Newborn pediatric surgery. Pediatric surgical diseases
Significant advances in neonatal surgery have become possible since the advent of specialized wards, departments, and then centers for the provision of surgical care for newborns, staffed by specially trained pediatric surgeons, pediatricians, anesthesiologists and nursing staff.
The outcome of treatment largely depends on timely diagnosis, identification and correct assessment of the first symptoms of the disease in the maternity hospital. Due to late diagnosis (within 1-2 days after the appearance of the first symptoms of the disease), the newborn develops severe complications: aspiration pneumonia with atelectasis, intestinal necrosis and peritonitis, irreversible changes in homeostasis, etc.
Surgery for newborns is 80% emergency surgery. The causes of emergency conditions may be malformations of various organs and systems and acute purulent surgical infection. All emergency conditions and the diseases that cause them can be divided into three large groups, identified on the basis of the leading clinical syndrome.
| Diseases accompanied by the development of intrathoracic tension | Diseases not accompanied by the development of intrathoracic tension |
| A. Respiratory distress syndrome |
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| Intrapulmonary: 1) congenital lobar emphysema 2) lung cysts 3) Extrapulmonary: 1) spontaneous pneumothorax 2) diaphragmatic hernia 3) pyopneumothorax with bacterial destruction of the lungs | Pierre Robin syndrome Atelectasis of the lungs Esophageal atresia Tracheoesophageal fistula |
| B. Vomiting syndrome |
|
| I. Congenital intestinal obstruction: 1) atresia 2) stenoses 3) inversion II. Acute inflammatory diseases of the abdominal cavity: 1)necrotizing enterocolitis 2) peritonitis of various etiologies III. Malformations and diseases of the esophagus and stomach: 1) chalasia of the esophagus 2) congenital short esophagus 3) hiatal hernia 4) pyloric stenosis | |
| B. Purulent surgical infection |
|
| 1. phlegmon of newborns 2. acute metaepiphyseal osteomyelitis 3. surgical sepsis 4. purulent diseases of soft tissues | |
In the children's department of a maternity hospital, to recognize surgical pathology, it is important to correctly assess changes in the child's behavior and condition over time (anxiety, breast refusal, vomiting, regurgitation, weight loss, breathing problems) and the use of all possible research methods under these conditions.
In addition to a thorough examination of the child, identifying symptoms of intoxication, dehydration, hypoxia, auscultation and percussion, palpation of the abdomen, gastric probing, rectal examination, direct laryngoscopy, and probing of the nasal passages should be used. Difficulty in passing the probe through the esophagus should suggest that the child has esophageal atresia. The discovery of a large amount of contents in the stomach with pathological impurities (bile, greens) indicates intestinal obstruction. Probing of the stomach, in addition to diagnostic, also has a therapeutic value - pathological contents that cause intoxication and gas are removed from the stomach, which increases the excursion of the diaphragm and improves breathing. Probing allows you to measure the amount of pathological losses and adequately replenish them.
The assessment of pathological symptoms in newborns should be approached especially carefully. Thus, when characterizing a symptom such as vomiting, it is necessary to take into account the following shades: time of appearance (hours, days of the child’s life), connection with feeding, nature of manifestation (regurgitation, regurgitation, vomiting “fountain”), nature of the vomit (unmodified milk, curdled , with an admixture of bile, greens, “coffee grounds”, “fecal” vomiting), assessment of the dynamics of the symptom (increases over time or decreases). In some cases, based on an assessment of the qualitative characteristics of this symptom, it is possible to determine the level and nature of intestinal obstruction and the degree of urgency of surgical treatment.
Changes in stool should also be carefully assessed: the norm is the appearance of fairly copious meconium stools during the first 24 hours after birth. Lengthening the timing of appearance, changes in the quantity, color, consistency and qualitative composition of feces is a pathology.
Purulent surgical infection in newborns also has its own distinctive features. Features of immunological reactions (rapid depletion of humoral immunity, incompleteness of phagocytosis), anatomical and physiological features of the structure of skin, fiber, bones and other organs and systems contribute to the rapid generalization of the process. Therefore, seemingly mild purulent diseases such as mastitis, lymphadenitis, and abscesses should be treated in a hospital setting. This is especially important for children born prematurely or from unfavorable pregnancies and births.
When a diagnosis of a surgical disease is established, preoperative preparation begins in the maternity hospital, which includes gastric probing, proper transportation of the patient, selection of the volume and nature of additional research methods aimed at clarifying the surgical diagnosis and the degree of homeostasis disturbance. The main component of this preparation is the provision of symptomatic therapy to correct these disorders and prevent infection.
Newborns must be transported in specialized transport equipped with a portable incubator. During transportation, therapeutic measures are carried out: mucus is sucked out of the mouth and nose, and oxygen is given. It is necessary to observe the temperature regime (temperature in the incubator 28-30°C).
When organizing specialized departments and wards, one should adhere to a strict epidemiological regime, including the separation of clean and purulent patients, the allocation of a special operating room, thorough hand washing, changing of gowns, disinfection of the room, equipment in contact with patients, etc.
X-ray examination of a newborn always begins with a plain radiography. Attention is drawn to the degree and uniformity of gas filling of the stomach and intestines, the symmetry of the location of the chest organs, the contours of the diaphragm, and the presence of pathological formations in the chest and abdominal cavities.
Only in cases where a survey study does not help the diagnosis, contrast contrast of the gastrointestinal tract is resorted to. A suspension of barium sulfate or iodolipol is often used as a contrast agent. Before the study, gastric contents are aspirated, then barium sulfate is given (1 teaspoon of an aqueous suspension of creamy consistency in 30-50 ml of breast milk). For children in serious condition, a contrast agent is administered through a probe. Radiographs and fluoroscopy are performed depending on the expected pathology after 20 minutes, 2 hours and then up to 24 hours. If necessary, the study begins with an examination of the esophagus. An exception to the use of a contrast agent is esophageal atresia (due to the possibility of it entering the tracheobronchial tree).
During surgery, you should be especially careful when handling tissues, using special instruments and atraumatic needles.
The key to the success of the operation is careful preoperative preparation and intensive care in the postoperative period.
Isakov Yu. F. Pediatric surgery, 1983.
In its development, minimally invasive surgery in children has gone from adaptation to pediatric practice of operations common in adults, such as, to the use of laparoscopy and for procedures that are found only in pediatric surgery, such as reconstruction of esophageal atresia and tracheoesophageal fistula. This article focuses on pediatric options for surgeries typically performed on adults, as well as some neonatal surgeries performed by general pediatric surgeons.
Children have specific anatomical and physiological characteristics, which is important to keep in mind when performing laparoscopic operations. In newborns and small children, the abdominal wall is elastic and the apex of the bladder is located intraperitoneally, making the insertion of trocars potentially dangerous. Most newborns and many children have umbilical hernias, which can provide convenient access to the abdominal cavity, and after surgery the hernia can be repaired. The liver of a newborn is usually proportionately large, and even minor trauma can lead to profuse bleeding that is difficult to stop. All laparoscopic ports in newborns must be placed well below the level of the costal arch, and special care must be taken when retracting the liver.
Short endoscopic ports with a diameter of 3.4 and 5 mm are available for use, both disposable and reusable. In children, there is often a need to install ports far from each other and at points that do not coincide with the installation points of trocars during operations on adults, in order to avoid a “duel” of instruments in the child’s small surgical field. Many pediatric surgeries are performed through incisions in the abdomen rather than through ports, except for camera ports or large instruments. A wide range of operations on the gastrointestinal tract, biliary tract, adrenal glands, spleen and genitourinary system can be safely performed without the use of ports, which significantly saves money. Laparoscopic cameras and energy sources for electrosurgery range from 3 to 5 mm in diameter, but ultrasonic coagulators are usually at least 5 mm in diameter, and an endoscopic stapler requires the installation of a 10 mm port. The size of these instruments sometimes limits the minimal invasiveness that could be achieved in neonates.
In children, the mechanical and physiological effects of pneumoperitoneum, insufflation of the pleural cavity and ventilation of one lung are usually enhanced. In a state of pneumoperitoneum, children absorb proportionately more carbon dioxide than adults, and the absorption and excretion of carbon dioxide depend on age. During insufflation for laparoscopic surgery in newborns, there is a decrease in systemic blood pressure, which can usually be corrected by increasing fluid infusion, but the increase in maximum end-tidal CO 2 concentration often cannot be returned to normal by increasing ventilation, so it is maintained until the end of the operation. Neonates with immature or compromised cardiovascular systems are particularly at risk for side effects during prolonged periods of insufflation and close monitoring during the perioperative period is warranted. Pneumoperitoneum causes reversible anuria in almost all neonates and oliguria in many children, and these changes in urinary output are independent of the volume of intraoperative infusion. Thus, in children during the maintenance of pneumoperitoneum, infusion therapy should not be strictly focused on the volume of urine excreted. Fortunately, the elastic abdominal wall allows many abdominal surgeries to be performed with insufflation pressures of 5–10 mmHg, and many thoracic surgeries require no insufflation at all. In all cases, insufflation pressure should be limited, with a maximum pressure of 12 mmHg. in infants weighing less than 5 kg.
Many modern open surgeries have acceptable cosmetic and excellent functional results. The benefits of laparoscopic and thoracoscopic operations in neonates and children must be assessed against modern criteria and the disadvantages of laparoscopic operations, which may take longer, be more expensive and lead to undesirable physiological effects, must be taken into account. As technology becomes more sophisticated and surgeons become more experienced in performing laparoscopic procedures, many laparoscopic and thoracoscopic procedures are likely to become routine in pediatric surgery.
The article was prepared and edited by: surgeonPEDIATRIC SURGERY- a branch of surgery that studies congenital and postnatal defects in children, acquired diseases and injuries, the treatment of which requires surgical intervention or other correction methods in surgical institutions.
The tasks of pediatric surgery are the study of the pathogenesis of diseases, the development of principles and methods for their diagnosis and surgical treatment, based on the physiological and anatomical and topographical characteristics of the growing child’s body at various periods of his life, pediatric propaedeutics, and general surgical principles. D. surgery, like adult surgery, includes a number of sections (abdominal, thoracic, cardiovascular surgery, traumatology, orthopedics, urology, neurosurgery, etc.); Its independent chapter is neonatal surgery. D. x. is closely related to genetics, embryology, normal and patol, physiology, pharmacology, biochemistry, pediatrics, general surgery, anesthesiology, obstetrics, radiology, etc.
Research methods in D. x. (x-ray, instrumental, biochemical, electrophysiological, pathomorphology, etc.) have distinctive features due to the age, condition of the patient and the nature of the pathology. Unlike adults, diagnosing surgical diseases in children, especially during the neonatal period, infancy and the first years of life, presents serious difficulties due to the limited opportunities for the patient’s active participation in the study of anamnesis and objective examination, as well as the small size of anatomical structures. The predominance of general symptoms of the disease over local ones increases the need to use objective research methods that contain the most informative indicators and are accompanied by minimal trauma. The principles of surgical treatment of children are constantly being improved (carrying out the vast majority of operations and painful manipulations under anesthesia, adequate compensation of blood loss, prevention of dehydration and over-hydration, gentle handling of tissues during surgical interventions, etc.). It is also necessary to take into account a number of factors - the possibility of damage to growing and developing structures, high reparative abilities of tissues and rapid depletion of compensatory mechanisms, reduced resistance to infection, growth and differentiation of organs and systems.
In the 19th century Surgical care for children was provided in hospitals for adults or in children's therapeutic departments. The first Russian manuals on surgery (I. F. Bush, 1807), operative surgery (X. X. Salomon, 1840), and pediatrics (S. F. Khotovitsky, 1847) contain chapters devoted to the description of a number of surgical diseases in children and methods of their treatment. Despite the active participation of general surgeons in providing surgical care to children, leading domestic pediatricians - N. A. Tolsky, N. F. Filatov, K. A. Rauchfus - spoke out for the need to open surgical departments in children's hospitals.
In Paris, the first pediatric surgical department was organized in the mid-19th century. in a pediatric hospital. In England in the 60s. 19th century Johnson's "Lectures on Pediatric Surgery" (A. W. Johnson), approved by the London Medical Center, are published. society, the monograph “Surgical Treatment of Diseases of Infants and Children,” written by T. Holmes, which were one of the first textbooks on D. x. in Europe. In 1909, the first “Textbook on Pediatric Surgical Diseases” in the USA, written by S. W. Kelley, was published.
In our country, the first department of pediatric surgery was opened in St. Petersburg in 1869 in a children's hospital on the initiative of the famous pediatrician K. A. Rauchfus. In Moscow, in 1876, a pediatric surgery department was opened at the Vladimir Hospital (now the I.V. Rusakov Hospital); in 1897 - in the Sofia hospital (now the N. F. Filatov hospital) and in 1903 - in the Morozov hospital (now the Children's clinic, hospital No. 1). In total, before the Great October Socialist Revolution in Russia, there were 15 pediatric surgical departments in 10 cities. In 1910-1919 The first domestic manual on pediatric surgery by D. E. Gorokhov “Pediatric Surgery, Selected Chapters” is published in 4 volumes.
After the Great October Socialist Revolution, a new stage in the development of chemical engineering began. Specialized traumatology, orthopedic, and burn departments for children are opening. In 1922, in Petrograd, at the Soviet Clinical Institute, for the improvement of doctors, the Department of D. Chemistry was organized, which until 1927 was headed by F. K. Weber, and later by N. V. Schwartz. A clinic of pediatric orthopedics and surgery opens at the Scientific and Practical Institute for the Protection of Maternity and Infancy, headed by R. R. Vreden from 1925 to 1934, who made a great contribution to the development and study of many issues in surgery of the musculoskeletal system in children .
In Moscow in the 20s. center of D. x. There was a department of pediatric surgery in the 1st Children's Clinic, a hospital headed by T. P. Krasnobaev. His closest assistants were S. D. Ternovsky and A. N. Ryabinkin. In this department, issues of organizing a pediatric surgical service, treating pyloric stenosis, appendicitis, hematogenous osteomyelitis, and pleural empyema were developed. The problem of treating osteoarticular tuberculosis in children occupies a large place in the works of T. P. Krasnobaev. For his monograph on osteoarticular tuberculosis (1950), T. P. Krasnobaev was awarded the State Prize.
In 1931, at the 2nd MMI, the department of D. x. was organized, which was headed by K. D. Esipov from 1931 to 1934, then by V. P. Voznesensky until 1941. From 1943 to 1960, this department was headed by S. D. Ternovsky, who created a school of domestic pediatric surgeons. S. D. Ternovsky and his students developed the most pressing problems of childhood surgery: issues of emergency and purulent surgery, orthopedics, thoracic surgery, esophageal surgery, anesthesiology. For the first time in the country, a newborn surgery center is being organized in this clinic. Students of S. D. Ternovsky - M. V. Volkov, S. Ya. Doletsky, L. A. Vorokhobov, V. M. Derzhavin, E. A. Stepanov, A. G. Pugachev, N. I. Kondrashin and others continued to develop the problems of this school. Since 1966, the department has been headed by Yu. F. Isakov.
In Leningrad, the department of D. x. pediatric institute, which was organized by R. R. Vreden, since 1959 headed by G. A. Bairov. The staff of this department deals with the issues of surgery of the esophagus, malformations of newborns, urology, intestinal obstruction, and anesthesiology in children.
A major role in the training of specialists in D. x. belongs to the departments of D. x. institute for advanced training of doctors. In Moscow, such a department was organized at the CIU in 1956 (V. A. Kruzhkov). Since 1959, this department has been headed by S. Ya. Doletsky. The department successfully works on the problems of neonatal surgery, thoracic surgery, urology, traumatology, and hepatology.
Current state of D. x. characterized by continued specialization and development of various sections (neonatal surgery, pulmonary surgery, surgery of the heart and large vessels, urology, proctology, etc.). Research into pathophysiol has received great development. problems - protecting the child from surgical trauma, correcting homeostasis in the pre- and postoperative period, developing a set of pathogenetic, diagnostic and therapeutic problems associated with surgical infection. Solving these problems requires complex research” with the participation of biochemists, physiologists, anesthesiologists, immunologists, etc.
In the post-war years, D. x. received further development in connection with qualitatively new conditions that immeasurably expanded its capabilities (modern intratracheal anesthesia with artificial ventilation, widespread introduction into the clinic, the practice of antibiotics, which contributed to the progress of pediatric thoracic surgery). In lung surgery, extensive experience has been accumulated in anatomical resections, and a gentle, economical principle has been developed.
Indications and techniques for surgical interventions have been developed for developmental defects (congenital cysts, congenital localized emphysema, sequestration, etc.), acute purulent processes (staphylococcal destruction, bronchiectasis). A great contribution to the development of this problem was made by P. A. Kupriyanov, A. P. Kolesov, S. D. Ternovsky, V. I. Geraskin, S. Ya. Doletsky, S. L. Libov, A. G. Pugachev, E A. Stepanov, M. N. Stepanova, etc. Fundamentally new treatment methods are being developed, for example, isolated removal of the affected bronchi (leaving parenchyma and vessels) for bronchiectasis, artificial sealing of the bronchial system by temporary occlusion of the affected bronchi for pyopneumothorax and pneumothorax. The undoubted achievements of the post-war period include surgery for congenital heart defects in children; its beginning in our country was laid by A. N. Bakulev, E. N. Meshalkin, V. I. Burakovsky. Surgical correction of congenital heart defects and large vessels in early infants is successfully carried out (V. I. Frantsev, Ya. V. Volkolakov, etc.). Progress has also been made in esophageal surgery.
Methods of surgical correction have been developed and successfully applied for congenital malformations - esophageal atresia, achalasia, congenital stenosis, malformations accompanied by gastroesophageal reflux (G. A. Bairov, Yu. F. Isakov, E. A. Stepanov, etc.) . The issues of creating an artificial esophagus are being widely studied, with the most widely used retrosternal plastic surgery of the esophagus from the colon; issues of diagnosis and surgical treatment of tumors and mediastinal cysts have been developed.
In the field of abdominal surgery, a number of studies have been carried out on the treatment of peritonitis, correction of malformations of gastrointestinal tract. tract in the * neonatal period (with congenital intestinal obstruction), malformations of the biliary tract, etc.
New methods of surgical interventions for congenital and acquired liver diseases in children - hron, hepatitis, portal hypertension, liver injuries have been developed and introduced into practice (V. G. Akopyan).
In pediatric urology, reconstructive and plastic surgeries on the ureters, bladder, and urethra have become common practice. The method of hemodialysis is being introduced for acute and chronic cases. renal failure.
The problems of surgical correction for defects of sexual development attract much attention.
Large sections of D. x. are pediatric traumatology and orthopedics. Domestic surgeons have studied and developed in detail the principles of repositioning fractures in children and indications for their surgical treatment. The diagnosis and treatment tactics for children with severe traumatic brain injury have been improved. New methods have been developed for the conservative and surgical treatment of congenital dislocation of the hip, pectus excavatum, torticollis, clubfoot, malformations of the hand, diagnosis and treatment of bone tumors in children (S. D. Ternovsky, N. G. Damier, M. V. Volkov, A. P. Biezin, N. I. Kondrashin, M. V. Gromov, etc.).
One of the main ones in D. x. is the problem of purulent surgical infection. Scientific research and organizational and practical activities are developed in three main areas: the impact on the macroorganism, on the infectious agent and the purulent focus.
Improving the organization of surgical care for children, diagnostic methods, the use of infusion therapy methods and correction of homeostasis, the use of modern antibiotics, and the improvement of surgical techniques contributed to a significant improvement in the results of treatment of children with acute appendicitis and peritonitis, especially at a young age, with acute hematogenous osteomyelitis, acute purulent lung diseases and pleura. Gnoto-biol provides new opportunities for protecting and treating patients from infection. methods (local gnotobiol isolation, abacterial surgery, general isolation), first used in the USSR in the pediatric surgery clinic of the 2nd MMI.
Great contribution to the development of D. x. contributed by foreign scientists: in the USA - Gross (R. Gross), Potts (W. Potts), Swenson (O. Swenson); in Switzerland - Coffin (M. Grob); in Germany - Oberniedermayer (A. Oberniedermayer); in the GDR - Meissner (F. Meissner); in England - Brown (J. J. Brown), Nixon (N. Nixon), O’Donnell (W. O’Donnell), White (M. White), Dennison (W. Dennison); in France - Fevre (M. Fevre), Duhamel (V. Duhamel); in Czechoslovakia - Tashovsky (V. Tasovsky); in NRB - D. Arnaudov; in Poland - Kossakowski (I. Kossakowski) and others.
Level of development of modern D. x. is of great importance for the practice of medicine and healthcare. Study and implementation in medicine. the practice of methods for early correction of developmental defects, performing surgical interventions in children of any age, determining the optimal timing and conditions for operations are tasks of paramount importance.
The experience gained by D. x. is used to solve a number of other medical problems. problems, in particular in the treatment of emergency conditions not related to surgical pathology.
The successes of modern D. x. are largely due to the development of methods of pain relief during surgery and in the postoperative period, principles and methods of intensive therapy, issues of correction and maintenance of basic vital functions. The prospects for its development are related to the study of the possibilities of using modern advances (the use of laser and ultrasound energy, low temperatures, hyperbaric oxygenation, extracorporeal blood purification using sorbents), development of issues of fetal surgery, organ transplantation and further development of the principles of abacterial surgery.
In our country, research institutions have been created in which topical problems of pediatric surgery are purposefully developed: research institutes of pediatrics and pediatric surgery M3 of the RSFSR, departments of pediatric surgery at the Research Institute of Pediatrics of the USSR Academy of Medical Sciences, Moscow Regional Research Clinical Institute those to them M. F. Vladimirsky and in the pediatric research institutes of a number of union republics (Georgian SSR, Kirghiz SSR, etc.).
Specialized departments of pediatric cardiac surgery and pulmonology are available in a number of research institutes of the USSR Academy of Medical Sciences and the USSR Ministry of Health.
In 1973, the All-Union Center for Pediatric Surgery, Anesthesiology and Reanimatology was created on the basis of the Department of Pediatric Surgery of the 2nd MMI.
D. x. represented in various international and national organizations. The British, Pacific, and American Associations of Pediatric Surgeons, which include scientists and specialists from many countries, have been created and are functioning. In the USSR, since 1965, a section of pediatric surgeons of the All-Union Society of Surgeons has been organized. In 1952, a section of pediatric surgeons was formed at the Moscow, and in 1958, at the Leningrad Scientific Society of Surgeons. In a number of socialist countries (GDR, People's Republic of Belarus, Czechoslovakia), sections and associations of pediatric surgeons have been created.
Special journals on D. x. published in France, Italy, Germany, jointly in England and the USA. In our country, scientific work on D. x. published in the journals “Surgery”, “Bulletin of Surgery”, “Clinical Surgery”, “Pediatrics”, “Issues of Maternal and Child Health”, “Anesthesiology and Reanimatology” and other periodicals.
Questions D. x. are widely discussed at numerous international and regional forums. In the USSR in 1965, 1969, 1974, 1976. All-Union conferences of pediatric surgeons were held. All-Union symposiums on topical issues of chemical medicine are held annually.
Teaching D. x. in the USSR it is conducted in honey. Institute for pediatric and treatment. f-tah. Specialization is carried out in a system of subordination and internship. Improvement of doctors is carried out at the departments and courses of pediatric surgery in the institutes for advanced training of doctors.
In total, there are 73 departments and courses in pediatric surgery in the country. in-tah, in-tah of improvement of doctors and un-tah.
Bibliography: Bairov G. A. Emergency surgery of newborns, L., 1963, bibliogr.; about n, Emergency surgery for children, L., 1973; BiezinA. P. Children's surgery, M., 1964, bibliogr.; Voznesensky V. P. Emergency surgery of children, M., 1944; Pediatric thoracic surgery, ed. V. I. Struchkova and A. G. Pugacheva, M., 1975, bibliogr.; Dimitrov, etc. Pediatric surgery, trans. from Bulgarian, Sofia, 1960; Doletsky S. Ya. and Isakov Yu. F. Pediatric surgery, parts 1-2, M., 1970; Doletsky S. Ya. and Nikiforova N. P. Development of pediatric surgery over 50 years, Surgery, No. 10, p. 88, 1967; Doletsky S. Ya., Gavryushov V. V. and AkopyanV. G. Surgery of newborns, M., 1976, bibliogr.; Multi-volume guide to pediatrics, ed. Yu. F. Dombrovskaya, vol. 9, M., 1964; Ternovsky S. D. Surgery of childhood, M., 1959; Shvarts N.V. Surgery of childhood, M.-L., 1937; Arnaudov D., Lukanov A. and Velichkova D. Ostar surgically rooted in childhood, Sofia, 1961, bibliogr.; G r about b M. Lehrbuch der Kinderchirurgie, Stuttgart, 1957; Gross R. E. The surgery of infancy and childhood, Philadelphia-L., 1958; Lehrbuch der Chirurgie und orthopadie des Kindesalters, hrsg. v. A. Oberniedermayr, Bd 1-3, B., 1959; Meissner F. Kinderchirurgie Erkran-kungen, Bd 1, Lpz., 1965; N i x o n H. H. a. O’ D o n n e 1 1 B. The essentials of pediatric surgery, L., 1966; Pediatric surgery, ed. by W. T. Mustard, v. 1-2, Chicago, 1969; Pediatric surgery, ed. by O. Swenson, N.Y., 1969; Rickham P. P. a. Johnston G. H. Neonatal surgery, L., 1970; Vereanu D. Chirurgie infantila $i ortopedie urgente, Bucu-re§ti, 1973.
Pediatric surgery is surgery of newborns (Bairov G. A.) ANESTHESIA IN NEONATOLOGY Shmakov Alexey Nikolaevich 2011
TRAUMA cell death and destruction COLD BLOOD LOSS ATP deficiency PAIN TNF, cytokines, eicosanoids SHOCK histamine, bradykinin hyperalgesia gluconeogenesis SEX (P, U) inflammation hypovolemia catecholamines MODS
INTRAOPERATIVE PREVENTION OF SURGICAL AGGRESSION Surgical measures Anesthetic measures Surgical trauma Preventive ataraxia and analgesia. Adequate intraoperative anesthesia and analgesia. Limiting the activity of the sympathetic nervous system. Optimal choice of the volume of intervention and surgical approach. Improving surgical techniques. Atraumatic instruments and suture material. Replacement of access from the incision with endoscopic surgery. Technical conditions of the operating room: no windows; temperature > +26°C; wall heating; table heating; infrared radiation directed into the wound. Improving surgical technique (reducing operation time). Timely clipping or blocking of bleeding sources. Careful surgical hemostasis. Cold Thermal insulation of all skin except the operating area (film with a reflective layer); heating of breathing gases; thermo-moisture-saving filter in front of the endotracheal tube; normal ventilation; warming infusion and transfusion solutions to 37 -38°C. Hypovolemia Preoperative infusion preparation. Adequate intraoperative replacement of water and electrolyte losses.
TEMPERATURE REGIME IN THE OPERATING ROOM temperature monitoring (central temperature - in the rectum or in the lower third of the esophagus) increased temperature in the operating room > 260 warming mattress cap and socks thermal insulating film surgical waterproof underwear heating the respiratory mixture heating solutions for washing cavities heating infusion media transporting the child in an incubator A 15-center US randomized trial of the effects of therapeutic hypothermia on neonates following severe asphyxia. N=208. Group 1 - 102. Hypothermia 72 hours (central t=33.5°C). 77 survived, 25 died (24%). Group 2 - 106. 67 survived, 39 died (37%). Of the survivors, disability: in group 1 - 35 (44%), in group 2 - 44 (62%). . NB! The difference in mortality is statistically insignificant: χ²=3, 127; P=0.077. The difference in disability is significant: χ²=5.125; P = 0.024. On average, there were 13.8 participants per center (6 in group 1).
COMPONENTS OF THE GENERAL RESPONSE TO PAIN: PERCEPTUAL (sensory-discriminative): position, magnitude, spatio-temporal characteristics of the pain stimulus. MOTIVATIONAL: emotional - affective (withdrawal or aggression); vegetative; motor. COGNITIVE (evaluative): attention; anxiety; experience; memory.
SYSTEMS OF CNS RELAY ACTION (second order neuron) + - + interneuron + nociceptor INPUT THEORY OF PAIN - small unmyelinated large myelinated + nociceptor (according to Yamada T., Alpers D. H. e. a., 1995)
stimulus AMPA (alpha-amino-3 hydroxy-5 methyl-4 isoxazole-propionic acid) Increased sensitivity of nociceptors to damaging stimuli Signal pain Primary sensitization of relay neurons Secondary sensitization of relay neurons NMDA (N-methyl-D-aspartate) Maladaptive pain stimulus
Histamine Cytokines Prostanoids Leukotrienes Purines CATECHOLAMINES GLUTAMATE ASPARATE BRADYKININ Membrane phospholipase “C” Elimination of the voltage-dependent “Mg 2+” block + NMDA Cytoplasmic Ca 2+ HYPERALGESIA The stress of childbirth and the need for bradykinin to straighten the alveoli of the lungs reduce the pain threshold and increase there is a risk of hyperalgesia in newborns, especially premature babies, at least up to 3 days of extrauterine life.
Features of the functioning of the pain perception system in newborns low pain threshold long-term reaction to pain overlap of receptor fields wider receptor fields immature system of descending pain control
NARCOSIS STATE Sedatives-hypnotics: barbiturates benzodiazepines propofol etomidate steroids Sedation, amnesia Analgesia, loss of pain sensitivity Activation of GABA receptors, Cl channels, inhibition of neurons Inhibition of glutamate receptors Ketamine Analgesics: opioids α 2 -agonists Presynaptic inhibition of Ca channels, activation of K -channels UNITARY MECHANISM Inhalation anesthetics Damage to intracellular Ca 2+ regulation
CRITERIA FOR CHILDREN'S READINESS FOR OPERATION Clinical and functional Hematological White spot ≤ 3 with K+ (plasma) 3.5 -7.0 (3 -5.5) mmol/l Diuresis ≥ 0.5 ml/kg h Na+ (plasma. ) 140 -157 mmol/l SBP by age (for newborns ≥ 40 mm Hg) Ca 2+ 0.8 -1.5 mmol/l Dopamine ≤ 10 mcg/kg min Glycemia (0 h) not less 2.2 mmol/l Adequate infusion Glycemia (72 hours) not less than 2.8 mmol/l (4 -8 mmol/l) Ultrasound: absence of hemodynamically significant shunts Hemoglobin: not less than 130 (90) and not more than 220 (150) g/l
ASSESSMENT OF OPERATIVE AND ANESTHETIC RISK (Balagin V. M. et al., 1987) I. Main factors condition score age score trauma score Satisfactory. 1 4 -15 l 1 Minor 1 Moderate 2 1 -3 g 2 Moderate 2 Severe 3 3 -11 months 3 High 3 Extremely severe 4
ASSESSMENT OF OPERATIVE AND ANESTHETIC RISK (Balagin V.M. et al., 1987) II. Additional factors increasing the risk by 1 point (for each factor) Emergency indications for surgery Presence of concomitant diseases Special conditions (poorly adapted premises, etc.) Surgery that complicates anesthesia (difficult access to the head, rare operating positions, change of positions) III. GRADING OF OPERATIONAL ANESTHETIC RISK Insignificant Moderate Average Significant Extreme 3 points 4 -5 points 6 -7 points 8 -10 points > 10 points
TIMELINES OF PREOPERATIVE PREPARATION (according to Mikhelson V.A., Zhirkova Yu.V.) of the disease duration of gastroschisis 1 -5 hours omphalocele 6 -48 hours high intestinal obstruction 22 -72 hours low intestinal obstruction 4 -30 hours diaphragmatic hernia 20 -120 hours atresia esophagus 10 -30 hours peritonitis 2 -4 hours or more cleft lip and palate elective surgery uretero/hydronephrosis, multicystic kidney 5 -14 days bladder exstrophy 24 -48 hours pyloric stenosis 24 -96 hours
PRINCIPLES OF PREOPERATIVE PREPARATION PURPOSE: PREVENTION OF SURGICAL AGGRESSION. PREVENTION OF REPERFUSION PATHOLOGY Infusion Rehydration, maintenance of volume, VER Transfusion Restoration of erythron; subsidy of antithrombin III Pharmacotherapy Maintenance of cardiac output, sedation Respiratory therapy Stabilization of ventilation and oxygenation PSYCHOTHERAPY Ataraxia; suggestion; distracting procedures
PREOPERATIVE FASTING PROLONGED FASTING DOES NOT GUARANTEE EMPTYING OF THE STOMACH, DOES NOT REDUCE THE RISK OF ASPIRATION, IS BADLY TOLERATED BY THE CHILD Taking clear liquids imitates eating food: intragastric pH increases. N; Residual gastric volume decreases Feeding is stopped before surgery Clear liquids 2 hours before Breast milk 4 hours before Formula milk 6 hours before
COMPONENTS OF ANESTHESIA (Mikhelson V. A., 2001) TURN OFF CONSCIOUSNESS AMNESIA ANALGESIA NEUROVEGETATIVE PROTECTION MYORELAXATION MAINTAINING ADEQUATE GAS EXCHANGE MAINTAINING ADEQUATE BLOOD CIRCULATION MAINTAINING ADEQUATE METABOLYSIS MA MONITORING OF VITAL FUNCTIONS
EFFECT OF INHALATION ANESTHETICS ON HEMODYNAMICS (Fiedler S. O., 2007) Parameters Cardiac output Heart rate Blood pressure Stroke volume Myocardial contractility General vascular resistance Pulmonary vascular resistance Coronary blood flow Cerebral blood flow Muscle blood flow Catecholamine level Isoflurane 0 ++/0 --* -* -0 + + + 0 Sevoflurane 0 0 --** -0 + + + 0 Halothane -* 0 -* -* ---* 0 0 0 +++ 0 N 2 O + + 0 -* 0 + 0 0 (* dose dependent; ** high dose dependent; + increase; - decrease; 0 no effect). anesthetic 0 -28 days MAK-50 (%) 1 -6 months. 6 -11 months 1 -2 years > 2 years halothane 0.87 1.2 1.98 0.97 0.87 isoflurane 1.6 1.87 1.8 1.6 1.15 sevoflurane 3.1 3.2 2.8 2 , 5 2, 49
INFLUENCE OF ANESTHETICS ON BRAIN METABOLISM AND INTRACRANIAL PRESSURE (according to Serov V.N. et al., 2002) Drugs Metabolic needs of the brain Cerebral blood flow Intracranial blood volume ICP Halothane -- +++ ++ ++ Enflurane -- ++ ++ ++ Isoflurane --- + ++ + Desflurane --- + ? ++ Sevoflurane --- + ? ++ Nitrous oxide - + ± + Barbiturates ---- -- --- Etomidate --- -- Propofol ---- -- -- Benzodiazepines -- ? - - Ketamine ± ++ ++ ++ Opiates ± ± Lidocaine -- ? -- --
NON-INHALATIONAL ANESTHETICS BARBITURATES. Saturation dose 2 -5 mg/kg for 10 minutes; maintenance infusion 1.52 mg/kg∙h. Toxicity is higher and the duration is longer than at other ages: high permeability of the BBB; delayed hepatic elimination. MIDAZOLAM (0.2 -0.5 mg/kg). In newborns it is excreted much more slowly, and in infants faster than in adults (T 1/2: newborns 8 hours, infants 90 minutes) KETAMINE (1-2 mg/kg into a vein). In newborns, the elimination of ketamine is slow due to the immaturity of metabolic processes in the liver. PROPOFOL. Long-term infusion is not recommended (heart failure with PROPOPOL fatal, risk of pneumonia). In infants, high doses are required (3-5 mg/kg). Under 2 years of age, bradycardia and arterial hypotension occur more often. In Russia, FENTANYL is allowed from 3 years of life, in the UK - from 29 days of life. Saturation boluses 10 -15 mcg/kg (according to some sources, up to FENTANYL 30 mcg/kg!). Maintenance infusion 1 -4 mcg/kg∙h. Wooden chest is less common than in adults. Cumulation of effect (insufficient monoamine oxidase activity of the liver of newborns). REMIFENTANIL. For induction 0.5 -1.0 mcg/kg∙min for 30 -60 s; for maintenance 0.1 REMIFENTANIL 0.5 mcg/kg∙min. The action is shorter and more stable than fentanyl. Does not require monoamine oxidase oxidation (destroyed by plasma esterases). Drug of choice for newborns. Not registered in Russia.
Some effects of non-inhalational anesthetics (according to V. A. Mikhelson, Yu. V. Zhirkova, 2007) drug breathing hemodynamics CNS dose-dependent depression weak depression dose-dependent decrease in ICP thiopental depression depression ↓BP reduces ICP ketamine depression stimulation of blood pressure HR increases ICP diazepam midazolam dose-dependent depression weak depression dose-dependent decrease in ICP Propofol dose-dependent depression depression ↓BP ↓HR reduces ICP GHB
CAUDAL ANESTHESIA equipment: 23 G needle with a sharpening angle of 45 -60 and a length of 2.5 cm (risk of puncture of 0 0 cartilaginous structures of the sacrum and penetration into the pelvis), syringe, sterile diaper and gloves, anesthetic solution maximum permissible dose of lidocaine 5 mg/ kg, bupivacaine 2 mg/kg volume of local anesthetic in newborns 1 ml/kg, in young children 0.5 ml/kg adrenaline is not used until 2 years of age. Opioid analgesics are not recommended due to the risk of delayed respiratory depression. catheter 22 -24 G t and constant infusion of anesthetic (bupivacaine 0.2 -0.4 mg/kg/hour) allows prolongation of anesthesia and postoperative analgesia.
CAUDAL ANESTHESIA lying position on the left side with knees brought to the chest, the sacral canal is punctured through the sacrococcygeal membrane covering the hiatus sacralis, at the level of the horns of the sacral bone, first the needle is inserted perpendicular to the sacrococcygeal membrane, after puncturing the skin and subcutaneous fat, the direction of the needle is changed by 300 -400 and move in the cranial direction the feeling of “loss of resistance” after puncture of the sacrococcygeal membrane - identification of the epidural space, then the needle is advanced another 2-3 mm, an aspiration test is performed. the anesthetic should be administered easily without resistance in 60 -90 seconds (0.0230, 033 ml/sec) the child is laid on his back with the head end raised
Surgery under spinal anesthesia in a newborn. From the report of L. Kachko (25.09.2006, Moscow). Schneider Children's Medical Center, Tel Aviv University, Israel.
CALCULATION OF THE AMOUNT OF INTRAOPERATIVE BLOOD LOSS D(l)=CBV(Htn – Hta)/Htn or D(l)=CBV(Hbn – Hba)/Hbn Where: CBV – normal circulating blood volume; Htn – normal hematocrit; Hta – real hematocrit; Hbn – normal hemoglobin; Hba – real hemoglobin; D – amount of blood loss. PLANNED INTRAOPERATIVE BLOOD LOSS: D(ml)=2 BCC(Hta – Htmin)/(Hta+Htmin), where D is the volume of permissible blood loss; Hta – actual hematocrit before surgery; Htmin is the minimum permissible hematocrit. The planned infusion rate is 4 ml/kg∙h from the moment of food deprivation
PRINCIPLES OF GENERAL ANESTHESIA 1. Preventive analgesia 2. Mandatory sedation and analgesia during manipulations (catheterization, puncture) 3. Prevention of vagal reflexes (Atropine 0.02 mg/kg) 4. With TVA, maintenance infusion of anesthetic 5. With inhalation anesthesia, the flow of fresh gas is not less than 2 l/min 6. Basic infusion 4 ml/kg∙h 7. Calculate in advance the permissible decrease in hematocrit 8. Fi. O 2≤ 0.6; Sp. O 2 92 -95% 9. DO NOT ALLOW BRADYCARDIA LESS THAN 110 min-1 10. Do not rush to extubate!
STANDARDS OF GENERAL ANESTHESIA 1. Mandatory suppression of vagal reflexes (atropine, metacin) 2. Initiation of anesthesia before admission to the operating room 3. In case of TVA, mandatory maintenance infusion of anesthetic after the introductory bolus USED REGIMENS 1. Mononarcosis with promedol: (atropine 0.01 -0.02 mg/kg) - 0.5 mg/kg – intubation – 1.5 mg/kg – maintenance infusion 1.5 -2 mg/kg∙h (30 min) – 11.5 mg/kg∙h (30 min) – then 0.7 -1 mg/kg∙h. 2. Ketamine anesthesia: unithiol 5 mg/kg – dormicum 0.5 mg/kg – ketamine 2 mg/kg IV (7-10 mg/kg IM). 3. TBA: atropine 0.01 -0.02 mg/kg - dormicum 0.3 -0.5 mg/kg - intubation - fentanyl 10 -20 mcg/kg - maintenance infusion of fentanyl 4 -6 mcg/kg∙h 4 Sevoflurane: rapid induction (8%); maintaining anesthesia 2 -3% with a fresh gas flow of 2 l/min; fentanyl 5 -8 mcg/kg (maintenance 2 -4 mcg/kg∙h). Adjuvants: dalargin (20 -30 mcg/kg∙h); clonidine (2 μg/kg before induction). Stress protection; decrease in OPS; potentiation of analgesia (reduction in opiate consumption by 30-40%).
NUANCES OF ANESTHESIA IN NEWBORNS There are no indications for the use of nitrous oxide! There is no collateral ventilation. Air traps. Diffusion into closed cavities. Pneumothorax, pneumoperitoneum, pneumatosis intestinalis, etc. Increased PVR. Increased pulmonary hypertension; reduction of preload; low cardiac output. THE USE OF SUCCYNYLCHOLINE IS PROHIBITED. RELAXANT OF CHOICE – ROCURONIUM BROMIDE=ESMERON) 0.6 -0.9 MG/KG, for rapid relaxation 1 -1.2 mg/kg
ALL NEWBORN UNDER OPERATION – MONITORING PRESSURE IN THE STOMACH! 5 -12 cm water. Art. 1 cm water Art. =0.735 mm. rt. Art. or 1 mm. rt. st = 1.36 cm water. Art. 1 cm water Art. ≈1 m. Bar
GASTROSCHISIS (LAPAROSHISIS) Preoperative preparation: the shorter the better! 1. Intubation with spontaneous breathing. Transfer to mechanical ventilation. Maintaining sedation. 2. Reliable heating and humidification of the defect. 3. Vascular access (superior vena cava). Infusion: water + sodium + glucose. Approximate composition for a child weighing 2.5 kg: Glucose 40% -62.5 ml (4 g/kg); Potassium chloride 7.5% -8 ml (1 mmol/5 g glucose); Magnesia sulfate 25% -1 ml; Calcium chloride 10% - 1.3 ml Quintasol to volume: 4 ml x 2.5 kg x 24 hours = 240 ml. High risk of infection, hypothermia, exicosis Risk of respiratory disorders after immersion of the intestine/liver into the abdominal cavity (correction of mechanical ventilation is required, manual ventilation is better!) Good muscle relaxation is necessary Temporary patch for a defect in the abdominal wall with pressure in the stomach >20 mm. rt. Art. Compression of the inferior vena cava - swelling in the legs Monitoring Sp. O 2 on the upper and lower limbs
OMPHALOCELE 1. In the absence of obstruction or volvulus, it does not require intensive care and does not require emergency surgery. 2. Conservative management: irrigation of embryonic membranes with solutions of Tannin 1 -5% or Potassium permangamate 1 -5% in order to coagulate the membranes. Gradual adaptation of the size of the abdominal cavity to the volume of organs to be moved. 3. Features of the operation: -high risk of blood loss; -high risk of adhesions. Other components of the operation and management tactics are the same as for laparoschisis.
DIAPHRAGMAL HERNIA Risk of asphyxial strangulation. In emergency operations, the mortality rate is 45-55%. Before surgery, the Fowler position is at least +45°! Decompression probe. Parenteral nutrition. It is advisable to delay the operation for 24-48 hours until hemodynamic stabilization, Sp. O 2, CBS, diuresis 1 -2 ml/kg∙h Indicated: HF mechanical ventilation, inhalation of nitric oxide Transportation to the operating room after adaptation to the ventilator and transfer tests High risk of arterial hypotension and respiratory disorders during surgery (correction of mechanical ventilation and doses of adrenergic agonists ) In case of sudden hypoxemia, hypercapnia, pneumothorax is most likely. After surgery, long-term mechanical ventilation is often required
ACUTE INTESTINAL OBSTRUCTION Emergency indications for surgery for low-grade obstruction. Preoperative preparation for decompression in high obstruction High risk of aspiration: nasogastric tube and aspiration evacuation Large fluid losses by sequestration in low intestinal obstruction Large intraoperative fluid losses High risk of bleeding High risk of sepsis and multiple organ failure Intraoperative jejunal intubation with a thin feeding tube For peritonitis, epidural anesthesia is contraindicated
ESOPHAGUS ATRESIA The simplest diagnosis: gastric probing immediately after birth Inferior fistula - 80%; top – 13%; no fistula – 7%. Difficulty with tracheal intubation (risk of intubation of tracheoesophageal fistula) Induction: inhalation or intravenous, muscle relaxant, tracheal intubation, conscious intubation abandoned (?). Ventilation with low inspiratory pressure and PEEP (discharge through the fistula into the stomach) The period from intubation to the start of the operation should be minimal; after ligation of the fistula, ventilation is normalized. High risk of hypoventilation due to compression of the overlying lung (stop the operation, high-frequency ventilation). As a rule, prolonged mechanical ventilation is performed after surgery. (according to V. A. Mikhelson, Yu. V. Zhirkova, 2007)
CHILDREN'S SURGERY IS NOT SO MUCH A MEDICAL PROBLEM BUT AN ETHICAL PROBLEM INFORMED CONSENT TO OPERATION (REFUSION TO OPERATION): in the first week after birth, the behavior of the mother, as the only legal representative of the newborn, is rarely adequate! DOES AN ANESTHESIOLOGIST HAVE TO OBTAIN CONSENT FOR CERTAIN TYPES OF PAIN MEDICATION IN INFANTS? IS REFUSAL TO SURGICAL TREATMENT OF A NEWBORN WITH AN CONSOLIDATED CENTRAL NERVOUS SYSTEM DEVELOPMENTAL MALFORMATION EUTHANASIA? !
