The baby with gastroschisis is at a higher risk for hypothermia, excessive fluid loss, shock, and infection due to lack of a covering peritoneal/amniotic membrane which gives rise to exposed viscera and peritoneal surfaces. Therefore, radiant heating should be available in the room and the baby should be kept in a warmed incubator with the incubator’s tempera- ture monitored frequently. Intestinal strangulation, necrosis, and obstruction may also occur due to the small size of the paraumbilical defect. Treatment starts immediately after delivery in order to prevent fluid loss and hypothermia (Box 8.2). Intubation and ventilation is carried out if required, and immediate resuscitation with adequate i.v. fluids (120 mL/kg/24hours) to overcome substantial water, electro- lyte, and protein loss is started. Because the fluid losses are primarily of serum and interstitial fluids, these neonates require isotonic fluids resuscitation, which consists of col- loids, saline, or lactate Ringer’s solution.25,26Pulse rate and mean arterial pressure are observed and blood is taken and glucose level measured. At the same time, vitamin K is given and broad-spectrum antibiotics (ampicillin, gentamicin, and metronidazole) are commenced to reduce contamination of
the exposed intestinal loops. A nasogastric tube is passed for intestinal decompression and prevention of pulmonary aspiration. A urinary catheter is passed to decompress the bladder and to monitor urinary output. In many instances, the viscera are wrapped in sterile gauze that has been soaked in warm sterile saline and then the abdomen, along with the covered defect, are wrapped in dry sterile gauze. This may, however, induce hypothermia as the gauze cools. If the gauze is allowed to dry, this may stick to the intestinal surface and cause serosal injury when trying to be removed.27Ideally, the bowel should be placed in a sterile clear plastic bag or silo (Fig. 8.2). If this is not available, the bowel is localized in the center of the abdomen and cling film is used to encircle the exposed intestine and is wrapped around the infant. These measures minimize heat loss and trauma to the exposed viscera.28The positioning of the infant is very important for preventing bowel ischemia. If the infant is supine and the
Box 8.2 Stabilization of a newborn with anterior abdominal wall defect prior to transfer to a referral center
Warm environment Evaluate respiratory status Nasogastric tube
Gastroschisis: wrap cling film around defect Omphalocele: wrap dry gauze around sac Intravenous fluids, correct deficits Antibiotics
Vitamin K
Figure 8.2 Gastroschisis with silo placement.
86 Transport of the surgical neonate
bowel lies on one side, there is a risk of ischemia to the bowel if the superior mesenteric artery becomes kinked. Hence, the best position is to keep the intestines directly above the abdominal wall defect so that the superior mesenteric artery exits straight from the defect.27
Omphalocele
As with any abdominal wall defect, the care of the neonate begins with resuscitation. The initial objectives for the neonatologist are to assess and treat respiratory distress, to protect the sac from rupture and infection, and to minimize heat loss.29,30 A nasogastric tube is passed immediately to decompress the stomach and bowel. Intravenous fluids, broad-spectrum antibiotics, and vitamin K should be started.
The defect must be inspected to ensure that the sac is intact.31 The sac should be stabilized in the middle of the abdomen to prevent kinking of the vessels and covered with a sterile, dry, non-adherent dressing to prevent trauma and heat loss. If the sac is ruptured, then the exposed bowel is treated as it is for gastroschisis.31
Pierre Robin syndrome
Babies with Pierre Robin syndrome carry a high risk of tongue swallowing and asphyxiation. The baby should be nursed prone to prevent the tongue from falling back into the airway, and an oropharyngeal airway inserted.7
Choanal atresia
Neonates with choanal atresia suffer from intermittent hypoxia. The baby should be nursed with an appropriately sized oral airway with the end or teeth cut off to keep the mouth open.5One must ensure the airway does not go too far into the pharynx as it may enter the esophagus and occlude the airway. This must be secured in place to prevent dislodging.
Myelomeningocele
The infant with myelomeningocele should be nursed prone in order to prevent trauma and pressure on the spinal area. A warm, sterile, saline-soaked dressing is placed over the lesion and cling film wrapped around the baby to prevent drying and dehiscence. If the sac is ruptured and cerebrospinal fluid (CSF) is leaking, or if the myelomeningocele is open, it should be covered with Betadine-soaked gauze and i.v. broad- spectrum antibiotics started. Care must be taken to prevent fecal contamination in sacral lesions.8 Careful observation and documentation of neurological function is essential before, during, and after transportation, including evaluation of the sensorimotor level and assessment of the degree of hydrocephalus.8,29
Bladder extrophy
At birth, the umbilical cord should be ligated close to the abdominal wall and the umbilical clamp removed to prevent mechanical damage to the bladder mucosa and excoriation of the bladder surface.6,32,33Trauma and damage to the exposed bladder mucosa and plate should be avoided by covering the defect with cling film wrapped around the baby to prevent the mucosa from sticking to clothing or diapers. This will allow urine to escape while establishing a barrier between the environment and the fragile bladder mucosa. Old urine, mucus, and any detritus should be washed from the surface of the bladder with sterile saline warmed to body tempera- ture at each diaper change and a clean layer of cling film applied, also during transfer.32,33 Prophylactic antibiotics should be started immediately.
Cloacal extrophy
The same measurements to protect the omphalocele sac as discussed under omphalocele are applicable.
Esophageal atresia with tracheo-esophageal fistula
Most babies with esophageal atresia become symptomatic soon after birth. Symptoms include excessive drooling, coughing, or choking with the first feed. Once the diagnosis of esophageal atresia is suspected, the baby should be transferred to a tertiary referral center for further investiga- tion and surgery. Some babies will require endotracheal intubation and ventilation. These infants are particularly at risk because mechanical ventilation is relatively ineffective due to the presence of a fistula. Therefore, the tip of the endotracheal tube should be placed proximal to the carina but distal to the fistula. Urgent transfer and ligation of the fistula are essential. Generally, the infant should be handled with care and crying avoided to reduce the risk of aspiration and abdominal distension and thereby, respiratory distress.6 Moreover, the baby should be well oxygenated at all times and kept in a warm environment. Regurgitation of gastric contents through the fistula during transport can be prevented by keeping the head of the baby in a slightly elevated position or nursing the baby prone or in a right lateral position and thereby decreasing the work of breathing and improving oxygenation.6,34The blind upper esophageal pouch should be kept empty. A Replogle sump catheter should be placed in the pouch and connected to low-intermittent or low-continuous suction in order to prevent accumulation of saliva. The perforations along the side of the catheter are located only near the tip and therefore minimize the possibility of suctioning oxygenated air away from the larynx.35However, these double lumen esophageal tubes have a tendency to become blocked with mucus and therefore should be irrigated at frequent intervals during transport. Intravenous fluids should be started to provide maintenance and supple- mental fluids and electrolytes to compensate esophageal secretion losses. Infection should be prevented and any Special considerations 87
existing pneumonitis treated by broad-spectrum antibiotics.
Vitamin K should be administered prior to transfer.
Congenital diaphragmatic hernia
The initial objective for the neonatologist and anesthetist is to stabilize the critically ill neonate before transport to the referral center (Box 8.3). A nasogastric tube should be passed immediately on diagnosis to decompress the gastrointestinal tract and to prevent further compression of the lung.
Endotracheal intubation should be performed promptly in a baby with respiratory difficulty or poor gas exchange. Full sedation and paralysis and gentle ventilation will reduce the risk of barotraumas in the setting of hypoplastic, delicate lungs. Mask ventilation should be avoided because it will distend the stomach and further compromise the respiratory status. Hyperventilation, using low pressures and high oxygen content, correction of acidosis and prevention of thermal and metabolic stress are recommended to prevent pulmonary hypertension.8Some infants need high frequency oscillatory ventilation (HFOV) when conventional ventila- tion proves ineffective. The rational is that small tidal volumes and gas transport by augmented diffusion result in a lower shear stress and less barotraumas.36 These patients may, however, pose a problem, as there is no oscillatory ventilation option commonly available on transport ventila- tors.37Clinical teams will usually have to convert oscillation to standard ventilation for the duration of transfer.37Careful attention to fluid balance with i.v. fluids, fresh-frozen plasma (FFP) and dopamine, if necessary, should be started to maintain adequate peripheral perfusion without causing pulmonary overload.36 Prophylactic antibiotics should be started and vitamin K administered. Venous access through the umbilicus is useful for obtaining mixed venous blood gas specimens and monitoring central venous pressures if passed across the liver into the right atrium. Arterial access with an umbilical artery catheter will allow monitoring of systemic blood pressure and blood gas measurements at the postductal level. The baby will also need a right radial arterial line to measure preductal blood gases, and a preductal pH ]7.2 and arterial oxygen pressure of ]6.5 kPa with an oxygen saturation of 8590% is acceptable.36This can be inserted on arrival at the referral center. Acute deterioration of the infant’s condition can occur during transfer due to a
pneumothorax. Equipment for intercostal drainage must be available since it can be a life-saving maneuver.8,34
There has been tremendous growth in the use of extracorporeal life support for neonatal cardiopulmonary failure in the last decade. Extracorporeal membrane oxygena- tion (ECMO) has been used as a salvage procedure with an 80% survival rate in high-risk neonates with congenital diaphragmatic hernia who fail to respond to mechanical ventilation and meet entry criteria. ECMO is able to partly take over oxygenation and carbon dioxide removal, and thereby may allow respiratory settings to be adjusted to the mechanical and gas exchange properties of the diseased lung.
In this way the goals of lung and protective mechanical ventilation can be reached.38The number of centers provid- ing ECMO is still limited, so special services are needed to transport critically ill neonates to these centers. These special transport teams should be familiar with the pathophysiology of cardiac and respiratory failure and be equipped to continue the monitoring and treatment started at the referral center. They must also be able to maintain that level of care during transport, and to treat complications of the disease or therapy itself.39,40 Now, transportable ECMO systems exist that can effectively stabilize and transport high-risk neonates to an ECMO-competent center.41The use of inhaled nitric oxide (NO) leads to a reduction in endogenous production of NO and its value in patients with congenital diaphragmatic hernia (CDH) is unclear.36 Recent studies have shown that there is an immediate short-term improvement in oxygena- tion seen in some treated infants and this may be of benefit in stabilizing infants for transport and initiation of ECMO.
However, for term and near-term infants with CDH and hypoxic respiratory failure unresponsive to conventional therapy, inhaled NO did not reduce the need for ECMO.42
Intestinal obstruction
Intestinal obstruction can occur as a result of a number of conditions, e.g. malrotation, duplication of the alimentary tract, intestinal atresias, necrotizing enterocolitis, Hirsch- sprung’s disease, meconium ileus, and anorectal anomalies.
The principles of care are the same irrespective of the level or cause of the obstruction.6 The main objectives are to decompress the bowel and prevent aspiration, accurately estimate and correct fluid losses and minimize heat loss. A nasogastric tube should be passed to minimize distension and suction carried out every 1530 minutes and left on free drainage between aspirations prior to and during transport.
Serum electrolytes and proteins sequester in the intestinal wall and lumen, and isotonic i.v. fluids and colloids should be started to correct acidbase and volume deficits.27 These must be reviewed and adjusted on a 68-hourly basis according to the needs of the infant.5 Broad-spectrum antibiotics should be started prophylactically.
Necrotizing enterocolitis
Neonates with necrotizing enterocolitis (NEC) are usually transferred only if surgery is required in case of perforation Box 8.3 Stabilization of a neonate with
congenital diaphragmatic hernia prior to transport
Maintain warm environment Nasogastric tube
Intubation and ventilation Intravenous fluids Arterial blood gases Antibiotics Vitamin K
88 Transport of the surgical neonate
of gangrenous bowel resulting in pneumoperitoneum or progressive clinical deterioration with evidence of peritoni- tis.5Usually they are critically ill with sepsis and shock. The transfer is done preferably while the infant’s condition is as stable as possible. Prompt resuscitation with crystalloids, colloids, or blood to correct acidosis is started prior to departure. Ventilation with intermittent positive pressure and inotropic support is often required.6 Blood pressure and blood glucose must be closely monitored in these patients. A sump nasogastric tube on continuous suction is passed and suctioned regularly prior to and during transport. Broad- spectrum antibiotics to cover for Gram-positive, Gram- negative and anaerobic coverage are started.27
CONCLUSION
The approach to the care of the high-risk newborn has changed dramatically in the past 20 years. The newborn with a serious congenital malformation requires assessment and stabilization by experienced staff prior to and during transport to the regional center. Several studies have demon- strated that stabilization of the high-risk newborn before transport is associated with a reduction in perinatal morbid- ity and mortality. The pediatric transport team plays a vital role in the transport of these patients to tertiary pediatric facilities. The overall aim of transport of the surgical neonate should be to bring the services of the Pediatric Intensive Care Unit to the patient’s bedside during transport to a specialist centre.
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