Initial postsurgical management of the infant with gastroschisis includes monitoring of vital signs, cardiovascular and respiratory status, fluid and electrolyte balance, and pain. After the repair, intra-abdominal pressure increases and can result in venous compression. Venous compression may compromise renal blood flow and the glomerular filtration rate, resulting in decreased urine output. A urinary catheter may be necessary to relieve bladder distention and to allow for a more accurate measurement of urine output. Maintenance fluid requirements may need to be increased because of third spacing into the distended bowel and abdominal cavity.[29,30,31] Alterations in electrolyte balance may ensue from this shift of fluids. The postoperative infant may require anywhere from 120 to 170 mL/kg/d of a crystalloid solution that is adjusted to provide for adequate tissue perfusion and urine output. A large-bore naso/orogastric tube placed to intermittent suction is needed to prevent gastrointestinal distention caused by hypoperistalsis. Hypoperistalsis or adynamic ileus is frequently seen in the postoperative period and may persist for several weeks. The initial gastrointestinal drainage is characteristically green because of the back up of biliary and pancreatic secretions in the immediate postoperative period. As gut motility improves, the drainage becomes clear in appearance. Volume loss from the gastric tube must be monitored, because it is possible for the infant to lose up to 100 mL/kg/d. Replacement of these losses is necessary to maintain homeostasis.
Because of the increased intra-abdominal pressure, close monitoring of respiratory status is essential for the first 48 to 72 hours postsurgery. Respiratory support, as indicated, is provided to optimize oxygenation and ventilation. The increase in abdominal pressure may interfere with optimal expansion of the diaphragm and venous return impeding both ventilation and oxygenation. Some infants may benefit from mechanical ventilation or continuous positive airway pressure (CPAP) to maximize lung expansion, lung volume, and oxygenation. Central venous pressure (CVP) must be monitored constantly during CPAP because of its hindering effect on the CVP. Other infants may not tolerate CPAP because of increased abdominal distention from the increased airflow to the gastrointestinal track. A properly functioning naso/orogastric tube will minimize this risk.
In the immediate postsurgical period, the infant with gastroschisis is usually returned to the NICU from the operating room intubated and on mechanical ventilation. While most infants can be extubated within 24 to 48 hours after surgery, infants who are small for gestational age, preterm, and/or have significantly increased intra-abdominal pressure may require a longer period of ventilator support. High peak inspiratory pressures (PIP), usually greater than 25 cm H2O, should be avoided if possible to minimize adverse effects to the renal and intestinal perfusion.[4,29] High-frequency ventilation can be an acceptable alternative because its effects on intra-abdominal pressure are not as great.
After the initial stabilization period, the main goal of management is to provide adequate nutrition and pain management. Initially, the infant will require parenteral nutrition. Gut motility is delayed because of the chemical peritonitis that occurred when the intestinal contents were exposed to amniotic fluid. Delayed gut motility may persist for weeks after surgical repair and is often influenced by the severity of the defect and other associated anomalies such as intestinal atresia.[29,31] Because of the postoperative ileus, total parenteral nutrition (TPN) is needed in all infants with gastroschisis and is usually initiated within 24 to 48 hours after surgery.[29,33] Because these infants may require TPN for weeks after surgery, a central line is recommended. The minimal daily requirements for postoperative TPN are 90 to 100 kcal/kg/d, 3 g/kg/d of protein, 3 to 4 g/kg/d of intravenous lipids, and dextrose to maintain euglycemia. Because of protein losses from the surgical stress, wound healing, and/or third spacing, additional protein in the TPN may be necessary.
Once gut motility returns, it is important to be proactive with the initiation of enteral feedings. A retrospective study found the age of initial enteral feeding was positively correlated with the time of discharge. These investigators also noted that for every additional day enteral feedings were delayed, hospital length of stay was increased by 1 day. Infants with gastroschisis have a tendency toward malabsorption of substrates and possible allergies secondary to gut inflammation. The use of elemental formulas, expressed human milk, or preterm formulas are indicated because they are more easily digested.[3,4,43] Typically, small volume feedings are initiated and advanced by 10 to 20 mL/kg/d as tolerated. TPN is usually decreased as the feedings increase.
Manipulation of bowel and the increase in intra-abdominal pressure postrepair may increase the need for analgesia in the first 48 to 72 hours after surgery. Infants should be routinely assessed for pain using a validated pain assessment tool, and analgesia should be provided as needed according to established pain guidelines. Pain may be controlled with analgesics such as morphine sulfate or fentanyl as a continuous intravenous drip or as a bolus at regularly scheduled intervals. The nurse should keep in mind that these medications may result in respiratory depression and slow gut motility.
NAINR. 2003;3(2) © 2003 W.B. Saunders
Cite this: Management of the Infant With Gastroschisis: A Comprehensive Review of the Literature - Medscape - Jun 01, 2003.