ANESTHETIC MANAGEMENT OF A SEPSIS/SIRS PEDIATRIC UNDERGOING ABDOMINAL SURGERY FOR DUODENAL ATRESIA : A SERIAL CASE


CASE 1
A 11 Days-old Female Neonates “M”, 3 kgBW, a suspect of Duodenal Atresia,  was diagnosed with, Leucocytosis, Fever, & SIRS, then he was planned for Laparotomy Exploration under General Anesthesia with physical status ASA II.

CASE 2
A 14 days-old male Neonates “E”, 2,2 kgBW,  was diagnosed with Duodenal Atresia, then he was planned for Laparatomy Exploration under General Anesthesia with physical status ASA II.
CASE 3
            A 19 days-old male Neonates “M”, 1,7 kgBW, was diagnosed with Doudenal Atresia, Hyperbilirubinemia High Risk Zone, Sepsis then planned for Laparotomy Exploration under General Anesthesia with physical status ASA III. Patient was Phototerapy to decerease value Bilirubin serum and give antibiotic to give neonate protocol sepsis management .


Table of Preoperative Findings


DATA
Case 1
Case 2
Case 3
AIRWAY
Clear
Clear
Clear
Vomiting
-
-
+
OGT
+
+
+
BREATHING



Respiratory Rate
30/min
30/min
30/min
SpO2
97-99%
97-99%
98-99%
Respiratory tract infection
-
-
URTI
Lung Rales
+/+
+/+
+/+
CIRCULATION



Heart Rate
140/min
135/min
150/min
Dehydration
-
-
Mild
Hematologic Disorder


-
DISABILITY



Condition
Normal
Normal
Weak
Consciousness
Conscious
Conscious
Lethargic
EXPOSURE



Abdominal Distention
-
-
-
Peristaltic
Diarrhea
-
-
-
Axillar Temperature
37 oC
37 oC
37,5 oC
Septicemia
SIRS
SIRS
SEPSIS
Abnormal Laboratory Tests


Hyperbilirubinemia
Radiologic Apperance
Double Bubble Apperance
Double Bubble Apperance
Double Bubble Apperance




















Table of Anesthetic Management

DATA
Case 1
Case 2
Case 3
GENDER
MALE
MALE
MALE
AGE
11 days
14 days
19 days
BODY WEIGHT
3 kg
2 Kg
1,7 Kg




PREMEDICATION



Metoclopramid
0,45 mg
0,2 mg
0, 2 mg
Atropine Sulphate
0,1 mg
0,1 mg
0,1 mg
Fentanyl
6  µg
4 µg
-




INDUCTION


RSI
Ketamine
 -
-
2 mg
Sevoflurane
8 Vol% Decrease Titration
8 Vol% Decrease Titration
-
Atracurium
1,5 mg
1 mg
1 mg
ET
3 Non Cuffed
3.0 Non Cuffed
2,5 Non Cuffed




MAINTENANCE



O2 : N2O
50% : 50%
50% : 50%
-
O2 : Air Bar
-
-
50% : 50%
Sevoflurane
3-3,5 vol%
3-3,5 vol%
-
Ketamin


50  µg/kg/menit
Fentanyl
  1 µg(4x)
  0,5 µg (4x)
  -
Metamizole
45 mg
30 mg
20 mg
Dexametasone
-
-
0,3 mg
Atracurium
0,3 mg (3x)
0,2 mg (3x)
0,2 mg (5x)




POST OPERATION



Emergence
Awake Extubation
Awake Extubation
  Preferred not to Extubate
PACU
NICU
NICU
 NICU
Ketamine drip
0,2mg/kgbw/hr
0,2mg/kgbw/hr
  0,2 mg/kgbw/hr
Metamizole
45 mg / 8hrs
30 mg / 8hrs
20mg / 8hrs
Caudal analgesia
-
-
-
VAS
0-1
0-1
0-1
OUTCOME
SURVIVED
SURVIVED
SURVIVED































    




Rounded Rectangle: Double Bubble Appreance sign of Duodenal Atresia













DISCUSSION
All cases were having the risk for vomiting or regurgitation during induction of anesthesia that require preoperative Oral Gastric Tube placement. 2 cases were suffered from dehydration and has been rehydrate in HCU Neonate preoperative and 1 cases has been diagnose with Hyperbilirubinemia high risk zone and require of phototherapy management in preoperative period. Presence of abdominal distention was not found in all cases. Presence of concomitant septicemia was found in 3 cases ( 2 SIRS and 1 Sepsis). Patients received Ketamine drip 0,2 mg/kgBW/hour and or Metamizole 10-15 mg/kgBW/8 hours for postoperative pain management.2 After the surgery FLACC Score was 0-1 in all cases. All cases were able to gain recovery and discharged from hospital.
CONCLUSIONS
Safe and good perioperative anesthetic management depends on full appreciation of the physiological, anatomic, and pharmacological characteristics of each age of the pediatric group. Anesthetic management is dictated by the severity of the vomiting, volume depletion and electrolyte imbalance, and the more general issues of the pediatric period. Other anesthetic considerations are obstruction, aspiration, Sepsis (bacterial translocation), prematurity, and associated anomalies.

Keywords : Duodenal Atresia, abdominal surgery, Sepsis



REFERENCES

1.    Holzman RS, Mancuso TJ, Polaner DM. A Practical Approach to Pediatric Anesthesia. 1st Edition. Philadelphia : Lippincott Williams & Wilkins; 2008. Chapter 17, Gut Development : Surgical and Anesthetic Implications; p.376-83

2.    Morgan GE, Mikhail MS, Murray MJ. Pediatric Anesthesia Clinical Anesthesiology. 4th Edition. New York : McGraw Hill Companies; 2006. Chapter 44, Pediatric Anesthesia ; p.922-51

3.    Coté CJ,  Lerman J, Todres I. A Practice of Anesthesia for Infants and Children. 4th Edition . Philadelphia : Saunders, an imprint of Elsevier Inc; 2009. Chapter 27, General Abdominal and Urologic Surgery; p.583-94


4.    Davis J Peter, Cladis P Franklyn, Motoyama K Etsuro. 2011. Smith’s Anesthesia for Infants and Children. 8th Edition Philadelphia : Saunders, an imprint of Elsevier Inc; 2009. Chapter 18, Anesthesia for General Surgery in the Neonate. p555