Neonatal pneumoperitoneum - The surgeon could wait awhile
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《美国医学杂志》
Department of Anaesthesiology and Intensive Care,Government Medical College and Hospital,Sector 32,Chandigarh, India
Pneumoperitoneum is a rare complication which occurs in about 1% of mechanically ventilated children in intensive care units.[1] We report the case of a 35-week, 2.3-kg premature male neonate with respiratory distress for congenital pneumonia. He was started on mechanical ventilation at 9 hours of life, developed septicemic shock at 12 hours of life, and was put on ventilatory support with synchronized intermittent mandatory ventilation (SIMV) with pressure support ventilation (PSV), and the peak inspiratory pressure (PIP) with peak end expiratory pressure was 18/4. At 25 hours of life, he developed bilateral pneumothorax confirmed by chest X-ray. Bilateral intercostal drainage tubes (ICD) were inserted and his oxygen saturation (SpO2) was noted to be 95%.
The patient's abdomen was soft and he passed meconium at about 28 hour of his life. Another chest X-ray after 2 hours revealed bilateral pneumothorax with gas under the diaphragm. Pediatric surgeons decided for emergency laparotomy with a provisional diagnosis of gut perforation. His general condition was poor even with IV dopamine 12.5 mg/kg/min. His SpO2 was 90-92% on FiO2 of 1, with ventilatory support. On auscultation, there was bilateral rhonchi and his blood gasses were grossly deranged. The abdomen remained soft and there was 1 ml of bilious aspirate from the Ryle's tube. Considering the poor general condition of the child and the possibility of pneumoperitoneum associated with pneumothorax, it was decided to continue the child on supportive management. Alternative provision of surgical exploration was kept in case the abdominal findings deteriorated any further.
The patient was continued on supportive management with antibiotics and ventilatory support. After 6 hours his SpO2 was 97% with FiO2 of 0.8. Bilateral ICD tubes were found to be working. His ventilatory settings were changed to PIP/PEEP of 16/7 with FiO2 of 0.5. A subsequent chest X-ray PA view revealed absence of pneumoperitoneum, although his right-sided pneumothorax persisted. The child was maintained with same line of management for the next five days, and he was gradually weaned off the ventilatory and inotropic support. He was discharged from the neonatal intensive care unit on the 8th day.
Pneumoperitoneum, most often occurring after the rupture of an abdominal viscus, may also be secondary to barotrauma in ventilated neonates, especially with severe respiratory disease.[2] Subdiaphragmatic air arouses clinical suspicion of ruptured abdominal viscus wherein peritoneal lavage may help.[3] Operating upon a very sick neonate in such a case could be life threatening and counterproductive.[4] Had we not taken an alternative decision of a 'non surgical attitude'[5], with the option of the surgery depending upon the deteriorating clinical findings - we would not have been able to save the neonate. Clinical awareness and proper vigilance in this regard can go a long way in averting life threatening situations in this already at-risk group of patients.
References
1. Benjamin PK, Thompson JE, O'Rourke PP. Complications of mechanical ventilation in a children's hospital multidisciplinary intensive care unit. Respir Care 1990; 35: 873-878.
2. Briassoulis GC, Venkataraman ST, Vasilopoulos AG, Sianidou LC, Papadatos JH. Air leaks from the respiratory tract in mechanically ventilated children with severe respiratory disease. Pediatr Pulmonol 2000; 29: 127-134.
3. Rommelsheim K, Kalbhenn E, Franken T. Pneumoperitoneum induced by artificial respiration and its diagnosis by peritoneal lavage. Prakt Anaesth 1979; 14: 174-181.
4. Andrew TA, Milne DD. Pneumoperitoneum associated with pneumothorax or pneumopericardium: a surgical dilemma in the injured patient. Injury 1979; 11: 65-70.
5. Martinez Banos A, Segura MD, Galicia Negrete H, Lozano Gonzalez CH. Massive pneumoperitoneum secondary to barotrauma in a newborn infant. Bol Med Hosp Infant Mex 1981; 38: 649-656.(Mitra Sukanya, Gombar Kan)
Pneumoperitoneum is a rare complication which occurs in about 1% of mechanically ventilated children in intensive care units.[1] We report the case of a 35-week, 2.3-kg premature male neonate with respiratory distress for congenital pneumonia. He was started on mechanical ventilation at 9 hours of life, developed septicemic shock at 12 hours of life, and was put on ventilatory support with synchronized intermittent mandatory ventilation (SIMV) with pressure support ventilation (PSV), and the peak inspiratory pressure (PIP) with peak end expiratory pressure was 18/4. At 25 hours of life, he developed bilateral pneumothorax confirmed by chest X-ray. Bilateral intercostal drainage tubes (ICD) were inserted and his oxygen saturation (SpO2) was noted to be 95%.
The patient's abdomen was soft and he passed meconium at about 28 hour of his life. Another chest X-ray after 2 hours revealed bilateral pneumothorax with gas under the diaphragm. Pediatric surgeons decided for emergency laparotomy with a provisional diagnosis of gut perforation. His general condition was poor even with IV dopamine 12.5 mg/kg/min. His SpO2 was 90-92% on FiO2 of 1, with ventilatory support. On auscultation, there was bilateral rhonchi and his blood gasses were grossly deranged. The abdomen remained soft and there was 1 ml of bilious aspirate from the Ryle's tube. Considering the poor general condition of the child and the possibility of pneumoperitoneum associated with pneumothorax, it was decided to continue the child on supportive management. Alternative provision of surgical exploration was kept in case the abdominal findings deteriorated any further.
The patient was continued on supportive management with antibiotics and ventilatory support. After 6 hours his SpO2 was 97% with FiO2 of 0.8. Bilateral ICD tubes were found to be working. His ventilatory settings were changed to PIP/PEEP of 16/7 with FiO2 of 0.5. A subsequent chest X-ray PA view revealed absence of pneumoperitoneum, although his right-sided pneumothorax persisted. The child was maintained with same line of management for the next five days, and he was gradually weaned off the ventilatory and inotropic support. He was discharged from the neonatal intensive care unit on the 8th day.
Pneumoperitoneum, most often occurring after the rupture of an abdominal viscus, may also be secondary to barotrauma in ventilated neonates, especially with severe respiratory disease.[2] Subdiaphragmatic air arouses clinical suspicion of ruptured abdominal viscus wherein peritoneal lavage may help.[3] Operating upon a very sick neonate in such a case could be life threatening and counterproductive.[4] Had we not taken an alternative decision of a 'non surgical attitude'[5], with the option of the surgery depending upon the deteriorating clinical findings - we would not have been able to save the neonate. Clinical awareness and proper vigilance in this regard can go a long way in averting life threatening situations in this already at-risk group of patients.
References
1. Benjamin PK, Thompson JE, O'Rourke PP. Complications of mechanical ventilation in a children's hospital multidisciplinary intensive care unit. Respir Care 1990; 35: 873-878.
2. Briassoulis GC, Venkataraman ST, Vasilopoulos AG, Sianidou LC, Papadatos JH. Air leaks from the respiratory tract in mechanically ventilated children with severe respiratory disease. Pediatr Pulmonol 2000; 29: 127-134.
3. Rommelsheim K, Kalbhenn E, Franken T. Pneumoperitoneum induced by artificial respiration and its diagnosis by peritoneal lavage. Prakt Anaesth 1979; 14: 174-181.
4. Andrew TA, Milne DD. Pneumoperitoneum associated with pneumothorax or pneumopericardium: a surgical dilemma in the injured patient. Injury 1979; 11: 65-70.
5. Martinez Banos A, Segura MD, Galicia Negrete H, Lozano Gonzalez CH. Massive pneumoperitoneum secondary to barotrauma in a newborn infant. Bol Med Hosp Infant Mex 1981; 38: 649-656.(Mitra Sukanya, Gombar Kan)