1. Dr. Ravi Prakash Kanojia
Assistant Professor
Dept of Paediatric Surgery
PGIMER
CME: Anaesthesia for neonatal surgical emergencies: Pearls & Pitfalls

2. Neonatal surgical emergencies
Common cases
Emergencies Semi -Emergencies
 Congenital diaphragmatic  Bladder exstrophy
hernia  Hirschsprungs
 Tracheoesophageal fistula
 Neural tube defects
 Anorectal malformation
 Obstructive uropathies -
 Intestinal atresias
PUV
 Malrotation

3. What does the surgeon wants in the neonate
before starting for surgery (pt optimization)
What does the surgeons expects from the
anaesthetist
Surgeons
Perspectives

4. What does the surgeon wants in the neonate
before starting for surgery (pt optimization)

5. How do we define preoperative
stabilisation (optimisation)
Neonate is
 Normothermic
 Normal hydration and electrolyte
 No acid base disturbance
 Adequate renal and respiratory function

6. What does the surgeon wants in the neonate
before starting for surgery (pt optimization)
 Before embarking on the surgery the baby needs to be
stabilized on various parameters and aspects
 Temperature control
 Fluid balance
 Blood gasses
 Urine output
 Identifications of decompensate systems like
hypoplastic lungs, cardiac shunts, dysplastic kidneys
 Specific condition related requirements

7. Identification optimisation strategy

8. Fluid
Identify Optimize
The physiological shifts Balance early natriuresis
occurring during first 48 and diuresis by fluid
hours of life
The ongoing fluid
losses via
• Nasogastric aspirates
• Loss through respiratory tract
• Evaporative losses by exposed Image
mucosa/ epithelial surfaces eg
gastroschisis
• renal loss – Post obstructive
diuresis in obstructive uropathies
like PUV

9. Temperature control
• Inherent • Active
propensity to warming
hypothermia
• Avoid
• Temperature loss
due to exposed unnecessary
Identify surfaces Optimize exposure
temperature • Hypothermia due Thermore • Cotton wraps
loss and its to long surgery
gulation • Covering
consequence • Hypothermia exposed
induces acidosis by
viscera

10. Blood gases
• Respiratory system • Metabolic
disease – CDH acidosis
• Uropathies – • Treatment of
PH Is inadequate renal shock
buffer – PUV,
altered dysplastic kidneys
Corrections • Correction of
in • Intestinal volume and
obstruction with electrolyte
loss of ions and deficit
bicarbonate
• Alkali therapy

11. Sepsis & Antibiotics
 Infection and Sepsis go hand  Recognise sepsis
 Indirect method
in hand with surgical
 Refusal to suck
conditions  Poor cry
 Often compounded by  Lethargic
ventilation, surgical site  Poor capillary refill time
infection & nosocomial  Abdominal distension
component  Low urine out put
 Fever / hypothermia
 Most common organism in  Tachypnea
our settings are  Direct method
 E coli  Positive culture from blood
urine csf
 Staph aureus
 Raised CRP
 Klebsiella  Leucopenia
 Fungal  Neutropenia

12. Antibiotics
 Know the bug
 Know the susceptibility (or likely susceptibility)
 Identify the site of infection
 Host Factors
 In vitro response is not the same as in vivo

13. Identify

15. Antibiotic choice
Type of infection Expected pathogen First choice 2nd choice
Intra-abdominal S Aureus, e coli Ceftriaxone Imipenum ,
infection Kleibsiella, cefotaxime meropenum
enterococci Ampi-sulbactum Piperacillin
tazobactum
CNS infection S Aureus, S Ceftriaxone Vancomycin
Epididermis cefotaxime Meropenum
Pseudomonas
Biliary tract E coli, enterococci , Cefoperazone – Imipenum ,
infection kliebsiella , sulbactum , meropenum
clostridium perfringes
Gentamicin/ Amika for enterobacter, pseudomonas & S epididermis
Vancomycin for coag neg staph/MRSA
Metronidazole if anerobes are suspected (liver abscess). Fluconazole for yeast

16. Transport
(journey in & out of OR)
Temperature
control
Transport Care of
team and drains and
vehicle tubes
Neonatal
transport
Monitoring Respiratory
on the move assistance

17. What does the surgeon expects from the
(Neonatal)Anaesthetist

18. What does the surgeon expects from the
(Neonatal)Anaesthetist
 A dedicated neonatal anaesthetist
 Dynamics of neonatal physiology
 Know the condition
 The abnormal anatomy
 The compromised systems
 CDH – Respiratory
 PUV – renal
 Hydrocephalus – CNS
 Impact of the condition on the tolerance of anaesthesia

19. Stabilisation in individual conditions
requiring emergency neonatal surgery
 Tracheoesophageal fistula
 Frequent suction to avoid aspiration
 As far a possible avoid intubation and mask ventilation
 Causes stomach distension
 If intubation is required try to place the bevel of tube
away from fistula to the left
 Avoid excessive positive pressure

20.  Congenital diaphragmatic hernia
 No bag mask
 Early intubation
 High frequency ventilation
 Optimisation of arterial blood gasses
 GIT atresia
 ARM – single stage repair in prone position
 Intestinal atresias – nasogastric loses / resection of
bowel – short bowel

21. Understanding the urgency in the
emergency
 Malrotation (with volvulus)
 Understand the urgency of the condition and
impending gangrene
 Hirschsprung's
 Intestines can be decompressed by rectal washes but sub
acute obstruction still persists and delay increases the
chances of enterocolitis and sepsis
 Spina Bifida – thin membranes over swelling,
impending rupture and meningitis waiting to happen

22. Surgeon’s message
 Neonatal emergency surgery requires highest level of
scientific precision when it comes to manage and
needs experience by a full time neonatal anaesthetist
well versed by the dynamic physiology and pathology
 Identification – optimisation strategy
 Normothermic, hydrated baby with no electrolyte and
acid base disorder is the basic requirement which will
improve outcome.
 Understanding the disease anatomy and specific
morbidity factors will save the baby