Chapter 34

A 2.8-kg 2-day-old male born at 33 weeks’ gestation is scheduled for elective resection of a very large sacrococcygeal teratoma. He is on room air with nasal continuous positive airway pressure (CPAP).

• Vital signs: BP = 55/35, P = 150

• Laboratory: Hematocrit (Hct) = 45%

### PREOPERATIVE CONSIDERATIONS

Sacrococcygeal teratoma is the most common tumor of the newborn, occurring in 1 in 35 000-40 000 live births. It occurs more often in females, with a 3-4:1 ratio. Often the tumor is small and presents as a lump in the sacral region.

This tumor can present prenatally secondary to the abnormal size of the uterus for the calculated gestational age of the fetus and can even outgrow the fetus in size. It can be associated with fetal hydrops leading to polyhydramnios and premature delivery or can rapidly progress to fatality in utero secondary to the high-output cardiac failure resulting from the “vascular steal” of blood flow through the tumor. Maternal symptoms may mimic the fetal symptoms, also jeopardizing maternal health.

### ANESTHETIC MANAGEMENT

• If the tumor is large, positioning may be difficult, and creative padding may be required to allow the patient to lie supine without distortion from the tumor.

• Use standard American Society of Anesthesiologists monitors with two IVs and an arterial line, and consider central venous pressure monitoring if the tumor is large.

• Use IV or inhalational induction.

• Consider IV or inhalational maintenance with short-acting opioids such as remifentanil or fentanyl.

• Avoid hypothermia in such small patients by using a forced warm air device, and consider using a fluid warmer.

### POSTOPERATIVE CONSIDERATIONS

Extubation at the conclusion of the case is probably not a good idea, since these patients tend to be premature and have a high incidence of apnea and bradycardia in the postoperative period. In addition, the patient may need to be maintained in the prone position, so airway access may be more difficult in an emergency situation.

DOs and DON’Ts

• ✓ Do aggressively maintain fluid volume, as large amounts of fluid may be lost evaporatively.

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

• ⊗ Do not extubate at the end of the case, especially if the patient is premature.

### FACTOID

The majority of these neonatal tumors are benign, so the prognosis after surgery is excellent.

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