1. PART II
ANAESTHETIC
MANAGEMENT

2. 1. Pyloric Stenosis
2. TEF
3. CDH
4. Omphalocele & Gastroschisis
5. Intestinal Obstruction
6. Necrotising Enterocolitis
7. Congenital Lobar Emphysema

3. PYLORIC STENOSIS
• Incidence:1 in 2000
• Male > female (first male child)
• Preterm = full term
• Etiology:Autonomic N system imbalance
& humeral disorder(?)
• Pathology : gross thickening of circular
smooth muscle of pylorus---gradual
obstruction of gastric outlet.

4. PYLORIC STENOSIS
• Diagnosis:
clinical: projectile vomits, mass in upper abd.
(‘olive in abdomen’)
upper G.I.series with barium
Ultrasound
• Anaesthetic concerns: - dehydration
- acid-base
abnormalities
-risk of aspiration

5. PYLORIC STENOSIS
• Pathophysiology:
Hypochloremia, hypokalemia, hyponatremia
& metabolic alkalosis.
• Preparation:
Medical emergency- parameters for surgery:
normal skin turgor,
Na>130mg/l
k at least 3meq/l,
Cl <85 meq/l
urine output 1-2ml/kg/hr
Resucitation c balanced salt soln, pot chlor after
urination.

6. PYLORIC STENOSIS
• Induction of Anesthesia:
-preoxygenation with 100% O2
- Ryles tube asspiraton
-Pentathol – 5 mg/kg.
-Suxa2mg/kg…intubation
-surgeon needs relaxation twice
a) at the time of delivery of pylorus
b)at the time of putting pylorus into abdomen

7. – Atracurium 0.5 mg/kg-best nondepolarizing
relaxant after induction followed by caudal
epidural 1.25ml/kg bupivacaine 0.25% with
1:200000 adrenaline.
– Reversal as usual
• Post-op care:respiratory depression is
common.

8. Tracheo - Esophageal Fistula,
with/without Esophageal Atresia
1. Incidence-1:3-4.5000 births
20-25% assoc. with
VSD,ASD,TOF,Coarctation of aorta.
another 20-25% with TEF are premature
wt<2kg

9. Tracheo Esophageal Fistula,
• Anatomy/Classification:
– Mostly TEF &EA occur together
– 90% lesions are type’C’ – i.e. fistula between
trachea & lower esophagus above carina.upper
esophagus ends blindly.

10. Tracheo Esophageal Fistula,
• Associated anomalies:
– TEF with other anomalies in 30-50% pts.
– VATER association – 1973 by Quan & Smith
• V- vertebral defect / VSD
• A- anal defect
• T-TEF
• E- atresia
• R- radial dysplasia / renal dysplasia

11. Tracheo Esophageal Fistula
• Diagnosis:
– Early diagnosis is imp.to prevent pulmonary
complications- which determines prognosis.
– In utero-polyhydramnios-
– At delivery-pt.has excessive salivation,drooling,
cyanotic spells, cough-relieved by suction.
– Resp.depression
– Inability to pass a catheter(feeding tube#8)
– X-ray-radioopaque cath ending in proximal esophagus-
simple & diagnostic

12. Tracheo Esophageal Fistula,
• Pre-op management:
– ‘has the baby suffered any pulmonary insult’?
Aspiration pneumonia-more morbidity-delay the
procedure; stomach decompression by gastrostomy
– Avoid feeding
– Nurse in propped up position
– Intermittent suction
– Antibiotic therapy & physiotherapy
– Hydration

13. Tracheo Esophageal Fistula,
• Surgical management:
– Primary repair in 24-48 hrs.
– Gastrostomy under LA, delay thoracotomy for 48-72
hrs.,which allows proper hydration & assessment of
resp. & CVS.
• Anesthetic considerations:
– Pre-medication:inj.atropine IM.
– OT- AC off, warmers kept ready,(heat loss is more in
thoracotomy).
– Monitors:ECG,BP,FIO2,pulse oximetry,rectal
temp,arterial line,foley cath,precardial steth.

14. Tracheo Esophageal Fistula
– Induction /intubation.
• Decompression of stomach (gastrostomy tube allowed to vent,
& kept at head end of patient),
• Pre-oxygenation
• Awake/anesthetic intubation
• Correct position of ETT
• Induction with N2O+O2+ halothane
• IPPV cautiously attempted before NMJ blocker.
– ETT might enter fistula during intubation,or during
surgery difficulty in ventilation saturation and
ETCO2

15. Tracheo Esophageal Fistula,
• Maintenance:
– Continue inhalational agents.discontinue N2O if gastric
dilatation occurs
– Non depolarising muscle relaxant , conc of halothane
–less CVS depression
– O2 conc by ABG sampling. High FiO2 if pulmonary
pathology is present.
– Manual ventilation best- changes can be detected
easily. Airway obstruction can occur during surgery &
due to accumulation of blood & secretions in tube.
– Blood loss 20-30%. If Hct <30,and EBL >10-15%,vol.
replacement with blood.
– IV fluids for maintenance

16. Tracheo Esophageal Fistula,
• PostOperative care:
– Analgesia by caudal 0.25% bupivacaine1.25ml/kg with
epinephrine1:200000.Postop. ventilation if necessary
(prematurity, RDS, CHD)
• Complications:
– Esophageal dysmotility,esophageal stricture,recurrent
URI&LRI, tracheomalacia, gastroesophagreal reflex.

17. CONGENITAL
DIAPHRAGMATIC HERNIA
• Incidence:
1:4000 live births
mortality with heroic post-op measures-30%
(earlier 40-50%)
• Def: herniation of abdominal contents into chest
through a defect in the diaphragm.
– Types: Lt.posterolateral defect in foramen of
Bochdalek(75-85%) - commonest
– anterior opening (foramen of Morgagni) -rarely

18. CONGENITAL DIAPHRAGMATIC HERNIA…
• Associated anomalies:
still borns c CDH – 95% of other anomalies
live borns –20% CVS (esp. PDA) defects
• Clinical presentation:
variable
– Early hernia,pressure on lung bud small lung
– Hernia in late fetal life normal lung,but compressed
infants c severe hypoplasia symptoms in 1st hour
less severe forms symptoms in 24 hrs.

19. CONGENITAL DIAPHRAGMATIC HERNIA…
• Triad:
– Cyanosis
– Dyspnea
– Apparent dextrocardia
• O/E: scaphoid abdomen,bulging
chest,breath sounds ,bowel sounds in chest
x-ray:mediastinal shift

20. CONGENITAL DIAPHRAGMATIC HERNIA…
• Diagnosis:
antenatal:1) 30% c polyhydramnios
2) ultrasound
after delivery: x-ray chest
• Anesthetic considerations:
delay surgery till infant stabilises
(24-48hrs.to 1week)…levin 1987

21. 1. Pre-op care:
– Decompress c nasogastric tube
– Don’t ventilate c mask
– Awake intubation paralyse, sedate, ventilate
c 100% O2
– Lowest possible inflation pressure (30cmH2O)
used (vs.-in pneumothorax)
– Tr.of acidosis-ventilation,soda bicarb,improve
circulation by fluids& inotropes

22. CONGENITAL DIAPHRAGMATIC HERNIA…
2.anesthetic management:
– Intubation & paralyses before arrival to OT,or
preoxygenation-rapid sequence awake intubation-low
airway pressure & high resp.rate
– Frequent blood gas estimations,ET CO2 & pulse
oximetry-maintain effective ventilation
– Prevent hypothermia
– Low conc.of inhalational agent c high inspired O2 or
high doses of narcotics (fentanyl). Avoid N2O
– Primary closure of abdomen,or chimney prosthesis,or
silastic pouch
– Continue paralysis & controlled ventilation post-op,
except in infants c small defects & good gas exchange .

23. CONGENITAL DIAPHRAMATIC HERNIA…
Options:
– in infants c severe lung dysplasia,tr. c ECMO
preop, wean then schedule for surgery
– Repair defect when on ECMO & maintain
ECMO post-op for 30 days
– Neonates c CDH have surfactant deficiency,
using ECMO will improve surfactant

24. CONGENITAL DIAPHRAGMATIC HERNIA…
– Pts. given ECMO with NO before & after ECMO &
after surgery. NO was ineffective pre-ECMO. NO after
ECMO followed by surgery was able to increase
oxygenation. (Karamanaoukian et al.)
– UK study- pts. c CDH not treated c ECMO but c preop
stabilisation & supportive care had same results as c
ECMO therapy.
– ‘what is the best time to operate?
operation should be postponed till PVR is decreased as
revealed by Doppler EchoCardiography.

25. CONGENITAL DIAPHRAMATIC HERNIA…
• Post-Op problems:
– Determination of outcome
• a) extent of Pulmonary Hypoplasia
• b) degree of pulmonary hypertension
Infants with post-op PaCo2 < 40mm.Hg. who could be
hyperventilated c airway pressure < 20 cm. H2O , & who had
a resp.rate < 60 /mt. survived well.(Bohn.,J.Paediatrics,1984)
Reducing PVR & prevention of Rt.to Lt. Shunt is accomplished
by ----- hyperventilation, ligation of PDA & drugs include
tolazoline, PGE1, & ECMO.

26. INTESTINAL OBSTRUCTION
• Upper G.I. Obstruction (duodenum)
• Lower G.I. Obstruction (ileum, colon, imperforate
anus).
– Upper GI problems – 24 hrs.
– Lower GI problems –2- 7 days.
• Triad of Obstruction:
– Vomiting
– Constipation
– Abdominal distension

27. INTESTINAL OBSTRUCTION
• Upper GI obstruction:
– Persistent bilious or non-bilious vomiting
deficit of fluids & electrolytes.(Stomach contains
100-130 meq/l/Na.,& 5-10 meq/l of K.
– To prevent aspiration, awake / RSI.
• Anesthetic considerations:
– Pre-op preparation-
• Correction of dehydration
• Correction of electrolytes
• Ryles tube decompression

28. INTESTINAL OBSTRUCTION
• Anesthesia:
– Awake, rapid sequence intubation
– Repair of congenital defect & closure of abdominal
defect.
– N2O can be used.
• Extubation
– Possible only with good g.c.
– Patient debilitated,extensive surgery,big incision,
– Post-op ventilation c PEEP.

29. INTESTINAL OBSTRUCTION
• Lower GI obstruction:
– Problem develops between 2-7 days
– Incomplete anus can be evident after birth
– Vomiting secondary to obstruction
electrolyte or fluid disturbances.Large fluid
sequestration within GI tract, (ECF c high Na+
content)
– Na must be >130meq/l , & urine volume of
1.2ml/kg/hr.

30. INTESTINAL OBSTRUCTION
• Anesthetic considerations:
– Decompression of stomach
– Electrolyte & fluid management
– Awake, rapid sequence intubation
– N2O should not be used.
– Adequate relaxation
– If patients g.c. is good,reverse & extubated with post-
op O2 supplementation
– If patients g.c. is not good, post-op ventilation is
continued c PEEP.

31. OMPHALOCELE &
GASTROSCHISIS
Omphalocele:
• herniation of intestine into base of umbilical
cord.
Gastroschisis:
• defect of abdominal wall lateral to base of
umbilicus
• Incidence: omphalocele-1:10000 births
gastroschisis – 1: 30000 births
boys : girls 1:1
25-30% are premature or LBW

32. OMPHALOCELE & GASTROSCHISIS
Omphalocele:
• membrane covering peritoneum inside,
amniotic membrane outside.
• Sac may be small or large containing
liver,spleen etc.
• Prematurity 25-30%
• Associated anomalies:77%

33. OMPHALOCELE & GASTROSCHISIS
Gastroschisis:
• Eviscerated abdominal contents,involves small or
large lntestines
• Umbilical cord is to left of defect
• Prematurity is 58%
Anesthetic considerations:
• Pre-op management:
– Search for associated anomalies,
– Ruptured omphalocele is a surgical emergency.

34. • Fluid resuscitation:
– Fluid loss is high,
– 3rd space loss,protein loss, increased fluid
requirements
– 150-300 ml / kg / day RL or 5% Albumin is
used.
– Correct acid – base status
– Insensible loss – wrapping the child in
polythene bag filled c warm saline.

35. OMPHALOCELE & GASTROSCHISIS
• Atropine
• Temperature regulation
• Hypoglycemia & hyperglycemia are
avoided.
• Nasogastric tube for decompression of
stomach.

36. OMPHALOCELE & GASTROSCHISIS
• Peri-operative management:
– Monitoring
– Induction c I.V. inhalation
– Awake intubation
• Maintenance:
– FiO2 to maintain saturation of 95-97%
– N2O should be avoided,
– Maintenance by balanced anesthesia,
– Airway pressure to be monitored
– Post-op ventilation for 24-48 hrs.
– Excellent skeletal muscle relaxation
– Repair is staged if primary closure is not possible

37. OMPHALOCELE & GASTROSCHISIS
• Post-op complications:
– Respiratory insufficiency
– Ileus,
– Venacaval compression due to tight closure.
– Sepsis is major cause of mortality & morbidity
– Temperature regulation

38. NECROTISING
ENTEROCOLITIS
• Incidence:
– 2.4/1000 live births
– Premature or low birth weights
– Wt.< 2.5kg & <38 wks.of gestational age
• Etiology:
– H/0 intra uterine fetal distress/ birth asphyxia
– H/O RDS,apnea,
– Prematurity & umbilical catheterisation

39. NECROTISING ENTEROCOLITIS
• Clinical Signs:
– Retained gastric secretions,
– Vomiting , bloody , mucoid diarrhea,
– Thermal instability,
– Abdominal distension c bloody, sticky stools
– Signs appear in first few days of life/2or 3 days after
feeding
– Lethargy & apnea, metabolic acidosis, jaundice,
– DIC c prolonged PT & APTT.
– X-ray abdomen: early – distended gas filled loops,
– Late gas in the bowel., (pneumatosis intestinalis ).

40. NECROTISING ENTEROCOLITIS…
• Non – surgical management:
– Decompression of stomach,
– Cessation of feeding, broad spectrum antibiotics,
– Fluid & electrolyte therapy
– Ionotropic agents, steroids in septic shock
• Indications for surgery:
– Peritonitis, air in portal system, ascitis,progressive
deteriotion.

41. NECROTISING ENTEROCOLITIS…
• Anesthetic management:
– Pre-op evaluation, correction of respiratory, metabolic,
circulatory & hematological disorder,
• Investigations:
– ABG, glucose,electrolytes, BT,CT,platelet count,
– Monitoring: arterial cannula, CVP,
– IV fluids,
– Induction & Intubation:
• Awake intubation,
• Thiopentone or ketamine + suxamethonium

42. NECROTISING ENTEROCOLITIS…
• Maintenance:
– FiO2 to maintain PO2- 50-70mmHg.
– Avoid N2O, inhalational anesthetics
– Atracurium supplemented c ketamine or
narcotics
– Correct hypothermia,
– Inotropes to maintain perfusion

43. CONGENITAL LOBAR
EMPHYSEMA
• Overinflation & air trapping ,
• Compression collapse & mediastinal shift
• Left upper lobe >Rt. middle lobe > Rt.upper
lobe
• Males twice affected than females.
• Cause unknown, 50% show deficiency of
bronchial cartilage.
• 10% have CHD

44. CONGENITAL LOBAR EMPHYSEMA…..
• Clinical presentation:
– Respiratory distress in newborns,
– Distress intermittent, aggravated by feeding or
coughing, tachypnea, chest retraction,wheezing.,
cyanosis.
– Mediastinal shift & contralateral lung compression,
– Decrease in CO, compression of healthy lung
– X-ray: emphysematous lobe c basal atelectasis
– Mediastinal shift, diaphragmatic displacement
– Atelectasis of opposite lung

45. CONGENITAL LOBAR EMPHYSEMA…..
• Diff.Diagnosis:
– Pneumonia,
– Cystic disease of lung,
– Tension pneumothorax
• Pre-op evaluation:
– Rapid deterioration, urgent operation
– Chest tube placement, needle aspiration, mechanical
ventilation worsens prognosis,
• Monitoring: Pulse oximeter, NiBP, capnography

46. CONGENITAL LOBAR EMPHYSEMA…..
• Anesthesia:
– Crying, struggling amount of trapped air
– IPPV emphysema
– Halothane + O2 c mask , intubation c or c out
relaxation.
– IPPV postponed until thorax is opened.( cote,1978)
– Extubated at the end of lobectomy.
– Humidity, coughing mininises atelectasis in post-op
period,
– Results are good.

47. REFERENCES
• 1. Wylie & Churchill Davidsons :
– ‘A practice of anesthesia’ ; 6th Ed.,Chapter 30th
by James.M.Steven & John Downes.
• 2. Physiology of the neonate of importance to
anesthesiologists , by Frederic.A.Berry, M.D., 42nd
anesthesiology review course lectures.
• 3. Emergency neonatal surgery , by
Frederic.A.Berry, M.D., 42nd anesthesiology review
course lectures.
• 4. Anesthetic management of neonatal
emergencies, by Anna Lucia Pappas, M.D.,
asst.prof. Loyola University Medical Centre.

48. THANK YOU