Download Surgical Emergencies in the Neonate

Objectives
Identify presenting symptoms of various
neonatal surgical conditions.
 Describe initial management of the
neonate with abdominal wall defects.
 Identify three factors that contribute to
the development of Necrotizing
Enterocolitis.

Josanne M. Paxton RN,MS,CNNP
Banner University Medical Center Tucson
Sometimes we encounter the
unexpected in the delivery room
NRP S.T.A.B.L.E.
 Airway
 Breathing
 Circulation
 Thermoregulation
 Glucose
Homeostasis
What is your next step?
STAT call….
You are called STAT to the evaluation
room. Mom is a 33 y.o. G6 P5 with no
prenatal care.
Infant is 4 minutes old when you arrive.
She is in the warmer and the L&D staff are
stimulating her vigorously.
However she is limp and dusky with poor
respiratory effort.
WAIT…Upon further exam you
notice this
a. Put the baby on mom’s abdomen for
some skin to skin
b. Continue to stimulate
c. Give BB oxygen 21%
d. Initiate positive pressure ventilation
A scaphoid abdomen – What are your
thinking now???
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Diaphragmatic Hernia
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Prenatal Diagnosis

May be notable for polyhydramnios

Allows for maternal counseling and
expectant management in an
ECMO/surgical center
Presentation of DH
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Initial Management
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Intubate (use of B&M ventilation
contraindicated)
Immediate passage of a large bore gastric
tube
Correct acidosis
Prevent thermal and metabolic stress
Prepare and observe closely for
pneumothorax
Failed closure of the pleuro-peritoneal canal
with migration of the intestines into the
thoracic cavity
Results in pulmonary hypoplasia
Left sided involvement (80%)> right
~1:4000 live births
Can be associated with chromosomal and
structural abnormalities (Turner’s, Trisomy 18,
CHD)
Respiratory distress in the first 24 hours (if
in 1st 6 hours higher morbidity/mortality)
Audible heart tones on right
Decreased breath sounds on affected side
and possibly presence of bowel sounds
Scaphoid abdomen
Cyanosis
Shock
Development of PPHN
Diagnosis


Made by CXR
when loops of
bowel are visible
in the chest
Shift of
mediasteinum
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Respiratory Management
Additional Considerations
Best results with “delayed” surgery – from
a few days to even to a few weeks to
ensure acceptable oxygenation and stable
pulmonary pressures
 Gentle ventilation with low pressure and
increased FiO2 or HFV
 Inhaled nitric oxide and surfactant
replacement therapy
 ECMO support if needed


Manage hypotension with judicious use
of boluses and early initiation of
inotropes
 Cardiac ECHO to evaluate for presence
of CHD
 Total parenteral nutrition
 Sedation and pain management
 Surgery when cardio-respiratory status
is stable
Long term considerations
Next Case
You are caring for a 12 hour old
infant. She delivered to a 25 y.o.
G 2 now P2 female with good
PNC. Mom has requested some
rest and while feeding you
notice copious secretions and a
bout of severe coughing. The
abdomen is soft, non-distended
and the infant has passed
meconium.
Overall survival greater than 80%
 Chronic lung disease with need for long
term oxygen therapy
 Gastroesophageal reflux is common
 Neurodevelopmental deficits and
hearing loss

What are you thinking??
Esophageal Atresia
Tracheal Esophageal Fistula
Failure of the tracheoesophageal
septum to divide into separate digestive
and respiratory segments
 1:3000-5000 live births
 History of polyhydramnios
 10% have VATER association –
vertebral defects, anal anomalies, TE
fistula, esophageal atresia, radial limb or
renal anomalies
Types of TEF/EA

>80% of
lesions
<1% of
lesions
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Presentation
Diagnosis TEF/EA
Excessive salivation/drooling/vomiting
Inability to pass gastric tube
 Respiratory distress secondary to
aspiration
 Abdominal distress secondary to air
trapping
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Passage of a nasogastric tube which
meets resistance
 Confirmation by x-ray which reveals the
NG tube in the upper esophagus
 Gasless stomach suggests isolated
esophageal atresia
 H type fistula may not be diagnosed until
later after recurrent aspiration episodes
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Stabilization of EA/TEF
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Maintain prone position with head elevated to
prevent reflux and aspiration of gastric
secretions
Placement of a replogle in the upper
esophagus with connection to low intermittent
suction
Keep replogle patent with q 2 hours irrigation
Keep infant quiet to minimize introduction of
air into the GI tract
Broad spectrum antibiotics
Avoid B&M ventilation
Choanal Atresia
Bone (90%) or membrane protrudes into
nasal passage causing a stenosis or
atresia
 Occurs in 2-4 infants per 10,000 births
 Associates anomalies including CHARGE
(coloboma, heart disease, atresia
chonana, retarded growth & developemnt,
genital hypoplasia and ear anomalies),
Treacher collins, TEF
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Presentation of Choanal Atresia
Cyanosis and retractions when infant is
sleeping which resolve with crying
 Respiratory distress and desaturations
 Difficulty with feeding
 Diagnosis is made when unable to pass
a naogastric tube through the nares
 Manage with oral airway and gavage
feeding until repair
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Omphalocele
Abdominal Wall Defects
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Gastroschisis
 Intestinal herniation
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Omphalocele
 Herniation of the
through a defect in
the abdominal wall
usually to the right of
the umbilical cord
abdominal viscera
into the umbilical cord
& usually contained
within the peritoneal
sac.
Gastroschisis
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Cause
unknown
1:5,00 live births
High incidence of
associated anomalies
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(30-50% cardiac,
10-40%
chromosomal)
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Gastroschisis
Stomach, large and small intestine are
commonly herniated, may also involve
bladder and uterus
1:4-10,000 births
Uncovered bowel is exposed to amniotic
fluid leading to problems (paralytic ileus,
ischemia)
Low incidence of associated defects
suggests mechanical problem
Overall survival 90% with higher mortaltiy if
complex
Initial Stabilization

Important to keep
bowel well perfused
by avoiding kinking
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Keep stomach and bowel decompressed
with passage of nasogastric tube
Cover with warm saline soaks and sterile
plastic wrap or isolation bag
Keep NPO
Broad spectrum antibiotics
+/- intubation
Prevent hypothermia
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Fluid resuscitation
may be necessary
especially in
gastroschisis
secondary to 3rd
spacing into tissue
and peritoneal space
with subsequent
hypovolemia and
shock
Long Term Complications
Prolonged postoperative dysmotilty is
common and interferes with enteral
feeds
 If a complex defect at risk for more
complications:

 Short bowel syndrome
 Bowel obstruction
 NEC
 Infection
What is your next question?
A.
B.
C.
D.
Was the emesis
projectile?
What color was the
emesis?
Did emesis come
out of the nose?
What is the volume
of the emesis?
Manage with a silo until
repair
Emesis in a Newborn
This is a 37 2/7 week gestation male infant
who delivered to a 21yo G1 now P1 mom by
c-sect for FTP. Normal pregnancy and
APGARS were 8 and 9. He has voided
normally and stooled once.
He is now 72 hours old and has been having
some difficulty with breast feeding. During a
lactation consult infant has a moderate
emesis and abdomen seems slightly
distended.
Remember
A well neonate
with bilious
vomiting is a
surgical
emergency and
should be treated
as a mid gut
volvulus until
proven otherwise
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Intestinal Obstructions
Bilious emesis is suggestive of an
intestinal obstruction
 Obstructions presenting with bilious
emesis
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 Intestinal malrotation and mid gut volvulus
 Intestinal atresias (distal duodenum, jejunal
and ileal)
 Meconium plug and ileus
 Hirschsprung’s
Malrotation with or without
Volvulus – surgical emergency
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Malrotation – failure of the intestines to
properly rotate and affix to the posterior
wall of the abdomen during fetal
development. Often associated with
other abdominal wall defects
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Volvulus – twisting of the bowel
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Can develop ischemia and necrosis
within one hour of clinical symptoms
Clinical Presentation
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1/3 of all cases occur within the first week
of life
Bilious vomiting persistent or intermittent
Dehydration and electrolyte depletion can
occur rapidly
Diarrhea and bloody stools
May present as a chronic problem or
progress to rapid deterioration and shock
What are your next steps
NG/OG placed to low continuous suction
IV hydration – may need bolus
 Blood gas to assess acid base status
 CBC, chemistry panel, blood culture
 Broad spectrum antibiotics
 Prevent thermal and metabolic stress
 Assist ventilation as necessary
 Radiologic evaluation unless critical
 Surgical consult
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Malrotation and Volvulus
Diagnosis and Management
X-ray with scanty or airless abdomen is
an ominous sign
 UGI is diagnostic if the infant is stable
enough for study
 Surgical repair must be done as soon as
possible to untwist the bowl and allow
for reperfusion.
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Duodenal Obstruction
Double Bubble
sign on plain
radiograph
May be diagnosed on prenatal
ultrasound with polyhydramnious (5060% of cases) and a dialted fluid filled
stomach
 Bilious emesis
 1/3 have associated Trisomy 21
 May have complex cardiac anomalies
and should have an evaluation before
surgery
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 Reflects distention
with air in the stomach
and duodenum
 If complete atresia air
will not be seen in the
rest of the abdomen
Meconium Ileus
Presentation
Intestinal obstruction which results from the
presence of thickened meconium at the
ileocecal valve
 Distention of the ileum and atrophy of the
colon
 Associated with Hirshpungs, prematurity,
hypomagnesemia and hypotonia
 Nearly all have Cystic Fibrosis (10-15% of
patients with CF present with meconium
ileus)
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Diagnosis
Additional Management
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Soap bubble appearance on x-ray
Distended loops of bowel with air fluid
levels
 Free air in the peritoneal cavity
 Gastrographin enema (used in
diagnosis, and may break up meconium
and relieve obstruction
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Abdomial distention
 Bilious vomiting
 Failure to pass meconium within 24-48°
 Not all meconium ileus is the same
 Simple – ileal obstruction with proximal
dilatation, bowel wall thickening and
calcifications
 Complicated - Intrauterine perforation may
occur resulting in calcifications, adhesions
and at worse, ascites and peritonitis
Warm saline enemas
Surgery with resection of the
compromised bowel and primary
anastomosis
 Long term
 Nutrition
 At risk for TPN cholestasis
 Pulmonary management
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Hirschsprung’s disease
Congenital aganglionic megacolon
Risk Factors
Can be genetic with abnormal locus on
chromosome 10 in some families
 Anoxic episodes prior to birth
 Those with Down’s Syndrome have a
higher risk
 Associated with cleft lip or palate
 Imperferate anus

Absence of ganglion cells that cause
ineffective conduction of peristalsis 
 Slowing of the fecal material
propulsion
 Functional obstruction
 Potential pertonitis and shock
 Incidence approximately 1:5,000 live
births
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Symptoms
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Delayed passage of meconium from 24-48
hours
Alternating constipation and diarrhea
Abdominal distention
Vomiting
Feeding may be tolerated several days
before symptoms occur
Enterocolitis
Failure to thrive
Diagnosis
Dilated loops of bowel on x-ray
Contrast enema MAY reveal dilated
bowel followed by atrophied bowel
 Retained contrast in colon on x-ray
following day
 Explosive stool following rectal exam
 Dx confirmed absence of the ganglion
cells rectal bx
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Treatment and Outcome
Saline rectal irrigation every 6 hours
Perineal pull through
 Colostomy may be indicated if there is
enterocolitis or the bowel is enlarged
 Most patients will have normal bowel
habits however 5-10% may have longterm problems with constipations or
incontinence
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Necrotizing Enterocolitis NEC
NEC - A Case Review
Most commonly acquired surgical
emergency in preterm VLBW infants
 Incidence is inversely proportional to
birth weight – 4 -11. 5%
 Mortality ranges from 10 – 50%
 Little progress has been made towards
the prevention

Labor History
Newborn Delivery Information
Admitted for severe preeclampsia at
32 weeks
 Treated with hydralazine and labetalol
 Given Magnesium and Betamethasone
 Received multiple doses of antibiotics
 Progressed to a NSVD
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Risk Factors for NEC
Multifactorial
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 32 yo G1 P0→now 1
 Good PNC
 History of hyperlipidemia
 Medications - PNV, folic acid
 GBS positive
 All other prenatal labs WNL
Delivery of an African American male
infant at 32 6/7 weeks
 Presented with good heart rate tone and
cry
 Onset of mild grunting
 Received CPAP at 40%
 APGARS 8 and 8
 Birth weight 1860gms AGA
Additional Risk Factors
Prematurity – most prevalent in VLBW
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 85% occur in infants <1500gms or <32
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weeks
 GI immaturity including impaired intestinal
motility and decreased nutritional absorption
PIH and intrauterine growth restriction
Maternal chorioamnionitis
 Maternal smoking
 Feeding
 Immature immunological response (IgA)
may facilitate bacterial translocation
 Abnormal intestinal colonization
 Increased pro-inflammatory response
resulting in intestinal damage and epithelial
cell death (apoptosis)
Maternal History
 Unstandardized approach
 Formula feeding
 Breast Milk fortifier
Prolonged antibiotic therapy > 5 days
 Blood transfusion
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Early Neonatal Course
Patient was admitted to NICU, placed on
CPAP, IV fluids and antibiotics
 Weaned to room air and off CPAP by 8
hours of life
 First week:
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 Hyperbili with phototherapy x 5days
Week 2
On DOL 8 infant appears to be tolerating
feeds - 34 ml every 3 hours, no aspirates or
emesis, voiding and stooling normally
 However nurse reports that infant is
hypotonic and pale
 Has also noted several brief apnea and
bradycardia episodes with lowest sat 80%

 Feeds started on DOL 1 EBM or DBM only
and advanced 1ml every 6 hours (11/kg/day)
 Antibiotics dc’d after negative culture at 48 ◦
Is there anything you are concerned about ?
On Further Exam
Presentation of NEC non-specific
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Infant is lethargic with minimal response
Abdomen does not appear distended
 Marked sensitivity to exam with
abdominal guarding and crying.
 And with the diaper change there is a
bloody stool
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Any additional concerns?
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Apnea and bradycardia
Unstable temperature
 Irritability or lethargy
 Emesis
 Bloody stools
 60-75% of tube fed infants will have guaiac
positive stools
Gastric aspirates
 Abdominal distention
Variable evidence that gastric
residuals predict NEC L Parker
What is abnormal (volume color) ?
Should they be re-fed or discarded?
 Does it verify feeding tube placement?
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 25-66 % error rate
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Can you accurately measure gastric
content volume?
 Depends on feeding tube size, if holes in
gastric fluid, aspiration technique
If I have to look at one more
aspirate tonight I am going
to pull my hair out…
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Dare we not check residuals??
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Small randomized, prospective study Torrazza,
Parker et al 2015 61 infants 23-32 wks <1250g
Hypothesis – NGR ↑ intake at 2 weeks full
feeds more quickly - not statistically significant
Group 1 without routine evaluation of GR
 reached full feeds nearly 6 days earlier
Group 2 with routine evaluation of GR
 Required parenteral nutrition 6 more days
Rate of adverse outcomes did not differ
between the 2 groups
Pre-Feed Abdominal
Circumference vs Residuals
Small randomized controlled trial by Kaur
et al
 80 patients 27-34 weeks less than 1500g
 Feeding Interruptions
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 Gastric residual group – feeding intolerance
bilious asp, asp >50% of previous feed or >3ml
 Abdominal circumference group – if >2cm above
baseline feeds were interrupted and residuals
were checked
Results
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When the AC measurement was used
as criteria for feeding intolerance
 Earlier achievement of full feeds by 4 days
 Less feeding interruptions
 Shorter duration of parenteral nutrition
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Staging of NEC Bell’s Criteria

Stage 1. Suspected NEC:
 Gastric residuals, abdominal distention,
occult or gross blood in stool, x-ray normal
to mild distention, temperature instability,
apnea, bradycardia

Stage 2. Definite NEC
 Mild to moderate systemic illness, absent
bowel sounds, abdominal tenderness,
pneumotosis intestinalis or portal venous
gas, metabolic acidosis, decreased platelets
Back To NEC
Staging of NEC Bell’s Criteria

Stage 3. Advanced
NEC
 Severely ill with acute
decompensation,
signs of peritonitis,
hypotension,
metabolic and
respiratory acidosis,
DIC, abdominal
distention,
pneuperitoneum
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Our Patient initial management
72 hours later

NPO Replogle to LIS
Initial WBC 11.2, Plts 244 no bandemia
 Blood gas pH 7.38 CO2 50 HCO3 30
 Lactate 1 Hgb 18
 Glucose 62
 Blood culture sent
 Ampicillin and Gentamicin started
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Laboratory changes
Diagnosis - radiologic
Respiratory acidosis
 Metabolic acidosis
 Thrombocytopenia
 Neutropenia
 Anemia
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Blood culture negative
Hgb remained stable
 Platelets were 20,000
Anything concerning?
Pneumotosis intestinalis (distal ileum &
proximal colon)
 Pneumoperitoneum (indicates
perferation)
 Gas in the portal vein
 Fixed dilated loops of bowel
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Medical Management
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NPO
Frequent abdominal films
Labs – Hcts, electrolytes, platelets
Maintain acid/base balance
Respiratory support as needed
Antibiotics
 Ampicillin
 Gentamycin
 MetroNIDAZOLE if worsening or perfs
Stabilization
Indications for Surgical
Intervention
Decompress stomach
 Support cardiovascular status with fluids
and low dose Dopamine
 Assist ventilation as necessary
 Prevent thermal and metabolic stress

Can We Predict NEC
Can We Prevent NEC?
Currently the only consistent predictors
are prematurity and formula feeds
 Identification of potential risk factors
 On the Horizon
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 Development of a risk assessment tool
GutCheck - Sheila Gephart PhD
May be peritoneal drainage or
laparotomy
 Clinical deterioration despite medical
treatment (thrombocytopenia, metabolic
acidosis, increasing respiratory support,
leukopenia, leukocytosis)
 Fixed dilated loops of bowel on x-ray
 Intraperitoneal air
 Tender abdominal mass
Single dose of antenatal steroids
Early preferential use of breast milk
 Standardized feeding guidelines
 Use of ibuprofen for PDA (vs
indomethacin)
 Avoid the use of H2 Blockers
(famotidine, ranitidine)

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Unanswered questions
Does supplementation with probiotics
reduce the risk of NEC?
 Does longer use of empirical antibiotics
increase the risk of NEC?
 Does the use of UAC’s affect NEC?
 If BM is not available should feedings be
delayed vs use of formula?
 Is donor milk as effective at preventing
NEC as mother’s milk?

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