Anemia of Prematurity - Portal Neonatal

Prognosis:
without extensively undermining the flaps. This was inadvisable because of the risk of
wound infection and the desire to avoid too tight a closure of the abdominal cavity, which
could compromise the infant's ability to ventilate by limiting diaphragmatic excursion and
compromise cardiovascular function by diminishing blood return. The patient was treated
with antibiotics and parenteral nutrition. Postoperatively, the wound appeared clean, and
the patch incorporated well into the baby's tissue. The patient was weaned from the
ventilator, despite copious respiratory secretions.
o Two weeks later, the patch was tightened, approximating the skin flaps. However, this
precipitated respiratory failure and ventilator dependency. The patient would not be able to
return to his family in Africa if he was ventilator-dependent. While the patient's respiratory
status was monitored, his patch became infected, and he became critically ill. The only
way to resolve the infection was to remove the patch. The author attempted to stretch the
abdominal wall and obtain wound closure without a patch; however, this was not possible
because hepatomegaly and soft tissue edema combined to produce a small rigid
abdominal cavity. The only recourse was to mobilize flaps and move skin from his flank
onto the exposed abdominal viscera, and skin graft the donor wounds.
o The patient's condition improved dramatically once closure of the abdominal cavity was
achieved. Again, the author tried to wean him from the ventilator, but his copious
secretions and episodes of high fever and drenching sweats prevented this. Finally, it was
determined that the patient was experiencing narcotic withdrawal. He had been
postoperative for so long, and narcotics had been used liberally to provide postoperative
pain relief.
o The need for long-term ventilator assistance was realized, and a tracheotomy was
performed. Although wound closure was achieved, a huge ventral (abdominal wall) hernia
had been created. The skin flaps were separated from the abdominal viscera, and a new
patch was inserted. This added rigidity to his abdominal wall, and, by stabilizing the
patient's trunk musculature, movements of his torso, including breathing, were facilitated.
The patch gradually separated from the rectus fascia, and this dehiscence required repair.
The patient was weaned from the ventilator to pressure support. Discharge from the
hospital seemed imminent.
o One night, a low-grade fever developed, and the patient became irritable. A culture was
taken, but the patient was not treated with antibiotics. Death occurred within 6 hours. The
blood culture grew group B streptococci, but the autopsy was otherwise unremarkable. The
initial wound culture grew Pseudomonas species, which was later cultured from the
patient's tracheal secretions. The wound infection, which required removal of the patch,
was caused by methicillin-resistant Staphylococcus aureus (MRSA).
• Omphalocele
o Prognosis is dependent upon the severity of the associated problems. Babies with
omphalocele are considerably complex, with involvement of many other organ systems.
o Even giant omphaloceles can be closed, although multiple procedures may be necessary.
o The limiting factor for many of these babies, however, is their diminutive thoracic cavities
and associated pulmonary hypoplasia and resultant chronic respiratory failure. Even so,
lung growth and development continue well into childhood, encouraging optimism
regarding the ultimate prognosis.
• Gastroschisis
o Prognosis is dependent mainly upon severity of associated problems, including
prematurity, intestinal atresia, short gut, and intestinal inflammatory dysfunction.
o Many pediatric surgeons believe that prognosis has improved because of maternal
ultrasound diagnosis and monitoring, which leads to expeditious delivery of babies at
tertiary centers.
o Years ago, obtaining primary closure of a baby with gastroschisis was unusual. Usually, it
was necessary to use a silo. Now, primary closure is commonly attained.