Surgery in the Neonatal Intensive Care Unit in Indian Scenario: Should It be "The New State of the Art" or Just "The Need of the Hour"?

INTRODUCTION: Critically ill surgical neonates are physiologically challenged and delicately poised on ventilator and inotropic support systems. They experience significant stress in the event of surgery. Shifting them poise further addition to this stress. We here share our experience of operating such surgical neonates for certain conditions in the neonatal intensive care unit (NICU).
METHODS: We retrospectively analyzed the data of operated patients in the NICU. We collected the demographic data, diagnosis, and preoperative stability of the patient, ventilator and inotropic requirements, need for extra anesthetic drugs, procedures performed, complications, and outcome. Operations were performed at bedside in the NICU in critically ill, unstable neonates who needed emergency surgery, neonates of very low birth weight (<1000 g), and neonates on special equipment such as high-frequency ventilators. We excluded minor routine procedures such as drain placement, central line placement, ventricular taps, incision and drainage, and intercostal drainage procedures.
RESULTS: We performed seven surgical procedures in the NICU. These included bowel resections and stoma creation, fistula ligation, lung biopsies, and ventricular reservoir placement. Gestational age ranged between 24 and 34 weeks (mean, 28 weeks). Birth weights ranged between 800 and 2500 g (mean, 1357 g). Age at surgery was between 2 and 18 days (mean, 10.2 days). All our patients were on inotropic support and were intubated and mechanically ventilated.
CONCLUSION: Doing surgery for critically ill neonates in the NICU definitely has a place. It was the need of the hour based on the condition of the neonates; however, we feel that neonatal surgery in the NICU should be the norm as it can improve survival. Surgery in the NICU can give a fighting chance to these patients; however, operation theaters in the NICU would be an ideal setting. Copyright:

INTRODUCTION

Neonatal physiology is quite complex and delicately poised. Various acquired environmental aberrations (e.g., hypothermia, sepsis) and congenital developmental variables (e.g., prematurity, placental insufficiencies) affect this delicate homeostasis.[1] In the course of events, many ailments require emergent surgical intervention, which is the most important modifiable variable on which survival depends. Many premature and very low birth weight infants are already on multiple lifesaving infusions such as inotropes, total parenteral nutrition, and ventilator/high-frequency oscillatory ventilation (HFOV)/extracorporeal membrane oxygenation/nitric oxide for stabilization.[234] Neonates in need of surgery are conventionally transferred to the main operation room outside the neonatal intensive care unit (NICU). However, transferring the critically ill neonates to the operating room (OR) outside the NICU risks complications.[15] A change in environment and personnel and further stress of surgery and transit may be an added burden to their delicately balanced physiology.[36] Thus, the concept of neonatal surgery in the NICU has come up to reduce the added stress involved in these selected cases. We share our experience of operating such cases in the NICU.

METHODS

We retrospectively collected data related to surgeries done in the NICU at various centers (Indore Newborn Care Centre, Indore; Amaltas Institute of Medical Sciences and Research Centre, Dewas) from January 2017 to December 2018. We included all the major cases done in the NICU and excluded routinely done procedures, such as drain placement, central line placement, ventricular taps, incision and drainage, and intercostal drainage procedures. We collected the demographic data, diagnosis, and preoperative stability of the patient, ventilator and inotropic requirements, need for extra anesthetic drugs, procedures performed, Indications, complications, and outcome.

Operations were performed at bedside in the NICU in critically ill, unstable neonates who needed emergency surgery, neonates of very low birth weight (<1000 g), and neonates on special equipment such as high-frequency ventilators. Written informed consent was taken from the patients' attendants explaining them the need to perform these procedures bedside in view of the risks involved in shifting the child to the OR. After our first case, we took ethical clearance and discussed the idea with the ethical committee, where the proposal for this study was accepted. We did four procedures in emergency (Cases 1–4) and three were planned (Cases 5–7).

Theater staff shifted all the necessary equipment including cauterization device, instruments, and drapes to the NICU. Routine work continued in the NICU for other critical neonates. All unsterile areas were covered with sterile drapes. No separation from other treated neonates was required as we have proper room space and norms for NICU and two warmers are wide apart, hence not interfering with the functioning of NICU. All monitoring equipment already available in the NICU such as pulse oximetry and noninvasive blood pressure measurements was used. All our neonates preoperatively had umbilical or peripheral arterial lines, which were used for monitoring. These highly sensitive monitoring apparatuses helped the anesthetist monitor these unstable neonates, during the operative procedures. Portable lights available in the NICU for minor procedures were used. Operative and postoperative care remained the same as in the operation theater. We use Bacillocid solution as surface disinfectant and ultraviolet rays for air filtration, in our NICU, similar to that used in operation theaters.

The surgical team consisted of neonatal surgeon, neonatologist, anesthetist, scrub assistant, and a circulatory nurse. Intravenous anesthetic agents were used in all cases.

OBSERVATION

We operated seven cases in the NICU [Table 1]. These included bowel resections and stoma creation, fistula ligation, lung biopsies, and ventricular reservoir placement. Gestational age ranged between 24 and 34 weeks (mean, 28 weeks). Birth weights ranged between 800 and 2500 g (mean, 1357 g). Age at surgery was between 2 and 18 days (mean, 10.2 days). All our patients were on inotropic support and were intubated and mechanically ventilated. All our patients were ventilator dependent; three on HFOV and four on conventional ventilation. Out of seven, five were already on muscle relaxants (vecuronium) and two were on sedation (midazolam). Muscle relaxants were used as continuous infusion for all five patients, and these did not require any further anesthetic drugs during surgery. The other two were given vecuronium for induction. There was no perioperative mortality. No anesthesia-related adverse events were documented. There were two mortalities. These two patients were preterms, extremely low birth weight (ELBW) infants who survived 10 days (Case 1) and 20 days (Case 4) postsurgery, and died of multiple factors, none related to surgery.

Table 1

Details of patients operated in neonatal intensive care unit

Indication for surgery	Surgery done	Additional procedure	Gestational age	Age at surgery	Birth weight	Ventilation	Inotropes	Extra anesthetic requirement	Outcome
NEC Stage III	Ileostomy with resection of gangrenous Ileum	Drain placement	28	8 days	900 g	CMV	Yes	No	Died
TEF	Fistula ligation	None	24	2 days	1200 g	CMV	Yes	No	Survived
ARM with perforation	HDSC	None	30	2 days	1500 g	CMV	Yes	Yes	Survived
NEC Stage III	Ileostomy with resection of gangrenous Ileum	Drain placement	24	12 days	800 g	CMV	Yes	No	Died
Intraventricular hemorrhage	Ventricular reservoir	Ventricular tap	32	15 days	1400 g	HFOV	Yes	No	Survived
Bronchopulmonary dysplasia	Lung biopsy	None	34	18 days	2500 g	HFOV	Yes	No	LAMA
Severe GERD	Gastrostomy and TGJI	None	24	16 days	1200 g	HFOV	Yes	No	Survived

NEC: Necrotizing enterocolitis; TEF: Tracheoesophageal fistula; ARM: Anorectal malformation; GERD: Gastroesophageal reflux disease, HDSC: High-divided sigmoid colostomy; TGJI: Transgastric jejunal intubation; CMV: Conventional mechanical ventilation; HFOV: High-frequency oscillatory ventilation; DOR: Discharge on request; LAMA: Left against medical advice

DISCUSSION

Operating neonates in the NICU in collaboration with neonatologist and neonatal nurses is not a new concept.[1] Various invasive procedures such as central line placement, Intraperitoneal drain placement for necrotizing enterocolitis (NEC) perforations, ventricular tapping, intercostal drainage procedures, and peritoneal dialysis catheter placements are routinely done in all NICUs in India and world over.[357] Patent ductus arteriosus (PDA) ligation is another routinely done surgical procedure in the NICU for neonates but is not that frequently done in India.[5] There have been variety of surgeries done previously in the NICU such as laparotomy for intestinal ailments, thoracic surgeries, congenital diaphragmatic hernia repair, tracheoesophageal fistula (TEF) repair, urinary diversions, and neurological procedures.[13567]

In most hospitals, neonates are transported to the OR outside the NICU for surgery.[5] In critical patients, previous studies have shown that complications such as hypothermia, change in variations in heart rate and blood pressure, and dislocation of vascular accesses or endotracheal tubes may occur in up to 70% of intrahospital transports.[134] The incidence of complications may relate to the duration of transportation, the severity of the patients' symptoms, and availability of expert personnel. Many of these events are equipment-related events too.[135] These transport-related events are potentially preventable by implementing protocolized standard guidelines for transport.[1] This usually involves the coordination of a multidisciplinary team and is a continuous quality improvement process to refine the plan, in cases of events.[157] All of the above involve high costs and continuous compliance and introspection.[137] All these are difficult to achieve in resource-limited scenarios in developing nations.

Most of the hospitals in India are prone to nosocomial infections.[5] The standard of hygiene protocols are the best in ICUs and ORs. Personnel handling neonates are inculcated in them strict hygiene protocols.[567] ORs used are not exclusive for neonates. OR personnel, especially the ward boys and nurses, handle various patients and products. OR personnel handling these neonates are a major source of nosocomial infections.[357] Thus, change of personnel handling these neonates is not advisable. Thus, having an exclusive OR in the NICU would decrease the chances of introducing nosocomial infections and ensure continuity of care by the same NICU personnel.[1]

Availability of expert neonatal anesthetist is a rarity in many setups, and in most setups, anesthetist available anesthetizes the case. Once the neonate is draped, access is limited. An expert in handling the fluid requirements, monitoring the ventilator settings, and proper continuation of lifesaving drugs, is required.[1357] It was observed in a study that with a goal of maintaining high saturation, the postoperation FiO2was significantly higher when neonates were operated in main OT.[1] The average amount of intravenous fluid given and the incidence of hyperglycemia were also more in this group.[1] These problems are decreased if a neonatologist attends surgery and cooperates the anesthetist.[5]

Performing surgery in the NICU on the warmer can have its own limitations in view of space, illumination, and ergonomics.[5] However, it still has its place for operations that are short and predictable.[5] Surgeries such as PDA ligation, ostomy creation in NEC, lung biopsies, and fistula ligation in case of TEFs can be done in the NICU. The condition of neonate also dictates this decision. More complex and unpredictable surgeries give better results in the surgical suite.[15] It has been argued that surgery on the NICU increases the risk of infection; however, recent studies have shown no such association.[57] Furthermore, some studies have shown a higher mortality rate in the NICU group related to underlying prematurity, illness, and anomalies, but not the operative location.[57] There have been many articles on surgery in the NICU published in literature and all have shown favorable results.[1234567]

Many trauma centers in India have in built theater complexes to avoid shifting critical patients to the main ORs. This can be done in cases of neonates too. These should be the norms rather than sudden forced decision for a few neonates. Newly established corporate hospitals and premier teaching institutes should lead by example so that larger studies can be done and meaningful inferences can be deciphered.

Our study is a retrospective study and lacks the comparison of two cohorts (with one operated in the theater and the other in the NICU) in terms of survival benefits. We started the study on the basis of previous adverse events experienced by us and saw encouraging signs among a few ELBW and preterms. It was more the need of the hour. Operating in the NICU gave these neonates a better fighting chance by decreasing the additional stress of transport and transport-related events.

CONCLUSION

In our case, it was the need of the hour based on the condition of the neonates; however, we feel that neonatal surgery in the NICU can improve overall survival. There have been discussions and reports on this topic from developed nations; however, this is probably the first report of cases being operated in the NICU from India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.