Neonatal anaesthesia
Special considerations in the premature and ex-premature infant

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Abstract

Advances in neonatal medicine have progressively increased the survival of premature infants. Increased survival has, however, come at the cost of increased number of infants with prematurity related complications. This is represented by high rates of respiratory distress syndrome, bronchopulmonary dysplasia, necrotising enterocolitis, sepsis, periventricular leukomalacia, intraventricular haemorrhage, cerebral palsy, hypoxic ischaemic encephalopathy and visual and hearing problems in survivors. In addition to prolonged hospital stay after birth, readmission to hospital in the first year of life is common if chronic lung disease exists. Individual congenital conditions requiring surgical intervention in the neonatal period are uncommon. Neonates have a higher perioperative mortality risk largely due to the degree of prior illness, the complexity of their surgeries and infant physiology. It is important to consider contributing anaesthetic factors during the perioperative period that may affect cerebral perfusion and neurocognitive outcome, such as alterations in haemodynamics and ventilation. Outside of the neonatal period, the most common surgical procedures performed in ex-premature infants are inguinal hernia repair and ophthalmologic procedures due to retinopathy of prematurity. After even minor surgical procedures, ex-premature infants are at higher risk for postoperative complications than infants born at term.

Section snippets

Definitions

Neonates are defined according to both their gestational age (GA), their chronological age (CA or time elapsed from birth postnatal age) and their postmenstrual age (PMA, which is GA plus CA). These definitions replace older definitions such as postconception age (PCA). The World Health Organization (WHO) further defines preterm birth (birth <37 weeks), extremely preterm (<28 weeks); very preterm (28 to <32 weeks); and moderate to late preterm (32–37 weeks). The estimated global preterm birth

Mortality and morbidity

Perinatal mortality is inversely proportional to gestational age with the highest rates near the limit of viability (Figure 1). In a population-based British study (EPICure-2 study), the survival and morbidity of 3378 extremely preterm infants (22–26 weeks) born in 2006 were reported. The live birth rate was 60% with 83% requiring admission to an intensive care unit (ICU) and active resuscitation was withheld in 9%. The survival to discharge for all live births was 51%, and the survival for

General principles

It is well established that perioperative complications occur more frequently and are more severe in the neonatal population. As such all neonatal anaesthesia should occur in centres appropriate for ongoing management (NHS directive E02/S/c 2013/14 Paediatric Surgery: Neonates). The general principles include appropriate airway management, reliable intravascular access, maintenance of temperature and metabolic homeostasis and adequate analgesia.

In a large prospective multicentre cohort study to

Neonatal surgical emergencies

Neonatal conditions requiring anaesthesia and surgery are uncommon but not rare. The most common conditions occur in the order of 1:10,000 live births (Table 1). In addition to the cardiac and chromosomal abnormalities there is a high proportion of neonates born prematurely electively or as a result of polyhydramnios. Many of the conditions are not detected antenatally.

Congenital diaphragmatic hernia (CDH) is a malformation of the diaphragm that allows bowel to enter the thoracic cavity,

Operating in NICU

Critically ill neonates in the neonatal intensive care unit (NICU) often require surgical procedures and the risks and benefits of surgical location need discussion. Transferring critically ill neonates to the operating theatre offers the best operating conditions but may increase perioperative risk. In a study of PDA ligation there was an increased risk of haemodynamic instability on transport postoperatively Surgery in NICU is recommended for neonates who require high-frequency oscillatory

Anaesthetic-induced neuroapoptosis

In 2016 the US Food and Drug Administration issued a warning that repeated or lengthy use of general anaesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children's brains. Three prospective studies examining the influence of early anaesthetic exposure on neurodevelopment all refute this statement. The GAS study compared awake regional anaesthesia to sevoflurane and reported

Inguinal hernia repair

The incidence of inguinal hernias is approximately 3%–5% in term infants and 13% in infants born at less than 33 weeks’ gestation. Inguinal hernias in both term and preterm infants are commonly repaired shortly after diagnosis to avoid incarceration of the hernia. The most common postoperative event in ex-premature infants undergoing lower abdominal surgery is apnoea. In a meta-analysis of infants having hernia repair with halothane or enflurane, the reported average apnoea rates was 25%.

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