Fluid balance in late preterm infants with prenatal gastrointestinal pathology -a report of two cases-
A 31-year-old pregnant woman (59 kg/170 cm, 34w+5, G4P2A1L2) was admitted for Caesarean section. The patient had no problems until fetal bowel obstruction was diagnosed by routine obstetrical ultrasonography taken 10 days earlier ().\nGeneral anesthesia was induced with 250 mg of thiopental sodium and 75 mg of succinylcholine. Ten minutes after skin incision, a 2.66 kg, 46 cm of male baby was born with an Apgar score of 7 at 1 min and 9 at 5 min. The newborn cried relatively well despite the moderately distended abdomen, so routine care was given, which included transfer to the neonatal intensive care unit (NICU).\nPeripheral oxygen saturation (SpO2) of the baby was maintained at 96-97% with 2 L/min of oxygen in the hood and first urine was passed at 4 h of age. However, abdominal distention was sustained and nothing was aspirated through the positioned oro-gastric tube. An infantogram, bowel sonography, and barium enema were performed. Distended small bowel loops up to 3 cm and microcolon were seen and no more contrast was passed proximal to terminal ileum, which suggested ileal atresia ().\nEmergency surgery was performed at 10 h of age. Under standard monitoring including electrocardiography (ECG), non-invasive blood pressure (NIBP), end-tidal CO2 (ETCO2), and SpO2 (dual monitor at right arm and left foot), the patient was intubated with a 3.5 Fr cuffed endotracheal tube. Two 24 gauge intravenous (IV) lines were started on the left arm and right leg, a 6 Fr feeding tube was inserted for gastric decompression, and a Foley catheter was inserted for hourly urine count. To minimize heat loss, the room temperature was increased, the patient was hatted, a warm air mattress and warmed IV fluids were used, and body temperature was monitored. The anesthesia was maintained with sevoflurane, FiO2 of 0.3-0.4 with air, pressure control mode of 18 mmHg, and a respiratory rate (RR) of 20 breaths/min. BP was maintained at 50-80/30-45 mmHg, heart rate (HR) at 140-160 beats/min, ETCO2 at 32-40 mmHg, and SpO2 98-100%. There were severe adhesions on the entire abdomen such that the anatomy was not easily distinguishable. After massive adhesiolysis, segmental resection of injured bowel and anastomosis were performed. Moderate amount of reactive fluid was seen and moderate bleeding was ongoing. At 90 min of the surgery, HR abruptly rose to 170 beats/min. Arterial blood gas analysis was taken, which showed pH 7.34, PaCO2 38 mmHg, PaO2 191 mmHg, HCO3 20.5 mM/L, Na 134 mEq/L, K 4.2 mEq/L, Hb 10.2 g/dl, and blood sugar 118 mg/dl. Packed red blood cells 30 ml were transfused and no other intraoperative symptoms were found. Total time taken for surgery was 2 h 45 min and for anesthesia, 3 h 20 min. Total fluid administered was SD 1 : 3 solution 20 ml, lactated Ringer's solution 50 ml, and normal saline 10 ml.\nAfter the surgery, the patient was extubated and SpO2 was maintained over 97% without supplemental oxygen. Urine output was 1 ml/h and 1.5 ml/h, respectively, during the first 2 h of surgery, however, no further urine was observed during last hour of surgery. However, 7 ml of urine was formed after 2 h of surgery without fluid loading and no further oliguria was seen. Hb after transfusion was 13.6 g/dl and hemodynamic parameters were stable thereafter. Breast feeding was started 5 days after the surgery and the baby was discharged at postoperative day 24.