Gastroschisis

umcRN, BSN, RN · May 4, 2011

I hope you have surgeons experienced with the condition...

Everything depends on the baby, most are not intubated at birth unless they are preemie/have RDS. On my unit surgery for gastroschesis is usually done almost immediately after admit, even if admit is at 2am, they will be intubated for surgery of course. It also depends on the size of the defect, the intestines may be placed in a silo for a few days to allow them to fall back into the abdomen via gravity before final closure. Then you wait for return of bowel function = days to weeks to months. We had a baby recently who after 6wks had no return of bowel function, was reopened and found with about 40cm necrotic intestines that had to be removed. Once stable after that surgery he was sent to our intestinal rehab floor (we are in a childrens hospital) so I don't know how much longer he was inpatient and when he was able to start feeding, he likely went home on TPN. Others heal much faster than that and do great. With this surgery as well the surgeons are basically shoving intestines back into the abdomen, there is risk for respiratory issues if the lungs cant expand enough and risk for strictures/malro/NEC/severe short gut etc. It can be a long road and I have seen the occaisional death from icomplications.

Omphalocele is a different story, if it is a small defect it may be repaired right away, they typically (or so I hear) have a better time getting return of bowel function than gastro kids, also if they have a very large defect they may stay inpatient until the protective sac is stronger and then go home with the family being educated on dressing changes and they will have their repairs when they are bigger, usually around 1yr old. They will have a special cast/brace made for the car seat to protect the defect.

prmenrs, RN · May 4, 2011

Don't know the size of the defect, but this could be a MAJOR problem if your unit is not used to handling "gut" babies. They frequently take weeks to months to recover to a point @ which they can be discharged.

They are very difficult to console and control pain; a challenge to find a feeding program that works. Plan (w/the pharmacy) for long term parenteral nutrition. They need respiratory support until they can breathe easily (a sore abdomen makes respiration difficult).

I would [respectfully] suggest you do some research and planning unless there is an alternative placement for this infant.

FlyingScot, RN · May 4, 2011

May I respectfully ask why the patient is being admitted to your hospital if there is no one with experience treating these types of babies? Please don't misunderstand me, I am not in anyway denigrating your facility or the care you provide to infants which I am sure is top-notch. It's just that these infants are very, very complex and will consume a lot of your resources.

qcumba · May 5, 2011

thank you for all your replies and advice, I had a giggle at the tact and the emphasis on conveying said advice with respect :) us South African's have very thick skins and dont get offended easily,so none taken, I just appreciate the insight you can give. I have been trying to do some research but most of what I could find was mainly aimed at parent's not much for us as nurses if you could give me some pointers that would be great. As far as why we are admitting the child in our facility, well now it's my turn to attempt to be tactful,the only other hospital in town who has treated these kinds of cases,is a state hospital and I personlly wouldntwant my worst enemy to end up there,if you can think of the worst developing country kind of facility this would be it,its a filthy disgusting place. Whereas our facility while small and unexperienced in caring for these kinds of cases, are a private facility with everything he could possibly need and the resources to get what we dont have . That is sad I know but now Im getting off topic

The paediatrician on the case has been in contact with a professor who is experienced and has got guidelines from him.

Baby was delivered yesterday at 38 wks via ceaser while I

was off, he has gastroschisis and not an omphalocele,he was

operated on straight away, they were able to get the intestines back into the abdominal cavity, but have left it open to allow the swelling to go down,he is ventilated and so far things are going well,its early days tho so we will have to see how he does.

thanks again for your help,

prmenrs, RN · May 5, 2011

OK. I kinda figured you had no choice.

Merenstein and Gardner has a little--pp838-841 in the seventh edition. A lit search focusing on Neonatal Network and NANN Journal might get you some more comprehensive info, too.

If you have any specific questions (or you just want to tell us off jk ), come on back. I hope you'll document what worked best for future reference!

qcumba · May 5, 2011

Thank you prmenrs, for that referance and I will do a more specific search as well,I will definately be back I'm sure, asking questions is kinda my thing. And I will try and keep you updated on how our little guy is doing

Thank you again to all of you and if anyone has anything more to share please do :)

EricJRN, MSN, RN · May 5, 2011

Just wanted to wish you good luck, gcumba. I was in Durban for a conference a few months ago and was able to see the disparities that exist between two neighboring hospitals. Here in the US, we think we have disparities in the level of care between hospitals, but it's nothing compared to the situation in Africa. Definitely come back and update us on anything you learn. It could help others in similar situations.

I know that sepsis is a huge issue for kids with abdominal wall defects in developing and middle-income countries. That's often linked to the fact that these babies tend to be born at facilities that cannot provide definitive management, leading to delays associated with referral and transport. It sounds like you've avoided that big hurdle with this baby, so hopefully everything will continue to move right along.

BabyLady, BSN, RN · May 5, 2011

Hi,
I was just wondering if those of you in bigger units have seen this condition before? we are due to be admitting a baby this week with suspected gastroschisis or omphalocele, it will be the first time we will be having a child with either of these conditions, in fact its a first for the Paediatrician as well, we are a very small unit only 6 beds
Basically I would just like to know in general the length of stay we can expect, how long typically do they wait before the first surgery and are they intubated and ventilated straight away at birth or is a wait and see situation?
thanks

Ok..baby already delivered.

EricJRN, MSN, RN · May 5, 2011

BabyLady,

See post #4. Looks like the baby already delivered and has undergone surgery. It's definitely an eye-opening experience to see the differences in care provided internationally.

While we would consider a pediatrician to be inadequate to manage sick neonates, in many parts of Africa the pediatrician is a luxury. In many parts of the continent, general practitioners are responsible for almost all of the medical and surgical management of adults, children and infants.

In the US, we're used to a system of seamless, rapid transports and ever-escalating levels of care. In much of the world, that just isn't a reality.

BabyLady, BSN, RN · May 5, 2011

BabyLady,
See post #4. Looks like the baby already delivered and has undergone surgery. It's definitely an eye-opening experience to see the differences in care provided internationally.
While we would consider a pediatrician to be inadequate to manage sick neonates, in many parts of Africa the pediatrician is a luxury. In many parts of the continent, general practitioners are responsible for almost all of the medical and surgical management of adults, children and infants.
In the US, we're used to a system of seamless, rapid transports and ever-escalating levels of care. In much of the world, that just isn't a reality.

...I didn't see that she was not in the USA...when they did a few updates to the website awhile back, you cannot readily see that info in a post anymore.

Bummer.

EricJRN, MSN, RN · May 5, 2011

Oops... I didn't see your post before mine! Haha. Have a good day.