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Neonates and preterm neonates are at significantly higher risk for perioperative complications compared with older children and adults.
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Children with major or severe congenital heart disease and pulmonary hypertension require specialized perioperative care.
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Former premature infants require postoperative monitoring because of an increased risk of apnea and bradycardia.
Anesthesia for Major Surgery in the Neonate
Section snippets
Key points
Evolution/history of anesthesia for the neonate
A newborn undergoing major surgery before the 1980s would have likely received an anesthetic consisting solely of nitrous oxide and muscle relaxant. Historically, this “Liverpool technique” of light general anesthesia devoid of opiates was the standard of care.1 The prevailing thought at the time was that neonates were not able to feel pain because they lacked a mature sensory nervous system. Analgesia for neonates undergoing any procedure was considered unnecessary or even contraindicated
Risk of perioperative cardiac arrest for the neonate
Beecher and Todd4 were some of the first to recognize that anesthesia mortality was “disproportionately high in the first decade of life.” Over the years, other groups have examined the risk of anesthesia in children grouping neonates with infants less than 1 year of age.5, 6 One study7 that did break down the patients into smaller age subcategories found that neonates and infants were at the highest risk of cardiac arrest from any cause compared with older children. With the advent of pulse
The neonate born prematurely
GA has been identified as an independent risk factor.9,10 The in-hospital mortality for noncardiac surgery is 5 times higher for preterm neonates than full-term neonates (10.5% vs 2%).11
The neonate with congenital heart disease
Analyzing data from the Pediatric Perioperative Cardiac Arrest Registry, Ramamoorthy and colleagues12 found that children younger than 2 years of age were more likely to have cardiac arrest, and that children with congenital heart disease (CHD) are more likely to have a cardiac arrest during noncardiac surgery than during cardiac surgery and the interventional cardiac catheterization laboratory combined. This study also determined that the causes of cardiac arrest in patients with CHD were not
The neonate with pulmonary hypertension
Children with pulmonary hypertension (PH) have been consistently described as having among the highest risk of major complications, including cardiac arrest and death with any anesthetic, with the risk increasing in proportion to severity of the PH.13 The cause of the PH does not appear to affect the risk. Bernier and colleagues15 found that patients receiving PH-targeted pharmacologic therapy (eg, prostacyclin analogue or inhaled nitric oxide) appear to have a lower incidence of minor
Risk stratification
Recent research into perioperative mortality has taken into consideration the interaction of patient comorbidities with the intrinsic risk of the surgical procedure (Table 2). Nasr and colleagues16 identified the following 5 major comorbid conditions that impact outcome:
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Weight of patient less than 5 kg
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American Society of Anesthesiologists (ASA) status III or higher
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Preoperative sepsis
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Inotropic support
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Ventilator dependence
When these 5 conditions were analyzed in the context of surgical procedures
Risk of neurotoxicity with general anesthesia
All commonly used anesthetic agents have been associated with neurotoxicity across a spectrum of animal species, including nonhuman primates, and there is no consensus whether these findings are translatable to humans.17 Taken collectively, the clinical studies in humans have been inconclusive because of the myriad of variables that are difficult to control.18 The sole prospective, randomized, controlled study of infants has provided the strongest and most reassuring evidence to date, that a
Anatomy and Physiology of the Neonate
One of the more challenging aspects of delivering anesthetic care to the neonate is their unique physiology. The following is a brief discussion by relevant systems of the challenges often faced when caring for a neonate.
Location: Operating Room Versus Intensive Care Unit
Certain surgical procedures are routinely performed at the patient’s bedside in the NICU (eg, PDA ligation). Occasionally a patient, particularly an ex-preterm very low-birth-weight infant, may be too unstable for transport, or may be receiving therapies that would make transport challenging (eg, extracorporeal membrane oxygenation, or high-frequency oscillatory ventilation). In these cases, the decision of the location for surgical procedures should be made after a discussion between the
Summary
The perioperative risk of morbidity and mortality for neonates is significantly higher than that for older children and adults.8 Patients at particular risk include neonates born prematurely, with major or severe CHD, and with PH. There is presently no consensus regarding the safest anesthetic regimen for neonates. The anesthesiologist caring for the neonate should be knowledgeable of the unique physiology of the neonate and maintain the highest level of vigilance throughout the case.
Disclosure
The authors have nothing to disclose.
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