Induction of Anaesthesia
🎯 Key induction points
- Treat as a full stomach → rapid-sequence induction (modified RSI); the orogastric/NG tube should already be draining.
- IV induction preferred (an awake or IV technique avoids gastric distension); intubate with titrated doses.
- Avoid vigorous mask positive-pressure ventilation — it distends the bowel and stomach, worsening the reduction.
- Nitrous oxide is AVOIDED — it diffuses into the gut, causing bowel distension and interfering with reduction of the hernia.
- Atracurium is a good relaxant choice (organ-independent Hofmann elimination); target SpO₂ ~95% (avoid hyperoxia/ROP in preterm).
- Anti-anxiety premedication is not needed in the neonate.
Fluid, Glucose & Blood Management
Fluids & glucose
- Maintenance dextrose-containing fluid (e.g. 5–10% dextrose + 0.2% saline) to prevent hypoglycaemia
- Replace ongoing third-space losses generously — often ~8–15 mL/kg/h of balanced crystalloid — titrate to perfusion & urine output
- Avoid fluid overload (worsens bowel oedema, hinders closure)
Blood products
- Group & cross-match; replace blood loss to an Hb goal ~10–12 g/dL
- FFP in ~10 mL/kg aliquots as indicated
- Warm all fluids & blood
Monitoring — Extreme Vigilance
Extreme clinical vigilance and invasive monitoring are recommended. Standard monitors (ECG, NIBP, SpO₂, EtCO₂, temperature, urine output) plus — for the sicker neonate — an arterial line and, crucially, intragastric & intravesical (bladder) pressure monitoring and airway pressures, because these numbers decide whether primary closure is safe (next tab). A precordial stethoscope and depth-of-anaesthesia monitoring are useful adjuncts. Warm the theatre and everything that touches the baby.