Use warm IV fluids & Blood especially in neonates & children with Thermal Angel

During major surgical procedures in neonates & children, to avoid the hypothermia, anesthesiologist prefers to infuse warm IV fluids or blood products. In adults, during resuscitation in major trauma or hemorrhagic shock, one needs to infuse the IV fluids & blood rapidly. These are some areas of use for Thermal angel. It is a portable, lightweight, disposable & battery powered device, which helps in warming the IV fluid/ blood products & thus preventing hypothermia.

Previously, IV fluids & blood products, used to make warm by dipping them into the hot water. It was time consuming in an emergency & there used to be no hold on the temperature. Apart from this, there are many warming technologies came into use.But compare to older technologies, thermal angel provides warm fluid within 45 seconds & it is safe to use. There is no complexity of instrument, no maintenance required & because of its lightweight it can be carried anywhere in the remote areas.

Thermal Angel Blood Warmer Details are it is safe to use with temperature control, quick to use within 45 seconds, easy to use because of simple instrument, easy to carry as it is lightweight & no maintenance required because it is disposable. Thus, truly speaking it is an ‘angel’, which will help in emergency.

Undescended Testis

Undescended testis means absence of one or both of the testes into the scrotum since birth. A doctor will detect it immediately after birth during complete examination of child or the parents usually notice this while bathing the child. There may or may not be a history of reducible swelling in the inguino-scrotal region indicating associated hernia. Apart from this, there are no other complaints.

On examination, the scrotum feels empty & undeveloped. The testis can be felt in the groin as a nodular structure slipping beneath the hand while doing gentle palpation in different positions like lying down or squatting position. This is called palpable testis. Some cases, the testis is not palpable in groin but can be found in other ectopic sites like perineum, root of the penis, medial side of the thigh or other side of the scrotum. These are called ectopic testis. In some cases, the testis is not palpable anywhere from groin to ectopic sites, then it may be in the abdomen on his descended route. This is called non-palpable testis.

The palpable testis are directly subjected for orchiopexy i.e. fixation of testis into the scrotum after mobilizing length of the cord through a groin incision. The non-palpable testis are subjected to further investigation to find out whether it is present or absent, exact position & size. Though ultrasonography, CAT scan or MRI imagings are done to look for this testis, the best investigation is diagnostic laparoscopy.

During the laparoscopy, one can trace the testis & at the same time bring back the testis into scrotum after mobilization. This can be done in one stage if the testis is not far away from the groin or in two stages if the testis is far away up into the abdomen.

Fissure-in ano

Blood in stool occur because of many causes. One of the cause is fissure-in-ano. Fissure in ano means cut into anal mucosa. This occur because of hard motion. When a child is suffering from constipation, he tries to pass the hard motion resulting into cut in anal mucosa. This may lead to bleeding while passing subsequent motion & severe pain. The child cries or tries to hold the motion because of fear of pain. It again leads to more constipation & the cycle becomes vicious. On examination, there is redness & fissure (cut) in the anal mucosa. The immediate treatment is oral laxatives to make the motion soft, local application of analgesic jelly & oral metronidazole/ ornidazole, dietary modification. Long term treatment is dietary modification. Diet should contain high fiber diet, green leafy vegetables, milk intake should be less & lot of water. It helps to make the stool soft. The junk foods containing bread, pizza etc should be avoided. Avoid spicy food & lot of milk. If the child is older, then let him/her play outdoor games, exercises & cycling which helps in regulation of digestive system. Once the cut heals, then even enemas or suppository helps in softening of stool. Remember, the diet change & regular exercise needs lot of motivation. If you are doing it, then child adopt it very quickly so you need to change yourself first if you want your little one pain free.

Acute Appendicitis

Acute appendicitis that is inflammation of appendix is common in school going children & less likely occur at preschool age. The child usually complaints of pain around the umbilicus or in the right side of the lower abdomen. There may be h/o bowel disturbances in the form of constipation or diarrhoea i.e loose motions. They refused to eat because of vomiting sensation (nausea). If it progresses then the child starts vomitings & fever. You should immediately see a surgeon as it requires immediate medical attention. On examination, there is pain after touching/ on pressure in right side of the lower abdomen as the hand touches the inflammed appendix. There may pain all over the abdomen in the advanced stage. The blood test reveals increased leukocytes i.e. white blood cells in the body. X-ray abdomen may be suggestive of some air fluid levels in right iliac fossa. Ultrasonography is not the diagnostic of appendicitis unless it is ruptured but it may rule out other pathology like kidney stones, ureteric calculi, adnexal pathology (female child) etc. Though early presentation may be cured with oral or intravenous antibiotics, the majority of children requires appendicectomy. It can be done either by open or laparoscopic method.

Hydrocephalus

Hydrocephalus is enlargement of head because of increase in cerebrospinal fluid in the brain. There is increased intra cerebral pressure because of enlarged ventricular system. The child presented with enlarged head circumference, vomitings and eye abnormality (Sunset sign). The hydrocephalus may be congenital i.e. from birth because of the obstruction in the CSF pathway (Congenital aqueductal stenosis) or it may be acquired because of bacterial or tuberculous meningitis. The CAT scan of the brain shows enlarged ventricles. Anterior cerebral artery index (Resistive index) shows there is increased pressure inside the brain. Brain cortex gets compressed. The eye examination reveals papilloedema suggestive of increased intra cranial tension. The treatment is ventriculo-peritoneal shunt (VP shunt), in which the CSF is diverted from brain to the peritoneal cavity with a shunt tube. Shunt tube is placed in the subcutaneous space over the anterior chest wall. In obstructive hydrocephalus, third ventriculoscopy & removal of aqueductal diaphragm by fogarthy catheter is curative treatment.

Anorectal Malformation or Imperforate anus

Anorectal malformation is a birth defect in which the anus and rectum do not developed properly. Anus is opening through which stool is passed and the rectum is the lowest part of large intestine just above the anus. When the child is born, he/she will have one of the following abnormalities

1. No anal opening

2. A membrane may be present over the anal opening

3. Misplaced anal opening

4. Anal opening near to the vaginal opening in female child

5. Stool is passed through by way of vagina, base of the penis or scrotum or urethra

6. Abdominal distension with no passage of stool in 24 to 48 hours after birth.

Commonly it is diagnosed at birth, when your doctor examines the baby or if the baby fails to pass stool in 48 hours or passes but through abnormal opening. There is no need to become scared, this is correctable deformity. If you are in the hospital, your doctor will immediately consult to the pediatric surgeon. If by any chance (in case of home delivery or delivery in remote areas), you need to consult nearest pediatric surgeon immediately. Like majority of birth defects, there is no particular cause for this defect also.It occurs in about 1 out of 5000 newborns. Boys are at a slightly higher risk than girls.

Along with the physical examination to check the patency of anus and other anomalies, some tests are performed to further evaluate problem:

1. Abdominal X-ray

2. Ultrasonography of abdomen

3. Echocardiography to rule out heart problem

As soon as the problem is detected, the child undergoes some necessary tests.Surgical reconstruction of the anus is the aim of treatment. In low variety, it can be done immediately without the need of colostomy. But in other severe variety initially temporary colostomy is needed before definitive operation.

Tounge Tie

Tounge tie should be suspected when child cannot protrude his tounge out of oral cavity as his tip of tounge is held back with a tight band on the undersurface of tounge. Tip cannot reach the palate.There is problem in speech & swallowing. If you see carefully a white band of tissue is seen on the undersurface of tounge which limits it's mobility. This problem should be diagnosed as early as possible. Otherwise, the child can loose his/her confidence because he may not be able to speak properly. This is not a major problem. You need to see a pediatric surgeon & under general anaethesia surgeon cuts the band. This makes the tounge free. This is day care surgery or require one night stay. The child may need to take 2/3 sittings of speech therapy after a week of surgical procedure.

Cleft Lip

Cleft lip is the congenital deformity wherein the newborn born with the deformed lip. There is cleft in the upper lip. It may on one side or both the sides. It may or may not associated with cleft in palate also. This is psychological shock to all family members as they do not expect to take home the child with an abnormality on the exposed part of face. But this deformity is fully correctable & after surgery your child is as normal as any other child. Do not get depressed. You see a surgeon who is specialized in pediatric surgery or plastic surgery. Usually the repair is done at the age of 3 months when the child gains satisfactory weight, his/her Hb% are above 10 gm%. 10 kg/10weeks/10 gm% haemoglobin is the usual formula. The child with only cleft lip does not have any problems with sucking/ swallowing so breast feed can be continued. The aim of surgical treatment is to produce a intact lip with minimal or no cosmetic deformity, normal speech & normal dentition.The procedure is done under general anaesthesia.

Congenital Inguinal Hernia/ Hydrocele

Congenital inguinal hernia or hydrocele is because of the patent processus vaginalis. Processus vaginalis is the tract, which extends from groin to the scrotal sac. After birt, this tract gets fused. If this processus vaginalis remains patent then hernia or hydrocele develops. If the tract is wide enough to allow the intestines then hernia develops but if the tract is narrow which allow only fluid then hydrocele develops.

In case of hernia, the parents usually notice the bulge limited to the groin or extending into scrotal sac. This swelling comes after straining, crying, jumping, playing & reduces spontaneously or after lying down. It is not painful. In case of hydrocele, the swelling is limited to the scrotum & it does not reduces.The size remains almost same.

The diagnosis is by simply clinical examination and does not require any special test.

The management of hernia and hydrocele differs.In cases of hydrocele, one can wait till one year of age as there is chance of spontaneous regression while in case of hernia, the child needs to be operated as early as possible as there are chances of obstruction. The best person to treat this type of cases is the surgeons who are specialized in paediatric surgery.The operation can be done as a day care surgery or will require one day hospitalization. It is done under general anaesthesia and the child can be fed 4 hours after surgery.

Intussucception

Intussucception occurs when one part of bowel invaginates (intussusceptum) into an adjacent section (intussuscipiens) which results in intestinal obstruction and venous compression. If uncorrected it can result in arterial insufficiency and necrosis. It is the commonest abdominal emergency between 3 months and 2 years . Peak incidence is between 6 and 9 months. Most cases are idiopathic with the lead point due to enlarged Peyer's patches, Usually due to a viral infection.5% are due to polyp, Meckel's diverticulum, duplication cyst or tumour .Commonest site involved is the ileocaecal junction.

Clinical features are Intermittent colicky abdominal pain and vomiting, Each episode classically last 1-2 min and recurs every 15-20 min, there is Passage of blood - 'red currant jelly' per rectum. Per abdomen a Sausage shaped abdominal mass is felt in upper abdomen. Diagnosis confirmed with water soluble contrast enema or ultrasound.

Treatment is Resuscitation with intravenous fluids and nasogastric tube. Attempt reduction with air or contrast enema under radiological guidance. If peritonitis, shock or failed reduction requires surgery , If bowel necrosis require resection with primary anastomosis

Duodenal Atresia

Duodenal atresia is a condition in which the duodenum (the first part of the small bowel) has not developed properly. It is not open and cannot allow the passage of stomach contents. The cause of duodenal atresia is unknown, but it is thought to result from problems during the developmental stage in which the embryo's duodenum normally changes from solid to tube-like (recanalization).

Duodenal atresia is present in more than 1 in 3400 live births. Approximately 20-30% of infants with duodenal atresia have Downs syndrome. Duodenal atresia is often associated with other congenital abnormalities.

Symptoms are upper abdominal disension & bilious vomitings which is Continuous even when infant has not been fed for several hours in neonates.This condition may be suggested by fetal ultrasound showing polyhydramnios (excessive amounts of amniotic fluid in the uterus) or distension of the stomach and part of the duodenum.A plain abdominal x-ray may show air in the stomach and first part of duodenum, with no air beyond that classically called as double – bubble sign. An abdominal x-ray with contrast may be helpful

Treatment involves nasogastric tube for gastric decompression, correction of fluid and electrolyte abnormalities and surgical correction with either a duodenoduodenostomy or duodenojejunostomy

Malrotation

What is Malrotation? Malrotation is a type of mechanical obstruction caused by abnormal development of the intestines while a fetus is in the mother's womb. The small and large intestines are the longest part of the digestive system.If stretched out to their full length, they would measure more than 20 feet long by adulthood,but because they are coiled up, they fit into the relatively small space of abdominal cavity. Malrotaion occurs when the intestines don't "coil" properly during fetal development.Malrotation in itself may not cause any problems. However it may be accompanied by additional complications:

1] Bands of tissue called Ladd bands may form, obstructing the first part of the small intestine (the duodenum). 2] After birth, volvulus may occur. This is when the intestine twists on itself, causing a lack of blood flow to the tissue and leading to tissue death. Malrotation is often diagnosed when volvulus occurs, frequently during the first weeks of life.
Obstruction caused by volvulus or Ladd bands are both life-threatening problems. The intestines can stop functioning and intestinal tissue can die from lack of blood supply if an obstruction isn't recognized and treated. Surgery to correct bowel obstruction from malrotation is always necessary and is often performed as an emergency procedure to prevent irreversible, life-threatening injury to the bowel. During surgery, which is called a Ladd procedure, the intestine is straightened out, the Ladd bands are divided, the small intestine is coiled on the right side of the abdomen, and the colon is placed on the left side.

Pyloric Stenosis

Pyloric stenosis is a narrowing of the pylorus, the lower part of the stomach through which food and other stomach contents pass to enter the small intestine. Pyloric stenosis is fairly common - it affects about three out of 1,000 babies. Most infants who develop pyloric stenosis are usually between 2 weeks and 2 months of age - symptoms usually appear during or after the third week of life. It is believed that babies who develop the condition are not born with pyloric stenosis, but that the progressive thickening of the pylorus occurs after birth. An affected infant begins showing symptoms when the pylorus is so thickened that the stomach can no longer empty properly. The first symptom of pyloric stenosis is usually vomiting. Projectile vomiting, in which the breast milk or formula is ejected forcefully from the mouth, in an arc, sometimes over a distance of several feet. Projectile vomiting usually takes place soon after the end of a feeding. The vomit will not contain bile. Babies with pyloric stenosis usually have fewer, smaller stools because little or no food is reaching the intestines. Most babies with pyloric stenosis will fail to gain weight or will lose weight. As the condition worsens, they are at risk for developing fluid and salt abnormalities and becoming dehydrated. After feeds, increased stomach contractions may make noticeable ripples, or visible peristalsis, which move from left to right over the infant's belly. During the exam, there is a pyloric mass - a firm, movable lump that feels like an olive on the right side of abdomen.

USG of abdomen is the diagnostic modality, but sometimes the barium studies of upper tract is done which shows narrowing at pylorus & Delayed passage of barium through thickened pyloric channel. The enlarged, thickened & elongated pylorus can be seen on ultrasound images.

A surgical procedure called pyloromyotomy, which involves cutting through the thickened muscles of the pylorus, is performed to relieve the obstruction from pyloric stenosis. The pylorus is examined through a very small incision, and the muscles that are overgrown and thickened are spread to relieve the obstruction.