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Common Neonatal Emergencies. Dr. Mohammad Saquib Mallick,FRCS Dr. Mohammad Saquib Mallick,FRCS Consultant Pediatric Surgeon Consultant Pediatric Surgeon
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Principles of Neonatal Surgery l l Types of Newborns: – – Full-term: >38 weeks and weight > 2.5 kg – – preterm infant: <38 weeks with appropriate weight – – SGA: >38 weeks and weight< 2.5 kg – – VLBW: <32 weeks and <1.5 kg l l There are physiologic differences between all these infants
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Common Neonatal Emergencies l l The newborn suspected of having surgical emergency should be studied in a logical step by step manner. l l It is important to establish that the infant has a surgical problem before surgery is performed. l l Resuscitation must be done before operation l Every condition will be dealt accordingly
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Principles of Neonatal Surgery l l Metabolic considerations 1: Thermoregulation 2: Glucose homeostasis 3: Calcium and Magnesium homeostasis 4: Blood volume 5: Jaundice 6: Energy requirement l l Fluid & Electrolytes Concepts 1: water metabolism
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Principles of Neonatal Surgery 2: Maintenance needs 3: Monitoring fluid & electrolytes 4: perioperative management l l General considerations 1: GIT decompression 2: Antibiotic therapy 3: Vitamin K 1 mg I/M or I/V 4: Diagnostic study 5: Transport of neonates
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Common Neonatal Emergencies l Congenital Diaphragmatic Hernia Bochdalek Hernia Incidence: 1:2000 to 5000, female more affected, prematurity and low BW, Left side
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Diaphragmatic Hernia l l Symptoms: None to severe ( Onset may be immediate or may be delayed up to 48 hrs.) l l Tachypnea, grunting respiration, cynosis, chest retraction. l l Signs Scaphoid abdomen Audible bowel sound in the chest
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Diaphragmatic Hernia l l Diagnosis: – –Prenatal <25wks, prognosis bad – –Clinical – –CXR – –10% >after neonatal period
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Diaphragmatic Hernia
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l l Management – –Reussciataion and stabilization l Endotracheal Intubation l Orogastric or nasogastric decompression l Echocardiography
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Diaphragmatic Hernia l l Surgery: – –Laparotomy l l Primary l l Patch by silo or muscle – –Laparoscopic repair
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Eventration of Diaphragm l Def: Abnormal elevation of diaphragm that results in paradoxical motion of affected hemidiaphragm during inspiration and expiration l Cause: –Congenital –Acquired l Symptoms: –None –Resp. distress –Wheezing, repeated URI,
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Eventration of Diaphragm l Diagnosis: –CXR –Fluoroscopy or –Real time US
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Eventration of Diaphragm l Management: –Conservative –plication
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Respiratory Distress l l Pneumothorax: The collection of air in the pleural cavity in neonates. Causes: Hyaline membrane disease Meconium aspiration Pulmonary hemorrhage Traumatic Rupture of cong.lung cyst
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Respiratory Distress l l Diagnosis: Clinical Radiological
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Respiratory Distress
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l l Treatment: 1, Decompression by inserting chest tube 2, Treat the cause
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Oesophageal atresia & TOF l Incidence: 1: 5000 live births, 50% associated with anomalies l Types: VACTERL Syndrome
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Oesophageal atresia & TOF Symptoms and Signs: –Excessive salivation –Respiratory Distress –Inability to pass NG tube –Choking and coughing on feeding
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Oesophageal atresia & TOF l Diagnosis – Clinical & CXR l Management: Resuscitation –Common type l Right thoracotomy Division and repair of TOF l Primary anastomosis –Pure TOF l Division and repair –Isolated atresia l >3 vertebra Staged surgery (gastrostomy and followed in 3-6 months by delayed repair. If fails then need esophageal replacement (stomach or colon)
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Common Neonatal Emergencies l Neonatal Intestinal Obstraction
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High intestinal obstruction in neonate High intestinal obstruction in neonate Pyloric Atresia: l Duodenal obstruction: –Duodenal atresia or web or stenosis l Annular pancrease –Ladd band (malrotation) l Proximal jejunal obstruction: –Atresia, web, stenosis.
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Duodenal obstruction l Divided into: –Complete (atresia) –Partial (web, stenosis, ladd band, annular pancreas)) l Antenatal diagnosis: –Polyhydramnios – Dilated stomach and 1 st part Duodenum l Down syndrome 30% l Symptoms and Signs: –vomiting, bilious 80% – High gastric aspiration: >30ml High intestinal obstruction in neonate
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Duodenal obstruction l X-rays: –Double bobble shadow
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Duodenal obstruction l Management: –Exclude the Volvulus and resuscitation –NGT, Vitamin K, –stabilized before surgery –Duodeno-duodenostomy High intestinal obstruction in neonate
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Proximal jejunal obstruction l Normally present within 24 to 48 hrs after birth with Bilious vomiting and Bilious vomiting and Abdominal distention Abdominal distention
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Proximal jejunal obstruction AtresiaWebStenosis –Treatment: End to end anastomosis
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Clinical presentation Low intestinal obstruction in neonate
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Low intestinal obstruction in neonate- Differential Diagnosis l l Ileal/Colon atresia l l Meconium ileus l l Hirschsprung's Disease, l l Meconium plug syndrome, Left micro-colon syndrome, l Malrotation with volvulus l ((Anorectal malformation)) l Medical causes- –sepsis, ileus, electrolytes imbalance
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Common presentations l Bilious vomiting l Failure or delayed to pass meconium l Abdominal distension l Multiple fluid levels in plain AXR Low intestinal obstruction in neonate
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Ileal /Colon atresia
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Meconium ileus
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Hirschsprung's Disease Pathology cont.. l Due to congenital absence of ganglion cells in the distal bowel. Incidence: 1/4500-5000 live births Incidence: 1/4500-5000 live births Sex: 4:1 male predominance, Sex: 4:1 male predominance, Age: 96% Full term & 4% premature Age: 96% Full term & 4% premature l Site: Commonly: l Site: Commonly: rectum/rectosigmoid Less commonly: total colonic with or without small intestine Less commonly: total colonic with or without small intestine
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Hirschsprung's Disease Diagnosis l l Neonatal: Delayed or failure to pass meconium with low intestinal obstruction. ● ● late presentation: *Failure to thrive, *Poor feeding *Diarrhea with abdominal distension and occasionally with enterocolitis. l l Examination: Abdominal Distension PR: tight sphincter with gush of loose stool Malnutrited child, Enterocolitis
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Hirschsprung's Disease Management At birth Pull through operation At 6-9 months of age *Primary pull-through procedure without colostomy*
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Anorectal Malformation (imperforate anus) l Incidence 1:5000 live births l Common in boys than girls(55%-65%) l Low - below levator sling l High - above levator sling l Intermedate - not fit above l Rectovestibular fistula - commonest in girls l Rectourtheral fistula - commonest in boys
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No anal opening
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ARM
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Management at birth
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Posterior sagittal anorectoplasty (PSARP)
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QUESTIONS ? QUESTIONS ?
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Principles of Neonatal Surgery l l The newborn suspected of having intestinal obstruction should be studied in a logical step by step manner. l l It is important that it be definitely established that the infant has a surgical problem before surgery is performed. l l Resuscitation must be done before operation l Every condition will be dealt according
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Respiratory Distress in Neonates Respiratory Distress in Neonates Dr.Mohammad Saquib Mallick, FRCS Consultant Paediatric Surgeon, Consultant Paediatric Surgeon, King Fahd Medical City. Riyadh
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Respiratory Distress l l Causes – –Surgical l l Upper airway obstruction l l Congenital diaphragmatic hernia l l Eventration of Diaphragm l l Esophageal atresia with TOF l l Pneumothorax l l Congenital lobar emphysema l l Congenital cystic adenomatoid malformation l l Pulmonary Sequestration
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Respiratory Distress l l Congenital Lobar Emphysema: “ massive over distension of a lobe or a segment of the lung that causes compression of normal lungs and medistinum“
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Respiratory Distress Etiology; air trapping due to abnormalities in the bronchial cartilages. bronchial cartilage may be absent, hypoplastic, or dysplastic
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