The document discusses various pediatric surgical conditions and their anesthetic management, including pyloric stenosis, tracheoesophageal fistula, congenital diaphragmatic hernia, intestinal obstruction, omphalocele, gastroschisis, and necrotizing enterocolitis. For each condition, it covers topics like incidence, etiology, clinical presentation, pre-operative preparation and management, induction and maintenance of anesthesia, as well as post-operative care and complications.

1. PART II
ANAESTHETIC
MANAGEMENT

2. 1. Pyloric Stenosis
2. TEF
3. CDH
4. Omphalocele & Gastroschisis
5. Intestinal Obstruction
6. Necrotising Enterocolitis
7. Congenital Lobar Emphysema

3. PYLORIC STENOSIS
• Incidence:1 in 2000
• Male > female (first male child)
• Preterm = full term
• Etiology:Autonomic N system imbalance
& humeral disorder(?)
• Pathology : gross thickening of circular
smooth muscle of pylorus---gradual
obstruction of gastric outlet.

4. PYLORIC STENOSIS
• Diagnosis:
clinical: projectile vomits, mass in upper abd.
(‘olive in abdomen’)
upper G.I.series with barium
Ultrasound
• Anaesthetic concerns: - dehydration
- acid-base
abnormalities
-risk of aspiration

5. PYLORIC STENOSIS
• Pathophysiology:
Hypochloremia, hypokalemia, hyponatremia
& metabolic alkalosis.
• Preparation:
Medical emergency- parameters for surgery:
normal skin turgor,
Na>130mg/l
k at least 3meq/l,
Cl <85 meq/l
urine output 1-2ml/kg/hr
Resucitation c balanced salt soln, pot chlor after
urination.

6. PYLORIC STENOSIS
• Induction of Anesthesia:
-preoxygenation with 100% O2
- Ryles tube asspiraton
-Pentathol – 5 mg/kg.
-Suxa2mg/kg…intubation
-surgeon needs relaxation twice
a) at the time of delivery of pylorus
b)at the time of putting pylorus into abdomen

7. – Atracurium 0.5 mg/kg-best nondepolarizing
relaxant after induction followed by caudal
epidural 1.25ml/kg bupivacaine 0.25% with
1:200000 adrenaline.
– Reversal as usual
• Post-op care:respiratory depression is
common.

8. Tracheo - Esophageal Fistula,
with/without Esophageal Atresia
1. Incidence-1:3-4.5000 births
20-25% assoc. with
VSD,ASD,TOF,Coarctation of aorta.
another 20-25% with TEF are premature
wt<2kg

9. Tracheo Esophageal Fistula,
• Anatomy/Classification:
– Mostly TEF &EA occur together
– 90% lesions are type’C’ – i.e. fistula between
trachea & lower esophagus above carina.upper
esophagus ends blindly.

10. Tracheo Esophageal Fistula,
• Associated anomalies:
– TEF with other anomalies in 30-50% pts.
– VATER association – 1973 by Quan & Smith
• V- vertebral defect / VSD
• A- anal defect
• T-TEF
• E- atresia
• R- radial dysplasia / renal dysplasia

11. Tracheo Esophageal Fistula
• Diagnosis:
– Early diagnosis is imp.to prevent pulmonary
complications- which determines prognosis.
– In utero-polyhydramnios-
– At delivery-pt.has excessive salivation,drooling,
cyanotic spells, cough-relieved by suction.
– Resp.depression
– Inability to pass a catheter(feeding tube#8)
– X-ray-radioopaque cath ending in proximal esophagus-
simple & diagnostic

12. Tracheo Esophageal Fistula,
• Pre-op management:
– ‘has the baby suffered any pulmonary insult’?
Aspiration pneumonia-more morbidity-delay the
procedure; stomach decompression by gastrostomy
– Avoid feeding
– Nurse in propped up position
– Intermittent suction
– Antibiotic therapy & physiotherapy
– Hydration

13. Tracheo Esophageal Fistula,
• Surgical management:
– Primary repair in 24-48 hrs.
– Gastrostomy under LA, delay thoracotomy for 48-72
hrs.,which allows proper hydration & assessment of
resp. & CVS.
• Anesthetic considerations:
– Pre-medication:inj.atropine IM.
– OT- AC off, warmers kept ready,(heat loss is more in
thoracotomy).
– Monitors:ECG,BP,FIO2,pulse oximetry,rectal
temp,arterial line,foley cath,precardial steth.

14. Tracheo Esophageal Fistula
– Induction /intubation.
• Decompression of stomach (gastrostomy tube allowed to vent,
& kept at head end of patient),
• Pre-oxygenation
• Awake/anesthetic intubation
• Correct position of ETT
• Induction with N2O+O2+ halothane
• IPPV cautiously attempted before NMJ blocker.
– ETT might enter fistula during intubation,or during
surgery difficulty in ventilation saturation and
ETCO2

15. Tracheo Esophageal Fistula,
• Maintenance:
– Continue inhalational agents.discontinue N2O if gastric
dilatation occurs
– Non depolarising muscle relaxant , conc of halothane
–less CVS depression
– O2 conc by ABG sampling. High FiO2 if pulmonary
pathology is present.
– Manual ventilation best- changes can be detected
easily. Airway obstruction can occur during surgery &
due to accumulation of blood & secretions in tube.
– Blood loss 20-30%. If Hct <30,and EBL >10-15%,vol.
replacement with blood.
– IV fluids for maintenance

16. Tracheo Esophageal Fistula,
• PostOperative care:
– Analgesia by caudal 0.25% bupivacaine1.25ml/kg with
epinephrine1:200000.Postop. ventilation if necessary
(prematurity, RDS, CHD)
• Complications:
– Esophageal dysmotility,esophageal stricture,recurrent
URI&LRI, tracheomalacia, gastroesophagreal reflex.

17. CONGENITAL
DIAPHRAGMATIC HERNIA
• Incidence:
1:4000 live births
mortality with heroic post-op measures-30%
(earlier 40-50%)
• Def: herniation of abdominal contents into chest
through a defect in the diaphragm.
– Types: Lt.posterolateral defect in foramen of
Bochdalek(75-85%) - commonest
– anterior opening (foramen of Morgagni) -rarely

18. CONGENITAL DIAPHRAGMATIC HERNIA…
• Associated anomalies:
still borns c CDH – 95% of other anomalies
live borns –20% CVS (esp. PDA) defects
• Clinical presentation:
variable
– Early hernia,pressure on lung bud small lung
– Hernia in late fetal life normal lung,but compressed
infants c severe hypoplasia symptoms in 1st hour
less severe forms symptoms in 24 hrs.

19. CONGENITAL DIAPHRAGMATIC HERNIA…
• Triad:
– Cyanosis
– Dyspnea
– Apparent dextrocardia
• O/E: scaphoid abdomen,bulging
chest,breath sounds ,bowel sounds in chest
x-ray:mediastinal shift

20. CONGENITAL DIAPHRAGMATIC HERNIA…
• Diagnosis:
antenatal:1) 30% c polyhydramnios
2) ultrasound
after delivery: x-ray chest
• Anesthetic considerations:
delay surgery till infant stabilises
(24-48hrs.to 1week)…levin 1987

21. 1. Pre-op care:
– Decompress c nasogastric tube
– Don’t ventilate c mask
– Awake intubation paralyse, sedate, ventilate
c 100% O2
– Lowest possible inflation pressure (30cmH2O)
used (vs.-in pneumothorax)
– Tr.of acidosis-ventilation,soda bicarb,improve
circulation by fluids& inotropes

22. CONGENITAL DIAPHRAGMATIC HERNIA…
2.anesthetic management:
– Intubation & paralyses before arrival to OT,or
preoxygenation-rapid sequence awake intubation-low
airway pressure & high resp.rate
– Frequent blood gas estimations,ET CO2 & pulse
oximetry-maintain effective ventilation
– Prevent hypothermia
– Low conc.of inhalational agent c high inspired O2 or
high doses of narcotics (fentanyl). Avoid N2O
– Primary closure of abdomen,or chimney prosthesis,or
silastic pouch
– Continue paralysis & controlled ventilation post-op,
except in infants c small defects & good gas exchange .

23. CONGENITAL DIAPHRAMATIC HERNIA…
Options:
– in infants c severe lung dysplasia,tr. c ECMO
preop, wean then schedule for surgery
– Repair defect when on ECMO & maintain
ECMO post-op for 30 days
– Neonates c CDH have surfactant deficiency,
using ECMO will improve surfactant

24. CONGENITAL DIAPHRAGMATIC HERNIA…
– Pts. given ECMO with NO before & after ECMO &
after surgery. NO was ineffective pre-ECMO. NO after
ECMO followed by surgery was able to increase
oxygenation. (Karamanaoukian et al.)
– UK study- pts. c CDH not treated c ECMO but c preop
stabilisation & supportive care had same results as c
ECMO therapy.
– ‘what is the best time to operate?
operation should be postponed till PVR is decreased as
revealed by Doppler EchoCardiography.

25. CONGENITAL DIAPHRAMATIC HERNIA…
• Post-Op problems:
– Determination of outcome
• a) extent of Pulmonary Hypoplasia
• b) degree of pulmonary hypertension
Infants with post-op PaCo2 < 40mm.Hg. who could be
hyperventilated c airway pressure < 20 cm. H2O , & who had
a resp.rate < 60 /mt. survived well.(Bohn.,J.Paediatrics,1984)
Reducing PVR & prevention of Rt.to Lt. Shunt is accomplished
by ----- hyperventilation, ligation of PDA & drugs include
tolazoline, PGE1, & ECMO.

26. INTESTINAL OBSTRUCTION
• Upper G.I. Obstruction (duodenum)
• Lower G.I. Obstruction (ileum, colon, imperforate
anus).
– Upper GI problems – 24 hrs.
– Lower GI problems –2- 7 days.
• Triad of Obstruction:
– Vomiting
– Constipation
– Abdominal distension

27. INTESTINAL OBSTRUCTION
• Upper GI obstruction:
– Persistent bilious or non-bilious vomiting
deficit of fluids & electrolytes.(Stomach contains
100-130 meq/l/Na.,& 5-10 meq/l of K.
– To prevent aspiration, awake / RSI.
• Anesthetic considerations:
– Pre-op preparation-
• Correction of dehydration
• Correction of electrolytes
• Ryles tube decompression

28. INTESTINAL OBSTRUCTION
• Anesthesia:
– Awake, rapid sequence intubation
– Repair of congenital defect & closure of abdominal
defect.
– N2O can be used.
• Extubation
– Possible only with good g.c.
– Patient debilitated,extensive surgery,big incision,
– Post-op ventilation c PEEP.

29. INTESTINAL OBSTRUCTION
• Lower GI obstruction:
– Problem develops between 2-7 days
– Incomplete anus can be evident after birth
– Vomiting secondary to obstruction
electrolyte or fluid disturbances.Large fluid
sequestration within GI tract, (ECF c high Na+
content)
– Na must be >130meq/l , & urine volume of
1.2ml/kg/hr.

30. INTESTINAL OBSTRUCTION
• Anesthetic considerations:
– Decompression of stomach
– Electrolyte & fluid management
– Awake, rapid sequence intubation
– N2O should not be used.
– Adequate relaxation
– If patients g.c. is good,reverse & extubated with post-
op O2 supplementation
– If patients g.c. is not good, post-op ventilation is
continued c PEEP.

31. OMPHALOCELE &
GASTROSCHISIS
Omphalocele:
• herniation of intestine into base of umbilical
cord.
Gastroschisis:
• defect of abdominal wall lateral to base of
umbilicus
• Incidence: omphalocele-1:10000 births
gastroschisis – 1: 30000 births
boys : girls 1:1
25-30% are premature or LBW

32. OMPHALOCELE & GASTROSCHISIS
Omphalocele:
• membrane covering peritoneum inside,
amniotic membrane outside.
• Sac may be small or large containing
liver,spleen etc.
• Prematurity 25-30%
• Associated anomalies:77%

33. OMPHALOCELE & GASTROSCHISIS
Gastroschisis:
• Eviscerated abdominal contents,involves small or
large lntestines
• Umbilical cord is to left of defect
• Prematurity is 58%
Anesthetic considerations:
• Pre-op management:
– Search for associated anomalies,
– Ruptured omphalocele is a surgical emergency.

34. • Fluid resuscitation:
– Fluid loss is high,
– 3rd space loss,protein loss, increased fluid
requirements
– 150-300 ml / kg / day RL or 5% Albumin is
used.
– Correct acid – base status
– Insensible loss – wrapping the child in
polythene bag filled c warm saline.

35. OMPHALOCELE & GASTROSCHISIS
• Atropine
• Temperature regulation
• Hypoglycemia & hyperglycemia are
avoided.
• Nasogastric tube for decompression of
stomach.

36. OMPHALOCELE & GASTROSCHISIS
• Peri-operative management:
– Monitoring
– Induction c I.V. inhalation
– Awake intubation
• Maintenance:
– FiO2 to maintain saturation of 95-97%
– N2O should be avoided,
– Maintenance by balanced anesthesia,
– Airway pressure to be monitored
– Post-op ventilation for 24-48 hrs.
– Excellent skeletal muscle relaxation
– Repair is staged if primary closure is not possible

37. OMPHALOCELE & GASTROSCHISIS
• Post-op complications:
– Respiratory insufficiency
– Ileus,
– Venacaval compression due to tight closure.
– Sepsis is major cause of mortality & morbidity
– Temperature regulation

38. NECROTISING
ENTEROCOLITIS
• Incidence:
– 2.4/1000 live births
– Premature or low birth weights
– Wt.< 2.5kg & <38 wks.of gestational age
• Etiology:
– H/0 intra uterine fetal distress/ birth asphyxia
– H/O RDS,apnea,
– Prematurity & umbilical catheterisation

39. NECROTISING ENTEROCOLITIS
• Clinical Signs:
– Retained gastric secretions,
– Vomiting , bloody , mucoid diarrhea,
– Thermal instability,
– Abdominal distension c bloody, sticky stools
– Signs appear in first few days of life/2or 3 days after
feeding
– Lethargy & apnea, metabolic acidosis, jaundice,
– DIC c prolonged PT & APTT.
– X-ray abdomen: early – distended gas filled loops,
– Late gas in the bowel., (pneumatosis intestinalis ).

40. NECROTISING ENTEROCOLITIS…
• Non – surgical management:
– Decompression of stomach,
– Cessation of feeding, broad spectrum antibiotics,
– Fluid & electrolyte therapy
– Ionotropic agents, steroids in septic shock
• Indications for surgery:
– Peritonitis, air in portal system, ascitis,progressive
deteriotion.

41. NECROTISING ENTEROCOLITIS…
• Anesthetic management:
– Pre-op evaluation, correction of respiratory, metabolic,
circulatory & hematological disorder,
• Investigations:
– ABG, glucose,electrolytes, BT,CT,platelet count,
– Monitoring: arterial cannula, CVP,
– IV fluids,
– Induction & Intubation:
• Awake intubation,
• Thiopentone or ketamine + suxamethonium

42. NECROTISING ENTEROCOLITIS…
• Maintenance:
– FiO2 to maintain PO2- 50-70mmHg.
– Avoid N2O, inhalational anesthetics
– Atracurium supplemented c ketamine or
narcotics
– Correct hypothermia,
– Inotropes to maintain perfusion

43. CONGENITAL LOBAR
EMPHYSEMA
• Overinflation & air trapping ,
• Compression collapse & mediastinal shift
• Left upper lobe >Rt. middle lobe > Rt.upper
lobe
• Males twice affected than females.
• Cause unknown, 50% show deficiency of
bronchial cartilage.
• 10% have CHD

44. CONGENITAL LOBAR EMPHYSEMA…..
• Clinical presentation:
– Respiratory distress in newborns,
– Distress intermittent, aggravated by feeding or
coughing, tachypnea, chest retraction,wheezing.,
cyanosis.
– Mediastinal shift & contralateral lung compression,
– Decrease in CO, compression of healthy lung
– X-ray: emphysematous lobe c basal atelectasis
– Mediastinal shift, diaphragmatic displacement
– Atelectasis of opposite lung

45. CONGENITAL LOBAR EMPHYSEMA…..
• Diff.Diagnosis:
– Pneumonia,
– Cystic disease of lung,
– Tension pneumothorax
• Pre-op evaluation:
– Rapid deterioration, urgent operation
– Chest tube placement, needle aspiration, mechanical
ventilation worsens prognosis,
• Monitoring: Pulse oximeter, NiBP, capnography

46. CONGENITAL LOBAR EMPHYSEMA…..
• Anesthesia:
– Crying, struggling amount of trapped air
– IPPV emphysema
– Halothane + O2 c mask , intubation c or c out
relaxation.
– IPPV postponed until thorax is opened.( cote,1978)
– Extubated at the end of lobectomy.
– Humidity, coughing mininises atelectasis in post-op
period,
– Results are good.

47. REFERENCES
• 1. Wylie & Churchill Davidsons :
– ‘A practice of anesthesia’ ; 6th Ed.,Chapter 30th
by James.M.Steven & John Downes.
• 2. Physiology of the neonate of importance to
anesthesiologists , by Frederic.A.Berry, M.D., 42nd
anesthesiology review course lectures.
• 3. Emergency neonatal surgery , by
Frederic.A.Berry, M.D., 42nd anesthesiology review
course lectures.
• 4. Anesthetic management of neonatal
emergencies, by Anna Lucia Pappas, M.D.,
asst.prof. Loyola University Medical Centre.

48. THANK YOU