PRINCIPLES OF NEONATAL SURGERY

BY

DR JAMEEL ISMAIL AHMAD

SURGERY DEPT, AKTH 22ND JANUARY, 2008

OUTLINE

INTRODUCTION NEONATAL CONSIDERATIONS PRE-OPERATIVE CARE PEROPERATIVE CARE POSTOPERATIVE CARE CURRENT TRENDS CONCLUSION REFERENCES

INTRODUCTION

A neonate is an infant of age 1-28 days Neonates are classified based on gestational age and birth weight Classification by gestational age Pre-term- <37 weeks Term- 37-42 weeks Post-term- >42 weeks

INTRODUCTION

Classification by birth weight SGA- <10th percentile AGA- 10-90th percentile of GA LGA- >90th percentile of AGA Full term- SGA- <2.5kg AGA- 2.5-3.5kg LGA- >3.5kg

INTRODUCTION

Pre-term LBW- 1.5-2kg VLBW- 1-1.5kg ELBW- <1kg A normal full term infant has a GA of >37 completed weeks and birth weight of >2.5kg Pre-term is born <37 GA but AGA SGA has birth weight of <10th percentile and not AGA

INTRODUCTION
Common neonatal surgical conditions GIT- OA, TOF, Cong. Diaphragmatic hernia, intestinal atresia, anorectal malformations, Hirschsprungs disease, Gastroschisis, Omphalocoele, biliary atresia etc UGS- Hypospadias, Epispadias, Bladder exstrophy, multi/polycystic kidney disease, AEG, undescended testis CNS- Hydrocephalus, NTDs MSS- Congenital Hip Dislocation, talipes, sacrococcygeal teratoma CVS- Congenital Heart Diseases,COA

ANATOMICAL CONSIDERATIONS OF THE NEONATE

Wider abdomen, broader chest and shallower pelvis Liver edge is more palpable per abdomen Urinary bladder is intra abdominal Ribs are horizontal and respiration almost dependent on diaphragm

PHYSIOLOGICAL NEONATAL CONSIDERATIONS

A neonate is not a small adult but better considered an immature adult There many considerations of a surgical neonate which include: body fluids and electrolytes renal function cardiovascular function respiratory function thermal control Metabolism and nutrition Immune function

BODY FLUID AND ELECTROLYTES

TBW @ birth is 80%, ECF is 45% and ICF is 35% of body weight In Pre-term it is 84%, 60% and 24% resp The body water is redistributed during the 1st week through the following phases: pre-diuretic phase- 1st day (1ml/kg/hr) diuretic phase- 2nd-3rd day (7ml/kg/hr) and natriuresis post-diuretic phase- 4th-5th day

BODY FLUID AND ELECTROLYTES

Fluid administration in early neonatal period should be guided more in Pre-term to prevent overload Pre-term neonates tolerate fluid restriction more than overload Sodium regulation is controlled by RAAM which is immature in neonates Negative Na balance leads to Na retention but in positive Na balance the capacity to excrete Na is poor

RENAL FUNCTION

7% of normal neonates may not pass urine in 24hrs Renal handling of water depends on GFR and renal tubular function GFR is about 25% of adults It is function of renal perfusion pressure & renal vascular resistance which are low and high respectively in the neonate Tubular urine conc capacity is low with urine osmolality 500-600mosm/kg (cf 1200mosm/kg in adults) The tubules are relatively insensitive to ADH

CARDIOVASCULAR FUNCTION

Fetal circulation undergoes transition to adapt the extra uterine life Crying and 1st breath leads to lung expansion, increased O2 tension, decreased pulm artery, increased pulm circulation Clamping of umbilical cords causes increased systemic artery, LA & LVP which leads to closure of foramen ovale and functional closure of DA The sphincter closes @ the ductus venosus leading to its closure

BLOOD VOLUME

Pre-term- 90ml/kg ~10% body weight Term- 80ml/kg ~7.5% body weight Hb level- 20-22g/dl & haematocrit 6065% at birth which decreases as the infant grows Hb 0f 8g/dl or hct of 30% call for blood transfusion

PULMONARY FUNCTION

Small and narrow airways- tracheal diameter of 2.5-4mm and can easily be blocked by secretions Diaphragm is the only muscle of respiration and the sneezing/cough reflexes are absent Lungs are not fully developed & some alveoli not functional for gas exchange Tidal volume- 6-10ml/kg and RR up to 60cpm

THERMAL CONTROL

The mechanism is immature Normal body temp of a neonate is 370c The thermoneutral temp is 32-340c, 28-300c, 30-320c and 350c for pre-term, term SGA & ELBW neonates respectively The poor thermal control is due to large BSA/ BW, less subcut fat and thin non-keratinized skin, rich surface skin capillaries and poor vasomotor control, absent sweating & shivering mechanism Heat loss occur by convection, conduction, evaporation and majorly by radiation

NUTRITION AND METABOLISM

Small nutritional reserve as main energy source (glucose) via placenta is cut and then depends on hepatic glycogen store, gluconeogenesis and enteral feeding All are inadequate in a surgical neonate Total energy requirement in term neonates is 100kcal/kg/day Proteins provide 15% of total calories, carbohydrate & fat provide 70 and 30% of non-protein calories Prematurity, sepsis, burns increase requirement

NUTRITION AND METABOLISM

GLUCOSE Glu control mechanism is immature in neonates and are predisposed to hypo/ hyperglycaemia Normal blood glucose is 50-60mg/dl (3.33mmol/dl) in term neonates Hypoglycemia-blood glu <30mg/dl(1.67mmol/dl) in term and <20mg/dl(<1.1mmol/dl) in LBW may be caused by Low liver glycogen, low gluconeogensis & hyperinsulinism Prolonged hypoglycaemia leads to seizures & brain damage Premature neonates, prolonged NPO, diabetic mothers may predispose to hypoglycemia

NUTRITION AND METABOLISM

BILURUBIN Physiological jaundice (25-50%) vs. neonatal jaundice May be due to short RBC life span, immature hepatic glucoronyl transferase enz or high bilurubin from ABO/ Rh incompatibility, sepsis, G6PD deficiency Major concern is kernicterus Surgical jaundice- biliary atresia should be identified to offer early treatment

IMMUNE FUNCTION

It is immature and are predisposed to infection Low opsonins: IgA, IgG, IgM, C3b Poor phagocytosis

CONGENITAL ANOMALIES

neonatal surgery is more or less the surgery of congenital malformations They are not usually isolated but affect various organ systems of the body Could be caused by genetic, chromosomal, teratogenic or unknown causes CNS- Hydrocephalus, NTDs GIT- OA TOF, intestinal atresia, ARM, Hirschsprung's disease Ant abd wall- Omphalocoele, Gastroschisis UGS- PUV, hypo/ epispadias, PKD

PRE-OPERATIVE CARE
AIM: to maintain the baby in a physiologically optimal condition for the surgical procedure RESUSCITATION: Best done in SCBU Most of our surgical neonates are out born, traveled a long distance, in bad shape and require resuscitation Ensure good airway by gentle suctioning, O2 & ventilatory support Fluid,electrolyte & glu mgt-guided and monitored Normal body core temp maintenance NGT for decompression Vital signs monitoring

PRE-OPERATIVE CARE
HISTORY GA Antenatal Hx- polyhydramnios, maternal illness, drug hx Family Hx of congenital anomalies Passage of meconium Micturition Bilious vomiting Abdominal distention

PRE-OPERATIVE CARE
EXAMINATION Gen-colour, cry, activity, temp, hydration, resp distress, apnoea Features of Prematurity abdominal distension, anal orifice CVS examination Detailed other systemic examination to detect any anomaly

GENERAL CARE
RESPIRATORY SYSTEM:

Ensure patent airway by gentle sterile suctioning Monitor respiratory rate, rhythm and volume Watch for apnoeic attacks and manage Monitor O2 saturation Humidified O2 in incubator or via O2 hood and not by face mask or nasal catheter NGT-decompression & to prevent vomiting and aspiration Pulmonary physiotherapy

GENERAL CARE
CARDIOVASCULAR FUNCTION:

Fluid loss could occur from vomiting, excessive NGT aspiration, third space loss and evaporation esp. in anterior abd wall defects and need early replacement Blood loss may be from birth trauma or haemorrhagic disease Blood loss should be replaced volume for volume Hb deficit x bw x constant (6,4 & 3 for whole blood, sedimented or packed cells) Prior to any surgery blood should be grouped and cross matched

FLUID AND ELECTROLYTES

Fluid and electrolyte derangements usu set in after 24 hours Mgt is to correct deficit, daily maintenance and replacement of on-going losses and should be strictly according to weight Fluid requirement first 24hrs- 60-70ml/kg/day 24-48hrs- 70-90ml/kg/day after 48hrs- 100ml/kg/day Na, K and Cl req are 2, 2 & 3 mmols/kg/24hrs respectively

FLUID AND ELECTROLYTES

50% Ringers lactate(Na-65meq/l and Cl54meq/l) is the ideal fluid but 4.3% dextrose in 0.18% saline is commonly used Neonates under radiant heater or phototherapy have higher fluid requirement Incubators and ventilatory circuits add up to 15-20% of TBW Monitoring of fluid treatment by input-output chart & vital signs

GENERAL CARE
TEMPRETURE REGULATION: Surgical neonates should have neutral core body temp and kept in a thermoneutral environment Overhead radiant heaters provide more access in case of emergencies than incubators NUTRITION: most surgical patients are not on enteral feeding and require parenteral nutrition commonly via peripheral access TPN is the best in some situations but limited by availability and cost and the neonate need monitoring BILURUBIN Hyperbilurubinaemia may require phototheraphy or EBT

GENERAL CARE
RENAL FUNCTION

Serial measurement of urine output and kidney function is essential in monitoring fluid mgt Measurement may not be adequate expect where a urethral catheter is in situ May be due to hepatic immaturity, low Vit K or thrombocytopathy Should be sought and managed Parenteral vitamin K should be given DIC may occur and FPP is given

COAGULATION ABNORMALITIES

GENERAL CARE
VASCULAR ACCESS

24/22G cannular may be used and should be fixed well to avoid reinsertion Arterial lines may be used for BP monitoring or blood sampling and CVP lines are for TPN

ANTIBIOTICS Prophylactic or curative and parenteral Empirical Broad spectrum before culture result Group B haemolytic streptococcus and E.coli are the commonest

GENERAL CARE
INVESTIGATIONS FBC, U/E/Cr, RBS, Ca, bilurubin, GCM Blood gasses, PH, Clotting Profile, Blood culture Caution and care in amount of blood taken to avoid CV derangement Micro methods reduces the amount taken PARENTS COUNSELLING

TRANSPORT

Prenatal diagnosis allowed in-utero transfer of surgical neonates to tertiary/specialist centers Post-natal transfers are still the commonest here Before transfer the neonate should be optimised and accompanied by a paediatritian or Nurse trained in ET intubation and ventilator mgt Detailed reason for referral and parents counseling are essential The vehicle should be equipped with life support facilities, IVF & drugs The neonates should be in incubator or wrapped in thick clothing

TRANSPORT

In gastroschisis and ruptured omphalocoele the exposed viscus are covered by a plastic sheet wrapped with cotton wool Most of these are not available and the neonates are transported by their parents after visiting several hospitals a referral note The theatre should be proximal to the SCBU Transfer to or from the theatre should also be in an incubator or with an overhead radiant heater, wrapped & accompanied by a Doctor or Nurse IVF & NGT should be maintained

PEROPERATIVE CARE
TIMING OF SURGERY: Emergency-surgery mandatory due to life threatening conditions -OA, CD Hernia, intestinal obstruction, leaking MM, Gastroschisis, Ruptured omphalocoele, ARM Urgent-surgery done as soon as diagnosis is confirmed -cong hydrocephalus, PDA, sacrococcygeal teratoma, CD hip, inguinal hernia, AEG, Talipes Elective -Biliary atresia, umbilical hernia, undescended testis, Hypo/ Epispadias, PSARP, Pull through

PEROPERATIVE CARE
HYPOTHERMIA PREVENTION & INTRAOP MONITORING Use of thermal mattresses, maintaining a thermoneutral theatre env, radiant heater, warn anaesthetic gasses, IVF, antiseptics and avoiding over wetting during cleaning Fluid and blood loss monitoring and replacement Vital signs-HR, BP, Temp, PSO2, ECG FBC, U/E/Cr, Blood Gasses, RBS in prolonged procedures

PEROPERATIVE CARE
ANAESTHESIA Neonatal anaesthesia now a recognised subspecialty Pre-op preparation and evaluation Fasting 3hrs, vit K, NGT decompression, GCM Premedication- Atropine Anaesthetic equipements -breathing system-light, low resistance & dead space (Tpiece system) -ET tube- appropriate length, diametre & uncuffed -straight blade laryngoscope

PEROPERATIVE CARE
ANAESTHESIA Anaesthetic techniques and agents -induction-inhalational(O2,N2O2, & volatile agent-halothane, isoflurane) intravenous-thiopentone, ketamine -maintenance-halothane, isoflurane -neuromuscular blockage-suxamethonium, tubocurare -analgesics-narcotics not used, parenteral paracetamol -reversal-stop inhalational(10mins), neostigmine

PEROPERATIVE CARE
OPERATIVE SURGERY

Transverse abd incisions preferred Meticulous gentle technique, appropriate instruments and fine sutures needed Observing general principles of surgery Adequate haemostasis and use of bipolar diathermy Single layer extra mucosal intestinal anastomosis adequate Stappling devices and endoscopic procedures used Skin closed with single layer absorbable subcuticular sutures

POSTOPERATIVE CARE

Neonates recover quicker than adults Monitoring-cont ECG, temp, BP, RR blood gasses Analgesia Fluid, electrolyte & input-output chart- maintenance and replacement Urine output- >1ml/kg/hr suggest good outcome Renal failure managed by kidney challenge or Dialysis Temperature regulation

POSTOPERATIVE CARE

Identifying and treating hypoglycaemia Hypocalcaemia (<1.5mmol/L) occur in critical neonates in 1st 24-48hrs of life, infant of DM mothers, after large vol transfusion Post-op haemorrhage- clotting profile, plat to differentiate surgically correctable haemorrhage Stoma care Long term complications- vit B12 from ileal resection, incontinence, sexuality, infertility, psychosocial adaptability, malignant potential (undescended testis)

CURRENT TRENDS
PRENATAL DIAGNOSIS USS: in oligo/polyhydramnios, to diagnose abd wall defects, urinary tract anomalies, intestinal atresia Amniocentesis-USS guided @ 18weeks for karyotyping to detect inherited/ metab abnormalities Chorionic venous sampling-USS guided @ 8-10weeks for karyotype,gene probe,enz studies Maternal serum AFP in NTD, duod atresia etc Others: PUBS, MRI Aim: to determine mode of delivery, need for elective abortion and need for prenatal transfer

CURRENT TRENDS
FETAL SURGERY 1st open fetal surgery in 1981 @ university of california Now less invasive procedures eg fetendo and fetal image guided surgery Procedures include Vesicostomy, CD hernia closure, excision of sacrococcygeal teratoma, cong heart disease

CONCLUSION

Neonatal surgery has developed over the last 4 decades due to better understanding of neonatal physiology and its application to improve surgical outcome

REFERENCES

Kulshrestha, R.(2006) Common problems in pediatric surgery, 2nd edition. CBS publishers and distributors, New Delhi, India Russell, R.C.G. et al (2004) Bailey & Loves short practice of Surgery, 24th edition. Edward Arnold Publishers Ltd Puri, Prem(1996) Newborn Surgery. ButterworthHeinemann, Oxford Obianyo, Nene(1996) physiological considerations of the
paediatric patient. A lecture

Mohammed A. M. neonatal and paediatric considerations. Undated Sabiston, D.C. (1997) Sabiston Textbook of Surgery, 15th edition. W.B. Saunders Co. Philadelphia, Pennsylvania