What is
the anesthetic plan, and what are the intra-operative and postoperative
concerns in this patient?
The patient should be transported to the
operating room in a warmed isolette and placed on a forced-air warming blanket.
Gastric decompression should be done if it has not already been performed.
Monitors should be placed before preoxygenation. The pulse oximeter probe
should be placed on the right hand in order to monitor preductal oxygen
saturations. If post-ductal oxygen satura-tions are measured, you may be
delivering a higher con-centration of oxygen than necessary, increasing the
risk of retinopathy of prematurity. Premedication with atropine will help to
reduce secretions and prevent the bradycardia sometimes seen in infants during
laryngoscopy. A rapid sequence intravenous induction with cricoid pressure
fol-lowed by endotracheal intubation should be performed. An awake intubation
may cause further extrusion of abdominal contents. A mixture of air and oxygen
is used, maintaining the oxygen saturation between 90% and 95%. A balanced
technique using a volatile anesthetic and intravenous opioid, such as morphine
or fentanyl, may be used for the anesthetic maintenance. In order to avoid
distention of the gastro-intestinal tract, nitrous oxide is avoided. Maximal
muscle relaxation should be provided in order to facilitate the sur-geon’s
attempt to replace the bowel in the abdomen.
The decision whether a primary closure will be
tolerated or whether a gradual reduction of the hernia will be neces-sary is
determined intraoperatively. A primary closure can lead to multiple organ
system dysfunctions, including the pulmonary, circulatory, renal and
gastrointestinal systems, if there is excessive intra-abdominal pressure.
Intra-abdom-inal pressures of up to 20 mmHg are usually well tolerated.
Visualizing the lower extremities as well as measuring pulse oximetry and blood
pressure in the lower extremities may help determine whether primary closure
will be tolerated. Monitoring peak airway pressures during the closure will
also provide information about the appropriateness of the primary closure.
Alternatively, intra-abdominal pressures can be indi-rectly measured through
either the nasogastric tube or the Foley catheter. If central venous pressure
is monitored, increases greater than 4 mmHg are associated with compro-mised
venous return and a decrease in cardiac index.
Ventilation and fluid management are the major
concerns both intraoperatively and postoperatively. Ventilatory requirements
may change during the surgical procedure as the bowel is returned to the
abdomen. Large amounts of balanced salt solutions are often necessary to
replace losses from the exposed bowel. Peripheral circulation, urine output,
blood pressure, and acid-base measurements are helpful in assessing the
adequacy of fluid resuscitation.
If a primary closure is performed in a patient
with a large defect, the patient is kept intubated and muscle relax-ation is
continued until the intra-abdominal pressure has decreased to an acceptable
level. If a silon chimney is used for a gradual reduction and closure, the patient’s
trachea can usually be extubated. A daily reduction is done without anesthesia
in the neonatal intensive care unit. The patient is returned to the operating
room for final closure of the abdominal defect.
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