Skip to Main Content

++

YOUR PATIENT

++

A male child born via cesarean section at 35 weeks’ gestation presents with protrusion of bowel outside the abdominal cavity.

++

The patient was prenatally diagnosed with an abdominal wall defect.

++

Physical examination shows an alert, awake baby with protrusion of the small intestine outside the abdomen with no peritoneal covering.

++

PREOPERATIVE CONSIDERATIONS

++

Major defects in closure of the abdominal wall result in exposure of the viscera. In omphalocele, the viscera herniate through the umbilicus and are covered with the peritoneum. In gastroschisis, the viscera herniate through a defect lateral to the umbilicus, usually to the right, and have no covering.

++

The incidence is 1 in 6000-10 000 live births for omphalocele and 1 in 30 000 live births for gastroschisis. About two-thirds of patients with omphalocele have associated congenital anomalies, such as cardiovascular, genitourinary, gastrointestinal, or craniofacial anomalies, trisomy 13, or Beckwith-Wiedemann syndrome (visceromegaly, macroglossia, microcephaly, and hypoglycemia).

++

These patients are cared for expeditiously to minimize the potential for heat loss from the exposed viscera, minimize the possibility of infection, and prevent direct trauma to the herniated organs. The stomach is decompressed with a nasogastric tube, and broad-spectrum antibiotics are initiated.

++

Aggressive fluid resuscitation with a balanced salt solution (150-300 mL/kg/d) is initiated to maintain urine output at 1-2 mL/kg/h.

++

ANESTHETIC MANAGEMENT

++

  • Prior to induction, suction the stomach.

  • Use preoxygenation.

  • Use either awake intubation or rapid-sequence induction with endotracheal intubation.

  • Ensure adequate fluid resuscitation with a balanced salt solution.

  • Prevent hypothermia.

  • Maintain with a narcotic-based anesthetic and a nondepolarizing muscle relaxant.

++

POSTOPERATIVE CONSIDERATIONS

++

Patients require postoperative ventilation with fluid resuscitation along with broad-spectrum antibiotics. Patients are at risk of developing abdominal compartment syndrome if the abdominal closure is too tight.

++

Criteria used as guidelines to monitor intraabdominal pressure are intragastric pressure <20 cm H2O, intravesical pressure <20 cm H2O, and maximum peak ventilatory pressure <30 cm H2O.

++

DOs and DON’Ts

  • ✓ Do obtain a preoperative echocardiogram in patients with omphalocele.

  • ⊗ Do not mask ventilate the patient.

  • ✓ Do aggressive fluid resuscitation.

  • ✓ Do communicate with the surgeon if abdominal closure is too tight.

  • ✓ Do give adequate nondepolarizing muscle relaxant to facilitate abdominal closure.

++

SURGICAL CONCERNS

++

The goal is to place the exposed viscera into the abdomen. If the defect is small, primary complete closure is attempted. If a large amount of viscera is exposed, then a staged closure with a silastic silo is performed; the silo is secured at the edge of the defect and gradually reduced over 3-7 days. The patient is then brought to the operating room for complete closure.

++

FACTOID

++

Premature labor and delivery is common with gastroschisis, possibly because of ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.