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!!