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
|
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