Pre op stabilization and management

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  • On post partum day 1 neonate is oligouric followed by diuresis and natriuresis also resulting in weight loss. The diuresis is regardless of the fluid intake
  • Pre op stabilization and management

    1. 1. Dr. Ravi Prakash Kanojia Assistant ProfessorDept of Paediatric Surgery PGIMER CME: Anaesthesia for neonatal surgical emergencies: Pearls & Pitfalls
    2. 2. Neonatal surgical emergencies Common cases Emergencies Semi -Emergencies  Congenital diaphragmatic  Bladder exstrophy hernia  Hirschsprungs  Tracheoesophageal fistula  Neural tube defects  Anorectal malformation  Obstructive uropathies -  Intestinal atresias PUV  Malrotation
    3. 3. What does the surgeon wants in the neonate before starting for surgery (pt optimization) What does the surgeons expects from the anaesthetist SurgeonsPerspectives
    4. 4. What does the surgeon wants in the neonatebefore starting for surgery (pt optimization)
    5. 5. How do we define preoperativestabilisation (optimisation) Neonate is  Normothermic  Normal hydration and electrolyte  No acid base disturbance  Adequate renal and respiratory function
    6. 6. What does the surgeon wants in the neonatebefore starting for surgery (pt optimization) Before embarking on the surgery the baby needs to be stabilized on various parameters and aspects  Temperature control  Fluid balance  Blood gasses  Urine output  Identifications of decompensate systems like hypoplastic lungs, cardiac shunts, dysplastic kidneys  Specific condition related requirements
    7. 7. Identification optimisation strategy
    8. 8. FluidIdentify Optimize The physiological shifts Balance early natriuresis occurring during first 48 and diuresis by fluid hours of life The ongoing fluid losses via • Nasogastric aspirates • Loss through respiratory tract • Evaporative losses by exposed Image mucosa/ epithelial surfaces eg gastroschisis • renal loss – Post obstructive diuresis in obstructive uropathies like PUV
    9. 9. Temperature control • Inherent • Active propensity to warming hypothermia • Avoid • Temperature loss due to exposed unnecessary Identify surfaces Optimize exposuretemperature • Hypothermia due Thermore • Cotton wraps loss and its to long surgery gulation • Coveringconsequence • Hypothermia exposed induces acidosis by viscera
    10. 10. Blood gases • Respiratory system • Metabolic disease – CDH acidosis • Uropathies – • Treatment of PH Is inadequate renal shock buffer – PUV,altered dysplastic kidneys Corrections • Correction of in • Intestinal volume and obstruction with electrolyte loss of ions and deficit bicarbonate • Alkali therapy
    11. 11. Sepsis & Antibiotics Infection and Sepsis go hand  Recognise sepsis  Indirect method in hand with surgical  Refusal to suck conditions  Poor cry  Often compounded by  Lethargic ventilation, surgical site  Poor capillary refill time infection & nosocomial  Abdominal distension component  Low urine out put  Fever / hypothermia  Most common organism in  Tachypnea our settings are  Direct method  E coli  Positive culture from blood urine csf  Staph aureus  Raised CRP  Klebsiella  Leucopenia  Fungal  Neutropenia
    12. 12. Antibiotics Know the bug Know the susceptibility (or likely susceptibility) Identify the site of infection Host Factors In vitro response is not the same as in vivo
    13. 13. Identify
    14. 14. Antibiotic choiceType of infection Expected pathogen First choice 2nd choiceIntra-abdominal S Aureus, e coli Ceftriaxone Imipenum ,infection Kleibsiella, cefotaxime meropenum enterococci Ampi-sulbactum Piperacillin tazobactumCNS infection S Aureus, S Ceftriaxone Vancomycin Epididermis cefotaxime Meropenum PseudomonasBiliary tract E coli, enterococci , Cefoperazone – Imipenum ,infection kliebsiella , sulbactum , meropenum clostridium perfringesGentamicin/ Amika for enterobacter, pseudomonas & S epididermisVancomycin for coag neg staph/MRSAMetronidazole if anerobes are suspected (liver abscess). Fluconazole for yeast
    15. 15. Transport (journey in & out of OR) Temperature controlTransport Care ofteam and drains and vehicle tubes Neonatal transport Monitoring Respiratory on the move assistance
    16. 16. What does the surgeon expects from the (Neonatal)Anaesthetist
    17. 17. What does the surgeon expects from the (Neonatal)Anaesthetist A dedicated neonatal anaesthetist Dynamics of neonatal physiology Know the condition  The abnormal anatomy  The compromised systems  CDH – Respiratory  PUV – renal  Hydrocephalus – CNS  Impact of the condition on the tolerance of anaesthesia
    18. 18. Stabilisation in individual conditionsrequiring emergency neonatal surgery  Tracheoesophageal fistula  Frequent suction to avoid aspiration  As far a possible avoid intubation and mask ventilation  Causes stomach distension  If intubation is required try to place the bevel of tube away from fistula to the left  Avoid excessive positive pressure
    19. 19.  Congenital diaphragmatic hernia  No bag mask  Early intubation  High frequency ventilation  Optimisation of arterial blood gasses GIT atresia  ARM – single stage repair in prone position  Intestinal atresias – nasogastric loses / resection of bowel – short bowel
    20. 20. Understanding the urgency in theemergency Malrotation (with volvulus)  Understand the urgency of the condition and impending gangrene Hirschsprungs  Intestines can be decompressed by rectal washes but sub acute obstruction still persists and delay increases the chances of enterocolitis and sepsis Spina Bifida – thin membranes over swelling, impending rupture and meningitis waiting to happen
    21. 21. Surgeon’s message Neonatal emergency surgery requires highest level of scientific precision when it comes to manage and needs experience by a full time neonatal anaesthetist well versed by the dynamic physiology and pathology Identification – optimisation strategy Normothermic, hydrated baby with no electrolyte and acid base disorder is the basic requirement which will improve outcome. Understanding the disease anatomy and specific morbidity factors will save the baby

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