Neonatal Surgery

Neonatal Surgery
By:Juan E Gonzalez, CRNA, MS, ARNP
Based on prior lecture by
John P. McDonough, CRNA, Ed.D., ARNP
Professor & Director
Anesthesiology Nursing

Anatomical Differences
Pedi vs. Adult Airway
More Vertical
Less vertical
R mainstem bronchus
V-shaped
U-shaped
Shape of Epiglottis
Glottis
Cricoid
Narrowest Point
C3-C6
C2-C4
Laryngeal location

Head Position
Visual Alignment of Oral/Pharyngeal/Laryngeal axes
Attempt to achieve “sniffing” position will OBSTRUCT pt
Intubation
To intubate or not to intubate…
Is that a question??
Choice of Intubating Technique
Choice of Intubating Technique
(patient factors)
Blood Pressure Control
Emergence
Surgeries in the First Week of Life
* Congenital Diaphragmatic Hernia (CDH)
* Omphalocele & Gastroschisis
* Tracheoesophageal Fistula (TEF) (hrs-days to diagnose)
* Intestinal Obstruction (hr-days to diagnose)
* Meningomyelocele
Confounding Factors
* Prematurity
* Associated Congenital Anomalies
Maternal Cocaine Use in Pregnancy
Congenital Diaphragmatic Hernia
Embriologic features of CDH
CDH scenarios
CDH Clinical Presentations
Surgery & CDH
Anesthesia & CDH
Omphalocele
Gastroschisis
Delivery Room Management of Gastroschisis
Gastroschisis Periop Concerns
Postop Care of Gastroschisis & Omphalocele
Tracheoesophageal Fistula (TEF)
TEF Clinical Presentation
TEF Anesthetic Considerations
Tracheoesophogeal Fistula
“VATER” syndrome
Vertebral defects
Anal atresia
TEF
Esophageal atresia
Renal dysplasia
Intestinal Obstruction (Upper GI obstruction)
Intestinal Obstruction (Lower GI obstruction)
Lower GI obstruction
Meningomyelocele
Meningomyelocele
Hydrocephalus
Hydrocephalus Anesthetic Approach
Surgical Procedures in the First Month of Life
Inguinal Hernia Repair (IHR)
Inguinal Hernia Repair Anesthetic Techniques
Inguinal Hernia Repair Post Op Apnea in Premies
Ligation of PDA
Placement of Central Venous Catheter
References

Neonatal Surgery.ppt

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Abdominal Wall Defects: Omphalocele vs. Gastroschisis

Abdominal Wall Defects: Omphalocele vs. Gastroschisis
By:Joanna Thomson,
Surgery Clerkship

Embryology Review
* The Midgut gives rise to:
o Duodenum distal to the bile duct
o Jejunum
o Ileum
o Cecum
o Appendix
o Ascending colon
o Hepatic flexure of the colon
o Proximal two-thirds of transverse colon.

Physiological Umbilical Herniation
* As a result of rapid growth and expansion of the liver, the abdominal cavity temporarily becomes too small to contain all the intestinal loops.
* The intestinal loops enter the extraembyronic cavity within the umbilical cord during the sixth week of development.
* As herniation occurs, the loop undergoes a 90 degree counterclockwise rotation around the superior mesenteric artery.

Return to Abdominal Cavity
* During 10th week of development, herniated intestinal loops begin to return to the abdominal cavity.
* Undergoes additional 180 degree counterclockwise rotation about the superior mesenteric artery.
* Factors responsible for this return are not precisely known... It is thought that regression of the mesonephros (kidney), reduced growth of the liver, and expansion of the abdominal cavity all play roles.

Omphalocele
* Herniation of abdominal viscera through an enlarged umbilical ring.
o Failure of the bowel to return to the body cavity following physiological umbilical herniation. Defective mesodermal growth causes incomplete central fusion and persistent herniation of the midgut.
* Extruded viscera may include LIVER, small and large intestines, stomach, spleen, or bladder.
* Covered by amnion and peritoneum

Gastroschisis
* Herniation of intestinal loops through the anterior abdominal wall.
* Defect lateral to the umbilicus (right>left)
o Abnormal involution of the right umbilical vein or vascular accident involving the omphalomesenteric artery causes localized abdominal wall weakness.
* No sac covers the extruded viscera.

Prenatal Diagnosis
* Elevated maternal serum alpha fetoprotein
* Ultrasound
Omphalocele Gastroschisis

Epidemiology
* Prevalence:
o Omphalocele: 1/5,000 births
o Gastroschisis: 1/10,000 births
+ Increasing in frequency, especially in young women.
* Mortality:
o Omphalocele: 25%
+ Related directly to presence of chromosomal and other abnormalities
o Gastroschisis: <5%

Omphalocele Associated Anomalies
* Chromosomal abnormalities (50%)
* Neural tube defects (40%)
* Beckwith-Wiedemann syndrome
* Pentalogy of Cantrell

Gastroschisis Associated Anomalies
* Additional gastrointestinal problems
Initial Management
* Acute management aimed at maintaining circulation to bowel and preventing infection while stabilizing infant (temperature/fluids) :
o Cover the defect with sterile dressing soaked in warm saline to prevent fluid loss
o Nasogastric decompression
o IV fluids with glucose
o Antibiotics

Surgical Treatment
* Surgery performed to return the viscera to the abdominal cavity and close the defect.
o Primary Surgical Closure: Success dependent on size of the defect and size of the abdominal and thoracic cavities.

o Staged Closure: Gradual reduction of the contents into the abdominal cavity using an extra-abdominal extension of the peritoneal cavity (termed a silo) and using gentle pressure. Usually requires 1-3 weeks, after which the defect is then primarily closed.

Abdominal Wall Defects.ppt

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Sexually Transmitted Diseases What’s New?

Sexually Transmitted Diseases What’s New?
By:Linda Creegan, FNP
California STD/HIV Prevention Training Center


Common STDs

* Humanpapilloma Virus
* Trichomoniasis
* Chlamydia
* Genital herpes
* Gonorrhea
* Hepatitis B
* Syphilis

Overview of Complications of Sexually Transmitted Diseases

Fetal Wastage*
Low Birthweight*
Congenital Infection*
Upper Tract Infection
Systemic Infection
STDs
Infertility
Ectopic Pregnancy*
Chronic Pelvic Pain
HIV Infection*
Cervical Cancer*
* Potentially Fatal
Increased Transmission of HIV in the Presence of Other STDs
* Transmission increased 3-5 times
* Increased susceptibility
* Increased infectiousness
Chlamydia
Gonorrhea
Risk Factors
Recommendations
Syphilis
P&S Syphilis
Genital Herpes
Herpes simplex virus type 2
Genital Warts
What’s New with Chlamydia Infection?
Chlamydia Infections in Women and Neonates
Genital Chlamydia in Women: Complications
Untreated genital CT infection
Ectopic pregnancy
Infertility
Chronic pelvic pain
Public Health Approaches to Chlamydia Control
Chlamydia Screening & Treatment
CT Screening Cost-Effective
Chlamydia Screening Recommendations
Chlamydia Testing Current Diagnostic Methods
Chlamydia Testing Nucleic Acid Amplification Tests
Hybrid Capture
Genital Chlamydia Diagnostic Tests
Sensitivity
Urine-Based CT Tests
Cost Effectiveness of NAAT
Chlamydia Follow-up
Is Test-of-Cure Necessary?
Chlamydia Partner Management
What’s New with Gonorrhea?
Gonorrhea Infection
Gonorrhea Clinical Presentation
Gonorrhea Complications
Gonorrhea Diagnosis
Gonorrhea Anal and Pharyngeal Infections
Gonorrhea Treatment
Uncomplicated Genital and Rectal Infections,
Non-Pregnant Adults
GC Partner Management
Use of Fluoroquinolones to Treat GC Infection:Recommendations
GC LCR Screening
Gonorrhea Screening Recommendations
What’s New with Syphilis?
Syphilis Elimination Public Health Importance
National Plan for Syphilis Elimination Five Key Strategies
Understanding STD Trends in MSM
Syphilis Management in HIV Co-Infected Patients
Syphilis Diagnostic Testing
Syphilis New Therapies
What’ s New with Genital Herpes?
Herpes: Overview
Genital Herpes Infection Epidemiology
HSV-2 Seropositivity
Human Herpesvirus Family
Genital Herpes Transmission
Genital Herpes Natural History
Genital Herpes Categories of Infection
Genital Herpes First Clinical Episodes
Genital Herpes Reactivation of Virus
Genital Herpes Educating to Recognize Symptoms
Genital Herpes Patient’s Perception of Etiology
Genital Herpes Asymptomatic Shedding
Genital Herpes Spectrum of Presentations
Neonatal Herpes Infection
Herpes Transmission in Pregnancy
Herpes Diagnostic Tests
Herpes Diagnosis Serologic Tests
HSV Serology Testing
Genital Herpes Principles of Treatment
Antiviral Medications for Uncomplicated HSV
Genital Herpes What’s New in Treatment?
Genital Herpes Treatment in Pregnancy
Genital Herpes Vaccine Development
Dermal HPVs
Thin-Layer Pap Preparations
ThinPrep Pap Specimen Collection
ThinPrep Pap Test
HPV DNA Tests
Utility of HPV Testing
Conduct HPV test on stored specimen
HPV Disease Management of HIV Infected MSM
Prevention of Genital HPV Infection and Sequelae:
Abnormal Flora in Bacterial Vaginosis (BV)
BV: Complications in Pregnancy
BV: Diagnostic Criteria
Amsel Criteria
BV: Screening in Pregnancy
BV: Treatment Non-Pregnant Women
Trichomoniasis
Trichomoniasis: Diagnosis
Culture System for T. vaginalis
Trichomoniasis Treatment During Pregnancy
Recommended regimen:
Trichomoniasis
Role in Urethritis

Sexually Transmitted Diseases What’s New?.ppt

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