tapering
How long can it take to get feeds going?
Weeks. Just watch and wait
Do surgeons usually remove Duodenal webs?
No, they usually just bypass them.
Jejunal and ileal atresias are caused by?
Intra-Uterine vascular events
10% of jejunal and ileal atresias are what?
Multiple
What does surgical tx of Jejunal and ileal atresias involve?
Resection of stenotic or dilated bowel and anastomoses with or w/o tapering
What is a type 1 Membraneous Atresia?
Is significant length lost w/this type of atresia?
There’s continuity of the bowel wall but no Luminal continuity (probably a late-gestation insult)
No, they sew the ends back together, babies do quite well.
What is notable with a type 2 Atresia?
When did insult likely happen?
There is an intestinal remnant and a large size discrepancy.
Very early in gestation (providing time for the bowel to become very dilated)
Dilated intestine is not very ________
Functional
W/type 2 Atresia the baby may have a prolonged ______, but not __________.
Ileus
not Malabsorption
What is notable w/type 3 Atresia?
There is a small amount of intestine and a very, very dilated colon
With an Antenatal Volvulus there is almost what?
No colon
Very little midgut
What procedure can be done w/Jejunal & Ileal atresia?
Primary STEP procedure
What is the goal of a primary STEP? (serial transverse enteroplasty)
Increase mesenteric length but decrease it’s caliber.
Increase contact between luminal contents and enterocytes to promote absorption
How is a Primary STEP procedure achieved?
Created by surgical staples. As the child grows, the area becomes dilated and they get another STEP procedure
T/F: Jejunal & Ileal atresias are less affected by congenital anomalies vs. Duodenal atresias
True
What might the abdomen feel like in a baby with a meconium ileus?
“Doughy”-it’s filled w/tenacious Meconium
What can be seen on contrast enema in an infant w/meconium ileus?
A negative impression of the meconium cast
Many infants w/CF who have meconium ileus will have what after contrast enema?
Persistent obstructive symptoms
Persistent ileus
Distension
& Require an operation
___% infants w/CF will have a meconium ileus
20%
True/False: Most infants with a meconium ileus will have CF
True
Infants w/meconium ileus sometimes need an ________ or _______ the contents into the colon
enterotomy
milking
What medication instilled can thin and clear meconium nicely and possibly avoid enterostomy
Mucomist 1-2%
Can meconium ileus cause a volvulus?
Yes, occasionally
What are nursing considerations of Meconium Ileus?
GI decompression pre-op
Intestinal irrigation, enzyme replacement post-op (via t-tube left in after surgery)
What do you suspect in an infant w/progressive abdominal distension who does not pass meconium at 36 hrs life, w/patent anus?
Hirschprung’s Dz
What test is done first to eval Hirschprungs? Can this diagnose it?
Why?
Contrast enema. No.
Look for Recto-Sigmoid ratio
What is the only thing that can dx Hirschprung’s?
Rectal Biopsy
What is Hirschprung’s Dz?
What does it cause?
Failure of migration of ganglion cells to the hindgut (a continuous segment of intestine beginning at anorectal junction)
No coordinated peristalsis, internal sphincter won’t relax and baby can’t pass stool or gas
What is the incidence of Hirshprung’s Dz?
Male vs. Female?
___ - ___ have trisomy 21
11-30% have associated anomalies:
1:5,000
70-80% Male
3-16%
GU, Cardiac, GI
Hirschprung’s can present as what in older children/toddlers?
Chronic constipation
What is the tx for Hirschprung’s Dz?
Endorectal pull-through with or without colostomy
remove non-functional section and split the internal non-functional sphincter
What are long-term problems of Hirschprungs?
Constipation
Internal Sphincter can remain hypertonic despite splitting in neonatal period (they can botox it)
What are pre-op nursing considerations
GI decompression
Avoid rectal stimulation just prior to contrast enema
Serial colonic irrgations
What are post-op nursing considerations
Sign over bed “nothing per rectum”
If a newborn has excessive oral secretions respiratory distress after feeding, and resistance when NG is passed, what would you suspect?
Esophageal Atresia w/distal Tracheoesophageal fistula
What type of Esophageal Atresia and TE fistual is most common?
Esophageal Atresia w/distal Tracheoesophageal fistula
What is the second most common type of Esophageal Atresia and TE fistula?
What would you see on x-ray w/this type?
No fistula, just Esophageal atresia
A gasless abdomen would be noted on x-ray
What is the 3rd most common type of esophageal atresia w/TE fistula?
“H” type
What does VACTERL stand for?
Vertebral anomalies (70%) Anal anomalies (55%) Cardiac Anomalies (66%) Tracheoesophageal fistula/atresia (70%) Renal anomalies (50%) Limb anomalies (70%)
Why does VACTERL matter?
If you have a pt w/tracheoesophagela fistula/esophageal atresia-you need to check out the other areas for anomalies.
What can be a complication of ventilation w/high settings in a pt w/tracheoesophageal fistula/atresia?
the GI tract will be ventilated not the lungs
With surgical repair of tracheoesophageal fistula/esophageal atresia, when and where is an ETT placed?
What is the back of the trachea like?
What size NG is placed across the repair site? can it be easily removed/replaced?
These pts will have a chest tube in until what is done?
ETT is placed in the OR
Deep in the throat (has to pass the repair site)
Like wet toilet paper, very friable
5 or 6 Fr, no can not easily be replaced
Until swallow study is done to check for leaks (15-20% have leaks)
What is the surgical concern with an esophageal atresia?
The distal esophagus is not anchored to the chest/back of trachea.
Called “long-gap” esophageal atresia
What’s a big thing to avoid with repair of the “H” type TE fistula?
Avoid the Vagus Nerve.
What is expected post-op for a baby with an H-type repair?
Feeding difficulties
Hoarseness
With “H” type repair, which part of the esophagus doesn’t work well?
The proximal esophagus
- problems swallowing
- is most prone anastomoses to develop strictures (some require surgical dilation in the 1st yr)
What are pre-op nursing considerations for H type repair?
Gastric Decompression
What are post-op nursing considerations for H type repair?
Chest tube
OG tube in place across the esophageal anastomosis
ETT position is critical
Gastroschesis is typically to which side of the umbilical stump?
Right side
Can gastroschesis have adhesive bands?
Yes
How long is a Silo placed?
5-7 days for staged reduction, allows abdomen to accommodate the viscera
Which defect defines:
“Bad bowel, Good baby”
“Good Bowel, Bad baby”
Gastroschesis
Omphalocele
15% of this defect will have intestinal atresia
Gastroschesis
-may wait or make a stoma
What does amniotic fluid do to the intestines toward the end of gestation?
It is caustic to them toward the end
Which defect?
Has adhesive bands or thick, inflamed rind over the intestine–>prolonged ileus (wks)
Gastroschesis
Which defect is A/W midline defects?
Omphalocele
A small omphlalocele is like a ?
umbilical hernia –don’t seem to carry the associated anomalies
A large omphalocele is more dificult. Can it be repaired all at once?
Not typically & if the sac is removed, is more complicated
What wound-healing type is used to get the skin to grow over the omphalocele?
Scarification of wound care
If scarification of wound care is done, when is the omphalocele repaired?
When they are older. They create a compression brace for it and then repair later.
