(体外膜肺ECMO课件)-Blood-and-Neoplastic.ppt
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- 体外膜肺ECMO课件 体外 ECMO 课件 Blood and Neoplastic
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1、Eric L.Lazar,MD MS FACS FAAPSURGICAL TOPICSV:Fetus and NewbornB.Abnormal newborn4.Conditions and Diseases k.Recognition and stabilization of surgical conditions l.NEC m.intestinal obstruction n.TEF o.abdominal wall defectsVI:Fluid and Electrolyte MetabolismD.1.pyloric stenosisCONTENT OUTLINEXII:Gast
2、rointestinal A.Abdominal Pain,Acute b.appendicitis c.cholecystitis d.pancreatitis e.intussusception,volvulous,malrotation f.trauma g.obstructionG.2.b.Obstructive JaundiceH.3.Meckels DiverticulumSURGICAL TOPICSXIII:RespiratoryC.2.Congenital Malformations(lower airway)XV:Blood and Neoplastic G.2.Solid
3、 Tumors a.neuroblastoma b.Wilms TumorXXIII:Ear,Nose,and ThroatF.3.Neck MassesCONTENT OUTLINEXXXI:Emergency(Trauma)Misc:ImagingNeeded at all?Neck sinuses-no TGD-noContrast where?Above or Below?Scan or sono?Virtually no anatomic cause of newborn respiratory distress requires emergent surgery.(exceptio
4、n:airway lesions)A period of resuscitation and investigation is almost always mandated and usually reveals the nature of the defect.A term 2.9 kg baby is immediately noted to be in moderate respiratory distress with tachypnea and worsening cyanosis.Pulse oximeter on the right hand measures 82%.On pr
5、enatal US,there was some suggestion of a mass in the left chest but this was attributed to artifact.The pregnancy was otherwise uncomplicated.You are asked to evaluate this baby and manage the acute process which is unfolding.What is your differential diagnosis?What is the initial management and wor
6、kup?Congenital diaphragmatic herniaCongenital cystic adenomatoid malformation(CCAM)Pulmonary sequestrationIntralobarExtralobarCongenital Lobar EmphysemaBronchogenic CystABCs-dont hesitate to intubate this patient.Excessive bagging for most of these infant is not a good ideaPE:scaphoid abdomen;bowel
7、sounds in chest;decreased breath soundsLabs and linesPre and post ductal saturation probesNGT is criticalCXR statNGTNot a surgical emergencyDelayed surgical approach when stable on low vent settings Conventional Vent,Oscillator,“gentle ventilation”,possible ECMO(10-15%)Primary repair;patch sometimes
8、 neededOverall survival 50-80%Bochdalek:posterolateral defect;usually on leftMorgagni:retrosternal(anterior);presents lateLung hypoplasia affects both sides.Pulmonary HTN/persistent fetal circulation are the greatest challenges.Most repairs do not necessitate a postoperative chest tube.Honeymoon per
9、iod can end very quickly!CONGENITAL LOBAR EMPHYSEMA:-isolated idiopathic hyperinflation of one lobe-respiratory sx.often at birth or in infancy-worsens with time(air trapping)PULMONARY SEQUESTRATION:-a segment of lung without anatomic bronchial communication to lung-systemic arterial supply from tho
10、racic or abdominal aorta-“Extralobar”:often incidental(associated with CDH)-“Intralobar”:found within normal lung parenchyma(lower lobes);prone to infection-Generally not an acute presentation at birthCONGENITAL CYSTIC ADENOMATOID MALFORMATION(CCAM)Solid/cystic lung malformation-Presentation:-prenat
11、al U/S If large,can cause fetal hydrops.-resp distress at birth-infection in first few years of life.Bronchogenic Cyst-Cyst found in hilum,mediastinum,or within lung parenchyma.-Can compress airway and cause atelectasis,pneumonia,air trapping.-Onset is generally gradual,later in infancy and childhoo
12、dJaundice not present at birthBut may blend with physiologic jaundiceMild hyperbilirubinemiaConjugatedClay colored stoolsFirm liver edgeMOST significant factor is age at diagnosisOperation at less than 10 weeksBiopsy is keyDuctal proliferationHIDA scan is recommendedphenobarbitolKasai procedure in y
13、ounger infantsTransplant as salvage therapyTransplant as primary therapyA 2.8 kg baby boy is born via NSVD with normal Apgars and no prenatally diagnosed anomalies.Attempts to feed the baby lead to copious secretions from the mouth and bouts of severe coughing and cyanosis.The abdomen is completely
14、soft and the baby has passed meconium.He appears well once feedings are stopped.What is your very next intervention?What is your diagnostic workup?(V.b.4.n.)Place an NGT-coils in the upper pouch.Leave in place to suction secretions.CXR-presence of abdominal air confirms TEF;absence suggests pure EA.
15、Try and avoid positive pressure ventilation if possible.Be on the lookout for gastric/abdominal distension-may lead to surgical emergency.Contrast studies ARE NOT NEEDED.EA DISTAL TEF(TYPE C)PURE EA(TYPE A)AirV:vertebral anomalies-pelvic xray,US of sacrum to look for tethered cord.A:anorectal malfor
16、mations-PEC:cardiac anomalies-echo(confirm R.sided aortic arch)TE:tracheoesophageal fistulaR:renal anomalies(US)L:radial limb deformities.Polyhydramnios 30%Associated cardiac defects 15 39%,most commonly ASD,VSD.Genetic defects 19%with Trisomy 21 most common.Other GI anomalies are 28%.Classification
17、 System:8%1%86%1%4%Right thoracotomy,retropleural dissection and primary esophagoesophagostomy.Chest drain for possible leak.Transanastomotic feeding tube controversial.Contrast study on POD#7.Anastomotic leakMissed/recurrent TEFEsophageal stricture;Tx=dilatation and aggressive reflux managementTrac
18、heomalaciaOften presents with bilious emesis.May or may not present with abdominal distension.MALROTATION WITH MIDGUT VOLVULUS IS A SURGICAL EMERGENCY.Key is to differentiate proximal from distal obstructions.(V.b.4.m)(XII.A.e)A healthy 4 day old infant presents with a 12 hour history of bilious vom
19、iting,lethargy and decreased urine output.His last bowel movement was blood tinged.The parents called the pediatrician who immediately told them to go to the pediatric ER.His abdomen is soft,non-tender,and non-distended.What is your differential diagnosis?How would you work up this patient?“Lots of
20、loops”=DISTAL OBSTRUCTION“Not a lot of loops”=PROXIMAL OBSTRUCTIONDDx:Hirschsprungs disease,jejuno-ileal atresia,meconium ileus,meconium plug,imperforate anus,MALROTATIONDD:MALROTATION,duodenal atresia/stenosis,proximal jejunal atresia,pyloric atresiaMalrotation with midgut volvulus until proven oth
21、erwise.NPO,IVF,NGTUGI series if stableCorkscrew duodenumLigament of Treitz normally located to the left of midline at the level of the gastric antrum.ABSOLUTE SURGICAL EMERGENCYBirds beak on UGI-midgut volvulus;Detorse counterclockwise-“turn back the hands of time”Ladds procedure-appendectomyAssocia
22、ted with Downs syndrome and congenital heart diseaseNon-bilious emesisDouble bubble on x-ray.Associated with annular pancreasTreated with duodenoduodenostomyNot emergent but make sure that you are not dealing with malrotationCaused by intrauterine vascular accident.Must check for additional atresias
23、 intraoperatively.Microcolon on contrast enema.A 3 day old infant has been vomiting bilious material all day.His abdomen is now markedly distended although he does not seem have any abdominal pain.Of note,he has failed to pass any meconium since birth.A rectal exam is met with explosive foul smellin
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