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YOUR PATIENT

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A 3.1-kg 1-day-old male born at term is scheduled for an exploratory laparotomy for meconium ileus.

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  • Vital signs: BP = 55/35; P = 130

  • Laboratory: Hematocrit (Hct) = 45%

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PREOPERATIVE CONSIDERATIONS

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Meconium ileus is seen soon after birth when an infant with a distended abdomen fails to pass meconium. It is often possible to palpate a mass in the right lower quadrant that corresponds to the distended ileum obstructed by the abnormal meconium. Perforation may occur in utero. When this occurs, meconium peritonitis with calcification follows and may be visualized radiographically. This may lead to atresia or stenosis of the bowel segment, volvulus, and necrosis. The cause is the presence of abnormally viscid meconium with an increased protein content that cannot be propelled by the bowel. When a single or multiple ileal atresias are present in the newborn or meconium ileus is found, the diagnosis of cystic fibrosis should be suspected. Respiratory symptoms of cystic fibrosis are generally not present in the neonatal period.

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Intestinal anomalies other than ileal atresia are rarely associated with meconium ileus.

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ANESTHETIC MANAGEMENT

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  • Two peripheral IVs.

  • Consider an arterial line. Monitoring acid-base status and hematocrit may be helpful in guiding fluid resuscitation.

  • Rapid-sequence induction vs awake intubation—consider providing oxygen during laryngoscopy to delay or decrease the amount of desaturation that may occur.

  • Use narcotics judiciously if planning extubation.

  • Warm forced air and fluid.

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POSTOPERATIVE CONSIDERATIONS

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Extubation of the trachea at the conclusion of the case should be entertained.

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DOs and DON’Ts

  • ✓ Do aggressively maintain fluid volume, as large amounts of fluid may be lost as evaporative and third space losses.

  • ✓ Do warm the patient aggressively, since a significant portion of the patient’s body surface area may be exposed.

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SURGICAL CONCERNS

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If surgical evacuation of the meconium is unsuccessful, an enterostomy will need to be created.

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FACTOID

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Meconium ileus is found almost exclusively in patients with cystic fibrosis. However, only about 20% of the patients with cystic fibrosis will have meconium ileus.

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