Neonates and chest surgery - thorax.bmj.comthorax.bmj.com/content/thoraxjnl/20/1/1.full.pdf7Torax(1965), 20, 1. Neonates and chest surgery H. E. BELL From the Newcastle Region Thoracic

7Torax (1965), 20, 1.

Neonates and chest surgery

H. E. BELL

From the Newcastle Region Thoracic Surgical Unit, Seaham Hall Hospital. Co. Dxrham

The theme of this article is the management ofthoracotomy in the neonate in respect of anaes-

thesia, ventilation, blood replacement, and post-operative care.

The principles of management of a chest opera-

tion in the newborn are much the same as duringother periods of life, but the margin of safetyin the neonate is small; many of these babiesare premature and many have other congenitalabnormalities.

ANAESTHESIA AND VENTILATION

I believe that, of the various techniques available,light cyclopropane anaesthesia is the least likelyto jeopardize survival. I use manual ventilationthroughout the operation.The anaesthetic equipment is simple, but to

avoid trouble during the operation the variouscomponents must be chosen with care. Odd bitsgathered together just before operation will notdo. A new plain rubber Magill tube is used foreach case and checked for patency beforehand.A stock of tubes, 2 5, 3, and 4 mm. in diameter,are kept (those made by J. G. Franklin & SonsLtd. are suitable). The appropriate length of tubefor a particular baby is found by measuring thedistance between the suprasternal notch and themouth, following the curve of the air passages.

A 3 mm. diameter tube is the appropriate sizefor most neonates, but sometimes a final decisionas to the right size can only be made after intuba-tion has been attempted. Any attempt to screw

home too big a tube is likely to result in laryngealoedema, whereas a troublesome gas leak willaccompany controlled ventilation with a tube thatis too small. The endotracheal tube is attachedto a miniature Magill (right-angled with port forsuction) connexion and bound on with a few turnsof adhesive strapping; this prevents splitting ofthe tube and separation from the connexion. Aright-angled connexion is chosen because a suctioncatheter can be passed quickly and easily throughit, and it can easily be anchored in stable positionat the mouth. A clear airway is better established

and maintained by this method than by any other.Any objections on the score of turbulent gas flowand a consequent increase of respiratory work areof little significance because, during controlledrespiration, the respiratory work is done by theanaesthetist. The endotracheal connexion is joinedin succession to a short, loose-fitting cathetermount, an Ingle valve, a 3 oz. (85 g.) soda-limecanister and a 0 5 litre reservoir bag.

Atropine, gr. 1/800 (0-08 mg.) s.c.i., is givenhalf an hour before operation with the intentionof reducing bronchial secretions. Since cyclo-propane anaesthesia is used, atropine is probablyunnecessary; nevertheless, one should not lightlydispense with any measure that may contribute toa clear airway in a small baby. Atropine isconventionally given before cyclopropane anaes-thesia to prevent vagal slowing of the heart. I donot know of any evidence to establish that aneonate under anaesthesia is better off with a fastheart rate, and I would not prescribe atropineexcept to reduce secretion. Cyclopropane doesnot cause cardiac irregularities in children(Shannon, D. W., 1950, personal communication).When all is ready in the theatre the baby is

brought along in his incubator, removed andplaced in warm towelling on the table. If cyanosisis evident oxygen is given before intubation. Noparticular position of the head or neck seems tohave any advantage over the horizontal in so faras intubation of the newborn is concerned; butgentle pressure on the larynx from the outsidemay help one to see the laryngeal opening. Astraight-bladed Magill laryngoscope, slightlylubricated, is used, and before the endotrachealtube is inserted a bacteriological swab of thepharyngeal secretions is taken. The endotrachealtube should not be daubed with lubricant; theslightest smear is enough.Most authorities now recommend intubation

before an anaesthetic or relaxant is given; I thinkthis is sound advice. With the tube in position,from the start the baby is spared any period ofprecarious ventilation control; bronchial secre-tions can be cleared out straight away, and

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abnormalities of the larynx discovered in favour-able circumstances. In one baby with oesophagealatresia the larynx and upper parts of the tracheaand oesophagus were one common passage. Alarge endotracheal tube pushed into 'theoesophagus' provided good ventilation, but thedefect was irreparable.

After intubation the baby is quickly put to sleepwith 50% cyclopropane in oxygen. When bodymovements cease and the breathing becomesregular the concentration of cyclopropane is cutto 5 to 10% and manual inflation is begun. Thetotal gas flow necessary depends on the amountof laryngeal leak but in any case must not be lessthan 1,000 ml./min. (e.g., 900 ml. O , 100 ml.C H6). A troublesome leak can be reduced by thepressure of a finger on each side of the larynxwith the head and neck slightly extended. Packingof the pharynx is not effective as a seal. Suitablefullness of the reservoir bag is achieve,d bybalancing the total flow rate, leaks, and expiratoryvalve setting.The baby is usually turned on to his side, the

head and the soda-lime canister resting on a whitetowel; this makes assessment of the colour easier.The reservoir bag should protrude over the topend of the table for ease of handling. A piece ofCramer wire inserted under the table covering andsuitably bent serves as an anaesthetic screen; thesterile towel placed over this should be white. Agood light beamed on to the baby's face completesthe arrangements. Everything must be in orderbefore the operation is begun; faults are hard tocorrect later.

Anaesthesia for neonatal chest surgery shouldprovide sleep, a still baby, and good ventilation.Deep anaesthesia is not necessary to fulfil theseconditions. Neonates willingly surrender theirrespiration to intermittent positive pressure (Rees,1958), and anaesthesia deep enough to preventbody movement will provide sleep. The aim is tokeep the baby at a depth that prevents movement,and no more. At this depth muscular tone ispresent in the limbs, and this is a valuable guide;relaxed flaccid limbs mean that the anaesthesia isdeeper than need be. (I have cyclopropane solelyin mind here, and not, of course, the use ofrelaxants.)

Anaesthesia is established with 50% cyclo-propane, after which manual ventilation with 10%cyclopropane is begun. Subsequent managementis determined by the response of the baby: mostwill gradually become lighter on 10% cyclo-propane, as shown by increasing muscle tone and

eventually movements. (The presence and degreeof muscle tone is most easily assessed by movinga hand to and from the shoulder.) The anaesthesiais thereupon deepened by inflation with 50%cyclopropane until muscle tone disappears, whena return to 10% cyclopropane is made. This cycleis repeated, when indicated, throughout the opera-tion. Small babies in poor general condition arelikely to remain immobile and flaccid on 10%cyclopropane: in this case the concentrationshould be reduced to 5%, with deepening asbefore by 50% cyclopropane as occasiondemands. It is best to keep to the concentrationsof cyclopropane mentioned (50% and 10% or5 %), a variety of concentrations resulting inconfusion and erratic anaesthesia.Cyclopropane used as described above is more

satisfactory than any other form of anaesthesiafor neonatal chest surgery. It is, however,explosive, which precludes the use of diathermy;this is unfortunate as light cyclopropane anaes-thesia results in more bleeding, from the chestwall in particular, than other anaesthetics. The useof relaxant drugs with nitrous oxide anaesthesiain a newborn baby, for the main purpose ofallowing diathermy, is based on questionablepriorities. Relaxant drugs are not predictable intheir effects on the newborn; respiration at theend of the operation, even in a wide awake baby,is often critical enough without any lag effect froma relaxant. Since I believe a blood transfusion isalways necessary to maintain blood volume, theextra loss brought about by cyclopropane can bemade good by a small transfusion.The lungs are ventilated by rhythmic manual

compression of the reservoir bag. The rate shouldbe slightly higher than the physiological norm,and I think the tidal volume is usually increasedas well. Whether it is the result of cyclopropane,hyperventilation, the imposition of a conflictingrhythm, or more likely a combination of all three,control of respiration is easily maintained. A highrate of inflation must be avoided because it willprobably be accompanied by inadequate expira-tion and deterioration of the general clinicalcondition (Engstrom, Herzog, Norlander, andSwensson, 1962). The reservoir bag must be ofsmall capacity (0-5 litre) or it will not be possibleto appreciate the small volume change and flowsensation indicative of effective inflation. Resist-ance to inflation is due to respiratory obstructionor lung compression by the primary pathologicalcondition. Obstruction of an endotracheal tube bykinking could be obviated by the use of anarmoured tube, but these have disadvantages, and

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kinking has not occurred with the arrangementsdescribed here.The other causes of obstruction are mucus,

mucopus, radio-opaque material' or blood in theair passages; bronchospasm is rare. Some degreeof bronchitis is invariably present in babies whohave a tracheo-oesophageal fistula; it is caused bythe spill of digestive secretions into the tracheathrough the fistula. The presence of secretionsand mucopus can be heard (rattling respiration)before obstruction becomes evident; but this maynot be so. When in doubt aspirate. Fresh bloodin the air passages of a small baby is dangerous:it is prone to solidify at the end of the endo-tracheal tube and to produce obstruction that can-not be removed. From the first sign of blood,aspiration must continue until it has been cleared;0.5 ml. normal saline or dilute sodium bicarbonateinjected down the endotracheal tube may help.A haematoma of the lung caused by retraction isthe commonest cause of blood in the bronchi inthese cases.

In conditions of lung compression ventilationmay be a problem. The tidal volume may be sosmall as to be imperceptible on bag compression.In such a situation the temptation to use a highinflation pressure must be resisted. High inflationpressure contributes little improvement to ventila-tion when the basic fault is restricted lung volumeand carries the risk of lung rupture. An ear placedon the bag may enable one to hear gas movementto and from the lungs, and, provided that cyanosisdoes not appear, things are probably not too bad.At any rate one can hope for an improvementonce the chest has been opened (though in thecase of a large gastrogenous cyst arising from theupper mediastinum improvement had to awaitaspiration of the cyst fluid). Lung compression bythe primary condition may not be responsible forinflation difficulty, and in these cases one shouldbe alert for a coexistent respiratory obstruction;the free passage of a catheter, followed by aspira-tion, will establish that no obstruction exists. Arubber Jaques catheter, No. 6-7 F.G., can easilybe passed down the endotracheal tube for suctionpurposes, and it is soft enough not to damage thebronchial mucosa, an important point whenaspiration has to be repeated. The end containingthe lateral hole should first be cut off so as toprovide an end hole, and the edge should beI The malpractice of diatnosing oesophaReal atresia by radio-opaque swallow has not yet been eradicated. Some of the radio-opaque medium invariably enters the lungs, with detrimental effect.A diagnosis of oesophageal atresia is made when a size 12 F.G.Jaques catheter, passed down the oesophagus. is halted at a distanceof 4-41 in. (10-11.25 cm.) from the mouth: no further proof isneeded.

trimmed. If this is not done the lateral openingsticks to the inner wall of the endotracheal tubeand to the mucosa, making introduction difficultand suction ineffective.There is no place for mechanical ventilators.

The primary concern of the anaesthetist is toprovide adequate ventilation, and to this end heshould devote his attention. To attach a baby toa ventilator 'so that the anaesthetist is free to doother jobs' is dangerous.A Malecot catheter is inserted by the surgeon

into the pleural cavity before closure of the chestand joined by narrow tubing to a water seal drain-age bottle. The tubing should be of appropriatebore for a neonate, and this applies particularlyto the glass part of the tube (inside the drainagebottle), wherein a column of water swings up anddown on respiration. The height of the swing isirrespective (within reasonable limits) of the boreof the tube, but the volume of water representedby the swing is greater in a large tube than in asmall one. This volume is dead space over andabove physiological dead space. Taking physio-logical dead space in a baby as 1 ml. per lb. bodyweight (Radford, 1955), the use of a large tubecould double the total dead space, with consequentdyspnoea. (There is also the extra respiratorywork involved in raising a large weight of water.)

Five minutes before the end of the operation100% oxygen is given, and spontaneous respira-tion is encouraged. When the baby is breathingand moving vigorously, the bronchial tree andpharynx are aspirated and the endotracheal tubeis removed after a full inspiration.

BLOOD TRANSFUSION

To maintain a baby in the best condition forsurvival after a chest operation, blood lost atoperation should be replaced by transfusion. Theguiding principle of blood replacement in infantsis that a slight over-transfusion is less harmfulthan under-transfusion. Blood loss estimatesusually err on the low side. I do not think thatthe loss of blood during thoracotomy in a neonateis ever so small that transfusion can be omitted.Potts (1959) has stated that a 5 lb. infant maynot need more than 50 ml. of blood during opera-tion, but that amount is the difference betweensuccess and failure. Rickham (1957) maintainsthat blood lost during operation should bereplaced, and that while over-infusion is harmful,he has seen no ill-effects from slight over-trans-fusion during operation. Despite defects, I findthe weighing of swabs useful as a coarse indication

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of the loss of blood and in deciding on the amountof blood to be given. The estimate from weighingswabs, general condition, body weight, andtendency to ooze are all taken into consideration.As a rough guide, the old transfusion formulafor babies, 10 to 15 ml. per lb. body weight foran operation of moderate severity, fits well withthe other estimates.

Since the major part of the loss of blood occursduring opening of the chest it is a good plan toaim at getting 20 to 30 ml. blood into the babyby the time the operation begins. Pre-loading with30 ml. does no harm and effectively cushions sub-sequent losses; it is an insurance against the effectsof drip failure should this occur early in the opera-tion. The supervision of the drip should bedelegated to some experienced person: it is notsatisfactory for the anaesthetist to have this todo as a sideline. The blood must enter the baby'scirculation and not escape through looseconnexions under the operation towelling.The best site for the drip is the umbilical vein

and, when possible, this is used. Owing to the largesize of this vein the drip runs freely and too muchblood must not be run in. When the baby is morethan 4 to 5 days old, the umbilical vein cannot beused, and the saphenous vein at the ankle iscannulated under local anaesthesia. In distinctionto the umbilical vein, drips here tend to besluggish, though an improvement in rate can bebrought about by injecting 0 5 to 1 mg. pethidinein 1 ml. saline directly into the drip near theankle. This small amount of pethidine does thebaby no detectable harm, and I do not know ofany other substance that has such a beneficialeffect on a slow drip. A scalp vein drip is notsatisfactory; it is precarious and slow, and,though the rate of transfusion can be boostedfurther by incorporating a tap and syringe in thedrip line, considerable haemolysis results fromsquirting blood through small needles. In anemergency, blood can be injected directly intothe aorta or superior vena cava by the surgeon.There are advantages in using freshly drawn

heparinized blood for neonatal surgery (Carter,Waterston, and Aberdeen, 1962).Good ventilation, light anaesthesia, and replace-

ment of blood lost are the fundamentals ofmanagement of thoracic surgery in the newborn.If the general clinical condition deteriorates, littlecan be done apart from giving 100% oxygen andattending to blood balance. A guide to the generalclinical condition I find useful is this: baby pinkand pulses palpable-condition good; baby pale,pulses palpable or baby pink, pulses not palpable

-condition satisfactory, but check ventilation andblood balance; baby pale, pulses not palpable-condition serious. I do not think that cardiacstethoscopes (the heart action can be seen inthoracic operations), sphygmomanometers, pulsemonitors or E.C.G. tracings contribute enoughadditional information about a baby's conditionto merit their use; they may be distracting.

TEMPERATURE

An effort should be made to prevent thetemperature of these babies from falling duringoperation. Cold predisposes to sclerema inpremature babies and has a depressant effect thatmay result in apnoea (Bush and Stead, 1962). Thefactors responsible for a fall in temperature arethe exposure of a large area of open chest,reduced heat production, and the transfusion ofcold blood.The large loss of heat from an open pleural

cavity was remarked on by Wright (1952), andchest operations are long. To combat this loss thetheatre temperature should be high-certainly notless than 750 F.-and ideally the humidity shouldalso be high to reduce evaporation from moistsurfaces (latent heat of vaporization). To counter-act losses, some heat may be contributed to thebaby by laying it on a heated blanket or someother device; care must be taken to avoid burns;the blanket temperature must not exceed 420 C.One of the advantages of light cyclopropane

anaesthesia is the preservation of some muscletone and consequently of heat production. Bloodfor transfusion should be warmed to a tempera-ture approaching that of the body before beinggiven.The effective remedy for a steadily falling

temperature is to get the operation finished with-out delay and return the baby to a warmincubator.

POST-OPERATIVE CARE

Respiratory complications are the main cause ofdeath (DeBoer and Potts, 1957): post-operativecare centres on the prevention of these. The babyis nursed in a warm, humid, bacterially cleanatmosphere under antibiotic cover. Survivaldepends on nursing care. The standard of this carewill be higher if the nursing staff understands thetreatment.Warmth and humidity are closely connected:

a warm atmosphere must be moist or therespiratory secretions dry and obstruct the airway,

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with ultimate infection if not immediate asphyxia.Respiratory secretions are increased afterthoracotomy and this excess must be removed.Coughing is the normal mechanism of removalfrom the major bronchi, but the cough reflex isweak in the newborn and may be non-existentwhen the baby has undergone a chest operation(DeBoer and Potts, 1957). Crying also clears thebronchial tree, and if the secretions can therebybe expressed as far as the pharynx by the babythey can be aspirated by suction; at the same timean excess of saliva can also be aspirated. Disposalof saliva is a special problem in patients with oeso-phageal atresia: although swallowing is madepossible by operation it is nevertheless defective.At the site of anastomosis the oesophagus isnarrow, and peristalsis is absent for some distanceabove and below; if saliva is not regularlyremoved by suction there is a risk that it will beinhaled.

In summary, the baby is stimulated to cry-by squeezing the tendo Achillis-every quarterhour, and secretions, both salivary and bronchial,are cleared from the pharynx by suction. To beeffective, the rubber Jaques catheter used for thepurpose must be inserted as far as the larynx,but no further for fear of damaging the anasto-mosis; the catheter is marked at the appropriatedistance from the tip and inserted as far as thismark.The baby is turned on to his other side at

quarter-hourly intervals to counteract gravita-tional pooling of secretions. It is both convenientand desirable for the suck-out of the pharynx tobe done just before the turning. If, as time goeson, the secretions are scanty, the intervals betweenturning may be lengthened. If at any timebubbling respiration persists and the secretionscannot be got rid of by oro-pharyngeal suction,direct tracheo-bronchial suction will be needed(q.v.).An additional benefit from a humid atmosphere

is the decreased insensible loss of water. This notonly minimizes the need for parenteral fluids butreduces loss of heat (latent heat of vaporization).The oxygen content of the atmosphere in the

incubator is kept at 30% to 35% until the babyis over the immediate effects of operation andthe colour is pink without oxygen enrichment. Inthe absence of cyanosis this concentration ofoxygen should not be exceeded. Apart from thedanger of retrolental fibroplasia, a high concentra-tion of oxygen has a depressant effect onrespiratory movement with an increased dangerof lung collapse. (The activity of the neonatal

respiratory centre is governed more by °2 thanCO2 concentration) (Rutten, 1962). If cyanosisappears, there should be no hesitation in usingas high an oxygen concentration as is necessaryto prevent it. If used in this way there is no dangerof oxygen causing retrolental fibroplasia.The principle of water-seal drainage of the chest

should be explained to all concerned with after-care. To be effective, the drainage tube mustremain in free communication with the pleuralcavity until air leaks have ceased and the lunghas fully expanded. Free communication is shownby the respiratory swing of the water column inthe tube at the bottle end. This respiratory swingdecreases progressively in size and disappearswhen the tube inlet becomes covered by expandedlung and sealed off from the rest of the pleuralcavity by exudate; this is usually complete by24 hours after operation, when the tube isremoved. A big respiratory swing indicatesincomplete lung expansion and pneumothorax;the baby should be made to cry, so as to expandthe lung and blow off the pneumothorax. Noswing means an expanded lung or a blocked tube.The danger of a blocked tube is tension pneumo-thorax, but provided that there is no evidence ofrespiratory distress the absence of swing meansthat the tube is ready for removal.The earliest sign of respiratory distress is jerky

breathing. Normally an infant's respiratoryexcursions are smooth and the colour is pink;cyanosis or jerky breathing means that complica-tions are developing.

Physical methods of examination are of limiteduse in post-operative care. Auscultation revealsthe presence or absence of air entry andadventitious sounds, and is supporting evidencefor the condition of the lungs. (Auscultation ismade easier by the use of Nobecutane insteadof gauze and adhesive strapping as a wounddressing.) But for the positive establishment of thenormal, or the elucidation of complications, achest radiograph is essential. Accordingly, a chestradiograph is taken on each of the first threepost-operative mornings and is repeated wheneverthere is doubt about the presence of complica-tions. All films are taken with the baby heldupright; thus effusions are apparent and are seenas soon as they have developed so that action canbe taken without delay.The main complications are pneumothorax or

aspiration collapse-pneumonia. The reappear-ance of pneumothorax after the water seal drainhas been removed is sinister after the repair ofoesophageal atresia. It may mean that the anasto-

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mosis has broken down. Whatever the reason,water-seal drainage must be reinstated. Atelectasiscalls for aspiration of the trachea and bronchias soon as possible. This may be done by broncho-scopy, but I prefer to pass an endotracheal tubeand through it a suction catheter. This is lessshocking to the baby and less damaging to themucosa than bronchoscopy, a feature of somesignificance when sucking out has to be repeated.A recent successful case of oesophageal atresiahad to be sucked out 12 times within a week. Themain disadvantage is that the right or leftbronchus cannot be selectively entered, but sincethe right lung is the commoner source of trouble(oesophageal atresia being dealt with by rightthoracotomy) and can more easily be enteredblindly, this matter is of little moment. In theadult, the angle that the right bronchus makeswith the trachea is less than that made by the leftbronchus, hence a suction catheter introducedblindly enters the right bronchus. Smith (1959)stated that in infants these angles are equal(both 50°) so that the chances of the catheterentering either side will also be equal. Be this asit may, when collapse occurs on the right sidethe mediastinum moves across to the right, bring-ing the trachea more in line with the rightbronchus. If suction by a catheter introducedblindly fails to produce a clear radiograph,recourse must be had to bronchoscopy. Broncho-scopy should not be undertaken lightly in aneonate. Gentleness is imperative; contusion ofthe bronchial mucosa will be followed by swellingand exudate, producing further obstruction andin turn necessitating a repeat bronchoscopy; avicious circle is thus entered and the baby canbe 'bronchoscoped to death'. The arrangementsfor bronchoscopy are the same as for a suck-outby endotracheal tube and catheter. It is importantto have facilities ready for inflating the lungswith oxygen via the bronchoscope. A large endo-tracheal tube inserted into the end of the broncho-scope and connected up to a reservoir bag andoxygen supply makes a suitable appliance.

Attendants who have a cold must avoid contactwith the baby. Disposal of respiratory tract secre-tions is a serious problem in these babies innormal convalescence; the additional infectedsecretion of the common cold may prove over-whelming.The air supply to the incubator should be

passed through a bacteria filter or led in by aduct from the outside atmosphere. As a bulwarkagainst infection, the antibiotic therapy mostlikely to be effective against the ambient hospital

bacteria is given from the start: this appliesparticularly to patients with oesophageal atresiain whom infection is likely to be quicklydisastrous.The avoidance of chest complications is in

conflict with the need for feeding after the repairof the oesophageal atresia. Repair of oesophagealatresia does not equip the baby with a normaloesophagus: the lumen is at first narrow at thesite of anastomosis, and peristalsis is absent forsome distance above and below. Swallowing isconsequently slow, with the risk of overflow ofthe feed into the lungs. This problem is most acutefor the first week after operation; thereafteroedema of the suture line subsides, the lumenof the oesophagus increases in size at this level,and an improvement in swallowing can beexpected. Early feeding of premature babies isnow recommended so as to avoid the dangers ofneonatal hypoglycaemia-apnoeic attacks, con-vulsions, permanent brain damage, and death. Itwas thought that the use of a small calibre naso-gastric tube (I mm. external diameter) would bethe solution to feeding difficulties in the post-operative phase of oesophageal atresia: the babycould be fed easily without risk of food aspirationand with minimal swallowing strain on the anasto-mosis; and the small calibre of the tube wouldnot block the lumen of the oesophagus for saliva.But our experiences have been disappointing. Thepresence of the tube stimulates production ofmucus and swallowing (Rutten, 1962), and,despite its small calibre, the tube obstructs theoesophagus-for sticky mucus in particular-atthe level of anastomosis. The danger of bronchialinfection from the aspiration of mucus isincreased. In addition, stagnant mucus within theoesophagus favours infection at the suture line;another possibility is that the ascent of gastricjuices to the suture line is facilitated (capillary flowbetween the outside of the tube and the oeso-phageal mucosa). The net result of tube feedingis that although feeding itself is easy, the chancesof breakdown of the anastomosis throughmechanical, infective, or chemical processes areincreased by the presence of the tube, and thereis a greater risk of aspiration of mucus and itsconsequences. An important contribution to thesolution of the feeding problem was made byPotts (1962); he stated that the baby is going toswallow anyway, and he might just as well swallowa little clear water and keep his oesophagus clean,thus aiding the passage of swallowed mucus andpreventing stagnation and the risk of infection atthe site of anastomosis. If the anastomosis is

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watertight at the time of operation, the oeso-phagus is fit for use straight away and is probablythe better for being used. If the oesophagus is notwatertight after anastomosis, the chances of itsbecoming so later are negligible and are notimproved by withholding oral feeding. Should onehold opposite views, then to be logical oral feedingmust be withheld for over one week. (Rutten(1962) states that the critical period for theanastomosis lies between the fifth and eighth daysafter operation.) To maintain a satisfactory fluidbalance during this period by parenteral meansis not easy. Gastrostomy also has its difficulties.

In summary, the indications are that early oralfeeding offers the baby the best prospect forsurvival. For those interested in the detailedtechnique of oral feeding after repair of oeso-phageal atresia, I can do no better than refer themto an article by DeBoer and Potts (1957).

I should like to thank my colleagues Mr. S. G.Griffin, Mr. R. Dobson, Dr. J. B. Heycock, andDr. T. C. Noble.

REFERENCESBush, G. B., and Stead, A. L. (1962). The use of D-tubocurarine in

neonatal anaesthesia. Brit. J. Anaesth., 34, 721.Carter, R. E. Bonham, Waterston, D. J., and Aberdeen, E. (1962).

Hernia and eventration of the diaphragmn in cbildhood. Lancet,1, 656.

DeBoer, A., and Potts, W. J. (1957). Congenital atresia of theesophagus with tracheo-esophageal fistula. Surg. Gynec. Obstet.,104,475.

Engstrom, C.-G., Herzog, P., Norlander, 0. P., and Swensson, S. A.(1962). Ventilation nomogram for the newborn and smaUlchildren to be used with the Engstrom respirator. Acta anaesth.scand., 6, 175.

Potts, W. J. (1959). The Surgeon and the Child, p. 24. Saunders,Philadelphia.- (1962). Quoted by Rutten (1962).Radford, jun., E. P. (1955). Ventilation standards for use in artificial

respiration. J. appl. Physiol., 7, 451.Rees, G. J. (1958). Neonatal anaesthesia. Brit. med. Bull., 14, 38.Rickham, P. P. (1957). The Metabolic Response to Neonatal Surgery,

p. 77. Harvard University e?ress, Cambridge, Mass.Rutten, A. P. M. (1962). Oesophageal Atresia, p. 106. Koersen en

Zonen, Amsterdam.Smith, R. M. (1959). 4nesthesia for Infants and Children, p. 28.

Mosby, St. Louis.Wright, S. (1952). App!ied Physiology, 9th ed., p. 369. Oxford Univer-

sity Press, London.

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Neonates and chest surgery - thorax.bmj.comthorax.bmj.com/content/thoraxjnl/20/1/1.full.pdf7Torax(1965), 20, 1. Neonates and chest surgery H. E. BELL From the Newcastle Region Thoracic