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Management of an Infant born with Gastroschisis

Antenatal Management:

• Often young maternal age

• Ultrasound: o Usually identified as early as 12 weeks o Defect lateral to umbilicus (usually to the right) o Other abnormalities less likely o Often have oligohydramnios. Polyhydramnios may indicate

intestinal atresia o Note presence of any bowel dilatation

• Counselling with Neonatal and Surgical team Labour and Delivery:

• Notify the Neonatal and Surgical team of impending delivery

• Delivery may be vaginal or by Caesarian section

• Anticipate associated problems (Prematurity, IUGR)

• Prepare for specific management of the defect Delivery Room Management:

• ABC

• If respiratory support is required, intubation and ventilation is preferable to nCPAP to minimize gaseous distension of the gut

• Stabilize the bowels in the midline with doughnut ring

• Wrap the bowels with cling film

• Pass a wide bore orogastric/nasogastric tube to decompress and aspirate the gastric contents

• Avoid unnecessary handling of the bowels Pre-operative Management:

• ABC

• Assess perfusion and give fluid bolus if necessary

• 2 x large bore i.v. cannulae (Avoid veins suitable for long line)

• Avoid unnecessary handling of the bowel

• NG tube to low intermittent suction

• Routine investigation including group and crossmatch

• Vitamin K

• I.V Augmentin, unless additional risk factors for sepsis present (See separate guideline)

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Fluid Management:

Fluid requirements may be greatly increased in the peri-operative period due to evaporative loss from the exposed viscera and third space loss into the abdominal cavity and tissues

• 10% Dextrose maintenance initially

• Change to TPN when possible

• Use normal saline or 4.5% HAS for fluid boluses

• Replace NG losses with 0.45% saline with 1 mmol KCL per 50 ml

• Ensure adequate hydration by monitoring perfusion, urine output and blood pressure

Post-operative Management:

• ABC

• Review fluid management

• Regularly assess hydration status

• Aim for a urine output of at least 1 ml/kg/hr

• Adequate pain relief (morphine, paracetamol)

• Monitor NG losses and replace all losses

• Continue antibiotics as per the Surgical team plan

• Monitor serum electrolytes as necessary

• Place a percutaneous central venous line

• Nutritional support with TPN ( It may take ~4 weeks to establish full feeds)

• Commence enteral feeding when NG aspirates less than 10 ml/kg

• Use EBM for enteral feeding

Family Support:

• Ensure parents are aware of management plans

• Encourage mother to express breast milk

• Orientate family to unit References:

1. M Drewett, GD Michailidis, D Burge. Perinatal Management of Gastroschisis, Early Human Development, 2006

Dr. Jenny Calvert/ Dr. Raju Narasimhan To be re-evaluated June 2009

Alert Surgeons if features of compartment syndrome:

• Metabolic acidosis

• Worsening ventilatory requirements

• Lower limb oedema

• Increasing abdominal distension

• Decreased urine output despite adequate fluid management