CHHS15/084

Canberra Hospital and Health ServicesClinical ProcedureNeonatal SurgeryContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Alerts.........................................................................................................................................2

Section 1 – Gastroschisis/ Omphalocele...................................................................................2

Section 2 – Tracheoesophageal Fistula (TOF)/Oesophageal Atresia.........................................5

Section 3 – Neonatal Surgery-Pre & Post Operative Care.........................................................7

Implementation........................................................................................................................ 9

Related Policies, Procedures, Guidelines and Legislation.........................................................9

References.............................................................................................................................. 10

Definition of Terms................................................................................................................. 10

Search Terms.......................................................................................................................... 11

Doc Number Version Issued Review Date Area Responsible PageCHHS15/084 V1 5/3/2015 5/3/2019 Paediatrics and

Neonatology1 of 11

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/084

Purpose

The purpose of this document is to outline the safe and effective management of infants born with Gastroschisis, Omphalocele and Tracheoesophageal Fistula.

Scope

This document pertains to all babies nursed in the NICU at Canberra HospitalThis document applies to: Medical Officers Nurses and Midwives who are working within their scope of practice (Refer to Scope of

Practice for Nurses and Midwives Policy) Student Nurses under direct supervision.

Alerts

Strict hand hygiene should be adhered to at all times when performing all clinical procedures as per CH&HS Hand Hygiene SOP CED 11-50

Patient Identification-Correct Patient, Correct Site, and Correct Procedure- SOP CH&HS CED11-26 must be performed prior to all surgical procedures.

Call for time to check outo Correct patiento Correct siteo Correct procedure

With all staff and parents if they are present as per hospital protocol

Section 1 – Gastroschisis/ Omphalocele

BackgroundGastroschisis is a congenital anterior wall defect with the uncovered abdominal contents protruding through the defect. The defect is usually to the right of the normal umbilical cord. Usually the small and large intestine protrude through the defect but other abdominal organs may as well.Reduction of the abdominal contents by manual reduction, stoma or laparotomy should occur within four to six hours of birth as the neonate is at risk of water and heat loss from the exposed bowel plus compromised intestinal circulation with ischemia and infarction.

Omphalocele, also known as exomphalos, is a type of abdominal wall defect in which the intestines, liver and occasionally other organs remain outside of the abdomen in a sac because of a defect in the development of the muscles of the abdominal wall. The sac,

Doc Number Version Issued Review Date Area Responsible PageCHHS15/084 V1 5/3/2015 5/3/2019 Paediatrics and

Neonatology2 of 11

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/084

which is formed from an out pouching of peritoneum, protrudes in the midline, through the umbilicus.

Management in BirthingEquipment Alcohol Based Hand Rub (ABHR) Open care centre to facilitate access or incubator for extremely premature infant. 8FG gastric tube (length 100cms)and associated tapes/wipes IV fluids as ordered-have volume expanders on hand. Waterproof material such as bowel bag or polyethylene film wrap

Procedure The defect should be placed inside polyethylene wrap. Lie infant on right side with defect supported by bedding to prevent traction/pressure

or supine with displaced bowel directly over wound site enclosed in donut shape roll Inspect for colour and perfusion of gastrointestinal organs through wrap Umbilical cord should be left long (~4 cm) and should preferably not be accessed for

umbilical catheters A large bore orogastric tube (8Fg) must be inserted as soon as possible after birth,

aspirated regularly (15 minutely) and left on free drainage

Alert: Do not use gauze or Saline on bowel as lint will adhere to the bowel and saline will promote further heat loss and increase potential for infection with the frequent need to moisten the dressing and observe the wound

Stabilisation of baby prior to either surgical management or manual reduction:1. Ensure surgical consult has been sought as soon as possible 2. Connect baby to ECG monitor, BP monitoring and pulse oximeter3. Insert intravenous (IV) cannula and collect blood for pathology (FBC, Type & X-match,

CRP, Blood Culture, NICP & BGL)4. Insert a Peripheral arterial line for blood sampling as heel pricks should be avoided5. Start fluids at 60 ml/kg/day or as ordered6. Assess pain using the pain scale. Commence pain relief as ordered7. Continue to aspirate NGT 15 minutely + PRN8. Maintain normothermia 9. If possible, take photos of the baby or bring the parent/s in to see and touch their baby

and update parents on the subsequent treatment 10. Paediatric Surgeon will inspect and assess the bowel after the patient is stabilised11. Commence IV dextrose 10% at a rate to accommodate insensible fluid loss, as fluid

requirements may be two to three times greater than normal. Monitor blood glucose level 6 hourly

12. Monitor for hypo perfusion, hypotension and/ or metabolic acidosis. If present consider normal saline bolus or Inotrope infusion

13. Consider prophylactic antibiotics after collecting blood cultures14. Examine infant for associated anomalies

Doc Number Version Issued Review Date Area Responsible PageCHHS15/084 V1 5/3/2015 5/3/2019 Paediatrics and

Neonatology3 of 11

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/084

15. Organise X-rays as required

Alert: If possible avoid placing IV lines in lower extremities due to potential for post-operative inferior vena cava compression.

16. Measure strict urine output. (urinary catheter or weigh nappies) Test urine each shift for specific gravity whilst defect is exposed.

17. Assess for signs of hypovolemic shock 18. Monitor hourly:

o Temperatureo Heart Rateo Respiratory Rateo Blood Pressure (3)

19. Frequently assess intestinal perfusion and capillary perfusion to lower limbs as pressure on the inferior vena cava may cause compromise

20. Provide parents with explanations of equipment and procedures and answer questions21. If the baby is for Operating Theatre (OT), ensure preparation for theatre is complete as

per Preparation for operating theatre policy.

Manual Reduction of Gastroschisis The manual reduction of the gastroschisis may occur in OT, in Birthing or in the NICU

Equipment Comfeel wipes x4 Alcowipes x4 UAC/UVC insertion pack Green drapes (warmed) Powder free gloves – size 8 Sterile gowns x2 Warmed Normal Saline for irrigation of bowel-bottle/ ampoules Sterile gauze squares x4 Silk tie or sterile white tie to put around umbilical stump

Procedure1. Place a large disposable sheet on the open care system to absorb losses and irrigation

fluids2. During the procedure the infant will be monitored, provided with pain relief and IV fluid 3. Remove wet and cold bedding immediately post procedure4. Manage pain according to pain scale

Post Surgical/manual Reduction Care1. Monitor haemodynamic status by assessing skin colour and blood pressure2. Observe for development of abdominal compartment syndrome and report to medical

officer. This includes the following symptomso Tense and possibly tender abdomen

Doc Number Version Issued Review Date Area Responsible PageCHHS15/084 V1 5/3/2015 5/3/2019 Paediatrics and

Neonatology4 of 11

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/084

o Discolouration of abdominal wall and lower limbs o Requirement of higher dose of morphineo Progressive worsening of metabolic and or respiratory acidosis verified by arterial

blood gaseso Hypotension requiring inotrope supporto Decreased or absent urine output

3. Continue IV antibiotics as ordered 4. Measure electrolytes and FBC 8 hours post-op or as indicated5. Record and replace Nasogastric losses with IV fluids as ordered 6. Manage pain according to pain scale7. Feeds are commenced when gastric losses are minimal as per Paediatric Surgeon

Infant with Gastroschisis

Back to Table of Contents

Section 2 – Tracheoesophageal Fistula (TOF)/Oesophageal Atresia

BackgroundFailure of the normal development of the oesophagus and separation of the trachea from the oesophagus results in a spectrum of anomalies that can result in one of the following: Oesophageal atresia and distal tracheoesophageal fistula Isolated oesophageal atresia Isolated tracheoesophageal fistula Oesophageal atresia with proximal or proximal and distal tracheoesophageal fistula

Infants can present with the following signs and symptoms: Copious secretions post delivery Inability to swallow feedsDoc Number Version Issued Review Date Area Responsible PageCHHS15/084 V1 5/3/2015 5/3/2019 Paediatrics and

Neonatology5 of 11

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/084

Coughing and choking with feeds Aspiration of feeds/secretions Inability to pass an oro/naso gastric tube

Tracheoesophageal Fistula (TOF)/ Oesophageal Atresia ManagementEquipment1. Feeding tube2. Replogle tube3. Normal saline4. Securing tapes

Method1. If an infant presents with signs of oesophageal atresia or a tracheoesophageal fistula an

attempt should be made to gently pass a size 6, 8 or 10Fg feeding tube depending on the size of the infant, this must only be done by a registered nurse.

2. If this is met with resistance an X-ray should be ordered with the feeding tube in place3. If the X-ray is indicative of an OA or TOF then follow the steps below

Preoperative Care1. Follow standard steps for preoperative care see Section 4 of this document Surgery in

the NICU or Operating Theatre2. Elevate the head of the radiant heater bed or incubator – this is maintained at all times

even during x-rays to prevent gastro-oesophageal reflux/ aspiration into the trachea via fistula

3. Replogle tube is inserted to provide adequate drainage of the upper pouch o Place infant in the supine positiono Gently insert the tube over the tongue until resistance is felt o Connect syringe to tube and aspirate pouch contents

4. Secure the replogle tubeo Mark the correct position with a texta at corner of moutho Secure with tapes o Skin must be free of undue pressure

5. Connect tubing to the wall suction and gently increase the suction to achieve a flow of secretions through the tube, no more than 15KP - there must be a continuous flickering movement of fluid within the tube

6. Flush with normal saline every 15 to 30 minutes 7. Extra flushes may be needed if Replogle tube shows signs of blocking8. Observe for abdominal distension – there may be excessive abdominal distension from

ventilation of the stomach through the distal fistula 9. Ensure the infant remains nil by mouth10. Evaluate for other anatomical anomalies that may be associated with TOF for e.g.

VACTERYL syndrome

Post Operative Care1. Follow standard steps for post operative care see Section 4of this Operating Procedure

Doc Number Version Issued Review Date Area Responsible PageCHHS15/084 V1 5/3/2015 5/3/2019 Paediatrics and

Neonatology6 of 11

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/084

2. Infant is nursed with head up to prevent gastric contents going over the anastomosis suture line

3. The infant will generally have a nasogastric tube placed in theatre which acts as a stent for the oesophageal repair

Alert: Under no circumstances should the tube be removed without the surgeons permission or feeds to be administered until ordered by the surgeon or medical staff

4. If the nasogastric tube inserted in theatre is accidentally dislodged. DO NOT reinsert the tube and notify the surgeon immediately

5. Measure and record gastric aspirates which may be replaced if excessive6. Suctioning - carefully measure the required length of the suction catheter

Alert: Do not suction past the end of the ETT

7. The initiation of feeds will be determined by the Surgeon in consultation with the Neonatologist

8. A contrast study to evaluate the anastomosis will be performed within the first week

Prior to Discharge Home, ensure the following: Follow-up arranged with paediatric surgeon Follow-up arranged with a general paediatrician Follow-up arranged with Genetics Team if required

Back to Table of Contents

Section 3 – Neonatal Surgery-Pre & Post Operative Care

PurposeSurgical procedures can be performed within the neonatal intensive care unit (NICU) in the Procedure room, or in the Hospital Operating Theatres. Surgery in the NICU is performed only on neonates whose condition will not allow them to be transferred safely to the Operating Theatres or those that are having Laser Surgery for ROP

Procedure

Equipment Open care centre Warming blanket (kept in the cupboard in the Procedure room) Blood/ fluids as ordered Patient notes and medication chart X-rays or scans

Method – Surgery in NICU1. Inform the parents of the need for surgeryDoc Number Version Issued Review Date Area Responsible PageCHHS15/084 V1 5/3/2015 5/3/2019 Paediatrics and

Neonatology7 of 11

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/084

2. Ensure parental consent has been obtained and consent has been signed3. Anaesthetist is to complete a pre-anaesthetic assessment of the infant and discussion

with the parents4. Transport infant to the NICU procedure room. If infant ventilated utilise portable

Neopuff (kept in Special Care Nursery) to ventilate infant in transit5. Theatre staff will bring all equipment with them to the NICU6. Ensure any special equipment is available7. Place the infant on the open care centre on the warming blanket 8. Ensure availability of X-rays and ultrasound reports9. Check blood is X-matched and available10. Withhold oral medications unless otherwise directed11. Fast infants for four hours prior to surgery (if time permits)12. Ensure I.V. access is available in addition to PICC line13. The PICC line should be reserved for maintenance fluids-it should be clearly identified 14. Complete the pre-op checklist15. Check correct ID bands (2) 16. Site to be marked by person performing the procedure17. The infant is continuously monitored throughout the procedure18. Ensure thermoregulation, fluid and ventilation needs are met19. Post procedure, assist the theatre staff to position the infant according to

developmental guidelines20. Allow parents to see their infant as soon as possible following procedure21. Only essential equipment, personnel and monitoring to remain in the NICU procedure

room

Method for Operating theatre1. Inform the parents of the need for surgery including time2. Anaesthetist is to do a pre-anaesthetic assessment of the infant and discussion with the

parents3. Obtain consent as per TCH correct patient, correct site, correct procedure protocol and

operational procedure (five step protocol)4. Ensure availability of X-rays and ultrasound reports5. Check blood is X-matched and available6. Withhold oral medications unless otherwise directed7. Fast neonates for 4 hours prior to surgery (if time permits)8. Check I.V. access is available and patent9. PIC lines should only be used for maintenance fluids or continuous infusion, not for

bolus medications. 10. Peripheral IV access should be established before the procedure for bolus medications. 11. Perform any other procedures as necessary including the pre-op checklist12. Check correct ID bands 13. If the infant is having routine surgery they may be able to be transported to theatre in

an open cot with Saturation monitoring. Portable oxygen and Laerdal Bag should be attached to the cot

14. Prepare Transport Cot if required as per check list

Doc Number Version Issued Review Date Area Responsible PageCHHS15/084 V1 5/3/2015 5/3/2019 Paediatrics and

Neonatology8 of 11

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/084

15. Place infant in transport cot ready for transport with notes/documentation16. Escort the infant to theatre and hand over to peri operative staff as per the 5 step

protocol17. Staff member must stay in operating theatre to advocate for the high risk infant 18. Ensure infant’s temperature is maintained between 36.5 and 37.50C19. Ensure fluids are accurately recorded20. Ensure ventilation needs are met and assist with intubation and securing the ETT if

required21. Ensure oxygen saturations are maintained between 88-95%22. Assist the theatre staff to transfer the infant back to the transport cot at conclusion of

the surgery23. On return to NICU/SCN, position the neonate according the developmental guidelines

or ventilation, post surgical needs24. Allow parents to see their infant as soon as possible following the procedure and

discussion regarding outcome of surgery should occur as soon as possible

Back to Table of Contents

Implementation

This Clinical Procedure will be communicated to staff working in the NICU/SCN during Orientation for new staff. Also those staff undertaking the New Graduate Program, the Transition Program or the Graduate Diploma in NICU/SCN Nursing will be informed of its existence during lectures relating to the topic.

Back to Table of Contents

Related Policies, Procedures, Guidelines and Legislation

ProceduresCH&HS Hand Hygiene SOP CED 11-50CH&HS Patient Identification SOP CED11-26

Back to Table of Contents

References

Askin DF & King J. (2003) Gastroschisis: Etiology, Diagnosis, Delivery Options, and Care. Neonatal Network. Vol 22 No 4 pp 7-12

Butler R, Sundem T & Williams T. (2003) Management of the Infant with Gastroschisis: A Comprehensive Review of the Literature. Newborn and Infant Nursing Reviews. Vol 3 No 2 pp 55-63

Doc Number Version Issued Review Date Area Responsible PageCHHS15/084 V1 5/3/2015 5/3/2019 Paediatrics and

Neonatology9 of 11

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/084

Caldwell AD, Jason P & Lockridge T. (2002) Neonatal Surgical Emergencies: Stabilization and Management. JOGNN. Vol 31 No 3 pp 328-337

Kimble RM, Singh SJ, Bourke C and Cass DT. Gastroschisis reduction under analgesia in the Neonatal Unit. Journal of Paediatric Surgery 2001: 36(11):1672-4.

Ho, T. & Mok, J. (2006) The infant with a long gap oesophageal atresia: A case report. Journal of Neonatal Nursing 12(3) 103-109

Hawley, A. (2001) Long gap oesophageal atresia: A nursing perspective. Journal of child health care. 5(1) 19-25

Verklan, M.T., & Walden, M. (2010). Core curriculum for neonatal intensive care nursing (4th Ed). St. Louis: Elsevier Saunders.Al-Shanafey, S. & Harvey, J. (2008) “Long gap esophageal atresia: an Australian experience” Journal of Pediatric Surgery 43(4) 597-601

Gustavo Stringel, G., Lawrence, C. & McBride, W. (2010) “Repair of long gap esophageal atresia without anastomosis” Journal of Pediatric Surgery 45(5) 872-875

Clarkson, L. (2002) Retinopathy of Prematurity Part 2. Current Treatment Options Journal of Neonatal Nursing 8 (1) 7 – 10

Back to Table of Contents

Definition of Terms

Tracheo-oesophageal fistulaA congenitally acquired communication between the oesophagus and the trachea.

Replogle tubeA tube which is inserted into the blind pouch of the oesophagus which provides continuous low suction.

VACTERYL syndromeA congenitally acquired sequence of anomalies affecting the vertebrae, anus, cardiac system, trachea, oesophagus , renal (urinary tract) and limbs.

Back to Table of Contents

Search Terms

Neonatal Surgery, Gastroschisis, Omphalocele, Tracheoesophageal Fistula, TOF,

Back to Table of ContentsDoc Number Version Issued Review Date Area Responsible PageCHHS15/084 V1 5/3/2015 5/3/2019 Paediatrics and

Neonatology10 of 11

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/084

Disclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

(to be completed by the HCID Policy Team)Date Amended Section Amended Approved By16 December 2017 Removed section on laser surgery

for ROP. This is now included in ROP Screening and Treatment

CHHSPC

Doc Number Version Issued Review Date Area Responsible PageCHHS15/084 V1 5/3/2015 5/3/2019 Paediatrics and

Neonatology11 of 11

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register