Neonatal Intestinal Surgery Guidelines (2020)

The guidelines on perioperative care in neonatal intestinal surgery were published in August 2020 by the Enhanced Recovery After Surgery (ERAS^®) Society.^[1]

Surgical Practices

Perform primary anastomosis as the first choice in patients with uncomplicated intestinal atresia.

Antimicrobial Prophylaxis

Administer appropriate preoperative antibiotic prophylaxis within 60 minutes before skin incision.

Discontinue postoperative antibiotics within 24 hours after surgery, unless ongoing treatment is required.

Prevention of Intraoperative Hypothermia

Continuously monitor intraoperative core temperature, and take preemptive measures to prevent hypothermia (< 36.5°C) and maintain normothermia.

Perioperative Fluid Management

Use perioperative fluid management to maintain tissue perfusion and prevent hypovolemia, fluid overload, hyponatremia, and hyperglycemia.

Perioperative Analgesia

During the early postoperative period, unless so doing is contraindicated, administer acetaminophen regularly (not on an "as-needed" basis) to minimize opioid use.

Use of an opioid-limiting strategy is recommended in the postoperative period. Manage breakthrough pain with the lowest effective dose of opioid with continuous monitoring.

Use regional anesthesia and acetaminophen perioperatively in combination with general anesthesia. Multimodal strategies, including regional techniques, should be continued postoperatively.

Provide lingual sucrose or dextrose to reduce pain during nasogastric or orogastric tube placement and other minor painful procedures.

Optimization of Hemoglobin

Restrict transfusions to maintaining hemoglobin at 9 g/dL or higher for a term neonate with no oxygen requirement. For term neonates within the first week of life who are intubated or have an oxygen requirement, transfusions should maintain a hemoglobin of 11 g/dL or higher.

Use written transfusion guidelines, and take into account not only a target hemoglobin threshold but also the clinical status of the neonate and local practices.

Perioperative Communication

Implement perioperative multidisciplinary team communication with a structured process and protocol ("pre- and postoperative huddle") utilizing established checklists.

Parental Involvement

Facilitate hands-on care and purposeful practice by parents that is individualized to meet the unique needs of parents early during the admission. Sustain these to build the knowledge and skills of parents for taking on a leading role as caregivers and to facilitate their readiness for discharge.

Postoperative Nutritional Care

When possible, start early enteral feedings within 24-48 hours after surgery. Do not wait for formal return of bowel function.

Use breast milk as the first choice for nutrition.

Monitor urinary sodium in all neonates with a stoma. The target urinary sodium level should be greater than 30 mmol/L and should exceed the urinary potassium level.

Mucous Fistula Refeeding

Use mucous fistula refeeding in neonates with an enterostomy to improve growth.

For more information, please go to Evaluation of the Pediatric Surgical Patient.

For more Clinical Practice Guidelines, please go to Guidelines.

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