USA Surgery Today

Antenatal ultrasound allows diagnosis of many congenital anomalies early in pregnancy. Parents can receive counseling and referral to regional perinatal centers where obstetric, neonatal, and surgical services can be coordinated. ( Pravachol )
Despite advances in antenatal diagnosis and planning, undetected anomalies, unexpected changes in obstetric condition, and transfer within medical center complexes will continue to occur. Surgical conditions, including abdominal wall defects, thoracic anomalies, and intraabdominal pathologies, require special considerations for support and care in transport.

Infants with abdominal wall defects, including gastroschisis and omphalocele, may have large areas of exposed viscera. Heat and fluids are readily lost across the exposed surface. In these infants, fluid losses include free water, electrolytes, and protein. Care of these babies includes special attention to thermal support and fluid management.

Exposed bowel should be examined and positioned to assure vascular integrity. Viscera are covered with sterile saline-soaked gauze and clear plastic wrap, or a sterile bowel bag, to minimize trauma and evaporative heat and fluid losses. The infant should be positioned on his or her side to avoid compromise of visceral perfusion. Nasal or oral gastric tubes are placed for drainage and decompression of the bowel. Once intravascular access is established, fluid administration rate and composition must provide adequate metabolic support, as well as correct ongoing fluid and electrolyte losses. Adequacy of respiration and perfusion should be monitored closely throughout stabilization and transfer of these infants. ( Pravachol )

Congenital thoracic anomalies can impinge on lung growth and expansion. In congenital diaphragmatic hernia, abdominal organs present within the thorax limit lung growth, resulting in pulmonary hypoplasia. Congenital cystic adenomatoid malformation and pulmonary sequestration replace normal lung tissue, impairing pulmonary function. In severe cases the mediastinum may be compressed or displaced, causing hemodynamic compromise, effusions, or polyhydramnios. When congenital diaphragmatic hernia is diagnosed, prolonged bag-mask ventilation should be avoided. Endotracheal intubation and ventilatory support should be initiated when respiratory distress develops, and nasogastric decompression provided early in resuscitation. Transport management includes provision of adequate respiratory support for ventilation, pH balance, and oxygenation, while considering the deleterious effects of high oxygen tension and barotraumas/volutrauma from mechanical ventilation (66). Thoracic anomalies in the transitional newborn often lead to persistence of the fetal circulatory pattern and difficulty maintaining adequate oxygen delivery and perfusion. ( Pravachol )

Infants beyond the immediate newborn period may develop complications that require surgical consultation and transfer to centers with pediatric surgical staff. Necrotizing enterocolitis, bowel perforation, ischemia, and obstruction are intraabdominal emergencies that require prompt surgical evaluation. These conditions may be associated with peritonitis, respiratory compromise, sepsis, hemodynamic instability, and electrolyte and coagulation disturbances. ( Pravachol )
The infant’s clinical condition can change rapidly during transfer, and requires close monitoring for changes in respiratory and hemodynamic status. Maintaining adequate intravascular volume, correction of electrolyte and coagulation abnormalities, initiation of broad-spectrum antibiotics and bowel decompression are other important aspects of transport management for these infants.