bedside neonatal surgeries
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anesthesia implications of bedside neonatal surgeries, our experience at rainbow children's hospital.
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bedside neonatal surgeries
- 1. Bedside preterm Neonatal laparotomies: Anesthetic Challenges & Concerns Dr Gowri Shankar B Dr Sunidhara reddy
- 2. Introduction • Critically ill neonates in the NICU often require surgical procedures • Traditionally transferred to the main operation room outside the NICU
- 4. Challenges of neonatal transport • Hypothermia • Line displacements • Tube displacements • Risks of infection • Fluctuation of vitals • Change of ventilator and • ventilating team
- 5. Intra-Hospital Transport • Major physiological derangement, • Patient/relative dissatisfaction, • Prolonged hospital stay, • Physical/psychological injury and • Death were reported.
- 6. Bedside surgery in NICU • Indications – Extreme preterm – Sick Unstable ventilated baby – Multiple inotropes – HFO ventilation, inhaled nitric oxide therapy, and ECMO • surgery in the NICU provides continuity of care by the same intensive care team
- 7. Is it a new approach ?? • Abdominal laparotomy drain for NEC in 19771 • Ligation of patent ductus arteriosus (PDA) in 19822 • PDA ligation is the commonest surgery that has been safely performed in NICU safe as well as cost effective
- 8. Common Bedside Surgeries… • PDA ligation • Laparotomy for NEC • CDH repair • TEF repair • Abdominal wall defects • Tracheostomy • Gastrostomy
- 11. Level IV NICU
- 13. Perioperative concerns Pre-operative • Preterm , extreme low birthweight, ventilator dependent, haemodynamically unstable, ionotropic support. IV Access, Hemodynamics, Blood Reports, ABG, Blood and Blood Products, Consent
- 14. Perioperative concerns • Intra operative – Sterility and infection control – Access to baby limited – Long extension lines – No inhalational agents – Drug titration – Fluid and blood – Ventilator adjustments – Monitoring
- 15. Perioperative concerns • Intra operative – Sterility and infection control5 – Access to baby limited – Long extension lines – No inhalational agents – Drug titration – Fluid and blood – Ventilator adjustments – Monitoring
- 16. Perioperative concerns • Intra operative – Sterility5 – Access to baby limited – Long extension lines – No inhalational agents – Drug titration – Fluid and blood – Ventilator adjustments – Monitoring
- 17. Perioperative concerns • Intra operative – Sterility5 – Access to baby limited – Long extension lines – No inhalational agents – Drug titration – Fluid and blood – Ventilator adjustments – Monitoring
- 18. Perioperative concerns • Intra operative – Sterility5 – Access to baby limited – Long extension lines – No inhalational agents – Drug titration – Fluid and blood – Ventilator adjustments – Monitoring
- 19. Perioperative concerns • Intra operative – Sterility5 – Access to baby limited – Long extension lines – No inhalational agents – Drug titration – Fluid and blood – Ventilator adjustments – Monitoring
- 20. Perioperative concerns • Intra operative – Sterility5 – Access to baby limited – Long extension lines – No inhalational agents – Drug titration – Fluid and blood – Ventilator adjustments – Monitoring
- 21. Perioperative concerns • Intra operative – Sterility5 – Access to baby limited – Long extension lines – No inhalational agents – Drug titration – Fluid and blood – Ventilator adjustments – Monitoring
- 22. Perioperative concerns • Post-operative – Charting & Handover – Elective ventilation – Pain management – Regional?
- 23. Perioperative concerns • Post-operative – Charting & Handover – Elective ventilation – Pain management – Regional?
- 24. Perioperative concerns • Post-operative – Charting & Handover – Elective ventilation – Pain management – Regional?
- 25. Perioperative concerns • Post-operative – Charting & Handover – Elective ventilation – Pain management – Regional?
- 26. Perioperative concerns • Post-operative – Charting & Handover – Elective ventilation – Pain management – Regional?
- 27. Is it really worth ..?? • Many studies have shown better outcomes with bedside surgery in NICU. • One study recommends that babies with NEC and weighing less than 1.5 kgs should be operated at the bedside. (Frawly et al. Australia, 1999) • Laparotomy for NEC on NICU is a treatment option for neonates who are too unstable to transfer to theatre
- 29. Our Experience (10 years) Laparotomy for NEC 94 PDA Ligation 3 CDH 1 Resection Anastomosis Closure of Perforation Stoma Laparotomy & Closure 36 2518 12
- 30. Laparotomies in NICU • Indications – NEC 82/94 – SIP 12/94 • Average weight- 1.34kgs (470gms-2.4kgs) • Average duration of surgery- 73mins
- 31. Results of Laparotomies in NICU • Intra-operative complications - Bleeding • Intra-operative death – Nil • Discontinuation of care post Laparotomy due to poor prognosis- 18 • Immediate post-op Surgical complications – Wound infections- 7 – Adhesive Obstruction- 2
- 32. South Asia's smallest surviving premature baby-375gms
- 33. South Asia's smallest surviving premature baby-375gms
- 36. Take home.. • Neonatal surgery in NICU is a safe procedure and can be utilized in unstable or ventilated neonate. • Every neonatal ICU planner should always create infrastructure for surgery and anesthesia in NICU. • Team work , neonatal intensivist is our good friend…! • Sterility, fluid balance, ventilation & communication are the keys for successful NICU surgery management.
- 37. THANK YOU…!
- 38. Bibliography 1. Ein SH, Marshall DG, Girvan D. Peritoneal drainage under local anesthesia for perforations from necrotizing enterocolitis. J Pediatr Surg 1977;12:963-967 2. Eggert LD, Jung AJ, McGough EC. Surgical treatment of patent ductus arteriosus in preterm infants. Fouryear experience with ligation in the newborn intensive care unit. Pediatr Cardiol. 1982; 2:15–8. 3. Kumar Sinha S, Neogi S. Bedside neonatal intensive care unit surgery- myth or reality!. J Neonatal Surg. 2013;2(2):20. Published 2013 Apr 1. 4. Wallen E, Venkataraman ST, Grosso MJ, Kiene K, Orr RA. Intrahospital transport of critically ill pediatric patients. Crit Care Med 1995;23:1588e95 5. Lago P, Meneghini L, Chiandetti L, Tormena F, Metrangolo S,Gamba P. Congenital diaphragmatic hernia: intensive care unitor operating room? Am J Perinatol 2005;22:189e97
Editor's Notes
- Goodevening everyone , im dr gowrishankar , IAPa fellow from rainbow childens hospital. My presentation is on anaesthetic challeneges and concerns in bedside preterm neonatal laparotomies. My moderator is dr sunidhara maam.
- Hospital may have the most sophisticated transport incubators with all the amenities.. still ther are many challenges faced hwile transfereing the nenantes either one centre to other r within the hospital from nicu to OT.
- Most commonly reported challenges are
- In critical patients, previous studies have shown that clinical complications may occur in up to 70% of intrahospital transports. But why to take this risk , can surgery be performed bedside in nicu , is it an option to prevent all these??
- bedside surgery in (NICU) is a novel concept which has the potential to decrease the morbidity, mortality and cost of neonatal car.e general indications for same being Furthermore, performing the surgery in the NICU provides continuity of care by the same intensive care team.
- is it a new approach , no. first bedsid surgery abdominal laparotomy for necrotizing enterocolitis was done morethan 4decades ago in 1977 PDA ligation in 1982 and it’s the most common surgery performed bediside in nicu.
- Today most common surgeries done bedside are
- So as anaesthesiologist wat are the challenges and concerns for providing our service for this bedside surgeries.? First thing its not operating room ..so we cant expect all the luxuries of ot.
- American academy of paediatrics has classified nicus into four levels… Level I is nicu which can provide care new born
- Be it the most sophisticated level 4 nicu.
- As apparent from the table, very few extra instruments/ infrastructural changes are needed to perform surgery in NICU.
- Preoperatively important thing to note are we are dealing with We need make sure we have a proper IV Access ,preoparative Hemodynamics and Blood Reports noted including ABG, Blood and Blood Products are available and last but not Consent explained and taken.
- Infection prevention is major concern ,as neonates are immunocopromised. Some literature claimed that the rate of surgical infection is slightly higher when patients underwent bedside surgery in the NICU
- With Baby surrounded by one senior neonatal surgeon, one assistant surgeon, two surgical nurse,one neonatal intensivist access to the baby is limited. So before giving green signal for surgery we have make sure that baby is well positioned, all the lines, tubes and monitors are secured and accessible.
- Long extension lines increases the chance of disconnection, airbubbles, and volume deadspace. And this volume deadspace can lead to fluid overload . use of pressure lines decrease the deadspace and thus inadvertent fluid bolus .
- we miss our best friend in nicu Unable to use inhalational agents. so TIVA is the method of choice ,which is mainly opioid based , along with muscle relaxants.
- Preterm Neonates are in KG r subkg zone. Drug chart need to be prepared , and we should adhere to that. fluid and blood replacement r titrated against the ,blood loss, HR n BP. Most babies for laparotomies are anemic due to sepsis and haemolysis and require blood and blood products to tansfused.
- Neonatologist takes care of the ventilatory part especially when the baby is on HFOV or ECMO. We need to be in constant touch with them to adjust according to airway pressures especially when surgeons retractors are on.
- A lot of monitors to take of
- Detailed charting and handover to be given to the intensivist eventough they were present ..handover form should cover all th detailes like blood loss, intraop events, total fluid given including the flush used ,blood products used and so on..
- Post op ventilation neonates continue to be ventilated as preop n will be further managed by intensivist. abg/vbg can help to decide futher ventilatory strategy.
- Neonates do feel pain and require adequate analgesic cover mostly with opiods.
- Ther is Lack of adequate literature to give neuraxial/regional blocks bedside in preterm baby.
- With so many peri- operative concerns is it really worth, wat does literature say.
- Its basically nicu room which accommodating itself for an surgery to be done..