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Neo Pathophys 2 > Surgical Emergencies > Flashcards

Surgical Emergencies Flashcards

1
Q

What is the most common GI emergency in Neonates?

A

NEC

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2
Q

Name the clinical findings a/w NEC

A

Abdominal Distension
GI bleeding
Pneumatosis intestinales

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3
Q

Can NEC be reversed?

A

No, not even if you intervene early.

Have to ride it out.

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4
Q

Name 4 risk factors for NEC

A
  1. Prematurity
  2. CHD
  3. Neonatal Distress
  4. Enteral Feeding
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5
Q

Mortality is ___-___% higher for pan-intestinal necrosis

A

20-40% higher

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6
Q

Name the Absolute indications for OR intervention for NEC

A

-Pneumoperitoneum
-Peritonitis (diffuse)
-Clinical deterioration
-Sepsis refractory to medical therapy
-Intestinal obstruction or stricture
(happens w/healing from primary NEC epsiode/scarring ~3-4 wks after repair w/increased fdg vols-can’t advance)

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7
Q

Name Relative indications for OR intervention for NEC

A
  • Abdominal wall erythema
  • Fixed loop of intestine
  • Portal venous gas
  • Positive paracentesis
  • Thrombocytopenia
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8
Q

Bilious emesis + toleration of initial feedings = ? -until proven otherwise

A

Malrotation + Midgut Volvulus (twisting)

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9
Q

When Malrotation & Midgut Volvulus is suspected on x-ray, what test is ordered?
Why?

A 
Upper GI (limited series)
It looks at rotational anatomy
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10
Q

If a Malrotation & Midgut Volvulus is not caught early, it can be ?

A

Catastrophic

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11
Q

What might be seen on Upper GI w/Malrotation & Midgut Volvulus?

What should the Duodenum look like?

A

A corkscrew appearance to the contrast passing through the intestines.

A “C” shape

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12
Q

Besides Upper GI series, what else is likely needed w/Malrotation and Midgut Volvulus?

A

Emergency Surgery

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13
Q

What does Normal Rotational Anatomy do to the Mesentery?

A

Broadens the base of the mesentery preventing twisting

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14
Q

The mesentery takes blood vessels from the ______ out into the _________.

A

Aorta

Intestine

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15
Q

Failure of Rotation—>

A

Failure of broad base of mesentery. It will look like a tree trunk w/top heavy tree that can twist.

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16
Q

Malrotation w/Midgut Volvulus compromises what?

A

The entire Midgut

-intestines supplied by Superior Mesenteric Artery from Duodenal-Jejunal junction to mid-transferse colon

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17
Q

In surgical repair of Malrotation w/Midgut Volvulus, what do they do?

A

360 degree Counterclockwise Detorsion followed by a second 360 degree Counter clockwise Detorsion

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18
Q

What congenital attachments are noted during surgical correction of Malrotation w/Midgut Volvulus?

What do they do with them?

A

LADS bands

They try to remove them and broaden the base of the mesentery so the Duodenum is on the Rt & Cecum is in Left, upper quadrant, appendix removed.

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19
Q

Does the anatomy remain abnormal after surgery?

Is there chance of re-vovlulization?

A

Yes

5-15% chance re-volvulization

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20
Q

7 out of 10 times, bilious emesis is ?

A

Nothing, but check anyway.

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21
Q

Name the Nursing considerations for Malrotation w/Midgut Volvulus.

A

-GI decompression
-Prepare for transport (radiology, OR, transfer)
-Post-op (resumption of bowel activity-could take a week)
they tend to get an ileus and have bilious residuals (are TPN dependent for a little while)

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22
Q

What Dx do you suspect in an infant who begins vomiting bile stained fluid in first few hrs of life?

A

Duodenal Atresia

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23
Q

What might be noted on prenatal US with Duodenal Atresia?

A

Polyhydramnios

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24
Q

What other anomalies is Duodenal Atresia A/W?

A

50% a/w: Cardiac, GU, Anorectal, or esophageal abnormalities
40% have Trisomy 21
30% have Malrotation

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25
Q

Is repair of Duodenal Atresia a surgical emergency?

A

No, not usually-there’s time to do heart ECHO and Renal US first.
**unless a/w malrotation (15-30%)

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26
Q

85% of Duodenal Atresia occur where?

A

Post-Ampullary (after common bile duct drains into the Duodenum)

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27
Q

What is Duodenal Atresia thought to be caused from?

A

Failure of recannalization of the lumen of the intestine during development (wks 8-10).

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28
Q

What is the surgical treatment of Duodenal Atresia?

A

Web excision or Duodenoduodenostomy with or w/o tapering

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29
Q

How long can it take to get feeds going?

A

Weeks. Just watch and wait

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30
Q

Do surgeons usually remove Duodenal webs?

A

No, they usually just bypass them.

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31
Q

Jejunal and ileal atresias are caused by?

A

Intra-Uterine vascular events

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32
Q

10% of jejunal and ileal atresias are what?

A

Multiple

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33
Q

What does surgical tx of Jejunal and ileal atresias involve?

A

Resection of stenotic or dilated bowel and anastomoses with or w/o tapering

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34
Q

What is a type 1 Membraneous Atresia?

Is significant length lost w/this type of atresia?

A

There’s continuity of the bowel wall but no Luminal continuity (probably a late-gestation insult)

No, they sew the ends back together, babies do quite well.

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35
Q

What is notable with a type 2 Atresia?

When did insult likely happen?

A

There is an intestinal remnant and a large size discrepancy.

Very early in gestation (providing time for the bowel to become very dilated)

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36
Q

Dilated intestine is not very ________

A

Functional

37
Q

W/type 2 Atresia the baby may have a prolonged ______, but not __________.

A

Ileus

not Malabsorption

38
Q

What is notable w/type 3 Atresia?

A

There is a small amount of intestine and a very, very dilated colon

39
Q

With an Antenatal Volvulus there is almost what?

A

No colon

Very little midgut

40
Q

What procedure can be done w/Jejunal & Ileal atresia?

A

Primary STEP procedure

41
Q

What is the goal of a primary STEP? (serial transverse enteroplasty)

A

Increase mesenteric length but decrease it’s caliber.

Increase contact between luminal contents and enterocytes to promote absorption

42
Q

How is a Primary STEP procedure achieved?

A

Created by surgical staples. As the child grows, the area becomes dilated and they get another STEP procedure

43
Q

T/F: Jejunal & Ileal atresias are less affected by congenital anomalies vs. Duodenal atresias

A

True

44
Q

What might the abdomen feel like in a baby with a meconium ileus?

A

“Doughy”-it’s filled w/tenacious Meconium

45
Q

What can be seen on contrast enema in an infant w/meconium ileus?

A

A negative impression of the meconium cast

46
Q

Many infants w/CF who have meconium ileus will have what after contrast enema?

A

Persistent obstructive symptoms
Persistent ileus
Distension
& Require an operation

47
Q

___% infants w/CF will have a meconium ileus

A

20%

48
Q

True/False: Most infants with a meconium ileus will have CF

A

True

49
Q

Infants w/meconium ileus sometimes need an ________ or _______ the contents into the colon

A

enterotomy

milking

50
Q

What medication instilled can thin and clear meconium nicely and possibly avoid enterostomy

A

Mucomist 1-2%

51
Q

Can meconium ileus cause a volvulus?

A

Yes, occasionally

52
Q

What are nursing considerations of Meconium Ileus?

A

GI decompression pre-op

Intestinal irrigation, enzyme replacement post-op (via t-tube left in after surgery)

53
Q

What do you suspect in an infant w/progressive abdominal distension who does not pass meconium at 36 hrs life, w/patent anus?

A

Hirschprung’s Dz

54
Q

What test is done first to eval Hirschprungs? Can this diagnose it?

Why?

A

Contrast enema. No.

Look for Recto-Sigmoid ratio

55
Q

What is the only thing that can dx Hirschprung’s?

A

Rectal Biopsy

56
Q

What is Hirschprung’s Dz?

What does it cause?

A

Failure of migration of ganglion cells to the hindgut (a continuous segment of intestine beginning at anorectal junction)

No coordinated peristalsis, internal sphincter won’t relax and baby can’t pass stool or gas

57
Q

What is the incidence of Hirshprung’s Dz?
Male vs. Female?

___ - ___ have trisomy 21

11-30% have associated anomalies:

A

1:5,000
70-80% Male
3-16%

GU, Cardiac, GI

58
Q

Hirschprung’s can present as what in older children/toddlers?

A

Chronic constipation

59
Q

What is the tx for Hirschprung’s Dz?

A

Endorectal pull-through with or without colostomy

remove non-functional section and split the internal non-functional sphincter

60
Q

What are long-term problems of Hirschprungs?

A

Constipation

Internal Sphincter can remain hypertonic despite splitting in neonatal period (they can botox it)

61
Q

What are pre-op nursing considerations

A

GI decompression
Avoid rectal stimulation just prior to contrast enema
Serial colonic irrgations

62
Q

What are post-op nursing considerations

A

Sign over bed “nothing per rectum”

63
Q

If a newborn has excessive oral secretions respiratory distress after feeding, and resistance when NG is passed, what would you suspect?

A

Esophageal Atresia w/distal Tracheoesophageal fistula

64
Q

What type of Esophageal Atresia and TE fistual is most common?

A

Esophageal Atresia w/distal Tracheoesophageal fistula

65
Q

What is the second most common type of Esophageal Atresia and TE fistula?

What would you see on x-ray w/this type?

A

No fistula, just Esophageal atresia

A gasless abdomen would be noted on x-ray

66
Q

What is the 3rd most common type of esophageal atresia w/TE fistula?

A

“H” type

67
Q

What does VACTERL stand for?

A 
Vertebral anomalies (70%)
Anal anomalies (55%)
Cardiac Anomalies (66%)
Tracheoesophageal fistula/atresia (70%)
Renal anomalies (50%)
Limb anomalies (70%)
68
Q

Why does VACTERL matter?

A

If you have a pt w/tracheoesophagela fistula/esophageal atresia-you need to check out the other areas for anomalies.

69
Q

What can be a complication of ventilation w/high settings in a pt w/tracheoesophageal fistula/atresia?

A

the GI tract will be ventilated not the lungs

70
Q

With surgical repair of tracheoesophageal fistula/esophageal atresia, when and where is an ETT placed?

What is the back of the trachea like?

What size NG is placed across the repair site? can it be easily removed/replaced?

These pts will have a chest tube in until what is done?

A

ETT is placed in the OR
Deep in the throat (has to pass the repair site)

Like wet toilet paper, very friable

5 or 6 Fr, no can not easily be replaced

Until swallow study is done to check for leaks (15-20% have leaks)

71
Q

What is the surgical concern with an esophageal atresia?

A

The distal esophagus is not anchored to the chest/back of trachea.
Called “long-gap” esophageal atresia

72
Q

What’s a big thing to avoid with repair of the “H” type TE fistula?

A

Avoid the Vagus Nerve.

73
Q

What is expected post-op for a baby with an H-type repair?

A

Feeding difficulties

Hoarseness

74
Q

With “H” type repair, which part of the esophagus doesn’t work well?

A

The proximal esophagus

  • problems swallowing
  • is most prone anastomoses to develop strictures (some require surgical dilation in the 1st yr)
75
Q

What are pre-op nursing considerations for H type repair?

A

Gastric Decompression

76
Q

What are post-op nursing considerations for H type repair?

A

Chest tube
OG tube in place across the esophageal anastomosis
ETT position is critical

77
Q

Gastroschesis is typically to which side of the umbilical stump?

A

Right side

78
Q

Can gastroschesis have adhesive bands?

A

Yes

79
Q

How long is a Silo placed?

A

5-7 days for staged reduction, allows abdomen to accommodate the viscera

80
Q

Which defect defines:
“Bad bowel, Good baby”

“Good Bowel, Bad baby”

A

Gastroschesis

Omphalocele

81
Q

15% of this defect will have intestinal atresia

A

Gastroschesis

-may wait or make a stoma

82
Q

What does amniotic fluid do to the intestines toward the end of gestation?

A

It is caustic to them toward the end

83
Q

Which defect?

Has adhesive bands or thick, inflamed rind over the intestine–>prolonged ileus (wks)

A

Gastroschesis

84
Q

Which defect is A/W midline defects?

A

Omphalocele

85
Q

A small omphlalocele is like a ?

A

umbilical hernia –don’t seem to carry the associated anomalies

86
Q

A large omphalocele is more dificult. Can it be repaired all at once?

A

Not typically & if the sac is removed, is more complicated

87
Q

What wound-healing type is used to get the skin to grow over the omphalocele?

A

Scarification of wound care

88
Q

If scarification of wound care is done, when is the omphalocele repaired?

A

When they are older. They create a compression brace for it and then repair later.

Neo Pathophys 2 (20 decks)

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