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.
Tracheo oesophageal atresia and fistula A-Z for medical students
This powerpoint covers everything you need to know about tracheoesophageal fistula and atresia as a medical student.It is not intended for patients. Covers anatomy, embryology,types ,classification and treatment of tracheo-oesophageal fistula and atresia.
IHPS is a common problem in infancy presenting with vomiting after feeds. Undiagnosed cases present with profound dehydration.Initial intravenous fluids to correct fluid electrolyte imbalance,is followed by investigations and surgical correction of gastric outlet operation by a simple pyloromyotomy.
Tracheo oesophageal atresia and fistula A-Z for medical students
This powerpoint covers everything you need to know about tracheoesophageal fistula and atresia as a medical student.It is not intended for patients. Covers anatomy, embryology,types ,classification and treatment of tracheo-oesophageal fistula and atresia.
IHPS is a common problem in infancy presenting with vomiting after feeds. Undiagnosed cases present with profound dehydration.Initial intravenous fluids to correct fluid electrolyte imbalance,is followed by investigations and surgical correction of gastric outlet operation by a simple pyloromyotomy.
The surgical causes for neonatal respiratory distress are life threatening and challenging. Early diagnosis and immediate timely surgical intervention are the key for the final successful outcome.
Pfizer faces lawsuits due to zoloft causing omphalocele in babieszlhelpcenter
http://www.zoloftlawsuithelpcenter.com Mothers of newly born children harmed by the medical condition called omphalocele are filing lawsuits against Pfizer, demanding compensation for the difficulties they had gone through after Zoloft. Omphalocele is an abnormality in which the infant’s intestines, liver or other abdominal organ stick outside of the baby’s body through the belly button. A thin translucent member covers the protrudingorgans. Further, the infant’s abdominal cavity itselfmay be small due to underdevelopment during pregnancy. Incidents such as this leads couples to file lawsuit against Pfizer Inc.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
Neonatal necrotizing enterocolitis
NEC is the most common life-threatening emergency of the gastrointestinal tract in the newborn period. The disease is characterized by various degrees of mucosal or transmural necrosis of the intestine. The cause of NEC remains unclear but is most likely multifactorial. The incidence of NEC is 1-5% of infants in neonatal intensive care units (NICUs). Both incidence and case fatality rates increase with decreasing birthweight and gestational age. Because very small, ill preterm infants are particularly susceptible to NEC, a rising incidence may reflect improved survival of this high-risk group of patients.
Clinical Manifestations
Infants with NEC have a variety of signs and symptoms and may have an insidious or sudden catastrophic onset (Table 96-1). The onset of NEC is usually in the 2nd or 3rd week of life but can be as late as 3 mo in VLBW infants. Age of onset is inversely related to gestational age. The 1st signs of impending disease may be nonspecific, including lethargy and temperature instability, or related to gastrointestinal pathology, such as abdominal distention and gastric retention. Obvious bloody stools are seen in 25% of patients. Because of nonspecific signs, sepsis may be suspected before NEC. The spectrum of illness is broad, ranging from mild disease with only guaiac-positive stools to severe illness with bowel perforation, peritonitis, systemic inflammatory response syndrome, shock, and death. Progression may be rapid, but it is unusual for the disease to progress from mild to severe after 72 hr.
Diagnosis
A very high index of suspicion in treating preterm at-risk infants is crucial. Plain abdominal radiographs are essential to make a diagnosis of NEC. The finding of pneumatosis intestinalis (air in the bowel wall) confirms the clinical suspicion of NEC and is diagnostic; 50-75% of patients have pneumatosis when treatment is started (Fig. 96-4). Portal venous gas is a sign of severe disease, and pneumoperitoneum indicates a perforation (Figs. 96-4 and 96-5). Hepatic ultrasonography may detect portal venous gas despite normal abdominal roentgenograms .
Anesthesia consideration in intestinal obstruction is gastric aspiration, rapid sequence induction, electrolyte and acid base disorder, hydration, AKI and hemodynamic status.
Anaesthesia challenges in neonatal emergencies-1.pptxsouravdash24
Neonatal emergencies present unique challenges in anesthesia, requiring specialized knowledge and skills to ensure safe and effective care for these vulnerable patients. This presentation delves into the intricacies of providing anesthesia to neonates in emergency situations, discussing physiological differences, equipment considerations, medication dosages, and monitoring techniques tailored to this population. Explore essential strategies and best practices for managing airway, ventilation, and hemodynamic stability in neonatal emergencies, aiming to optimize outcomes and mitigate risks. Whether you're a seasoned anesthesiologist or a healthcare professional seeking insight into neonatal anesthesia, this presentation offers valuable insights into navigating the complexities of neonatal emergencies with confidence and expertise.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
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263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
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
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.
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.
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
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.
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.