Fluid balance in late preterm infants with prenatal gastrointestinal pathology -a report of two cases-
A 29-year-old, pregnant woman (70 kg/169 cm, 29w+5, G1P0A0L0) was transferred from outlying hospital for polyhydroamnios with fetal abdominal mass. On obstetrical ultrasonography and magnetic resonance image, a cystic mass about 8.5 × 7 cm in size was observed in the fetal peritoneal cavity ( and ). On the decision that the baby required more maturation, surgery was postponed until gestational age 35 weeks with steroid therapy and follow-up sonography. At 35 weeks, two operating theaters were prepared for surgery for both mother and the baby.\nGeneral anesthesia for Caesarean section was induced with 250 mg of thiopental sodium and 75 mg of succinylcholine. Ten minutes after skin incision, a profuse amount of meconium stained amniotic fluid was released and an approximately 2.5 kg male baby was delivered. Apgar scores were 5 at 1 min and 7 at 5 min. The baby's abdomen was markedly distended () and meconium stained secretion continuously flowed from the nose and mouth. After suction of the airway, intubation was tried with 3.5 Fr cuffed endotracheal tube. This failed, so a 3.0 Fr tube was inserted in the second attempt. A pulse oximeter was attached on the baby's right hand and left leg, which showed 97% with 100% oxygen after resuscitation. Two 24 gauge IV lines were started both on the right arm and right leg. A 6 Fr feeding tube was inserted for gastric decompression. We requested Foley catheter insertion. However, it was not performed. Anesthesia was maintained with sevoflurane and FiO2 of 0.3-0.4 with air under standard monitoring and temperature devices similar to setting of case 1. The ventilator was set by pressure control mode of 24 mmHg (TV near 25 ml) and RR of 30 breaths/min, however, SpO2 dropped and was maintained around 70%. Therefore, FiO2 was increased up to 1.0. However, SpO2 did not change so manual ventilation was applied with 100% oxygen for about 40 min until the abdomen opened and the cyst was evacuated. SpO2 was maintained at 90% during that period and, just after cyst evacuation, it abruptly increased to 98%, so the FiO2 was decreased to 0.3. The ventilator was set by a pressure control mode of 18 mmHg (TV near 30 ml), 25 breaths/min, and controlled according to the ETCO2 level. BP was maintained at 40-60/25-35 mmHg, HR at 130-160 beats/min, ETCO2 at 27-35 mmHg, and SpO2 at 97-100%.\nSurgery was complicated by lots of bowel manipulations. Severe adhesion to omentum, liver, and small bowel was seen and moderate ascites were found. After adhesiolysis, the cyst was removed and end-to-end anastomosis of the small bowel was performed. Total time taken for the surgery was 3 h 30 min and for anesthesia, 4 h 10 min. Total fluid administered was 5% dextrose in water (D5W) 35 ml and lactated Ringer's solution 130 ml. After 120 min of anesthetic induction, venous blood gas analysis was taken, which showed pH 7.29, PaCO2 44 mmHg, PvO2 34 mmHg, HCO3 21.2 mM/L, Na 133 mEq/L, K 3.7 mEq/L, Hb 18.7 g/dl, and blood sugar 121 mg/dl.\nJust after the surgery, we looked for evidence of urination on drape linen, but it was dry. The baby was sent to the NICU with a secured ET tube with manual assisted ventilation. Foley catheterization was done at the NICU and urine output was very poor after the surgery. Dopamin 5 µg/kg/min was infused with normal saline 60 ml, fresh frozen plasma (FFP) 40 ml, and 20% albumin 13 ml over 6 h. Furosemide 4 mg was IV injected two times during hydration period, however, only 4 ml of urine was formed. Generalized edema appeared with heart murmur, but urine starting to pass at 10-20 ml/h at the same time. The baby was extubated 20 h after the surgery and SpO2 was maintained over 95% without supplemental oxygen. Feeding was started 8 days after the surgery.