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1460 PART 5 ■ Anesthetic, Surgical, and Interventional Procedures: Considerations TABLE 86-14. Typical Anesthetic Management of a Neonate Presenting With Stridor Symptoms Preoperative investigations (if time allows) Monitoring Suggested anesthetic and recommendations Recommended Examinations and Management Inspiratory stridor, jugular and intercostal/subcostal retractions, cyanosis 1. Arterial blood gas, routine laboratory 2. Chest radiograph 3. Transthoracic echocardiography (can help to diagnose vascular ring abnormality) Routine monitoring only 1. No premedication 2. Establish I.V. access before induction, preferably in the neonatal intensive care unit 3. I.V. atropine (10 g/kg), preoxygenation 4. Inhalational induction sevoflurane or halothane in oxygen 5. Deep anesthesia needed to avoid laryngospasm, coughing or breath-holding. The more severe the obstruction the longer the time necessary to reach the appropriate level of anesthesia 6. Apply a continuous positive airway pressure (3–5 cm H 2 O). This helps distending the airways and prevent laryngospasm 7. Depending on the ear-nose-throat technique used, continuous supply of O 2 and volatile agent is provided through a bronchoscope attachment or holding the fresh gas tubing within the mouth; jet ventilation can be used (delivery of volatile agent usually not possible) 8. If the airway is left unintubated and tracheotomy is not performed, administration of I.V. hydrocortisone (1–2 mg/kg) may help counteracting postoperative airway edema (postoperative inhalation of epinephrine might be useful in this regard too) 9. Even if the airway obstruction is judged to be only minor to moderate, e.g., with a number of patients suffering from laryngotracheomalacia, the patient should be cared for in an NICU or high dependency area for the first postoperative 12–24 hours varies. In less severe cases there is only a cleft present in the posterior parts of the larynx with no involvement of the trachea and the esophagus. However, in the most extensive cases (Type IV) the cleft extends from the larynx to the carina. The existence of the cleft creates the possibility for regurgitation and aspiration of both saliva and stomach contents with repeated cyanotic episodes and pneumonias. Occasionally the diagnosis is suspected following repeated tracheal tube dislodgment. The final diagnosis is made at bronchoscopy. The anesthetic plan for later closure of the defect has to be individualized since the TABLE 86-15. Typical Anesthetic Management of a Neonate Undergoing Cleft Lip/Palate Repair Symptoms Preoperative investigations Monitoring Suggested anesthetic and recommendations Recommended Examinations and Management Usually apparent on inspection. Isolated palate lesion requires palpation of the palate 1. Search for other malformations 2. Echocardiography to search for associated cardiac anomalies 3. Blood type and compatibility tests 4. Order 1 unit blood Routine monitoring 1. No premedication 2. I.V. atropine (10 g/kg) 3. Preoxygenation 4. Induction technique according to the preference of the anesthesiologist 5. Tracheal intubation can be difficult (blade of the laryngoscope sliding into the cleft); packing the cleft with a small wet sponge will circumvent this problem 6. RAE tubes are useful. Careful that the distance from the tip of the tube to the preformed “knee” may be wrong and lead to bronchial intubation. If too long, cut appropriately before intubation or fixe the “knee” lower on the mandible 7. Throat packing is recommended to protect airway from blood and secretions; the end of the pack should be left outside the mouth to remind to remove it at the end. 8. Local anesthetic block of the infraorbital nerves will provide excellent intra- and immediate postoperative analgesia 9. Extubation should only be performed after the removal of the throat pack and following careful suctioning of the mouth and pharynx. Because of blood oozing following surgical reconstruction, extubation in the lateral position is preferable and when fully awake. If edema or bleeding and concern regarding the airway, the patient should be returned to NICU until safe extubation can be achieved
CHAPTER 86 ■ Management of the Neonate: Anesthetic Considerations 1461 TABLE 86-16. Typical Management of a Neonate Presenting With Tracheoesophageal Fistula Symptoms Preoperative investigations Monitoring Suggested anesthetic and recommendations Recommended Examinations and Management Coughing or choking when swallowing. Drooling. Can’t pass a nasogastric tube into the stomach 1. Chest radiograph with radio-opaque catheter or nasogastric tube inserted into the upper esophageal segment. Avoid use of radio-opaque dye to prevent aspiration 2. Echocardiography to search for associated cardiac anomalies 3. Routine laboratory and arterial blood gas 4. Blood type and compatibility tests 5. Order 1 unit blood and 1 unit plasma 1. Routine monitoring 2. Invasive blood pressure monitoring 3. Foley catheterization 1. No premedication 2. Establish venous access before induction of anesthesia if not yet in place 3. I.V. atropine (10–20 g/kg) 4. Evacuate any secretions from the upper esophageal pouch by aspirating the catheter 5. Preoxygenation 6. Rapid sequence induction with succinylcholine (1–2 mg/kg) for relaxation. Cricoid pressure is not meaningful since aspiration can still occur through the fistula 7. Avoid gastric distention. Gas insufflation of the stomach is greater in patients with decreased lung compliance. Bronchoscopy prior to tracheal intubation is occasionally used to identify the fistula and seal it with a small balloon tipped catheter. If severe gastric distention, rapid decompression (needle aspiration gastrostomy) is requested 8. Maintenance depends on the condition of the neonate and the postoperative ventilatory strategy. In the unstable neonate an opioid anesthetic (fentanyl 10–25 g/kg) is often preferable. Stable term neonates will benefit of inhalational agents. Low dose volatile agents is also a good choice if analgesia is provided by an epidural technique. Certain surgeons require that the patient be kept sedated, paralyzed and ventilated in the early postoperative period to “protect” the anastomosis, a high-dose opioid anesthetic is most indicated 9. Insertion of an arterial catheter for the unstable neonate 10. Placement of a continuous thoracic epidural regional block, either via the caudal approach or directly (by experienced anesthesiologists only) 11. During surgery, the lung, the trachea and the large veins will be compressed leading to desaturation, reduction of venous return and cardiac output. The surgeon must be alerted when this happens but must be given reasonable time to perform the different stages of the procedure. Brief periods of desaturation or blood pressure changes must be accepted without alarming the surgeon 12. Manipulation and ligation of the fistula leads to minor bleeding and secretions. Repeated suctioning of the tracheal tube might be needed to avoid partial or complete obstruction 13. Before the closure of the thoracic wound the lung should be carefully re-expanded in order to avoid unnecessary postoperative atelectasis procedure is a significant surgical and anesthetic ordeal. 195,196 Below are only some guidelines for the initial bronchoscopy. The main steps of anesthetic management are summarized in Table 86–17. Congenital Lobar Emphysema This congenital malformation consists of pathologic enlargement of one of the lung lobes, which can be caused by bronchomalacia, a vascular anomaly, or an intrabronchial obstruction. Depending on the size of the lesion, it can compress healthy lung tissue and also create an intrathoracic volume lesion with mediastinal shift and impeded venous return. Such patients will present with a combination of respiratory distress and cyanosis. Surgical intervention due to this condition will be undertaken either on a semiemergent basis or as an elective procedure. The condition is also frequently (35%) associated with congenital heart disease. The main steps of anesthetic management are summarized in Table 86–18. Patent Ductus Arteriosus In the neonatal period this is almost exclusively a disease of the premature baby. The presence of a patent ductus arteriosus (PDA) causes a left-to-right shunt across the ductus resulting in two different unfavorable situations. First, the resulting pulmonary overcirculation puts significant volume strain on the left side of the heart and causes enlargement of the left atrium and ventricle and causes high-output cardiac failure. Second, in severe cases the left-to-right shunting may become so pronounced that there can be reversal of the diastolic aortic blood flow in the descending aorta. In this situation, the blood supply to the lower body is jeopardized and patients with PDA are at increased risk of developing necrotizing enterocolitis as a result of splanchnic
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Chapter 86

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