Ver. 1.

0
18/04/2015

Guidelines of initial management in NICU / PICU for newborns with

Imperforate Anus

Diagnosis / Classification:
- Diagnosis in males:
- Absent Anus
- Small orifice not at the normal anal position
- Diagnosis in Females:
- Absent Anus
- Small orifice not at the normal anal position
- Single perineal orifice for urine, vagina and rectum( Cloaca)
- The type cannot be determined until 24 h of life: So the most important perineal
inspection and XRay should be done at 24 h of life.
- Meanwhile, while waiting, it is wise to evaluate the baby for other associated
anomalies (VACTERL).

Physical Exam:
- Perineal inspection: Any orifice seen ?
- Count fingers & toes. (R/O Limb defects)
- Listen for Cardiac murmur. (R/O Cardiac Abnormalities)
- Check Penis (R/O hypospadias)
- Check NG tube ( R/O Esophageal Atresia / Tracheo-Esophageal fistula)
- If female with cloaca: check for abdominal mass (r/o Hydrocolpos).

Initial Management:
- Insert NGT to gravity drainage
- IV hydration with D10 ¼ NS
- IV Antibiotics: Zinacef + Flagyl
- Administer Vitamin K before surgery.
- Labs: OR-screening, CBC, PT, PTT, electrolytes, Glucose, Type & Cross. Urine
analysis.
- Cardiac Echography (Urgent order, within 24h of life, to be done pre-op)
- Thoraco-Abdominal XRay: Check Limbs, Ribs, Vertebral anomalies, Sacral
anomalies.
- Abdominal Ultrasound
- If Female with cloaca: Abdominal Ultrasound is urgent ( R/O hydrocolpos)
- If possible: Spinal Ultrasound ( R/O tethered cord).
- Anesthesia consultation
- Have the parents available in holding bay at time of surgery for Anesthesia
consent.
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At 24h of Life:
- Cross-Table Lateral abdominal Xray with buttocks elevated
o Place child prone (on the belly)
o Place a bump on the pelvis to elevate the buttocks upward
o Place and tape a small metal clip on the skin of the expected anus
o Shoot the Xray with the film in a vertical position (lateral to the baby).

Surgical management (usually 24-48h after diagnosis):

- At 24 h, after investigations done, the Surgeon will decide if:
- Primary repair ( PSARP: Posterior Sagittal Anorectoplasty)
- Colostomy, with a delayed PSARP repair
- Fistula dilation
- Vaginostomy (If cloaca with hydrocolpos).
Ver. 1.0
18/04/2015
Ver. 1.0
18/04/2015

Post-op after Primary Repair:

- IV hydration with D10 ¼ NS
- IV Antibiotics: Zinacef + Flagyl
- IV Pelfalgan 15mg/Kg every 6h for pain.
- Start TPN on Post-op day #1 to 7
- NGT to gravity drainage.
- NPO for 7 days.
- Resume regular diet on Post-op day #7 if perineum looks like it is healing well.
- Foley is precious to remain in position for 7 days.
- Wound care: Wash perineum gently with soap and water, and apply fucidine
ointment after every change.
- Expect discharge on post-op day #8
- Follow-up 2 weeks for anal dilations

Post-op after Colostomy:

- IV hydration with D10 ¼ NS
- IV Antibiotics: Zinacef + Flagyl
- IV Pelfalgan 15mg/Kg every 6h for pain.
- NGT to gravity drainage.
- NPO until Colostomy starts giving stool
- Resume regular diet once Colostomy starts giving stool
- Wound care: Wash peri-stoma skin gently with soap and water, and apply
Sudocream.
- Expect discharge on post-op day #3-4 (after parental teaching for stoma care).
- Follow-up in 4 weeks