Neonatal Emergencies Joy Loy MD March 2009. 1. 1.discuss the underlying pathophysiology of selected...

Neonatal EmergenciesNeonatal Emergencies

Joy Loy MDMarch 2009

1.discuss the underlying pathophysiology of

selected neonatal emergencies,

2.explain the anesthetic implications and

3.describe safe anesthetic plans for each.

ObjectivesObjectivesParticipants will be able toParticipants will be able to

• Maternal and perinatal history

• Recreational drug use

• Birth history

• Minimum labs: glucose and CBC

• Look for associated anomalies

• Cardiac and respiratory status

• Metabolic and electrolyte imbalance

• Hydration status

• Coagulation profile

• IV access

Preoperative EvaluationPreoperative Evaluation

Pyloric StenosisPyloric Stenosis


Most common GI obstructive anomaly in neonates

Hypertrophy of the muscular layer of the pylorus

A medical emergency but not a true surgical emergency

Incidence: 1 – 3 :1,000 live births

2 - 5x more common in first born, M > F (4:1)


Etiology : unknown

? acquired condition with hereditary

predisposition

Symptoms are apparent between 2nd-6th wk of life

Presents with nonbilious projectile vomiting, signs of dehydration, jaundice (2%)


Physical Exam

visible gastric peristalsispalpable “olive-shaped” mass to the right

of the epigastric areasigns of dehydration

Labs: CBC serum electrolytes EKG ABG BUN


Diagnosis history and physical exam

abdominal ultrasound

upper GI series with barium contrast

not recommended

pathological

pyloric wall thickness ≥ 4 mm

pyloric length of > 16 cm


Metabolic Abnormalities

• hyponatremia

• hypochloremia

• hypokalemia

• 1° metabolic alkalosis

• compensatory respiratory

acidosis

• paradoxical acidic urine

Preoperative Preparation

supportive treatment

surgical management

check lab indices for safe

anesthesia

Pyloric Stenosis

Pyloric StenosisPyloric StenosisPreoperative PreparationPreoperative Preparation

Supportive therapy

• Correction of fluid deficits

maintenance: D5 0.2% NaCl + KCl

20 - 40 mEq/L

replacement: LR, albumin, normal saline

• Correction of electrolyte imbalance

• Prevention of aspiration : NGT


Surgical Management

Pyloromyotomy definitive treatment open or laparoscopic

Lab indices for safe anesthesia

serum Cl >100 mEq/L HCO3 < 28 mEq/L


Anesthetic Concerns

• pulmonary aspiration

• severe dehydration

• metabolic alkalosis

Pyloric StenosisPyloric StenosisIntraoperative ManagementIntraoperative Management

Monitors : ASA standard

Decompress the stomach

GA: Induction: controversial

awake intubation

rapid sequence IV induction and

intubation with cricoid pressure

inhalation induction with cricoid

pressure

± muscle relaxant

Pyloric StenosisIntraoperative Management

Cook-Sather, 1998 (CHOP)

• prospective, nonrandomized study

• awake vs paralyzed intubation (RSI and MRSI)

• faster and more successful tracheal intubation

with muscle paralysis

• awake intubation does not protect from

bradycardia and desaturation


IntraoperativeIntraoperative ManagementManagement

Maintenance

IV narcotics: rarely needed inhalational agents

Postop pain relief

acetaminophen 30-40 mg/kg PR caudal epidural LA infiltration of surgical incision


Extubate awake

Postoperative concerns

respiratory depression and apnea hypoglycemia

Congenital Diaphragmatic Congenital Diaphragmatic Hernia Hernia

a problem unresolveda problem unresolved

Congenital Diaphragmatic HerniaCongenital Diaphragmatic Hernia

Herniation of abdominal viscera into the thorax

Result from failure of the pleuroperitoneal canal

to close at ~ 8th wk of gestation or early

return of midgut to the peritoneal cavity

Most challenging and frustrating of all neonatal

surgical emergencies


50% mortality regardless of the method of treatment

Incidence: 1:2,000-5,000 live births

M<F 1:1.8, frequently full term

Etiology: unknown no genetic factors have been implicated

Antenatal history: polyhydramnios


Classification

• Absent diaphragm : rare

• Diaphragmatic hernia

80% posterolateral L >R

(Bochdalek)

2% anterior (Morgagni)

15 - 20% paraesophageal

• Eventration (15 - 20%)


Associated anomalies (20-50%)

cardiovascular 13 - 23%

CNS 28%

gastrointestinal 20%

genitourinary 15%

• increase the mortality rate

Congenital Diaphragmatic Hernia

Classic Triad

Dyspnea

Cyanosis

Apparent dextrocardia


Physical Exam

scaphoid abdomen and barrel chest

bowel sounds in the chest

displaced heart sounds

Laboratory Studies

CBC ABG

electrolytes calcium

glucose


Diagnosis: chest x-ray

• loops of bowel in the

chest

• mediastinal shift

• absent lung markings


IMMEDIATE

Intubation

+

Stomach Decompression


Determinants of Survival

• degree of pulmonary hypoplasia

ipsilateral lung > contralateral lung

• development pulmonary vasculature


Goals of Management

• maximize arterial oxygenation

mechanical ventilation: use low inflating

pressures

increases pulmonary blood flow

• prevention of pain

fentanyl infusion 3-10 mcg/kg/hr

• correction of acidosis

Standard Management Strategy

Reduce pulmonary HTN

Moderate alkalosis

pCO2 < 40 mmHg

PaO2 >100 mmHg


Recent Strategy

• Permissive hypercapnia and hypoxemia

• Pressure-limited ventilation (<25 cmH2O)

• Postductal pCO2 40-65 mmHg

• Preductal SpO2 85-90%

• Postductal SpO2 ignored unless pH is

< 7.20 or pCO2 > 65



Bohn (1986)

reevaluation of the traditional “mad dash” surgical strategy

recommended 24 – 48 hrs medical stabilization

assessment of efficacy of delayed approach

infants unresponsive to initial therapy will fail to survive with surgery or any other treatment including ECMO

The Relationship Between PaCO2 and Ventilation Parameters in Predicting Survival in CHD

• Arterial CO2 accurately reflects the degree of

lung development

• Poor survival in the presence of severe pulmonary hypoplasia

• CO2 retention and severe preductal shunting

have 90% mortality Bohn, DJ, et alBohn, DJ, et alJ of Pedia Surg 19: 666-671, 1884J of Pedia Surg 19: 666-671, 1884



nomogram:

to predict the degree of pulmonary hypoplasia in

the infants and chance of survival

used the preop PaCO2 and an index of ventilation (Vi)

If PaCO2 < 40 and Vi < 1000: survival almost universal

If PaCO2 > 40 and Vi > 1000: death virtually inevitable

Vi = mean airway pressure x respiratory rate ٭


Relationship of Alveolar-arterial Oxygen Tension Difference in Diaphragmatic

Hernia in the Newborn

A-aDO2 on 100% O2

< 400 mmHg: usually survive

400 - 500 mmHg: intermediate chance

> 500 mmHg: unlikely to survive

Harrington J, et al Anesthesiology 56: 473-476,

1982

High Mortality

pH < 7.0

pCO2 >60 mmHg

pO2 < 50 mmHg

Boix-Ochoa J, et al Boix-Ochoa J, et al

J Pediatric Surg 9:49-57, 1974J Pediatric Surg 9:49-57, 1974


Acid Base Balance and Blood Gases in Prognosis and Therapy of CHD

Indications of Surgical Repair

• Reversal of ductal shunting

• O2 index of < 40

• Arterial pCO2 maintainable under

40 mmHg

• Hemodynamic stability




• Look for associated anomalies

• Labs: CBC, electrolytes, ABG, glucose,

blood type and crossmatch

• Ancillary procedures: CXR, Echo

• Venous access: upper extremities

preferred

• Prevention of hypothermia


Intraoperative ManagementIntraoperative Management

Monitors:

ASA standard

invasive : arterial line ± CVP

foley catheter

* 2 pulse oximeters: preductal and postductal

* precordial stethoscope on the right axilla

NGT to decompress the stomach

Adequate IV access



Induction

awake intubation

rapid sequence IV induction and

intubation with assisted or controlled

ventilation

* avoid mask ventilation or PPV before intubation

Supine position, left subcostal incision


IntraoperativeIntraoperative

Maintenance of anesthesia

volatile agents + IV narcotics + muscle relaxants

TIVA

avoid nitrous oxide

avoid increase in PVR leading to R→L shunting:

hypoxia, acidosis, hypothermia, pain

treat metabolic acidosis

replace significant blood loss



Mechanical Ventilation

adjust FiO2 to achieve

PaO2 80 -100 mmHg

SpO2 95 - 98%

small tidal volume to keep airway pressure

< 20-30 cm H2O

high respiratory rate 60-120 /min to

PaCO2 25-30 mm Hg

Surgical repair

primary closure

staged procedure

Transabdominal subcostal incision

Thoracoscopic repair has been reported

Congenital Diaphragmatic HerniaCongenital Diaphragmatic HerniaIntraoperativeIntraoperative



Potential Problems

• Hypoxemia

distension of stomach

1° pulmonary hypoplasia / pulmonary

HTN

• Contralateral pneumothorax

• Hypotension or IVC compression

• Cardiac arrest


Postoperative Care Ventilatory support

Close fluid management

Hemodynamic monitoring

“Honeymoon Period” followed by deterioration

increase abdominal pressure

impaired peripheral and visceral perfusion

limited diaphragmatic excursion

worsening of pulmonary compliance


Management of PPHN

• Minimize ETT suctioning

• Vasodilators : rarely effectivetolazoline isoproterenol PGE1

nitroglycerin SNP

• Inhaled nitric oxideendothelium - derived relaxing factor

(EDRF)

selective pulmonary vasodilation

rapidly metabolized

has not been shown to improve survival

Extracorporeal Membrane Oxygenation (ECMO)

• Use: controversial

• Allows the lungs to develop & restructure

• Expensive

• improved survival in neonates with

> 80% mortality



Criteria for ECMO

• Gestational age ≥ 34 wks

• Reversible disease process present

• Weight ≥ 2000 grams

• Predicted mortality ≥ 80%

estimated by oxygenation index of > 40

FiO2 x mean airway pressure x 100

PaO2


Contraindications

Gestational age < 34 wks

Weight < 2000 grams

Preexisting intracranial hemorrhage (≥ grade II)

Aggressive respiratory treatment > 1 wk

Congenital heart disease

Congenital or neurological abnormality

incompatible with good outcome

TracheoEsophageal Fistula TracheoEsophageal Fistula (TEF)(TEF)

Tracheoesophageal FistulaTracheoesophageal Fistula

Incidence: 1:4000 live births

M > F (25:3)

10-40% are preterm

Antenatal history: polyhydramnios (60%)

Etiology: failure in mesenchymal separation of upper foregut


Clinical Presentation

choking on 1st feed

coughing

cyanosis

excessive salivation

aspiration pneumonia


Diagnosis

• inability to pass a suction catheter

into the stomach

• CXR: coiled orogastric tube in the

cervical pouch; air in the stomach

and intestine

Tracheoesophageal Fistula

Esophageal AtresiaEsophageal Atresia Tracheoesophageal Tracheoesophageal FistulaFistula

Turnage RH, et al, Sabiston Textbook of Surgery,17Turnage RH, et al, Sabiston Textbook of Surgery,17 thth Ed. 2004 Ed. 2004

TracheoEsophageal Fistula

5 Types (Gross and Vogt)

Gregory GA, ed, Pediatric Anesthesia, 3Gregory GA, ed, Pediatric Anesthesia, 3 rdrd edition, edition, 19961996

7.7% 0.8% 86% 0.7% 4.2%


35-65% have associated anomalies

VATER and VACTERL

V vertebral anomalies or VSD

A anorectal malformation

C cardiac anomalies (common)

T TEF

E esophageal atresia

R renal abnormalities

L limb/radial malformation



Minimize pulmonary complication

npo

head-up position

sump tube (repogle) on low continuous suction

± gastrostomy under local anesthesia

CXR, abdominal x-ray, renal ultrasound

12-L EKG and Echocardiogram : mandatory

IV access ± arterial line

Laboratory studies

CBC

Electrolytes

Glucose

Calcium

ABGs





24-48 hr medical stabilization

Antibiotics: ampicillin and gentamicin

Ensure availability of blood in the OR

Optimize volume status and metabolic state

Intubation preferably in the operating room

under controlled situation


Intraoperative Management

Main Concern

oxygenation and ventilation

securing the airway

Monitors

ASA standard

± invasive : arterial line

* precordial stethoscope in the L axillary area

Anesthetic Technique

• “classic approach”

GA without muscle paralysis

• combined light GA + epidural (Bosenberg)

• GA with muscle paralysis





Induction

• awake intubation

• rapid sequence IV induction

• inhalation induction spontaneous

ventilation without muscle

relaxant



Assessment of ETT position

Goal: ETT just above the carina and just below

the fistula

• Right mainstem intubation and withdraw ETT

until bilateral breath sounds

• Left mainstem intubation: poorly tolerated

due to insufficient pulmonary reserve

• If g-tube present, place

end of g-tube under water

seal: ETT above fistula

→ (+) bubbles

• Connect capnograph to

g-tube: (+) ETCO2 if ETT

above the fistula

• ? rigid bronchoscopy

- not proven





Berry FA, Anesthetic Management of Difficult and Routine Pediatric Patients, 2nd Ed. 1990



Beware of gastric distention

gentle positive pressure ventilation

gastrostomy: open if present

TEF + RDS combination

now what???!!

gastrostomy under local anesthesia

fogarty embolectomy catheter



Lateral decubitus position

Posterolateral thoracotomy

Maintenance of Anesthesia

Narcotic technique

Inhalation technique + regional

anesthesia

? Use of nitrous oxide



Surgical repair

• ligation of fistula

check air leak in suture line

• esophageal repair

identify the pouch

placement of feeding tube

• chest tube placement and closure of

thoracic cavity



Intraoperative problems

• Endobronchial intubation

• Intubation of fistula

• Obstruction of ETT

• V/Q mismatch

lateral decubitus position

nondependent lung retraction

• Vagal response to tracheal manipulation

• Return to transitional circulation and shunting


Postoperative Management

Early extubation desirable

caution: disruption of surgical repair with

reintubation

Postop Pain Management

1. IV narcotics

2. epidural infusion: 0.1% bupivacaine +

fentanyl 0.5 mcg/ml at 01.-0.2 ml/kg/hr

3. rectal Tylenol + LA infiltration of incision


Main Cause of Mortality

associated anomalies

survival rates 85-90%

Long Term Complications

GE reflux

anastomotic stricture

tracheomalacia

Abdominal Wall Defects

Gastroschisis

Omphalocoele

Gastroschisis

Greek word for “belly cleft”

Evisceration of gut through a 2-3 cm defect in

the anterior abdominal wall lateral to the

umbilicus, usually on the right

Absence of covering or sac

chemical peritonitis infection

ECF loss heat loss

Incidence: 1:15,000-30,000 live births

Gastroschisis

Etiology

exact cause unknown

Theories

• intrauterine occlusion of omphalo-

mesenteric artery → ischemia and

atrophy of abdominal muscles

• early fetal rupture of an omphalocoele

Gastroschisis

Gastroschisis

• rupture of umbilical cord at the site

of the resorbed right umbilical vein

• ? Maternal: smoking, ETOH,

recreational drugs, medications

(NSAIDS, pseudoephredrine)

• associated anomalies - rare

OmphalocoeleOmphalocoele

Omphalocoele

External herniation of abdominal viscera into

the base of the umbilical cord through a

central defect

Defect: small or large

Umbilical cord is inserted into the apex of the

lesion

Presence of covering or sac (amnion and

peritoneum)

Incidence: 1-5,000-10,000 live births

Omphalocoele

Omphalocoele

Etiology

• incomplete return of the gut to the

abdominal cavity due to an abdominal

lateral fold defect

• Failure of migration and fusion of cranial,

caudal and/or lateral folds of the embryonic

disc at ~ 3rd wk of gestation

Omphalocoele

Cranial Fold : Pentalogy of Cantrell

Epigastric omphalocoele

Sternum cleft

Diaphragmatic defect

Ectopia cordis

Cardiac anomaly

Omphalocoele

Lateral Fold

omphalocoele with cord coming of

the center of the sac

Caudal Fold

Hypogastric omphalocoele

Extrophy of the bladder

Imperforate anus

Colonic agenesis

Vesicointestinal fistula

Omphalocoele

Associated Congenital Anomalies: 75-80%

chromosomal: trisomy 13, 15, 21

cardiac anomalies: 20%

craniofacial

gastrointestinal

Beckwith-Wiedeman Syndromeomphalocoele microcephaly

visceromegaly hypoglycemia

macroglossia hyperviscosity

Pentalogy of Cantrell

Omphalocoele

Survival: 20% with heart disease

70% without heart disease

Major cause of mortality

cardiac defects

prematurity

Definitive Treatment: surgical repair

Gastroschisis Omphalocoele

Incidence 1:15,000-30,000 1:6,000

Peritoneal absent present covering/sac

Location of periumbilical within the umbilical defect cord

Herniated matted, edematous normal bowel Associated low (10-15%) high (40-60%) anomalies intestinal atresia congenital heart dis. (15%) Beckwith-Weidman syndrome

Gastroschisis Omphalocoele

Anesthetic Concerns

• Hydration / fluid status

warm moist sterile saline-soaked gauze

plastic bowel bag

initial fluid requirement 10 -15 ml/kg/hr; higher

with gastroschisis 100-200 ml/kg/hr

• Heat loss : neutral thermal environment

• Difficulties of surgical closure

• Associated congenital anomalies & prematurity

Abdominal Wall DefectsAbdominal Wall Defects

Preoperative ManagementPreoperative Management

• Infection and postop nutrition

• Postoperative ventilation

• Airway

• Metabolic status

• Aspiration precautions

• Direct trauma to herniated organ

Abdominal Wall Defects Preoperative Management

Abdominal Wall Defects Preoperative Management

Lab workup

CBC Electrolytes and Glucose

ABG

Ancillary Procedures

CXR

Echocardiography

Abdominal Wall Defects Intraoperative Management

Premedication: ± atropine

IV access: 2 large bore IVs preferably above the diaphragm

Monitors:

ASA standard : 2 pulse oximeters

invasive: arterial line

± CVP

foley catheter

intraop airway pressures


Choice of Anesthesia

general anesthesia

spinal (reported) in selected patients

Induction

decompress the stomach

rapid sequence IV induction with cricoid

pressure or

inhalation induction and intubation or

awake intubation



• Opiate technique or judicious use of

inhalational agents

• Avoid nitrous oxide

• Adjust FiO2: PaO2 50-70 mmHg

SpO2 97-98% term

87-92% preterm

• Muscle relaxant facilitates abdominal closure

Prevent hypothermia

full access body hugger heating

blanket

increase room temp plastic wrap

fluid warmer

Fluid requirement

maintenance: D5 0.2% NS

3rd space loss replacement

isotonic fluid 10 -15 ml/kg/hr

blood loss from adhesions



Surgical Closure

• optimal method remains controversial

1) primary fascial closure : 80%

± intraop and postop muscle paralysis

2) staged repair

silicone elastometer pouch

primary skin closure

• Closure dependent on the

1) size of the defect

2) development of abdominal wall

3) presence of associated anomalies




Primary Closure

• monitor: airway pressure, O2 saturation and ABG

• tight abdominal closure

1) impairs diaphragmatic excursion

→ ventilatory compromise

2) impedes venous return → profound hypotension

3) aortocaval compression → bowel ischemia, ↓ CO,

renal and hepatic dysfunction, wound

dehiscence


Unsafe for Primary Abdominal Closure

• Intragastric pressure > 20 cmH2O

• Intravesical pressure > 20 cmH2O

• Change in CVP 4 ≥ mmHg

• ETCO2 ≥ 50 mmHg

• Peak inspiratory pressure ≥ 35 cmH2O


Staged Reduction

• Dacron reinforced silastic silo

• Gradual reduction over 1- 2 weeks

• Ketamine or opioid ± muscle relaxant in

intubated patients or

• Titration of ketamine 0.5 -1 mg/kg IV with

spontaneous breathing unintubated infants

• Final closure in the OR


Silo closureSilo closure


To extubate or not to extubate?

• Size of patient

• Intraoperative events

• Prematurity

• Associated pathology

• Hemodynamic status

• Magnitude of the abdominal defect

• Type of repair

Abdominal Wall Defects Postoperative Management

NICU

Postop ventilation in most neonates for 24-48 hrs

Fluid requirements may remain high

Prolonged postop ileus: TPN or PPN

Prevent infection: higher with silo

Watch for circulatory compromise

cyanotic lower limbs

Postop HTN due to ↓ renal perfusion and

activation of renin-angiotensin-aldosterone


Early Postoperative Complications

• Necrotizing enterocolitis

• Renal insufficiency

• Pneumonia

• Abdominal wall breakdown

• PDA

• GE reflux

Necrotizing Necrotizing EnterocolitisEnterocolitis

(NEC)(NEC)

Necrotizing Enterocolitis (NEC)Necrotizing Enterocolitis (NEC)

Life-threatening intestinal inflammation

or injury

Caused by bacterial invasion of previously

injured or ischemic bowel wall

Incidence: 5 -10% in infants <1500g birth

weight

Mortality rate: 10 - 30%

Single most important factor

PREMATURITY

Can occur in:

premature infants

LBW infants

Full term infants

fed and unfed infants


Other factors

ischemia

bacterial infection

GI endotoxemia

enteral feeding

use of hyperosmolar formula

congenital heart disease

hx of umbilical arterial catheterization

hx of exchange transfusion


Early signs

↑ gastric residuals with feedings

temperature instability

poor feeding

bilious vomiting

lethargy

mucoid or bloody stool

apnea and bradycardia


Late Signs

Hemodynamic instability

Anemia

Thrombocytopenia

Coagulopathy, DIC

Prerenal azotemia

Metabolic acidosis

Necrotizing EnterocolitisNecrotizing Enterocolitis

Physical Exam

distended and tender abdomen

Labs:

CBC

electrolytes and glucose

platelets and coagulation profile

DIC profile

ABG


Abdominal X-ray

• signs of bowel obstruction

• ileus with edematous

bowel

• Pneumatosis intestinalis

or intramural air (arrow)

• portal vein air

• pneumoperitoneum


Medical Management

initial treatment, for 7-10 days

75% successful

Surgical Treatment

10 - 50% mortality



Medical Management

• No enteral feedings for 10-14 days

• NGT on intermittent suction

• Hydration and correction of electrolytes

• Ventilatory support

• Antibiotics

• Blood and platelet transfusion if needed


Surgical Indications

• Absolute Indications

1) bowel perforation

new mx: peritoneal drains

under local anesthesia

2) intestinal gangrene

• Relative Indications• clinical condition

metabolic acidosis

respiratory failure

oliguria, hypovolemia

thrombocytopenia

leucopenia, leukocytosis

• air in the portal vein

• bowel wall edema

• persistent dilated bowel loops


Necrotizing Enterocolitis

• Non-Surgical Indications

severe GI hemorrhage

abdominal tenderness

intestinal obstruction

gasless abdomen with

ascites



Anesthetic Concerns

• Fluid/volume status

• Significant 3rd space loss

• Full stomach / pulmonary aspiration

• Metabolic abnormalities

acidosis, hyperglycemia



• Electrolyte imbalance: hyperkalemia

• Coagulopathy: thrombocytopenia

• Respiratory failure

• Sepsis / hemodynamic instability

inotropic support

dopamine infusion

Adequate IV access

Monitors:

ASA standard

invasive: arterial line, ± CVP

foley catheter

Induction

rapid sequence if not intubated




• Narcotic based technique

• Avoid nitrous oxide

• Inhalational agents poorly tolerated

• Massive fluid requirements

• PRBC, FFP and platelets transfusion




• Avoid hypothermia

• Give blood early when indicated

Postop Management

• NICU

• Postop ventilation required

• Continue resuscitation

• Parenteral Nutrition

SummarySummary

• Almost all neonatal surgical “emergencies” Almost all neonatal surgical “emergencies”

are really “urgencies”are really “urgencies”

• Immaturity of organ system in neonates Immaturity of organ system in neonates

alters pharmacology and physiologyalters pharmacology and physiology

• Thorough preop assessment is required in Thorough preop assessment is required in

all neonatesall neonates

• One anomaly mandates a search for othersOne anomaly mandates a search for others

• Murmurs necessitate a cardiology consultMurmurs necessitate a cardiology consult

• Successful perioperative outcome depends Successful perioperative outcome depends on open communication and teamwork on open communication and teamwork between neonatologist, anesthesiologist and between neonatologist, anesthesiologist and surgeonsurgeon

• Initial resuscitation of neonatal surgical Initial resuscitation of neonatal surgical candidates includes:candidates includes:

airway protectionairway protection

adequate IV accessadequate IV access

fluid resuscitationfluid resuscitation

temperature stabilizationtemperature stabilization

gastric decompressiongastric decompression

administration of antibioticsadministration of antibiotics

identify associated anomaliesidentify associated anomalies

Omphalocoele

Embryology

Failure of the midgut to return to the

abdominal cavity by the 10th wk of

gestation

Neonatal Emergencies Joy Loy MD March 2009. 1. 1.discuss the underlying pathophysiology of selected...

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