Neonatal perioperative resuscitation (NePOR) protocol-An update.

Unexpected cardiac arrest in the perioperative period is a devastating complication. Owing to immaturity of organ systems, and presence of congenital malformations, morbidity and mortality are higher in neonates. There is abundant literature about early recognition and management of perioperative adverse events in children, but similar data and guidelines for surgical neonates is lacking. The current neonatal resuscitation guidelines cater to a newborn requiring resuscitation at the time of birth in the delivery room. The concerns in a newborn undergoing transition from intrauterine to extra uterine life is significantly different from a neonate undergoing surgery. This review highlights the causes and factors responsible for peri-arrest situations in neonates in the perioperative period, suggests preoperative surveillance for prevention of these conditions, and finally presents the resuscitation protocol of the surgical neonate. All these are comprehensively proposed as Neonatal Peri-operative Resuscitation (NePOR) protocol.

Surgical management of necrotising enterocolitis in Sweden: A national cohort study.

AIM: Necrotising enterocolitis (NEC) is the dominating surgical emergency in preterm neonates. The aims were to investigate indications, surgical management and mortality for surgically treated neonates with NEC. METHODS: Data were retrieved from the Swedish Neonatal Quality Register for Swedish neonates with surgically treated NEC from 1 January 2017 to 31 December 2021. Diagnosis was validated by surgical records and histopathology. Neonates with isolated spontaneous intestinal perforation were excluded. RESULTS: In total, 109 neonates were included. Median gestational age was 25 weeks (22-38), and median birth weight was 771 g (269-3920). Preoperative pneumoperitoneum was found in 32%, portal venous gas in 25% and clinical deterioration on conservative treatment in 26% of the neonates. Among the 97 neonates presenting with small bowel necrosis, single-focal NEC occurred in 38 (39%), multifocal NEC in 35 (36%) and panintestinal NEC in 24 (25%). A primary anastomosis was performed in 10/87 (11%) of the neonates with bowel resection at primary surgery. Clip-and-drop technique was applied in 24/87 (28%).Mortality rate was 37%. CONCLUSION: Mortality was well comparable with earlier reports considering exclusion of spontaneous intestinal perforation (SIP) and the low gestational age of the study population. Resection of necrotic bowel with stoma formation was the dominating surgical method.

Evaluation of Risk Factors Affecting Outcome in Outborn Surgical Neonates.

BACKGROUND: Mortality in surgical neonates contributes to neonatal mortality rates. The study was conceptualized to study clinical and nonclinical factors affecting mortality in surgical neonates so that timely intervention could result in improved survival of the neonates. MATERIALS AND METHODS: The study was initiated after approval from the institutional ethics committee and included 120 surgical neonates over a period of 18 months after obtaining consent from the parents/caregivers. Predesigned pro forma was used to record the details of antenatal care received, place of birth, travel history, maternal education and gestational age, and clinical condition at the time of admission. Values of biochemical tests such as serum electrolytes, serum creatinine, and arterial blood gasses were recorded. The need of inotrope support, blood or blood product transfusion, and postoperative ventilator support and intensive care unit (ICU) care was recorded. The results of the two groups, i.e., survivals and mortality, were compared. Outcome was recorded as mortality at 30 days or earlier. RESULTS: Irrespective of the surgical condition, the survival rate was significantly better in those babies who weighed more than 2.5 kg at the time of admission, had capillary refill time of <3 s, had serum ionized calcium levels more than 1 mmol/L, and did not require inotropes, blood or blood product transfusion, and postoperative ICU care and ventilator support. The place of birth, educational status of the mother, gestational age, and distance traveled for care had no statistically significant effect on survival. CONCLUSION: There is a statistically significant correlation between the survival of the babies who weighed more than 2.5 kg and are more physiologically preserved at the time of admission. Mortality rates can be decreased by timely interventions to reduce the need of inotropes, blood or blood products, and ICU care and ventilator support during their postoperative recovery.

La supervivencia en neonatos con afecciones complejas en Cirugía Pediátrica / Neonates' survival from complex conditions after Pediatric Surgery

RESUMEN Introducción: el análisis de supervivencia es uno de los métodos estadísticos más empleado en los estudios clínicos. Objetivo: determinar la influencia de factores de riesgo en la supervivencia de los neonatos con afecciones complejas en Cirugía Pediátrica. Método: en este trabajo se estudiaron los pacientes atendidos en el Centro Regional de Cirugía Neonatal de Holguín, desde el 1ro de enero de 1994 hasta el 31 de diciembre del 2015. El universo estuvo constituido por 382 niños y la muestra por 295, con un tiempo de seguimiento de hasta 28 días. Se analizaron las variables como: peso al nacer, edad gestacional y anomalías asociadas; según los factores de riesgo como: bajo peso al nacer, neonato pretérmino y anomalías asociadas; así como su influencia en la supervivencia. Con la ayuda del paquete estadístico SPSS versión 15 sobre Windows XP, se efectuó el análisis de las curvas de supervivencia por el método Kaplan-Meier, y los factores de riesgo por el método Log-Rank. Resultados: del total de la muestra (n=295), se obtienen 66 neonatos con nacimiento pretérmino (22,4%), 82 con bajo peso al nacer (27,8%) y 154 con anomalías asociadas (52,2%); siendo este el factor de riesgo predominante. En dichos pacientes, se aprecia un alto número de eventos con influencia en su supervivencia, durante el seguimiento del período neonatal. El evento final ocurrió en 61 neonatos (20,7%). La media en el tiempo de supervivencia de los neonatos con afecciones complejas en Cirugía Pediátrica fue de 23 días. Conclusiones: en la supervivencia de los pacientes influyeron los factores de riesgo estudiados. La sepsis severa fue la causa directa de muerte que predominó.

ABSTRACT Introduction: survival study is one of the most used statistical methods in the clinical field. Objective: to determine the influence of risk factors over neonates´ survival form complex conditions after Pediatric Surgery. Method: in this work we studied patients attended in the Regional Center of Neonatal Surgery of Holguín, from January 1st, 1994 to December 31st, 2015. Universe was 382 neonates and the sample was 295, monitored during 28 days. Analyzed variables were: birth weight, gestational age and associated anomalies; according to its risk factors like: low birth weight, preterm neonates and associated anomalies, as well as their influence on neonates 'survival. By the use of statistical package SPSS version 15 on Windows XP, survival curves were analyzed by the Kaplan-Meier method and the risk factors by Log-Rank. Results: of the total sample (n=295) 66 neonates were preterm births (22.4%); 82 low birth weight (27.8%) and 154 showed associated anomalies (52.2%) as the main risk factor. Patients studied showed high numbers of events and their influence on survival during neonatal period. The final event occurred to 61 neonates (20.7%). Conclusions: risk factors studied were influenced by patients´ survival and the direct cause of death was severe sepsis.

A Pilot Study on Neonatal Surgical Mortality: A Multivariable Analysis of Predictors of Mortality in a Resource-Limited Setting.

PURPOSE: The aim of this research is to study the predictors of neonatal surgical mortality (NSM)-defined as in-hospital death or death within 30 days of neonatal surgery. MATERIALS AND METHODS: All neonates operated over the study period of 18 months were included to evaluate NSM. The evaluated preoperative and intraoperative variables were birth weight, gestation age, age at presentation, associated anomalies, site and duration of surgery, intraoperative blood loss, and temperature after surgery. Assessed postoperative variables included the need for vasopressors, postoperative ventilation, sepsis, reoperations, and time taken to achieve full enteral nutrition. Univariate and multivariate logistic regression was applied to find the predictors of mortality. RESULTS: Based on patient's final outcome, patients were divided into two groups (Group 1-survival, n = 100 and Group 2-mortality, n = 50). Incidence of NSM in this series was 33.33%. Factors identified as predictors of NSM were duration of surgery >120 min (P = 0.007, odds ratio [OR]: 9.76), need for prolonged ventilation (P = 0.037, OR: 5.77), requirement of high dose of vasopressors (P = 0.003, OR: 25.65) and reoperations (P = 0.031, OR: 7.16 (1.20-42.81). CONCLUSION: NSM was largely dependent on intraoperative stress factors and postoperative care. Neonatal surgery has a negligible margin of error and warrants expertize to minimize the duration of surgery and complications requiring reoperations. Based on our observations, we suggest a risk stratification score for neonatal surgery.

Low birthweight, gestational age, need for surgical intervention and gram-negative bacteraemia predict intestinal failure following necrotising enterocolitis.

AIM: Necrotising enterocolitis (NEC) is associated with high morbidity and mortality. The aim of this study was to identify predictors of intestinal failure (IF), morbidity and mortality following NEC. METHODS: We performed a retrospective study of all neonates treated for NEC stage II or greater at a tertiary referral NICU between 2000 and 2009. Demographic data, need for surgery, residual bowel length and rates of bacteraemia, cholestasis, IF and mortality were analysed. RESULTS: During the 10-year period, 301 patients were referred with NEC and 152 had surgical intervention. Overall mortality was 32%. Of the 230 infants who survived >42 days, 97 (42%) had IF at 42 days, decreasing to 15% at >90 days. The rate of IF was significantly higher in the surgical group than the medical group (OR 2.04, 95% CI, 1.25-3.35, p < 0.004), but 23% of the medically treated infants with NEC also developed IF. There was a significant relationship between IF and gram-negative bacteraemia, the need for surgery, cholestasis, liver failure and mortality. CONCLUSION: Intestinal failure occurred in a significant proportion of infants with NEC. Predictors for IF among infants with NEC were low birthweight, low gestational age, need for surgical intervention and gram-negative bacteraemia.

Prognostic factors determining mortality in surgical neonates.

BACKGROUND: To assess the prognosis of surgical neonates at admission and the factors responsible for mortality in neonates. MATERIAL AND METHODS: A prospective study was conducted in a tertiary level hospital over 15 months and various clinical and biochemical parameters were collected and analyzed using STATA(®) and SPSS(®). RESULTS: On multivariate analysis of 165 neonates, early gestational age, respiratory distress and shock at presentation were the factors of poor prognosis in neonates. The factors could be related to poor antenatal care and sepsis acquired before transfer of the baby to the nursery. CONCLUSION: The improvement in antenatal care and asepsis during transfer and handling the babies is of utmost importance to improve the prognosis of surgical neonates.