For pediatrics anesthesia care providers.

1. Anesthesia Management for Surgical
Correction in the Neonatal period
By: Kanbiro G. (MSC in ACA)
kanbgedeno45@gmail.com

2. Case scenario:
 A 6 month old boy is brought to the hospital with a 2 day
history of vomiting, increasing lethargy and intermittent
crying. He has not passed urine for 12 hours and his last nappy
contained a bloody, jelly-like stool. On examination the baby
is pale and listless with sunken eyes. His heart rate is 160/min,
systolic blood pressure of 80 mmHg and capillary refill time 5
seconds. His abdomen is distended and tender on palpation.
 What is the likely dx and what is the main ddx?
 What further investigations could you do?
 How would you manage this child next?
 How would you anesthetize this child?
 What things do you need to think about during surgery to keep the
child stable?
 What fluids would you give?
 What analgesic techniques can you use?
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3. General outline:
 Objectives
 Introduction
 Perioperative mgt
o Tracheo-oesophageal fistula
o Diaphragmatic hernia
o Gastrochiasis/ omphalocele
o Intestinal obstruction
o Pyeloric stenosis
 Conclusion
 References
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4. Objectives
By the end of this seminar, you will be able to:
 Identify associated congenital anomalies
 Optimize a neonate with TEF, CDH,
abdominal wall defects, IHPS, and intestinal
obstruction preoperatively.
 Manage perioperative challenges related with
congenital anomalies
 Provide meticulous intraoperative and
postoperative monitoring & management.
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5. Introduction
 Neonates have great challenges to the
anesthesia and surgical team associated with
prematurity and congenital anomalies.
 Advances in obstetrics, anesthesia and
neonatology have greatly improved neonatal
survival especially for infants with complex
anatomical defect and preterm neonates.
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6.  Surgical procedures are divided into two periods:
Performed in the first week:
 CDH,
 Omphalocele and gastroschisis,
 Tracheoesophageal fistula (TEF),
 Intestinal obstruction,
 Meningomyelocele.
Performed in the first month:
 Laparotomy for NEC,
 Inguinal hernia repair,
 Correction of pyloric stenosis,
 PDA ligation,
 VP shunt
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7. Tracheo-oesophageal fistula and
Esophageal atresia

8. Introduction:
 Esophageal atresia (EA) is the most frequent
esophagus congenital anomaly , with an approximate
incidence of 1 in 2500-4000 neonates and more than
90% are associated tracheoesophageal fistula (TEF).
 Up to 50% have additional congenital defects
(VACTERL) and 30% to 40% are born prematurely=>
worsen the prognosis.
 The birth weight and the presence of a cardiac anomaly
determine survival rate.
 Weighing > 1500 g with EA/TEF but without a cardiac
anomaly survival rate more than 95%,
 But birth weight < 1500 g and a major cardiac anomaly have
only a 50% survival rate
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(Alan David Kaye et al, 2015)
(Spitz et al. 2007, & Schmidt A et al. 2017)
(Solomon BD et al. 2014)

9. Presentation and Diagnosis:
Prenatal diagnosis (U/S): sensitivity about 26-
57% with 99% specificity and 35% positive
predictive value.
 Maternal polyhydramnios??
 Small or absent fetal gastric bubble
 Preterm delivery
Postnatally:
 Children present with excessive salivation and
drooling, coughing, cyanosis, and difficulty swallowing.
 A suction catheter is unable to be passed into the
stomach
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(Bradshaw CJ et al. 2016)
(Mattei P et al. 2011 & Zaveri PG et al. 2014)

10. Perioperative anesthesia management:
 The operation of TEF is acceptable and
urgent, but not immediate (within 24–72 h).
 The time of surgery is determined by:
The general condition of the infant.
Long-gap EA: >2 vertebral bodies b/n
atresia.
Surgical approach:
o Primary closure of the fistula and anastomosis.
o Gastrostomy initially (staged surgical approach).
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(Schmidt A et al. 2017)
(Stoll et al. 2017)

11.  Preoperative optimization:
Aspiration pneumonia issues:
 Put on NPO and in the upright position(30o-40o).
 Continuous suctioning of the esophageal pouch
 Antibiotics treatment before surgery
Overdistention of the stomach & Inability to
ventilate=> air entry through the fistula.
 Preoperative gastrostomy=>*nutritional support
 Avoid excessive positive pressure ventilation
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(A. Holmquist et al. 2018 &Anju Gupta et al. 2017 )

12. Associated with other anomalies (VACTERL
syndrome)
 Preoperative work-up
 Cardiorespiratory status optimized
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13.  Airway management challenges & options:
Awake intubation with spontaneous ventilation
Minimizing fistula passage of gases
Increase ICP and IV hemorrhage (premature infant)
Inhalation induction:
Allowed to breath spontaneously.
Intravenous induction with muscle relaxant:
Minimize peak inspiratory pressure.
 Safest approach to airway management is an
awake intubation, OR inhalation induction with
spontaneous ventilation and avoidance of muscle
relaxation until the airway is secured avoids use
of PPV.
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(Anthony M et al.2015)

14.  Endotracheal tube placement challenge:
 ETT tip must be above the carina, and below
fistula.
 Advance tube to right main stem bronchus and
then pull back slightly until breath sounds are
heard bilaterally.
Localization confirmed by flexible fiberoptic/ rigid
bronchoscope, CXR, u/s, or gastrostomy bubbling
 Fistula ventilation=>prevention options
Use of low inspiratory pressure
Fogarty catheter consider??
Use of micro cuff ETT??
Specially modified bifurcated tracheal tube??
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(Nathan M et al. 2020, &
Kurniyanta, et al. 2021)

15.  Intraoperative issues:
 Selection of anesthetic technique=> consider
physiologic status of the neonate.
Low-dose volatile anesthetics with air, oxygen, and
an opiate.
Administer a nondepolarizing muscle relaxant after
secure the airway and satisfactory ventilation.
 Replace insensible and 3rd space fluid losses with
isotonic cryst. => 6 to 8 mL/kg/hr.
 Replace blood loss with packed red cells to
maintain Hct higher than 35%.
 Avoid Hypothermia
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16.  Lung retraction required to provide proper exposure=>
deterioration of oxygenation & accidental deep intubation
 Intermittent ventilation of collapsed lung and close cooperation
of surgical team improve oxygenation.
 Single-lung ventilation to be considered for video-assisted
thoracoscopy & TEF is at the carina or more distally.
 Blood from the surgical site enter the trachea and cause
plugging of the ETT=> strict vigilance is necessary to
prevent catastrophic complications.
 High risk of ETT dislodgement and fistula ventilation=>
Intubation of the fistula=> reposition
 Signs: increased airway pressures, difficult ventilation, and
stomach distension
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17. Monitoring:
 Precordial stethoscope
 Invasive arterial monitoring
 Pre- and postductal oxygen saturation
 Shunt fraction via patent ductus arteriosus
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18. Postoperative issues:
 Extubation of term infants at the end of surgery is
preferable.
 Postoperative pain: caudal epidural catheters
 Require postoperative ventilatory support in early
postoperative period (at least 24–48 h) in NICU.
 Anastomotic breakdown and leak are the most
common postoperativ complications.
 Avoid high PPV
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19. Summery:
 There are several anatomic variations of TEF/ EA, but the most
common lesion is a proximal, blind esophageal pouch with a
distal tracheoesophageal fistula associated with other anomalies
(VACTERL association).
 Safest approach to airway management in these children is an
awake intubation, inhalation induction with spontaneous
ventilation and avoidance of muscle relaxation until the airway
is secured avoids use of PPV.
 Intraoperatively, there is a high risk of ETT dislodgement and
inadvertent ventilation of the fistula tract.
 Anastomotic breakdown and leak are the most common
postoperative complications.
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20. Congenital diaphragmatic hernia
(CDH)

21. Introduction:
 CDH is a defect in the diaphragm with a variable
amount of intraabdominal organ extrusion into the
thoracic cavity.
 Incidence 1 in 2500-4000 live births, and mortality
rate of 40% to 50% traditionally, But currently
survival rates >75%.
 Associated with other anomalies or syndromes
(Beckwith-Wiedemann syndrome, CHARGE
association).
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(M. Lima et al. 2019)

22.  Left posterolateral pleuroperitoneal canal
(foramen of Bochdalek): most common and
largest defect accounts 75-90% of all cases.
 The remainder (10%): Right posterolateral
foramen of Bochdalek, anterior foramen of
Morgagni, and paraesophageal locations.
 Depends on the degree of intestinal herniation
and mediastinal shift:
Pulmonary hypoplasia, hypertension, remaining lung
volume for gas exchange less than 15% => poor
prognosis.
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(M. Lima et al. 2019)

23. Clinical Presentation
 Prenatal diagnosis has increased from
approximately 10% of cases in 1985 to nearly
60-70% in present day.
Fetal ultrasonography/ultrafast fetal magnetic
resonance image
 Classically, presence of cyanosis, dyspnea, and
apparent dextrocardia with
Scaphoid abdomen, decr. breath sounds, incr.
anteroposterior diameter of the chest, and bowel
sounds over the chest.
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(Kotecha A et al. 2012)

24. Preoperative optimization:
Timing of surgery issues:
 Previously referred to as a surgical emergency
and underwent surgical correction in the first
24 h of life.
 Nowadays, Initial resuscitation and medical
optimization prior to surgery.
MAP normal for gestation,
Preductal So2: 85-95% on FiO2 <0.5
lactate <3 mmol/l & UOP >1 ml/kg/h
 Repair before, on-ECMO, post-ECMO???
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(Reiss et al. 2010)

25. Ventilation strategies:
 Lung protective ventilation strategies:
Low tidal volume
Permissive hypercapnia (45 to 65 mm Hg)
Titrate FiO2 to maintain preductal so2 > 85%
Reduce PAP < 25 cm H2O and PEEP≤ 5 cm H2O.
 The RCT VICI trial compared CMV and high-
frequency oscillatory ventilation (HFOV) as
the initial mode of ventilation in CDH
concluded no statistically significant difference
in outcome of mortality or bronchopulmonary
dysplasia (BPD).
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(Reiss et al. 2010 & B. Das et al. 2018)

26.  Consider surfactant therapy, and ECMO
ECMO indication criteria:
 Inability to maintain preductal So2>85% /
post-ductal >70%
 PaCO2 >70mmHg and PH<7.15
 PIP>28 cmH2O /MAP> 17 cmH2O required
to maintain preductal So2 >85%
 Lactate >5mmol/L
 Refractory systemic hypotension
 Oxygenation index >40
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(Reiss et al. 2010)

27. Hemodynamic management issues:
 If hypovolemia, a bolus of 10 ml/kg with an
isotonic solution & consider
vasopressor/inotropic therapy.
 Optimal management of anticoagulation
(bleeding risk)=> if on ECMO with
anticoagulation
 Goals:
HCT=35-45%
PLT>100 k
Fibrinogen >150mg/dL
PTT≤ 60 sec
TEG/ ROTEM
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(Reiss et al. 2010)
(YIGIT GUNER et al. 2021)

28. Pulmonary hypertension mgt challenge:
 Hypoplastic lungs and vasculature =>PPHT=>
right-to-left shunting through PDA
=>Profound hypoxemia
 Inhaled Nitric Oxide (iNO): 1st line
 Consider Prostaglandin (PGE1), prostacyclin,
Milrinone
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(Merrill McHoney et al.2015)

29. Anesthesia management:
Anesthesia concerns:
 Hypoxemia and hypotension
Overdistention of the stomach(fistula
ventilation) and the mediastinum shift
Primary pulmonary hypoplasia & hypertension
Kinking of major blood vessels
 Pneumothorax of the contralateral lung:
High-pressure ventilation
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30. Airway management:
 Prevent further distention of the GIT and
pulmonary compression.
 Blunting of the stress response=>high dose
opioids
o Awake endotracheal intubation or
o Rapid-sequence tracheal intubation without
BMV
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31. Intraoperative:
 Avoid Hypothermia
 Low concentration of inhaled anesthetics and
avoid nitrous oxide.
 Control ventilation and oxygenation: aware
ventilation-associated lung injury &
pneumothorax.
PAP maintained (< 25-30cmH2O)
 Adequate Iv access, vasopressors, iNO &
maintenance fluid with dextrose
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32. Monitoring:
 Routine monitoring
 Two pulse oximeters (preductal and postductal)
To monitor the degree of shunting.
 Preductal arterial cannula (right radial artery)
is recommended.
 Avoid lower extremities venous access:
Hernia reduction =>IVC compression=> impair
Venous return.
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33. Postoperative management:
 Postoperative intensive care is necessary.
 Degree of pulmonary hypoplasia determine
long-term outcome.
Incidence of chronic lung disease in survivors is
33%–52%.
 Adequate nutrition and O2 supplementation
For remodeling of the pulmonary vasculature and
growth of more lung tissue.
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34.  Ventilatory support with low pressures and
the lowest safe Fio2.
 Provide Sedation and analgesia
Consider caudal or epidural analgesia
 Structured long-term multidisciplinary
follow-up care is essential.
*Pulmonary hypertension Tt.
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35. Omphalocele and Gastroschisis

36. Introduction:
 Omphalocele and gastroschisis are congenital
defects of the anterior abdominal wall that
permit external herniation of abdominal
viscera.
 In utero diagnosis allows planned delivery at a
medical center with resources for obstetric,
surgical, anesthetic, and neonatal care in high-
risk cases.
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37. Gastroschisis Exomphalos (Omphalocele)
Incidence &
Associated
Anomalies
1: 3000
Other anomalies rare
60% preterm
1: 5000
Other anomalies common:
Cardiac defect (30-40%),
30% preterm
Location of
defect
lateral to the umbilicus (usually right
sided).
Through umbilical cord
Covering sac Absent Present
Condition of
bowel
Bowel wall may be thickened,
May involve stomach, bladder, uterus,
rarely liver.
Minor herniation (<5cm)
small defect
Large defect, including liver,
Bowel looks normal
Complications Malrotation, volvulus, poor gut
motility, intestinal atresia, stenosis
(15%)
Malrotation (uncommon),
volvulus, intestinal atresia,
Stenosis
Immediate
management
Cover bowel with cellophane , IV
fluids, NG tube, antibiotics; urgent
surgery.
Semi urgent surgery unless
Sac ruptures
Surgical
management
Staged surgery common. Single stage surgery
staged for exomphalos major
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38. Perioperative management:
The major problems:
 Severe massive fluid loss and dehydration
 Heat loss
 Difficulty of surgical closure
 High association with prematurity and
other congenital defects
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39. Surgical Management challenge:
Single stage surgery for: exomphalos minor
*’Abdominal compartment syndrome’
Staged surgery for:
Exomphalos major & Gastroschisis
Intragastric pressures > 20mmHg or inspiratory
pressures > 30cmH2O,
 Requires application of a ‘silo’ /preformed silastic
spring loaded silo.
 Bowel contents are reduced under gravity over 4-7
days before definitive closure.
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(Hamid et al. 2015)

40. Anesthetic management issue:
 Assess the gestational age, birth history,
associated anomalies
o Echocardiogram & renal U/S
 Decompressing the stomach
 Assess hydration status:
Fluid resuscitation: 20ml/kg NS, reassess and repeat
UOP: 1 to 2 ml/kg/hr
 Antibiotic prophylaxis
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(B. G. Goudra et al. 2018)

41.  Monitoring required IVC, airway pressures,
intra abdominal pressure
High ventilatory pressures and excessive Fio2 =>
postponing immediate abdominal closure
 Modified rapid sequence induction with a
small amount of intravenous agent.
 Nitrous oxide is avoided
 Consider caudal anesthesia
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42. Heat loss management issue:
 Placing exposed intestine into a plastic
drawstring bowel bag immediately after
delivery
 Warm the theatre to 25-26˚C
 Prepare active warming device & cotton.
 Surgeon keep the bowel covered with warm
swabs during surgery and transfer with in a
warmed incubator.
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43. Postoperative issues:
 Mechanical ventilatory support in NICU
 Extubated when they are fully awake, with
regular spontaneous breathing.
 Measure blood glucose levels regularly and
treat hypoglycemia with 1-2ml/kg of 10%
glucose.
 Consider TPN until full feeds are established
 Check fluid balance and electrolytes to
determine subsequent fluid requirements.
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44. Summary:
 Neonates with abdominal wall defects
require particular attention to:
o Fluid resuscitation and temperature control
 Overenthusiastic attempts by surgeons to
close the defect inevitable causes:
o Decrease in blood pressure and cardiac output
and
o Interfere with ventilation
 The surgeon should be alerted and a silo
should be placed with a delayed closure.
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45. Infantile hypertrophy pyloric
stenosis:

46. Introduction:
 PS is one of the most common GIT
abnormalities in the first 6 months of life.
 Occurs 4xmales, more in 1st born infants.
 The incidence is approximately 1 in 300 live
births and usually an isolated, but <10% have
other anomalies.
 An acute medical emergency not a surgical
emergency.
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47. Pathophysiology :
 Hypertrophy pylorus muscle layers &
mucosa oedematous.
 Functional obstruction of the gastric outlet.
 High pressure => Emesis is usually projectile
=> metabolic disturbance:
Hypovolemic, Hypochloremic,
Hypokalemic, & Metabolic alkalosis.
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48. Diagnosis:
 Typical history
 Olive-like mass: just below the xiphoid
process
 Ultrasound: Pyloric muscle thickness >4mm,
length >14 – 20mm, &diameter >10-14mm
 Upper GI Imaging: classical signs
‘String sign’ (elongated pyloric canal) or
‘Double-track sign’ (thickened pyloric mucosa)
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49. Perioperative management:
Preoperative major concerns:
 Full stomach
 Metabolic disturbance
 Severe dehydration
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50. Optimization:
 Assesse severity of dehydration (skin turgor,
mucous membranes, anterior fontanelle, resting
vital signs)
 Assess electrolyte and acid-base abnormalities
Resuscitation:
 ‘ABC’ approach
 An initial bolus of 20ml / kg 0.9% normal saline.
 Potassium chloride(KCL) 10 to 20 mEq/L =>
adequate urine output.
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(Ross Andrew R et al. 2019)

51. Maintenance fluid :
 5% glucose/0.45% saline: hyper/normal Na
 5% glucose/0.9% saline: hyponatermia
 Keep UOP>2ml/kg/hr
 Perform Serial electrolyte, acid-base and
blood glucose/day.
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52. Resuscitation Goal:
 Good hydration
 pH <7.45
 Base excess <3.5 mmol/l
 Bicarbonate < 26 mmol/L
 Sodium > 132 mmol/L
 Potassium > 3.5 mmol/L
 Chloride > 100 mmol/L
 Glucose > 4.0 mmol/L
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(van den Bunder et al.2019)

53. Anesthesia management:
 Aspirating with large-bore NG tube before
induction in the “4 quadrant rotation”
 Use modified RSI with gentle positive pressure
ventilation(<10-12cmH2O)
 Maintained with short acting volatile agents &
non- depolarizing neuromuscular blocking drugs.
 Full intra-operative monitoring
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(M. Kamata et. 2015)

54. Pain management:
 IV opioids fentanyl: 1 mcg/kg
 Paracetamol: 30-40mg/kg PR.
 Wound infiltration: 2 mg/kg (0.8 ml/kg)
0.25%bupivacaine OR
 Caudal Analgesia: mid thoracic (1.25ml/kg)
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55. Postoperative Care
 Respiratory depression: O2 support
Related to a delayed correction of CNS alkalosis
affecting the pH of the CSF.
 Initiate oral feeding 6-8 hours after surgery.
 Continue maintenance iv fluids until oral
intake is adequate.
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(van den BUNDER et al. 2020)

56. Summary:
 A common condition, occurring in 2 – 4 / 1000 live
births and presentation is usually early, between 3 – 5
weeks of age.
 Initial management is aimed at resuscitation,
correcting of dehydration, alkalosis and electrolyte
disturbances before corrective surgery can occur .
 A variety of anesthetic techniques have been used
successfully, although rapid sequence intravenous
induction, endotracheal intubation and maintenance
with an inhalational agent is common and safe.
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57. Intestinal Obstruction

58. Introduction:
 Upper or lower GIT Obstruction due to:
o Congenital: atresia, stenosis
o Mechanical: malrotation, intussusceptions,
volvulus,..
o Functional: meconium ileus, Hirschprung’s
disease
 Surgical emergency following optimization
of electrolyte and fluid status.
 Incidence approximate 1/2000.
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59. Clinical presentation:
 Bilious vomiting, pain, bloody diarrhoea:
 Electrolyte imbalances, and dehydration =>
circulatory shock.
 The abdominal distension, and failure to pass
stool:
 Splinting of the diaphragm => respiratory
insufficiency.
 Infarction of the gut, bleeding and perforation =>
Infection => septic shock and coagulopathy
 On radiographs: Gas-filled loops of bowel
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60. Perioperative management
Preoperative evaluation & optimization:
 Associated congenital abnormalities
 Airway compromise & ventilation
difficulties
 Fluid and electrolyte mgt
 Signs of sepsis and/or shock
 Blood cross-matched and readily available.
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61. Intraoperative mgt challenges:
 Full stomach + Increased oxygen demand and
decreased FRC
o Gastric decompression
o Modified RSI & quick and careful intubation
o Backup tubes, blades, LMA available
o Induction: Ketamine is preferred (if presence
of hypovolemia)
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62.  Suxamethonium: relaxant of choice for RSI.
 Rocuronium (make sure that anatomical
abnormalities of the upper airway)
 Maintained by inhalational
Isoflurane and Sevoflurane are preferred
 Avoid nitrous oxide
 Controlled ventilation, with continuous
monitoring of EtCO2.
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63.  Monitoring: Pulse oximetry, capillary refill,
warmth peripheries, pre-cordial stethoscope and
urine output
 Fluid Management: sum of hourly maintenance
requirements, pre-existing deficits and ongoing
losses.
 Type of fluid: based on electrolyte imbalance
and blood glucose levels.
 Temperature management
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64. Analgesics:
 Paracetamol prescribed regularly
 Narcotics used judiciously (cause
hypotension).
 Consider caudal block (avoid if sepsis is
suspected)
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65. Postoperative management:
 ETT is left in place until the patient is
awake, adequate spontaneous ventilation, &
normal core temperature.
 Consider mechanical ventilation support.
 Maintain adequate analgesia
 Continue intravenous fluids until oral intake
is re-established.
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66. References:
 Stoeltings_Anesthesia_and_Co-Existing Disease_6th_Ed
 Clinical anesthesia/edited by Paul G. Barash [et al.]. – 8th ed
 Miller’s anesthesia / [edited by] Ronald D. Miller -- 9th ed.
 Infantile hypertrophic pyloric stenosis, ATOTW- 276, NOV 26th 2012.
 Anesthesia for intestinal obstruction in children, ATOTW- 74, NOV 18th 2007.
 Mineto Kamata, Richard S. Cartabuke1, & Joseph D. Tobias. Anesthesia and
pyloric stenosis. Pediatric Anesthesia 25 (2015) 1193–1206
 Fenne A. I. M. van den Bunder Nige J. Hall L. W. Ernest van Heurn1 Joep P.
M. Derikx. Delphi Analysis to Reach Consensus on Preoperative Care in IHPS.
European Journal of Pediatric Surgery 2020 (0939-7248).
 YIGIT GUNER. ECLS GUIDELINES FOR CDH: a ELSO Guidelines.
ASAIO Journal 2021
 Richard Keijzer. High-frequency vs. conventional ventilation at the time of
CDH repair : a retrospective cohort study. Pediatric Surgery International
(2020) 36:1275–1280
 Francesco Morini. Ventilation modalities in infants with congenital
diaphragmatic hernia. Seminars in Pediatric Surgery 26 (2017) 159–165
 Dingemann et al. Consensus on Esophageal Atresia: Follow-up and Framework.
European Journal of Pediatric Surgery (2019) 0939-7248.
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67. Thanks ALL!!!
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