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Prediction of successful primary closure of congenital abdominal wall defects using intraoperative measurements
M Yaster1, T L Scherer, M M Stone
1Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD 21205.
Insights
Intraoperative measurements of intragastric pressure (IGP) and central venous pressure (CVP) reliably predict successful primary closure for congenital abdominal wall defects in newborns. These vital signs guide surgeons, preventing complications and ensuring positive outcomes.
Area of Science:
- Pediatric Surgery
- Neonatal Intensive Care
- Surgical Physiology
Background:
- Congenital abdominal wall defects, such as omphalocele and gastroschisis, require careful surgical management in neonates.
- Predicting successful primary closure is crucial to avoid complications associated with increased intra-abdominal pressure.
Purpose of the Study:
- To evaluate intragastric pressure (IGP) and central venous pressure (CVP) as predictors for successful primary closure of abdominal wall defects in newborns.
- To establish an intraoperative management protocol based on IGP and CVP monitoring.
Main Methods:
- A prospective protocol was developed involving temporary fascial closure and monitoring of IGP and CVP.
- Primary closure was performed if IGP was < 20 mm Hg or CVP increase was < 4 mm Hg.
- Prosthetic silo placement was used if IGP was > 20 mm Hg or CVP increase was > 4 mm Hg.
Main Results:
- Eight of ten neonates (average weight 2.7 kg, 37 weeks gestation) met criteria for and underwent primary closure.
- Infants with primary closure had an average IGP of 14 +/- 4 mm Hg and CVP increase of 1 +/- 2 mm Hg.
- Two infants requiring staged repair had higher average IGP (25 +/- 1 mm Hg) and CVP increase (7 +/- 1 mm Hg).
- No postoperative complications related to intra-abdominal pressure were observed in either group.
- All patients were extubated within 48 hours.
Conclusions:
- Intraoperative monitoring of IGP and CVP changes reliably guides the surgical management of congenital abdominal wall defects.
- This approach effectively predicts successful outcomes following primary repair or staged closure.
Abstract:
To determine whether intragastric pressure (IGP) and central venous pressure (CVP) would reliably predict successful primary closure of congenital abdominal wall defects (omphalocele/gastroschisis) in newborn infants, we developed the following prospective intraoperative management protocol. Following a temporary trial of fascial closure, infants who had an IGP less than 20 mm Hg or an increase in CVP of less than 4 mm Hg were primarily closed. If IGP was greater than 20 mm Hg or if CVP increased by more than 4 mm Hg, the temporary closure of the abdomen was reopened and a prosthetic silo was placed. Ten infants who were less than 24 hours old and averaged 2.7 kg (range, 1.4 to 4.2 kg) and 37-weeks gestation (range, 32 to 41 weeks) were studied. Eight infants met criteria for primary closure. Their IGP averaged 14 +/- 4 mm Hg (+/- SD) (range, 8 to 19 mm Hg), and their increase in CVP averaged 1 +/- 2 mm Hg (range, -2 to 3 mm Hg). In the two infants who required staged repair, IGP averaged 25 +/- 1 mm Hg (+/- SD) (range, 24 to 25 mm Hg), and the increase in CVP averaged 7 +/- 1 mm Hg (range, 6 to 8 mm Hg). All patients were anesthetized with fentanyl (12.5 micrograms/kg) and paralyzed with metocurine (0.3 mg/kg) intraoperatively. There were no postoperative complications in either group of patients related to increased intraabdominal pressure, and all patients were extubated within 48 hours of the initial surgery. We conclude that the intraoperative measurement of changes in IGP and CVP can serve as a guide to the operative management of congenital abdominal wall defects and can reliably predict successful outcome following repair.