As clinicians in Neonatology, we understand both the benefits and risks of advancements in medical science and modern technology. As we are able to save more neonates on the cusp of viability, we acknowledge with that comes the greater risk of morbidity and mortality. As a function of that morbidity comes the risk of requiring surgery. Some neonates, while far beyond the limits of viability, will require surgical intervention for a congenital indication, whereas others may still require surgery for an acquired indication. Regardless of your geographic practice location or the level of the neonatal intensive care unit (NICU) you practice in, it is very likely you have been involved in the care of a neonate who has required, or will go on to require, a surgical intervention.
This Special Surgical Series was conceived and executed with you and the infants you care for in mind. Nurses and nurse practitioners in the NICU care for neonates undergoing surgical procedures for diagnoses such as patent ductus arteriosus, necrotizing enterocolitis, abdominal wall defects, Hirschsprung disease, bowel obstruction or atresia, tracheoesophageal fistula/esophageal atresia, congenital diaphragmatic hernia, retinopathy of prematurity, intraventricular hemorrhage (IVH), inguinal hernia(s), malrotation/volvulus, and cardiac indications. As the surgical neonate spans all gestational ages, we as NICU clinicians must be aware of the possible comorbidities or complications that may affect our surgical population.
It is important to continue to provide developmental care during the critical pre- and postoperative periods, as well as to provide positive oral stimulation for neonates who won't be able to feed enterally for some period after surgery or more importantly nil per os (NPO) for extended periods of time, in particular, neonates with long-gap esophageal atresia, gastroschisis, and congenital heart disease.1 We must empower mothers to continue to provide human milk for their surgical neonate, as human milk is often the key to enteral success after surgery.2 We must also provide timely, thorough, and accurate information regarding the diagnosis and surgical procedure. This will give families the power to work through the diagnosis and also be able to anticipate the perioperative course and potential complications or setbacks.
In the sample of articles for the Special Surgical Series, you will find diagnoses ranging from simple to complex, affecting the span of all gestational ages and including uncommon complications of common surgical procedures. In part I of the series, there is a comprehensive review of IVH and ventriculoperitoneal shunt, a rather commonplace procedure in the NICU. This article will serve the novice NICU nurse providing a foundation of knowledge as well as the more experienced nurse as a review of the diagnosis and surgical procedure. Part I of the series also brings the rarest diagnosis of the series as congenital infantile fibrosarcoma (CIF). In this case presentation, CIF is presented in a premature infant and highlights not only the natural history of the diagnosis but also the treatment implications in the setting of a premature infant.
Part II of the series showcases another foundation article that will again benefit the novice and expert nurses alike. This is a review of esophageal atresia and tracheoesophageal fistula. Another common diagnosis and surgical procedure in the NICU is gastroschisis with abdominal wall closure. A second paper in part II of the series undertakes abdominal compartment syndrome—an uncommon complication to this common procedure. Rounding out the series is the presentation of a topic that is just now emerging in our field and may be new to most of us. Telemedicine utilizes modern technology to aid in the transition to home for the medically complex surgical neonate.
Preparing families for discharge with a medically complex infant who may require multiple medications, respiratory support, equipment for feeding and monitoring, and wounds or ostomy is paramount to a successful transition home. NICU clinicians are perfectly poised to provide this invaluable education. Once home, however, families may need continued support to bridge the gap between the primary pediatrician and the surgeon. This support comes in the form of telemedicine. Telemedicine is the merging of modern technology with the medical community, and its emergence in the care of the medically fragile neonate is very exciting for our field.3 Utilizing telemedicine to evaluate the infant and the family after discharge allows for an additional layer of comfort for the family as the infant is evaluated by a team familiar with their child and the hospital course.4 In addition, telemedicine has been shown to decrease travel time for the family, number of emergency department visits, number of rehospitalizations, and overall healthcare costs.3,4
As I reflect on this Special Surgical Series, I would like to thank the authors for their time and dedication to the surgical neonate, as well as for their willingness to share their knowledge and educate their peers. In addition, I would like to thank our editors, Drs Brandon and McGrath, for the opportunity to bring this Special Series to you and also for the vision to highlight the Surgical Neonate. I hope you found this Special Surgical Series both interesting and applicable to your practice. I also hope the works presented here will serve to expand your knowledge of the issues affecting the surgical neonate and help enhance your practice when caring for a vulnerable neonate requiring surgery—regardless of the indication.
1. Pados BF, Thoyre SM, Estrem HH, Park J, Knafl GJ, Nix B. Effects of milk flow on the physiological and behavioural responses to feeding in an infant with hypoplastic left heart syndrome. Cardiol Young. 2017;27(1):139–153.
2. Edwards TM, Spatz DL. An innovative model for achieving breast-feeding success in infants with complex surgical anomalies. J Perinat Neonatal Nurs. 2010;24(3):246–253.
3. Burke BL, Hall RW. Telemedicine: pediatric applications. Pediatrics. 2015;136(1):e293–e308.
4. Toly VB, Musil CM, Bieda A, Barnett K, Dowling DA, Sattar A. Neonates and infant discharged home dependent on medical technology: characteristics and outcomes. Adv Neonatal Care. 2016;16(5):379–389.