• Users Online: 579
  • Print this page
  • Email this page


 
 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 2  |  Issue : 1  |  Page : 41-43

Anaesthetic Management in Newborn of High Anorectal Malformation Undergoing Primary Posterior Sagittal Anorectopexy


1 Addl. Professor, Anesthesiology & Critical Care Medicine, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, Bihar, India
2 DNB trainee, Anaesthesiology& Critical Care Medicine, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, Bihar, India
3 Professor & Head, Pediatric Surgery, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, Bihar, India

Date of Web Publication12-Feb-2016

Correspondence Address:
Sanjeev Kumar
Additional Professor, Dept. of Anaesthesiology & Critical Care Medicine, Indira Gandhi Institute of Medical Sciences, Patna
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


Rights and PermissionsRights and Permissions
  Abstract 


Newborn babies undergoing emergency posterior sagittal anorectopexy (PSARP) present several challenges for the anaesthesiologists. Such neonates require constant monitoring and immediate intervention during anaesthesia and multiple congenital anomalies pose further predicaments. Anaesthetic management of a newborn depends upon the type of surgical emergency and their condition. We report here four cases of high anorectal malformation admitted about same time for primary PSARP and were successfully managed under general anaesthesia.

Keywords: Neonates, Anorectal malformations, Posterior Sagittal Anorectopexy, General Anaesthesia


How to cite this article:
Kumar S, Raj D, Quari H, Kumar V. Anaesthetic Management in Newborn of High Anorectal Malformation Undergoing Primary Posterior Sagittal Anorectopexy. J Indira Gandhi Inst Med Sci 2016;2:41-3

How to cite this URL:
Kumar S, Raj D, Quari H, Kumar V. Anaesthetic Management in Newborn of High Anorectal Malformation Undergoing Primary Posterior Sagittal Anorectopexy. J Indira Gandhi Inst Med Sci [serial online] 2016 [cited 2022 Oct 2];2:41-3. Available from: http://www.jigims.co.in/text.asp?2016/2/1/41/303372




  Introduction: Top


Anorectal malformations (ARM) are the birth defects occur during 5th-7th weeks of intrauterine foetal developmental period where the anus and rectum do not develop properly. Incidence wise on average one per 5000 live birth of newborn is of ARM[1],[2] and slightly more commonly seen in males. In addition, usually it occurs in association with several syndromes like oesophageal atresia with tracheoesophageal fistula, vertebral and renal anomalies3 (VACTERLanomalies). In our case all four male neonates were delivered normal at primary health centres and nursing homes and from there referred here for further management. These neonates require emergency surgical intervention for high anal anomaly. The consideration of to use anaesthetic drugs depends on the maturity of various vital organs, while the aim is to titrate dose of anaesthetic drugs which are delivered to neonate to achieve optimum anaesthetic depth for surgery. Post operative survival of newborn babies has improved in the last few decades due to advancement in neonatology.


  Case Report: Top


All these four neonates were between 3-5 days and weighing around 2.2 - 2.5 kg. All were full term with normal delivery cried immediately after birth and of APGAR score 9-10. These new born babies were ill looking, poorly nourished, dehydrated and two of them were lethargic. On clinical examination pallor, icterus, cyanosis were absent. Two of them had sacral agenesis. Heart rate was between 120-160/min, regular. Respiratory rate was 30-40/min. Pulse oximetry showed SpO2 between 90-100% without oxygen support. Head circumference 33-35cm, crown heel length 45-47cm, anterior and posterior fontanelle were normal. Vital parameters were normal and urine output was normal for all. On systemic examination abdomen was distended and bowel sounds were exaggerated. Two of these neonates had loud vesicular breathing rest two normal vesicular breathing with air entry equal on both side. Cardiovascular examination showed normal S1 and S2, no murmur. Laboratory investigations were within normal limit for three of them except one with a little raised WBC count and also a little elevated level of urea and creatinine. All four cases were diagnosed on basis of clinical examination and invertogram. The 2D echocardiography were also done in all and found normal. Anaesthetic management for all these neonates was same. They were shifted to emergency operation theatre. Intravenous access was secured with 24G i.v. cannula over dorsum of the left hand and the i.v. fluid Isolyte-P was started according to Holliday & Segar’s principle. A Ryle’s tube of no 8 was inserted and stomach aspirated periodically. In order to prevent hypothermia, neonates were wrapped with cotton and supplemented with 100% O2 by mask. The temperature and humidity of operative room was kept around 27?C - 28?C and 74%-76% respectively. Intraoperative body temperature was maintained at 38±1?C. Pulse oximetry, temperature probe and ECG were attached. They were premedicated with fentanyl 2μi kg-1 i.v. and were preoxygenated with 100% O2 for 3 minutes. They were then induced with i.v. thiopentone 6mg kg-1, atracurium 0.5mg kg-1 and isoflurane whose dose was increased by stepwise with each 5-8 breathe till eye lash reflexes were abolished. All were intubated with a miller blade no 1 and endotracheal tube no 3. Anaesthesia was maintained with isoflurane and atracurium, N2O 50% in O2 via Jackson and Ree’s circuit. PSARP was done in an average of 1 to 1.5 hours. Two of neonates were given caudal analgesia of 0.125% bupivacaine 0.5 ml kg-1 single shot just after induction before positioning. Two neonates with sacral agenesis were given paracetamol 20mg kg-1 i.v. All were reversed and extubated after they become vigorous and shifted to NICU for postoperative care and were monitored continuously. Expressed breast milk feeding was started after 4th postoperative day. The remaining hospital stay was uneventful and the neonates were discharged from the hospital on 10th postoperative day.




  Discussion: Top


Anorectal malformations are defects that occur during 5th-7th weeks of intrauterine life. With these defects the anus and the rectum do not develop properly. Approximately 50% of newborn babies with ARM have other coexisting abnormalities. The aim of this case report is to highlight successful anaesthetic management of the neonates with improvised methods to manage hypothermia, hypoxia / hypoxaemia and hypoglycaemia too[4]. The preoperative optimization of a neonate with congenital anomalies is the key for successful anaesthetic management, which depends on several issues and one of these is O2 supplementation which require in a neonate with respiratory discomfort as in our case which was due to abdominal distension. Some of newborn may have breathing difficulty usually need postoperatively ventilatory support to avoid hypoxia and also to prevent aspiration pneumonities[5]. One of the important issues in these neonates is to replenish dehydration by appropriate fluid. Majorities of newborn with imperforate anus are diagnosed shortly after birth and few of them have recurrent vomiting due to obstructive path created by ARM, which further poses a challenge for fluid and electrolyte management. We had one neonate with this problem. In general, an enormous amount of fluid can be sequestered within the intestinal tract, which is basically ECF and contain abundant sodium. Hence these neonates should be prepared promptly for normalization of sodium and other electrolytes for uneventful surgery under anaesthesia. A balanced salt solutions was used as i.v. fluid in all four neonates[5],[6]. To avoid hypoglycaemia, appropriate glucose administration is of top priority and in majority of neonates the maintaining fluid containing 10% glucose, 0.2% Normal Saline with 10 mmol/l of potassium is replaced in first 2 days of life. Maintenance fluid requirement increases during the first few days of life. The i.v. fluid is estimated to be 60ml, 80ml, 100ml & 120 ml per kg body weight per 24 hrs for 1st four days of life respectively and for rest of the neonatal period, a maintenance rate of 100 ml/kg/24 hrs is appropriate.

The newborn is at a risk for significant metabolic derangements caused by hypothermia. As we know primary mechanism in newborn for heat loss is non- shivering thermogenesis and there is hardly any enhancement in body movement or constriction of vessel in response to lower temperature as in older children therefore neonates should not be shivered. In addition the newborn has large body surface area to weight ratio and low levels of subcutaneous fat for insulation which promotes heat loss; hence all effort should be made to prevent heat loss in newborn. Open transfer must be avoided and such newborn should be transported in incubator. Other ways to prevent hypothermia are to increase the temperature of OT up to optimum level, which can be achieved by placing the newborn on a forced air warming blankets as well as using plastic wrap or commercially available covers and hats to minimize heat loss from the head and rest of the areas other than surgical field[7]. A complicating factor is the anaesthetic agents also which usually reduce or eliminate the process of thermogenesis and minimise the capability to recompense body for hypothermic response[8]. So every essential step to prevent hypothermia was instituted in our cases.


  Conclusion: Top


Effective evaluation, preparation and appropriate anaesthetic management of the neonate depend on good knowledge, clinical skills and vigilance by the anaesthesiologist. Airway management, drug choice, optimum use of i.v. fluid, proper care of body temperature, expected surgical needs, adequate pain management and post-operative care are essential for monitoring of the neonate. In our cases we successfully and efficiently managed all four neonates.



 
  References Top

1.
Taksande A, Vilhekar K, Chaturvedi P, Jain M. Congenital malformations at birth in central India: A rural medical college hospital based data. Indian J Hum Genet. 2010; 16 (3):159-163.  Back to cited text no. 1
    
2.
Levitt MA, Pena A. Anorectal malformations. Orphanet Journal of Rare Diseases. 2007; 2:33.  Back to cited text no. 2
    
3.
Chowdhary SK, Chalapathi G, Narasimhan KL,Samujh R, Mahajan JK Menon P, et al. An audit of neonatal colostomy for high anorectal malformation: the developing world perspective. Pediatr Surg Int 2004 Feb; 20(2):111-3.  Back to cited text no. 3
    
4.
Sunil Kumar, V.M. Jha, K Damani, R Saraf, S Bokil, S Bhopale, et al. Anaesthetic management of a one day old neonate with multiple congenital anomalies posted for emergency colostomy. Pediatric anaesthesia and critical journal 2013; 1(2):46-49.  Back to cited text no. 4
    
5.
Dallavecchia LK, Grosfeld JL, West KW, Rescorla FJ, Scherer LR, Engum SA. Intestinal atresia and stenosis: A 25 years experience with 277 cases. Arch Surg 1998; 133(5):490-6.  Back to cited text no. 5
    
6.
Arya VK. Basics of fluid and blood transfusion therapy in paediatric surgical patients. Indian J Anaesth 2012; 56:454-62.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Kongsavreepong S, Gunnaleka P, Suraseranivongse S, et al. A reusable, custom made warming blankets prevents core hyperthermia during major neonatal surgery. Can J Anaesth 2002; 49:605.  Back to cited text no. 7
    
8.
Platter O, Semsroth M, Sessler DI et al. lack of non shivering thermogenesis in infants anaesthetized with fentanyl and propofol. Anaesthesiology 1997; 86:772.  Back to cited text no. 8
    




 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction:
Case Report:
Discussion:
Conclusion:
References

 Article Access Statistics
    Viewed820    
    Printed26    
    Emailed0    
    PDF Downloaded61    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]