# A 6-month-old infant with Hirschsprung's disease is scheduled for a pull-through procedure. Which nursing intervention is most important in the immediate preoperative period?

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## 문제

A 6-month-old infant with Hirschsprung's disease is scheduled for a pull-through procedure. Which nursing intervention is most important in the immediate preoperative period?

## 보기

1. Administer prophylactic antibiotics as ordered
2. Perform gentle rectal irrigations to decompress the bowel **✔ 정답**
3. Maintain strict NPO status for 12 hours
4. Monitor vital signs every 2 hours

**정답: 2**

## 해설

Gentle rectal irrigations are the priority to decompress the bowel and prevent enterocolitis before surgery. Other interventions like antibiotics, NPO, and vital sign monitoring are important but secondary to bowel decompression.

## 심화 해설

Understanding the Preoperative Priority in Hirschsprung's Disease

For an infant with Hirschsprung's disease, the primary pathophysiological problem is a functional obstruction caused by the absence of ganglion cells in a segment of the distal bowel. This aganglionic segment lacks peristalsis, leading to an accumulation of stool and gas, which can progress to severe abdominal distension and a life-threatening condition known as Hirschsprung-associated enterocolitis (HAEC). In the immediate preoperative period before a pull-through procedure, the most critical goal is to reduce the risk of HAEC and optimize the bowel's condition for surgery.

Why Bowel Decompression is the Most Important Intervention

The correct answer is performing gentle rectal irrigations to decompress the bowel. This intervention directly addresses the core problem of functional obstruction. The rationale is firmly grounded in the concept of preoperative bowel management, which is a cornerstone of care for these patients. According to the literature, preoperative bowel management not only prepares the child for surgery but is a continuous process that supports early recovery [1]. The goal is to evacuate the stagnant stool and gas from the dilated, normally innervated bowel proximal to the obstruction. This decompression serves several vital purposes:

- It reduces intraluminal pressure, thereby decreasing the risk of bacterial translocation and subsequent HAEC.

- It allows the chronically distended bowel to return to a more normal caliber, which is crucial for creating a safe and tension-free anastomosis during the pull-through procedure.

- It facilitates the possibility of a single-stage radical surgery without the need for a temporary diverting ileostomy, a key objective of modern preoperative management [2].

A study on preoperative management strategies demonstrated that with a systematic program, including trans-anal tube irrigation, 95% of infants (37 out of 39) successfully underwent single-stage radical surgery [2]. This high success rate underscores the effectiveness of decompression as a preoperative priority.

Analyzing the Other Options

While the other options represent valid nursing interventions, they are not the most important priority in the immediate preoperative context.

- Administering prophylactic antibiotics: While intravenous prophylactic antibiotics are a standard component of the surgical "time-out" to prevent surgical site infections, they do not address the underlying bowel distension full of stagnant fecal matter. The primary source of preoperative sepsis risk is the translocation of bacteria from the overloaded colon, which is best managed by mechanical emptying.

- Maintaining strict NPO status: Maintaining NPO status is a universal preoperative safety measure to reduce the risk of aspiration during anesthesia. However, for an infant with a distal bowel obstruction, simply withholding oral intake does nothing to evacuate the large volume of stool and gas already trapped in the colon, which poses a more immediate threat of enterocolitis and surgical complication.

- Monitoring vital signs every 2 hours: Routine vital sign monitoring is a fundamental part of nursing assessment. However, in a stable infant during the immediate preoperative phase, this is a passive monitoring task. The active intervention of bowel irrigation is a higher priority because it directly prevents a catastrophic complication (HAEC) and actively prepares the patient for a successful surgical outcome. The frequency of monitoring would also typically be more frequent than every 2 hours if the patient were showing signs of instability.

The preoperative management of Hirschsprung's disease is a proactive process centered on bowel decompression. This approach not only mitigates the immediate risk of enterocolitis but also creates the optimal surgical environment for a successful primary pull-through, directly aligning with the evidence-based goals of modern pediatric surgical care [1,2].References (research sources)

- [1]Bowel Management in Hirschsprung Disease-Pre-, Peri- and Postoperative Care for Primary Pull-Through.Research articleLindert J, Schulze F, Märzheuser S. (2024) · DOI: 10.3390/children11050588

- [2]Preoperative management comprising tube irrigation using a trans-anal indwelling tube for infants with hirschsprung disease can allow single-stage radical surgery.Research articleNakagawa Y, Uchida H, Hinoki A, Tainaka T, Shirota C, Sumida W, Makita S, Yokota K, Amano H, Yasui A, Maeda T, Kato D, Gohda Y. (2023) · DOI: 10.1186/s12893-023-02232-y

## 임상 시나리오

Preoperative Bowel Decompression in Hirschsprung DiseasePreventing Hirschsprung-Associated Enterocolitis (HAEC)
The immediate priority is to decompress the functional obstruction. Perform gentle rectal irrigations with normal saline to evacuate stool and gas from the dilated proximal bowel.

Decompression reduces intraluminal pressure, minimizing bacterial translocation and the risk of life-threatening Hirschsprung-associated enterocolitis (HAEC). This also optimizes bowel condition for the pull-through procedure.

CautionUse only normal saline for irrigations. Avoid tap water or soap suds to prevent water intoxication or electrolyte imbalances. Never use a large, rigid catheter; a soft, flexible catheter is essential to prevent perforation of the aganglionic bowel.

## 핵심 개념

- **Hirschsprung-associated enterocolitis (HAEC)** — A life-threatening inflammatory complication of Hirschsprung disease caused by intestinal stasis, bacterial overgrowth, and translocation, presenting with fever, abdominal distension, and explosive diarrhea.
- **Pull-through procedure** — A definitive surgical treatment for Hirschsprung disease where the aganglionic segment of the colon is resected and the healthy, innervated bowel is pulled down and anastomosed just above the anus.
- **Aganglionic segment** — The portion of the distal bowel in Hirschsprung disease that lacks ganglion cells, resulting in a loss of peristalsis and a functional obstruction.
- **Rectal irrigations** — A nursing intervention using saline to gently flush out the colon to evacuate stool and gas, thereby decompressing the bowel and reducing the risk of enterocolitis.

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