Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++Table Graphic Jump Location|Download (.pdf)|PrintDifferences between Omphalocele and GastroschisisOmphaloceleGastroschisisEtiologyFailure of gut migration from yolk sac into abdomenOcclusion of omphalomesenteric artery with ischemia to the right periumbilical areaLocationWithin umbilical cordPeriumbilicalPrenatal diagnosis by U/SYesYesIncidence1:6,000, M >F1:15,000, M >FPeritoneal coveringYesNoLocationCentral through umbilicusLateral to umbilicusAssociated anomaliesHigh incidenceLow incidenceCardiacGI—intestinal atresiaGI—Meckel’s diverticulum, malrotationGU—bladder extrophyMetabolic—Beckwith–Wiedemann (congenital disorder associated with macrosomia, macroglossia, organomegaly, and hypoglycemia)Chromosomal abnormalities (trisomy 21), congenital diaphragmatic herniaSurvival rate70–95%>90% ++ Broad-spectrum antibiotics to prevent contamination of the peritoneal cavity preoperativelySimilar preoperative management of neonates: preventing infection and minimizing fluid and heat lossCovering the exposed viscera or membranous sac with sterile saline-soaked dressings and plastic wrap immediately after delivery decreases evaporative fluid and heat lossSurgical correction of an omphalocele or gastroschisis is urgent but can be delayed until full anesthesia workup and resuscitationRule out associated anomalies; may need echocardiogram, renal U/SCorrect fluid and electrolyte abnormalitiesBecause of significant ongoing fluid losses with an open abdominal wall defect, administer an IV fluid bolus (20 mL/kg lactated Ringer’s solution or normal saline), followed by 10% dextrose in 1/4 normal sodium chloride solution at two to three times the baby’s maintenance fluid rateDecompress stomach with OGT ++ Standard ASA monitors with temperature + urine outputIndividualized for patient needsA-line helpful for monitoring pH and guiding fluid therapy:Also useful if concomitant cardiac defects presentA pulse oximeter probe on the lower extremity will detect a decrease in oxygen saturation that could be caused by congestion of the lower extremities due to obstruction of venous returnMeasurement of intragastric pressure, CVP, or cardiac index can aid in determining whether primary closure is appropriate ++ GETA + RSI. May also do awake intubation. Avoid N2O because of possibility of gastric distentionMaximal muscle relaxation mandatory ++ Anesthetic management involves volume resuscitation (˜50–100 mL/kg of isotonic fluids during the case) and the prevention of hypothermiaMajor complications from increased intra-abdominal pressure when replacing viscera into abdomen:Ventilatory compromise:Watch for increased peak airway pressures and decreased tidal volumesDecreased organ perfusionBowel edemaAnuriaHypotensionIf inspiratory pressure is >25–30 cm H2O or intragastric pressure >20 cm H2O, primary closure is not recommended ++ Postoperative management depends on the type of repair and whether or not the child has associated anomaliesFluid resuscitation should continue postoperatively because fluid loss through the viscera continues, especially in a staged repair, where the viscera are left extraperitoneallyParenteral nutrition can be needed, especially if prolonged ileusMost children remains intubated for 24–48 hours to monitor airway pressures postoperatively ++1. Liu LM, Pang LM. Neonatal surgical emergencies. Anesthesiol Clin North America. 2001 Jun;19(2):276–277. [PubMed: 11469065] ++2. Diu ... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.