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Inguinal Hernia of Inguinal Hernia of Premature InfantsPremature Infants
2005/02/03 2005/02/03 R1R1 林群博林群博
Brief HistoryBrief History
2 months old male infant2 months old male infant G3P1AA2G3P1AA2 GA: 28 weeks+6GA: 28 weeks+6 Birth body weight: 1302gmBirth body weight: 1302gm
Brief HistoryBrief History
Maternal APH, PPROM, placental Maternal APH, PPROM, placental abruptioabruptio
C/S on 2004/11/11C/S on 2004/11/11 Apgar score: 7Apgar score: 7→→88
Brief HistoryBrief History
Frequent apnea episodes on 11/13-Frequent apnea episodes on 11/13-14 and aminophylline was given14 and aminophylline was given
Abscess and osteomyelitis in Abscess and osteomyelitis in 2005/122005/12
Pre-op: BW: 2644gmPre-op: BW: 2644gm Herniorraphy for umbilical and right Herniorraphy for umbilical and right
inguinal hernia on 2005/1/21inguinal hernia on 2005/1/21
DiscussionDiscussion
1. When should repair of inguinal 1. When should repair of inguinal hernia be done?hernia be done?
2. Anesthetic risks for surgery of 2. Anesthetic risks for surgery of premature infantspremature infants
3. What kind of anesthetic technique 3. What kind of anesthetic technique is better?is better?
Inguinal Hernia in PrematurityInguinal Hernia in Prematurity
Incidence: 14-30%(children: 2%)Incidence: 14-30%(children: 2%) Higher incidence of incarceration in Higher incidence of incarceration in
infantsinfants Hernia repair when ready for discharge Hernia repair when ready for discharge
has be acceptedhas be accepted
Pediatr Surg Int (1999) 15: 36-39Pediatr Surg Int (1999) 15: 36-39
Inguinal Hernia in PrematurityInguinal Hernia in Prematurity
VLBW infants had a longer operation VLBW infants had a longer operation time and a longer waiting periodtime and a longer waiting period
Preoperative medical complication: Preoperative medical complication: RDS, sepsis, and cardiac failureRDS, sepsis, and cardiac failure→ → considered to delay surgeryconsidered to delay surgery
The shorting waiting group had The shorting waiting group had shorter operation timeshorter operation time
No correlation between operation No correlation between operation time and body weight at surgerytime and body weight at surgery
Inguinal Hernia in PrematurityInguinal Hernia in Prematurity
For long waits for surgery in VLBW For long waits for surgery in VLBW infants: hernia sac may grow large infants: hernia sac may grow large and thick, and fibrous adhesions may and thick, and fibrous adhesions may developdevelop
Difficult surgical repair and the risk of Difficult surgical repair and the risk of gonadal ischemia may be increasedgonadal ischemia may be increased
The Most Common Medical The Most Common Medical Problems in PrematurityProblems in Prematurity
Respiratory distress syndrome (RDS)Respiratory distress syndrome (RDS) Apnea of prematurityApnea of prematurity Anemia of prematurityAnemia of prematurity Patent ductus arteriosusPatent ductus arteriosus Intraventricular hemorrhageIntraventricular hemorrhage
The Formerly Premature InfantThe Formerly Premature Infant
Bronchopulmonary dysplasia (BPD): Bronchopulmonary dysplasia (BPD):
1. the sequelae of RDS1. the sequelae of RDS
2. the leading cause of chronic lung 2. the leading cause of chronic lung disease during infancydisease during infancy
3. periodic episodes of 3. periodic episodes of bronchospasm, especially during URIbronchospasm, especially during URI
Anesthetic Management of Anesthetic Management of Infants with BPDInfants with BPD
Optimization of respiratory statusOptimization of respiratory status Deep extubation to avoid Deep extubation to avoid
bronchospasmbronchospasm Regional analgesia in abdominal Regional analgesia in abdominal
procedures for pain controlprocedures for pain control
Laryngeal and Tracheal InjuryLaryngeal and Tracheal Injury
Prolonged intubation and mechanical Prolonged intubation and mechanical ventilationventilation
Subglottic stenosisSubglottic stenosis Smaller ET tube when intubationSmaller ET tube when intubation Stridor following extubationStridor following extubation
Postoperative ApneaPostoperative Apnea
May be accompanied by bradycardiaMay be accompanied by bradycardia Probably related to the effects of Probably related to the effects of
general anesthetic agents on the general anesthetic agents on the immature respiratory control centerimmature respiratory control center
Low gestational age, low Low gestational age, low postconceptional age, preoperative postconceptional age, preoperative apnea of prematurityapnea of prematurity
General VS Spinal AnesthesiaGeneral VS Spinal Anesthesia
GA<36wks and post-conceptual age GA<36wks and post-conceptual age (PCA)<46wks(PCA)<46wks
Exclude preexisting cardiac, Exclude preexisting cardiac, neuromuscular or metabolic diseasesneuromuscular or metabolic diseases
Preoperative hemoglobin and a history of Preoperative hemoglobin and a history of preexisting abnormal respiratory functionpreexisting abnormal respiratory function
British Journal of Anaesthesia 86 (3): 366-71 British Journal of Anaesthesia 86 (3): 366-71 (2001)(2001)
General Anesthesia (Group 1)General Anesthesia (Group 1)
Induction: 2 MAC sevoflurane and Induction: 2 MAC sevoflurane and atracurium 0.5 mg/kgatracurium 0.5 mg/kg
Maintenance: 0.5-1.0 MAC sevoflurane Maintenance: 0.5-1.0 MAC sevoflurane until completion of skin closureuntil completion of skin closure
Reversed with neostigmine 50 Reversed with neostigmine 50 μμg/kg g/kg and glycopyrrolate 10 and glycopyrrolate 10 μμg/kgg/kg
Caudal epidural injection with 0.25% Caudal epidural injection with 0.25% bupivacaine 2 mg/kgbupivacaine 2 mg/kg
Spinal Anesthesia (Group 2)Spinal Anesthesia (Group 2)
0.5% bupivacaine 1 mg/kg0.5% bupivacaine 1 mg/kg Caudal epidural injection with 0.25% Caudal epidural injection with 0.25%
bupivacaine 2 mg/kgbupivacaine 2 mg/kg
ResultsResults
Spinal anesthesia was attempted Spinal anesthesia was attempted unsuccessfully in four patients in unsuccessfully in four patients in group 2group 2
5 patients in group 1 demonstrated 5 patients in group 1 demonstrated an excess number of episodes of an excess number of episodes of postoperative cardiopulmonary postoperative cardiopulmonary complicationscomplications
3 patients had preexisting abnormal 3 patients had preexisting abnormal respiratory function and accounted respiratory function and accounted for 80% of the episodesfor 80% of the episodes
Prevention of Postoperative ApneaPrevention of Postoperative Apnea
Performing a regional anesthetic Performing a regional anesthetic instead of a general anestheticinstead of a general anesthetic
Perioperative administration of Perioperative administration of caffeinecaffeine
Selection of general anesthetic Selection of general anesthetic agents or opoids that are agents or opoids that are characterized by their limited characterized by their limited duration of actionduration of action
Regional AnesthesiaRegional Anesthesia
Lower incidence (not complete Lower incidence (not complete absence) of postoperative apneaabsence) of postoperative apnea
The risk is similar to general The risk is similar to general anesthesia hen adding systemic anesthesia hen adding systemic sedativessedatives
Potentially stressful for the infant and Potentially stressful for the infant and associated with a clinically significant associated with a clinically significant failure ratefailure rate
Thanks for Your Attention!!Thanks for Your Attention!!