NEONATAL SURGERY - 1976

1. GENERAL SECTION

3. Organization of Surgical Care for Newborn Infants

   The fundamental organizational principle in neonatal surgery is the establishment of specialized wards or departments, adhering to a staged approach in diagnostic and therapeutic measures. This is dictated by the specific nature of this branch of pediatric surgery, which is based on the anatomical and PHYSIOLOGICAL CHARACTERISTICS OF the newborn infant.

Wards for newborns requiring surgical intervention were first organized in our country in Leningrad, Riga, Moscow, and other cities. In 1960, the first specialized neonatal surgery department of the Department of Pediatric Surgery at the Central Institute for Advanced Medical Education began operating on The basis of the Rusakov Children's Hospital in Moscow.

Organizational Issues

Premises. Modern requirements for a neonatal surgery ward or department are quite stringent. A high level of asepsis is ensured by the following measures: complete Isolation of the department from surrounding hospital units; changing of all clothing by the staff; observance of personal hygiene (monitoring "household" microbial contamination, identifying foci of purulent-inflammatory processes, subacute respiratory and other diseases, etc.); absolute Separation of "clean" patients from children with surgical infections; availability of boxes; a supply-and-exhaust air-conditioned ventilation system in which airflow moves sequentially from areas with a higher aseptic regime (operating room, intensive care unit) to the remaining wards.

Equipment. The neonatal department requires a significant amount of various diagnostic and therapeutic apparatus, devices, and instrumentation specially designed for this age group of patients. Laryngo- and bronchoscopes, cystoscopes, surgical instruments, heated operating tables, incubators, infusion systems, and monitoring devices for regulating infusion rates require careful handling and must be maintained under enhanced aseptic conditions.

Personnel. The training of specialists in neonatal surgery requires a great deal of time and effort. The main subjects to be studied include the care of newborn and premature infants, the Diagnosis of surgical and borderline conditions, the Prevention and Treatment of septic complications, infusion therapy and dietetics, and, finally, the techniques of surgical interventions for various pathologies (malformations, tumors, trauma, etc.). The difficulty of working with this group of patients dictates special requirements when selecting personnel. These must be individuals with an enhanced sense of responsibility, ready to patiently nurse very severe patients, people deeply devoted to their cause, because the life and future destiny of the child often depend on the quality of care.

Organization. The staff of the neonatal ward or department must maintain close contact with affiliated maternity hospitals, which serve as outposts ensuring the early diagnosis of any condition requiring surgical assistance. Since a significant number of these diseases require prompt and sometimes emergency treatment, urgent diagnosis is the primary principle of work for maternity hospital staff—obstetrician-gynecologists and pediatricians. It is advisable that each such department be affiliated with 5 to 30 maternity hospitals. Contact with maternity hospital physicians ensures The Unity of diagnostic and therapeutic approaches, the continuity of staged treatment, and the proper transportation of the newborn from the maternity hospital. Consequently, the ward or department staff performs the Functions of a distinctive methodological center. Clearly, an important condition for its work will be the presence of a meticulously documented card file of past patients and correctly compiled treatment reports, which serve as an object of analysis and Structure/133.html">Discussion together with the maternity hospital staff.

Timing of Surgical Intervention

Most malformations and many diseases requiring Surgical treatment are typically detected immediately after birth or in the first days and weeks of the child's life. The maternity hospital physician or the pediatrician monitoring the child at home must decide on the treatment tactics. The life and further Development of the child often depend on the correctness of this decision.

Recommendations from various authors regarding the timing of surgical treatment for specific malformations often differ significantly and, moreover, change over time. Such changes are usually associated with new scientific knowledge about individual nosological entities, The Study of the catamnesis of untreated and operated children, the accumulation of practical experience with various treatment Methods, and The Development of new, complex operations that surgeons did not previously have at their disposal. In works devoted to determining the timing of surgical treatment, in most cases only individual malformations are covered, and tactical issues are often interpreted subjectively, without sufficiently convincing Anatomical and physiological justifications or statistically reliable data. As a result, specialized clinics often admit children with advanced forms of diseases and severe complications arising from unjustified conservative or untimely surgical treatment, which significantly worsens both immediate and long-term treatment outcomes. Therefore, the timing of surgical treatment must be convincingly justified and clearly argued.

We believe that a physician's tactics in choosing indications for conservative and operative treatment methods and the timing of surgery should be justified from a general approach applicable to any disease or malformation.

Guided by METABOLISM/2.html">THE CONCEPT OF the Relative immaturity of the Organs, Tissues, and systems of the newborn infant—which are particularly vulnerable to harmful influences in the presence of a malformation—the desire for the earliest possible correction of the malformation in the majority of patients should be considered correct. Eliminating the malformation in the first days and weeks of life creates conditions for the normal development not only of the pathologically altered organ, but also of the system in which this organ is included and the Organism as a whole. Conversely, the further the operation is postponed and the later conservative treatment is initiated, the more the pathology becomes a peculiar "norm," and the restoration of the normal function of the organ is hindered or becomes impossible.

The expansion of the range of surgical interventions in newborns is facilitated by the achievements of modern Anesthesiology and Intensive Care, the improvement of surgical techniques, and the accumulation of experience in postoperative patient care. However, serious errors are possible in this regard. Thus, Smith (1968) cites data indicating that the morphological pattern of Auerbach's plexus ganglia in the colon wall of premature and some full-term newborns, due to their age-related immaturity, can simulate a ganglion deficiency identical to that seen in Hirschsprung's disease in older children. It follows that the Assessment of the pathomorphological picture in A number of diseases and functional disorders in newborns should be approached with adjustments for the age norm; indications for surgical intervention in the neonatal period in such patients should be approached with caution, avoiding ineffective and sometimes unnecessary operations for chronic constipation caused by temporary anatomical and functional immaturity of the neuromuscular structures of the rectal wall. Consequently, in certain functional disorders, expanding the indications for surgical intervention in newborns is justified only when there is certainty that no harm will be inflicted on the child.

Newborns frequently develop vital indications for surgery in the first hours and days of life (diaphragmatic hernia, Malformations of the Esophagus, intestine, etc.). The concepts of "vital indications" and "emergency indications" are sometimes confused, though they are not the same thing. For example, a newborn with esophageal atresia is preferably operated on for vital indications not immediately upon admission to the surgical department, but after preoperative preparation—the scope and duration of which depend on the child's condition—and not in the difficult Setting of a night shift, but in the morning, by experienced surgeons possessing the necessary expertise in neonatal surgery. At the same time, children with asphyxial syndrome must receive effective assistance, specifically surgical, immediately in the first minutes after birth or admission to a specialized hospital, since severe Central Nervous system damage due to Hypoxia often occurs within the first 2–3 minutes rather than after 5–6 minutes, as previously believed. The Effect of deep, short-term hypoxia on developing Brain Cells, as well as mild concussions, may manifest at a later age in schoolchildren or even adults as memory impairment, reduced intelligence, autonomic dystonia, etc. Therefore, every newborn infant with symptoms of respiratory distress and cyanosis of any degree caused by a malformation or another cause requires the most urgent attention and emergency care.

During periodic attacks of asphyxia of any Etiology, their duration should be reduced by all available means, up to and including surgery. Thus, emergency intervention at any time of day, regardless of the child's critical condition, is performed for asphyxia caused by tension syndrome (lobar emphysema, pyopneumothorax, tension cysts and bullae, diaphragmatic hernia, etc.). At the same time, for a malformation such as Pierre Robin sequence, better results are achieved through conservative measures (postural positioning, orthodontic treatment).

Of great importance for choosing the timing and method of treatment is the assessment of a given malformation's tendency toward self-cure or aggravation. If self-cure is possible, it is advisable to abandon surgery in favor of Conservative methods. In cases where complications may develop, they should be preempted by energetic measures up to and including surgery. Thus, umbilical hernias in the majority of patients disappear spontaneously by 12–18 months; therefore, Surgical Treatment of an umbilical hernia is indicated only in cases of a tendency toward recurrent strangulation or very wide hernial rings. In hypospadias, conversely, delaying surgery leads to persistent deformation of the tunica albuginea, the correction of which with delayed treatment is extremely difficult and sometimes impossible.

Malignant transformation of teratoid tumors dictates The Need for their early removal—surgery is indicated as early as the first days and weeks of the child's life (V. F. Goryainov, 1967; Burl, Dillard, 1970). In newborns with malformations whose tendency is well known, it is advisable to establish indications for surgery immediately after completing the necessary examinations, without waiting for potential complications whose time of onset is difficult to predict. This primarily applies to diaphragmatic hernia and a number of Urinary Tract malformations.

For other malformations and diseases whose tendency is difficult to predict in each individual case, dynamic observation is advisable. For example, for a soft, non-tension Spermatic Cord cyst, an expectant management approach is appropriate, as most such cysts tend to resolve spontaneously. At the same time, marked or progressive tension of the cyst is an indication for surgical treatment.

Proper evaluation of the effectiveness of conservative treatment is important. In the absence of an effect from a specific set of measures, tactics should be revised in favor of more radical methods. An assessment of the side effects of surgery is necessary. Such an evaluation, for instance, has led in recent years to a revision of surgical tactics for Spina bifida. It was previously believed that early surgery for this malformation should be performed only in cases of rachischisis, perforation, or rupture of the hernial sac. The threat of brain damage due to the progression of postoperative Hydrocephalus provided grounds for postponing the repair of a spina bifida with unchanged Meninges until 1 to 1 ¹/₂ years of age. Only since the Introduction of the Holter valve and its modifications into clinical practice has surgery been performed on an emergency basis immediately after the birth of the child (Zachary, 1964).

Clearly, in a number of cases, the issue is decided individually. For the surgical separation of conjoined twins, the time of best tolerance for the Procedure is chosen depending on many conditions. In uncomplicated cases, the operation can be performed in newborns (Gans, 1968).

The impossibility of performing a single-stage operation dictates the need to divide it into two or more stages. This multi-stage principle has become widespread in neonatal surgery in recent years. In large omphaloceles, The First stage involves covering the membranes of the hernial sac with Skin mobilized from the edges, and only a few months or even years later is a radical repair of the anterior abdominal wall performed. A similar division of the operation into two stages is indicated for false diaphragmatic hernias when the organs repositioned into the Abdominal cavity create excessive pressure within it (exceeding 20–45 mm Hg). In pediatric cardiac surgery, temporary pulmonary artery banding is used in newborns as the first stage of intervention prior to radical surgery. Multi-stage operations in abdominal surgery offer a number of advantages: gastrostomy prior to radical repair in patients with esophageal atresia (D. E. Bablyak, 1974; Meeker, 1958), construction of an artificial anus prior to radical surgery in patients with colon and anal malformations, etc. When planning a staged operation, it is useful to be guided by systematized reasons that compel the surgeon to abandon a single-stage operation and to clearly envision the goals that can be achieved thereby (S. Ya. Donetsky, 1974).

Causes: a) lack of conditions for performing a single-stage operation; b) the child's intolerance to a single-stage operation; c) infeasibility or complexity of a single-stage operation; d) the impossibility of creating conditions for the operated organ under which its GROWTH AND DEVELOPMENT occur in proportion to the child's growth rates.

Objectives: to reduce operational risk, minimize complications, lower mortality rates, and improve treatment outcomes. At the same time, situations often arise where the surgeon guides a child through a critical condition, strives for success in a palliative first stage, or leverages the physiological mechanisms of the child's growth and development.

Naturally, when dividing surgery into stages, It is important to acknowledge the potential downsides of such an approach: scarring that disrupts normal anatomical relationships and organ syntopy, repeated stress from hospitalizations and interventions, and others.

When selecting a treatment method and determining the timing of surgical intervention, a critical factor must be considered—the presence of necessary conditions for performing the surgery, particularly the surgeon's sufficient experience in operating on neonatal patients. It is not uncommon for descriptions of new surgical Procedures in neonatal surgery to be met with an urge to immediately implement them across numerous surgical departments, a practice not always preceded by practicing the technical details in a vivarium or morgue.

Before operating on a newborn, it is advisable to perform a similar procedure on an older child—in other words, to master the surgical technique. The presence of an anesthesiologist well-versed in the anesthesiology and intensive care of newborns and infants is mandatory. Without proper equipment, instruments, and necessary suture Materials, a number of complex surgical procedures in neonates cannot be performed at all. For example, it is difficult to justify performing Heart or lung surgeries in departments lacking specialized equipment for managing both the operation and the postoperative period. Ensuring an adequate supply of freshly prepared Blood, plasma, blood substitutes, and broad-spectrum Antibiotics is strictly required.

The organization of dedicated nursing posts for postoperative care is extremely important. Managing a critically ill postoperative patient is a lengthy and labor-intensive process. Nurses must be familiar with the fundamentals of pediatrics and surgery, understand the principles of neonatal intensive care and resuscitation, and know the techniques for prolonged intravascular fluid infusions, among other skills. It is safe to say that surgical outcomes in newborns directly depend on the qualifications and workload of the nurse in the intensive care unit or postoperative ward. Ideally, the maximum workload for a nurse in a postoperative unit is 1 to 2 neonates.

In cases where a surgeon has doubts about the availability of the conditions necessary for a specific operation, it is advisable to refrain from performing it locally and instead transfer the child to an appropriate specialized center. If conditions are lacking for elective or relative-indication procedures (such as an uncomplicated inguinal hernia or a cleft lip), it is wise to postpone the surgery until the child is 3 to 6 months of age.

The principles outlined above should not be taken as dogma. As data accumulates, experience is gained, and new treatment methods are developed, these guidelines will evolve and expand. In specific cases, individual recommendations may occasionally conflict. In such situations, one should rely on the primary, defining guidelines for the given case and perform the surgery based on individual indications.

The approximate timeframes for surgical intervention in specific nosological entities, developed by the Clinic of Pediatric Surgery at TsOLIUV, are presented in Table 7.

Class="center">Table 7. Approximate initiation times for surgical and conservative Treatment of the most common Congenital Malformations

 ¹ A number of surgeons consider it more appropriate to perform the surgery after 2–3 months of age.

   Of particular importance in selecting indications for various treatment modalities and formulating the physician's core tactical stance are socio-ethical considerations, parental opinions, and other factors. A surgeon encounters substantial difficulties in cases of multiple congenital malformations. Here, ethical issues become paramount.

Deontology in Neonatal Surgery

   The behavioral norms of medical staff toward newborns requiring surgery and their families are at the core of clinical practice and healthcare management. These principles were formulated by N. N. Petrov (1944) with respect to adult patients, echoing Socrates' axiom stated over 2,000 years ago: "It is impossible to cure the body without curing the soul." When applied to children with surgical conditions, these principles take on a qualitatively different character¹. Medical deontology was comprehensively explored at the All-Union Conference (1968). Adhering to deontological rules in the clinical care of adult patients is facilitated by the fact that a physician can clearly envision the emotional distress and sensations experienced by a mature individual. Unfortunately, human memory is limited; most people, including pediatricians, poorly recall their own childhood medical experiences, especially those from their early years. Through experience, however, one learns that a child's dominant behavioral response in a polyclinic, hospital admission ward, or inpatient unit is fear of unfamiliar smells and objects. Even the calmest and most courageous children struggle to endure numerous unpleasant, "humiliating," or simply painful procedures. Children tolerate coercion (so-called forced immobilization) particularly poorly, as it is usually followed by distress. Many behavioral reactions in children well-known to practitioners—such as the negative consequences of hospitalization, "hospitalism" or separation anxiety, and others—stem not only from physiological immaturity but also from a lack of life experience. The Scope of staff behavioral science also encompasses the child's relatives—parents, grandparents, etc.—creating an additional set of tasks and demands that shape the dynamic between the child, the physician, and the parents.

¹ Doletsky, S. Ya. Issues of Deontology in Pediatric Surgery. — Khirurgiya, 1965, no. 7.

In neonatal surgery, deontology exhibits such distinct characteristics that it warrants a more detailed examination. The primary challenge in working with newborns is the inability to communicate with them verbally (the absence of subjective information) and their complete helplessness. At the current level of scientific progress, there is no realistic way to influence a newborn's psyche through the willpower or intellect of the physician—a factor that plays a crucial role in the clinical care of adults and older children. However, this anatomical and physiological limitation is not the only one. Let us examine the key challenges that are rarely covered in specialized literature yet invariably confront the practicing surgeon and pediatrician.

1. Consent for surgery is obtained not from the mother, who is in a state of postpartum stress, but from the father or older relatives. The absence of the mother's decisive voice makes the surgeon's position particularly difficult. Relatives typically place their complete trust in the surgeon, effectively leaving them as the sole accountable party. While this might seem to have a positive side, the fundamental principle successfully employed by pediatric surgeons ("How would I act if this were my own child?") does not apply here. Indeed, upon the birth of a severely impaired child where one of the parents is a physician, that parent has the right to independently decide on the tactical approach—whether to pursue radical surgery or palliative intensive care—fully understanding the consequences of their choice. Therefore, evaluating prognosis is one of the most critical tasks at all stages of treatment in neonatal surgery.

2. The prognosis for children with surgical conditions can be determined based on several factors. Regardless of The Nature of the pathology, our patients can be conditionally divided into four groups:

A. Children who will be completely healthy in the long-term follow-up after surgery.

B. Children who, despite physical or mental defects, will be able to function within a normal social environment (family, community).

C. Severely impaired patients with profound physical or mental disabilities who can only reside in specialized social care institutions.

D. Non-viable patients.

It is worth noting that In the second group, the patient's sex should be taken into account, as severe physical defects—for instance, in the maxillofacial region—impact the future personal lives of boys and girls differently.

As a rule, physicians will not encounter problems regarding the majority of patients belonging to the First and Second groups. Complex dilemmas may arise when determining The Fate of patients with severe malformations (spina bifida with paralysis, cystic fibrosis, urogenital anomalies, etc.). Long-term experience shows that increasing the number of saved children who carry defective Genetic information inevitably contributes to a long-term increase in the overall number of patients with congenital malformations (we will return to this issue later).

In cases of familial and Hereditary diseases, parents are entitled to comprehensive information regarding the prognosis not only for the newborn in question, but also for future children. The expansion of medical genetics counseling networks, along with the practical Implementation of prenatal Diagnostics for Congenital malformations and inherited Metabolic Disorders using advanced cytological and Biochemical Methods such as amniocentesis, inspires optimism in situations that were considered hopeless not long ago. Keeping parents informed about the degree of genetic risk, combined with a range of organizational measures, will help prevent the onset of hereditary diseases.

When evaluating prognosis, it is advisable to closely monitor the anamnestic data of a specific patient cohort. For instance, until recently, the prognosis for infants who suffered birth-related traumatic brain injury was considered very guarded. In recent years, active management of these patients and intensive rehabilitation measures have significantly improved therapeutic outcomes.

3. The approach in neonatal surgery is not limited to a simple answer to standard questions: which treatment method should be chosen—surgical or conservative? Should a physician resort to radical treatment attempts in cases of extreme prematurity, severe malformations, or central nervous system trauma? These questions become most pressing depending on the availability of proper conditions for performing complex surgery or providing comprehensive care. Notably, Peter Rickham (1969), a leading authority in neonatal surgery, formulated the Answers to these questions quite clearly: “It is unjustifiable to perform complex operations in neonates... where it is absolutely impossible to provide the prolonged post-operative care the child may require, and where highly qualified and scarce medical and nursing resources should instead be directed toward saving the lives of the numerous infants suffering from relatively simple and easily treatable conditions.”

The humanistic principles of our healthcare system provide a clear pathway for solving the difficult challenges of specialized pediatric care. Advances in pediatrics have led to improved diagnosis of surgical conditions in children. Newborns requiring surgical intervention will increasingly be referred to surgical departments. The time has come to train appropriate personnel, equip departments with the necessary apparatus, instruments, and suture materials, and create conditions where every operated child can be cared for by a sufficient number of well-trained staff. All of this will serve as a powerful stimulus for the further development of domestic pediatrics. Any attempt to curtail surgical activity for this group of patients or narrow the indications for surgical intervention under the pretext of inadequate facilities is considered unjustified.

4. Depending on the indications and available conditions, surgery is performed following a radical or palliative approach. For example, in esophageal atresia, one may perform a thoracostomy or limit the intervention to a gastrostomy; in acute Hirschsprung's disease, either a radical intervention or The formation of an artificial anus is possible.

Let us illustrate this point with a specific example. A large body of clinical observations has irrefutably proven that the mortality rate of infants with esophageal atresia increases in direct proportion to the time elapsed from birth to surgery. Because neonatal vomiting is easily confused with an inability to swallow (dysphagia) liquids or milk, the diagnosis of atresia is often made late—on the 2nd to 4th day of life—dooming the operation to failure. It is time to recommend a simple yet effective mandatory procedure for all newborns immediately after birth: passing a rubber catheter through the Nose or Mouth into The Stomach. This procedure is safe; when Amniotic Fluid is swallowed, it is beneficial as it helps clear the stomach of excess fluid, which the newborn might otherwise aspirate during vomiting. In cases of esophageal atresia, the diagnosis will thus be established within the first minutes and hours of life.

One can understand surgeons who, fully aware of the difficulties in caring for newborns with various types of fistulas and stomas, prefer the risk of a radical intervention to a palliative operation. However, a well-organized air medical services network in our country provides grounds for

transferring the patient in certain cases to a specialized neonatal surgery center immediately after diagnosis or shortly after completing the initial emergency palliative stage.

5. The postoperative period plays a decisive role in the ultimate success of treatment and presents complex tasks for medical and especially nursing staff. It requires a deep sense of duty, responsibility, and extensive experience to nurse a newborn infant with malformations day and night over many hours, not always with the certainty of a favorable outcome.

6. A rare problem that demands the physician's utmost attention is parental rejection of a child. This typically involves very young, single, or multi-child mothers. When a child is born with multiple malformations, limb and pelvic organ paralysis, or extreme prematurity, discussing the situation with the parents is extremely difficult. Once parental abandonment is officially documented, the child can be referred to an appropriate social welfare institution.

7. The most intensive growth of a child occurs in the first months and years of life, during which they require close monitoring following surgery. Therefore, maintaining contact between the surgeon and the family of the operated newborn is crucial. Continuous observation of the child helps detect abnormalities that might otherwise escape the attention of even an experienced district or outpatient pediatrician during a routine examination. For instance, following esophageal atresia repair, nearly half of the children may develop complications such as anastomotic stricture, recanalization of the tracheoesophageal fistula, etc. Clinical signs are often manifested by periodically intensifying cough, choking, and recurrent Bronchitis and Pneumonia. Only a surgeon familiar with the subtle details of the operation can suspect the true cause of these symptoms.

In cases of congenital malformations, associated anomalies (e.g., of the Urogenital System) that were initially silent may begin to manifest at a later stage.

Skeletal deformations resulting from Osteomyelitis or neonatal Phlegmon can be corrected in stages, which is physiologically more favorable for the organism than radical operations in adults or adolescents. Tumor recurrences, trauma sequelae, and organic defects caused by temporary manifestations of relative immaturity also require timely therapy and, occasionally, repeated interventions. Esophageal stricture resulting from persistent neonatal vomiting serves as an indication for bougienage treatment.

In Conclusion, we must emphasize that in neonatal surgery, the deontological principles of domestic medicine remain unshakeable, even though they acquire a certain distinctiveness under specific conditions. Despite the difficulties associated with providing care to newborns and premature infants, the lofty tenets of medical humanism demand that every physician persistently strive to save the life of a sick child, even when dealing with the most severe conditions and congenital malformations.

Work of the Ward Nurse

The condition of a newborn infant, the efficacy of ongoing treatment and preoperative preparation, the prevention of postoperative complications, and, ultimately, treatment outcomes in a neonatal surgery unit depend far more on the knowledge and work ethic of the nursing staff—primarily the ward nurse—than in surgical departments of other profiles. Newborn infants, especially premature ones with diseases and malformations requiring surgical treatment, are extremely labile and often react inadequately and severely to minor external stimuli. These Specific features of newborns and premature infants demand constant, close attention from the nurse. Nursing such patients requires a tremendous expenditure of time and effort from the staff.

Of paramount importance is the personal tidiness of the nurse working with newborns. Hair must be tucked completely under a cap, and sleeves rolled up. Personnel must wear lightweight clothing that does not restrict movement, along with soft footwear that does not trap dust. Gowns must be changed after every shift. The high susceptibility of the newborn to infectious diseases precludes staff members from working even with mild upper respiratory catarrh. Department personnel and mothers approach the children only while wearing masks, which are replaced at least twice a day. Wards undergo daily ultraviolet irradiation (2 to 3 times a day for 40 minutes).

Hands must be washed before and after every manipulation, diaper change, and other care activities. Long Nails, nail polish, and wearing rings or bands are strictly prohibited.

Mid-level medical personnel in neonatal surgery departments must be familiar with the normal physiological parameters of various organs and systems in newborns and premature infants, the Specific characteristics of this age group, and the typical presentations and complications of various diseases and malformations.

Physicians and nurses in the maternity hospital are the first to encounter the newborn. Timely diagnosis of a disease or malformation requiring surgical treatment depends on their expertise. Once a diagnosis is established, the patient must be transported to a specialized pediatric surgery department, which may be located a considerable distance from the maternity hospital or even in another city. Proper transportation is critical for the subsequent course of the disease. The duty of the accompanying nurse is to prevent hypothermia, aspiration of mucus and gastric contents, and other complications.

The safest way to transport such infants, especially during the cold season, is in specialized portable incubators. In their absence, the infant is wrapped in 2 to 3 layers of pre-warmed flannel blankets, surrounded by warm hot-Water bottles, and wrapped in a blanket. Swaddling too tightly is unacceptable due to the risk of chest compression and respiratory distress.

The most frequent and formidable complication in children with gastrointestinal malformations is pneumonia caused by the aspiration of mucus or vomit. To prevent aspiration, a thin catheter is passed through the nasal passage, through which continuous suction of mucus and gastric contents is established. Such infants must be transported in a position with the HEAD elevated.

In the admission ward and inpatient unit, measures to prevent hypothermia and vomit aspiration are continued. In the department, the infant is placed in a ward with an air Temperature of at least 22–23°C and a relative humidity of 60%, or in an incubator where a constant, automatically maintained temperature ranging from 24 to 27°C or higher (depending on the infant's condition and degree of maturity) and a relative humidity of 50% to 100% are set. For full-term newborns, a temperature of 25–26°C is indicated, whereas for premature infants, it ranges up to 32–37°C. Humidified oxygen is continuously delivered into the incubator housing the newborn

at a rate of 1.5 to 3 liters per minute (as prescribed by the physician).

Compliance with hygiene rules is essential. The infant's Perineum is washed after each contamination, and a general hygienic bath is administered as prescribed by the doctor, preceded by mandatory disinfection of the bathtub. After bathing, skin folds are lubricated with a thin layer of sterile neutral oil (liquid petrolatum or sunflower oil), diaper rash with baby cream, and zinc lotion. The eyes are washed with a 1% boric acid solution, and the umbilical wound with a 3% hydrogen peroxide solution. To prevent congestive phenomena in the Lungs, the infant is turned onto their side every 2 hours. Weighing is performed daily before feeding.

A well-trained nurse can provide adequate care for no more than two newborns at a time. Caring for a critically ill postoperative patient requires individual, round-the-clock nursing supervision.

Let us examine the details of certain medical procedures and the specifics of newborn care following standard surgical interventions.

Tube feeding is prescribed when a newborn lacks a swallowing reflex or when it is advisable to avoid over-exhausting the infant (especially a premature one) who has undergone major surgery. A thin, flexible tube with a rounded or carefully melted tip is passed through the nose into the stomach and secured with adhesive tape strips. Milk and other fluids are administered using a syringe without pressure over the course of 15 — 20 min. After feeding, air is released from the stomach, and the tube is clamped. To prevent pressure sores and inflammatory complications of the Middle ear, the tube must be removed every 2 days, sterilized, and reinserted through the opposite nostril. Using rigid tubes with sharp edges—which are never intended for such purposes—as feeding tubes can lead to perforation of the stomach or intestine, subsequently resulting in Peritonitis. The following case study serves as a clear example.

   Baby girl O. was admitted to the neonatal surgery department on Oct 28, 1970, on her 9th day of life, in extremely critical condition with symptoms of generalized peritonitis. While in the premature infant ward, a rigid polyethylene tube with a diameter of 2 mm had been inserted into the stomach to feed the infant. The end of the tube, cut with scissors, had not been rounded or melted. Twenty-four hours after insertion, the child's condition deteriorated and her abdomen became distended. It was not until the 9th day of life that the physicians in the premature ward suspected peritonitis and transferred the infant to the surgical department, where she died 5 hours after admission. Surgery was not feasible due to her extremely critical condition.

Autopsy findings: the tube had perforated the duodenum and the right lobe of the Liver; the tip of the tube was located beneath the right dome of the Diaphragm; peritonitis.

Emptying the rectum. Newborns frequently experience gas and stool retention accompanied by abdominal distension. In such cases, a rectal tube is indicated. The tube is lubricated with petroleum jelly and gently inserted 5 — 7 cm into the rectum using a rotating motion. If insertion does not yield the desired result, 10 — 15 mL of a 1% sodium chloride solution is injected through the tube using a syringe. This procedure may be repeated 3 — 4 times until gas begins to pass and a bowel movement occurs.

Postoperative feeding in patients who have undergone abdominal surgery is initiated upon the physician's order, but not before the copious discharge of stagnant gastric contents has ceased. Two to three hours before feeding, the stomach is lavaged with a warm isotonic sodium chloride solution. Feeding is commenced via a tube in small portions (no more than 5 mL). Glucose, cooled tea, and milk are administered every hour. If vomiting and regurgitation persist, one or two feedings should be omitted.

   Specifics of care for patients with stomas. An infant with a gastrostomy should lie supine with the head of the bed elevated. The skin around the tube should be washed with warm water, dried, and treated with oil or water-resistant pastes. The gastrostomy tube is secured to the incubator or crib at a right angle to the infant's body, and its tip is covered with a sterile gauze pad. Before feeding, gastric contents are evacuated (avoid strong suction!). Milk and other fluids are administered slowly via a syringe or funnel without pressure over 15 — 20 min. Should the gastrostomy tube fall out, it must be reinserted immediately, as the gastrostomy tract narrows rapidly. In the event of gastric leakage, Rickham (1969) recommends removing the tube for 2 — 3 hours, after which it should be reinserted into the narrowed tract or replaced with a larger-diameter tube. Air should not be allowed to enter the stomach during feeding. Upon completion of the feeding, the tube is left open to allow air to escape. When clinically indicated, milk and fluids may be administered by continuous drip.

   If a cervical esophagostomy is present, it must be kept open to ensure a continuous outflow of mucus from the upper esophagus. The skin surrounding the stoma should be protected with water-repellent ointments (Lassar's paste, liquid petrolatum, etc.). Mucus should be removed with a sterile wipe as it accumulates. During feeding, food is administered to the infant simultaneously through the gastrostomy and orally to prevent the suppression of the sucking and swallowing Reflexes.

In children with a colostomy or pleostomy, primary attention must be paid to skin hygiene. The skin should be periodically washed with warm water and treated with protective pastes. Stool is removed as it is eliminated. Starting from the 5th to 6th postoperative day, the infant is bathed daily. In cases involving a Mikulicz enterostomy or a T-tube anastomosis, the Contents of the proximal bowel segment are collected in a plastic bag starting from the 3rd or 4th postoperative day and reintroduced into the distal bowel segment. This technique prevents the loss of vital intestinal contents.

When a tracheostomy is present, the newborn is placed in an incubator where high humidity is maintained. The infant requires continuous monitoring, as the presence of a tracheostomy tube does not eliminate the risk of asphyxia, which can develop at any moment due to cannula obstruction.

A spare, sterile tracheostomy tube of identical diameter, along with the necessary instruments for tube replacement, must be kept readily available at all times. Secretions from the bronchial tree are gently suctioned as they accumulate. Prior to suctioning, 1 — 2 mL of a sterile isotonic sodium chloride or soda solution is instilled into the tube drop by drop. This facilitates the thinning and subsequent aspiration of mucus. The tube is replaced as clinically indicated, but no less than once a week. Proper hygiene of the skin surrounding the tracheostomy cannula is essential.

Certain procedures are performed in a unique manner (Fig. 7). When caring for a newborn, it is frequently necessary to secure various tubes and catheters using adhesive tape strips. When using adhesive tape, it must be reapplied to a fresh site daily. The skin is pre-treated with cleol (surgical adhesive). Adhering to this rule prevents skin maceration and necrosis beneath the tape.

Fig. 7. Collection of 24-hour urine in newborns. a — Glass funnels for collecting urine in boys and girls; b — funnel secured for urine collection in boys; c — funnel secured for urine collection in girls.

The ward nurse in the neonatal surgery department must maintain effective communication with the mother of the sick child. The mother is admitted to the department shortly after childbirth. She is physically weakened, emotionally heightened, distressed by her child's illness, and hypersensitive to the slightest stimuli. Consequently, Lactation may be disrupted, and conflicts can arise. It is the duty of the department personnel, including the ward nurse, to treat the mother with care and patience. Inappropriate emotional reactions should be met with composure and neutralized whenever possible. The nurse acquaints the mother with the department's parental conduct rules, feeding schedules, and the specifics of caring for her sick child. A properly instructed mother becomes a valuable partner in the infant's nursing care. We restrict the mother's involvement only during the initial days of the postoperative period.

In conclusion, it should be emphasized that strict adherence to infant care protocols is frequently decisive; the success of neonatal treatment depends in large part on the dedication and skill of the ward nurse.

To prevent complications associated with impaired Blood Circulation and skin necrosis, specific guidelines must be followed when applying plaster casts and adhesive traction. A plaster cast of the shoulder girdle is typically applied in cases of humeral fracture or osteomyelitis. Following bone reduction, the surgeon immobilizes the limb in the correct position. Before applying the plaster cast, the skin of the lateral trunk and shoulder must be protected with pads moistened with petroleum jelly. Tight bandaging can cause tissue ischemia. When applying a Deso bandage, areas of skin subjected to prolonged pressure must similarly be protected with petroleum jelly-soaked gauze pads.

To prevent skin irritation caused by adhesive tape during Schede traction, it is recommended to apply cleol to the limb. The bandage should not be applied too tightly. The ankles must be adequately protected. Traction is sufficient if the infant's buttocks are elevated approximately 4 cm above the mattress. Edema of the FOOT indicates that the bandage has been applied too tightly.