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Anaesthesiology
Neonatal Anesthesia
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
17 sections · 191 slides
Overview
- The newborn period is the first 24 hours of life; the neonatal period is the first 28 days. In those weeks the heart, lungs, kidneys and liver all change function fast. Anaesthesia must be matched to a body that is still rebuilding itself. The heart, lungs and kidneys change fastest in the first three days after birth. These systems are linked: trouble in one quickly drags down the others. A lung that will not expand keeps lung blood pressure high, which strains the heart.
- Key themes of neonatal anaesthesia
Physiology of the Infant and the Transition Period
- Fetal circulation: the parallel system
- Fetal shunts and where they send blood
- Fetal circulation compared with the newborn circulation
- Changes at birth: the shunts close and closure of the ductus arteriosus
- Trigger for ductus arteriosus closure
- The neonatal heart muscle cell
- Cardiac output falls with age
- Tolerance of hypoxia and preload and cardiovascular summary of the neonate
- Limited cardiac reserve of the newborn heart
The Pulmonary System
- Lung development before and after birth and breathing pattern of the neonate
- Normal blood gas values in the neonate
- Static lung volumes of infants and adults
- Ratio of minute ventilation to FRC and muscles of breathing in the newborn
- Why a neonate desaturates fast
- Risk of diaphragmatic fatigue and control of breathing in the neonate
- Comparison of normal respiratory values in infants and adults
- Comparison of normal respiratory values in infants and adults
- What controls the pulmonary circulation after birth
- Mean pulmonary artery pressure in the first 3 days of life
- Sequence of events in persistent pulmonary hypertension
- First steps in treating PPHN
- Supporting the right ventricle in PPHN and meconium aspiration at delivery
- Muscle extension along pulmonary arterial branches
- Airway management for meconium at delivery
- Suctioning decision at delivery with meconium
The Renal System
- The fetal kidney and concentrating and diluting urine
- Urine output as a monitor and anaesthetic consequences of immature kidneys
Fluid and Electrolyte Therapy in the Neonate
- Total body water changes with age
- Body water compartments after birth
- Plasma and interstitial fluid and electrolyte values in the neonate
- Blood volume and electrolytes in the newborn
- Maintenance fluid requirements by day of life
- Glucose in maintenance fluid
Blood Component Therapy in the Neonate
- What is different about neonatal transfusion and platelet targets
- Adult haemoglobin in transfused blood and leucocyte reduction
- Pretransfusion testing in the newborn
The Hepatic System
- Liver function at birth and drugs that behave differently
- Acetaminophen: less metabolism means more safety
Anatomy of the Neonatal Airway
- Nasal breathing in the newborn and position of the glottis
- Complicating anatomic factors in infants
- The infant epiglottis and the cricoid ring
- Configuration of the adult versus the infant larynx
- Glottis versus cricoid as the limiting point
- Anatomic differences of the neonatal airway
Anesthetic Drugs in Neonates
- Pharmacokinetic differences in the neonate
- Factors altering drug effect in the neonate
- Midazolam and propofol
- Ketamine and monitoring during dexmedetomidine
- Opioids in neonatal anaesthesia
- Morphine clearance in the newborn and methadone
- Neuromuscular blocking agents: why they are used
- Recognising succinylcholine hyperkalaemia and monitoring neuromuscular block
- Rocuronium and pancuronium
- Limits of pancuronium in neonates and reversal with neostigmine
- Sugammadex in neonates and sevoflurane
- Desflurane
- Two classes of local anaesthetic and bupivacaine concentrations in practice
- Systemic absorption by site of injection
- Choosing the total local anaesthetic dose and bupivacaine dosage limits
- Ropivacaine and lidocaine
- Lidocaine in the neonate and chloroprocaine dosing
- Local anaesthetic systemic toxicity and newer topical preparations
Anesthetic Management of the Neonate
- What safe neonatal anaesthesia requires and neonates feel pain
- Preanaesthetic history and the near-term and moderately preterm infant
- Subgroups of preterm birth
- Problems of the 30 to 34 week group and physical examination: hydration
- Respiratory distress syndrome by birth weight
- Abnormalities associated with the preterm infant: common anesthetic concerns
- Physical examination: cardiovascular system
- Polycythaemia and glucose targets and sodium and long-term parenteral fluids
- Coagulation in the newborn and clarifying the plan with the team
- Informed consent as a process and monitoring challenges in a small patient
- Standard monitors and clinical observation
- The electrocardiograph and umbilical lines and flushing
- Central venous access and capnography and airway pressure
- Semi-open nonrebreathing circuits and heat and humidity in the circuit
- Why the machine must deliver medical air
- Choosing an induction technique and when intravenous access must come first
- Why an artificial airway is nearly always used
- Preoxygenation and sequencing and tube choice in the newborn
- Insertion of the Miller blade down the right side of the tongue
- Cricoid pressure applied with the little finger
- Tube size and depth and options when intubation is difficult
- Fibreoptic and digital intubation
- Initial ventilator settings in the neonate
- Reading the ventilation strategy tables
- Common ventilator strategies in neonates
- Pressure control ventilation
- Volume-targeted ventilation
- High-frequency ventilation
- Surgical requirements shape the anaesthetic
- Why anaesthetic uptake is faster in infants
- Effect of age on minimum alveolar concentration
Regional Anesthesia
- Role of regional anaesthesia in neonates
- Regional anesthesia techniques useful in neonates
- Spinal anaesthesia in premature and high-risk infants
- Caudal block technique
- Detecting intravascular injection and caudal catheters and additives
- Epidural opioids and ultrasound and peripheral nerve blocks used in neonates
- Penile block and lateral femoral cutaneous and brachial plexus blocks
- Ilioinguinal nerve block under ultrasound
- Transversus abdominis plane block under ultrasound
- Supraclavicular and infraclavicular approaches and head and neck blocks
Postoperative Pain Management
- Framework for neonatal postoperative pain and rectal analgesia
- Postoperative pain control for neonates and infants
- Intravenous opioids and tolerance and deciding on postoperative ventilation
- When to keep the tracheal tube in
Special Considerations
- Maternal cocaine use and the neonate and why newborns lose heat
- Nonshivering thermogenesis and the neutral thermal environment
- Consequences of nonshivering thermogenesis
- Respiratory distress syndrome revisited
- Postoperative apnoea: who is at risk and caffeine prophylaxis
- Contributors to postoperative apnoea
- Who to admit and monitor after surgery
- Stages of retinopathy of prematurity
- Plus disease and the decision to treat
- Neurodevelopmental effects of anaesthetic agents
Surgical Procedures in the First Week of Life
- Stabilise before operating and prematurity and associated anomalies
- Cardiac anomalies with common neonatal lesions
- Congenital diaphragmatic hernia: the numbers
- Development of the diaphragm
- Eventration of the diaphragm and clinical presentation of diaphragmatic hernia
- Left-sided congenital diaphragmatic hernia on radiograph
- Right-sided congenital diaphragmatic hernia
- Why immediate surgery was abandoned and ECMO in diaphragmatic hernia
- Perioperative care in diaphragmatic hernia
- Cardiac development in diaphragmatic hernia
- Omphalocele on day 1 of life
- Gastroschisis
- Omphalocele compared with gastroschisis
- Other associated defects and delivery room care of gastroschisis
- Preoperative stabilisation of abdominal wall defects
- Problems with closing a large defect and managing the staged silo reduction
- Silo placement in a neonate with gastroschisis
- Why monitoring during reduction matters
- Mechanism of postoperative hypertension after abdominal closure
- Five common forms of esophageal atresia and tracheoesophageal fistula
- Clinical presentation of oesophageal atresia
- Three approaches to intubation for open TEF repair
- Endoscopic TEF repair and long-term problems after oesophageal atresia
- Classifying intestinal obstruction
- Causes of lower gastrointestinal obstruction
- Jejunal atresia
- Preanaesthetic focus in intestinal obstruction
- Detecting neural tube defects and why Chiari II occurs and what it causes
- Symptoms of brainstem dysfunction and latex allergy in myelomeningocele
- Positioning for myelomeningocele surgery
- Anaesthesia for hydrocephalus and necrotising enterocolitis: who gets it
Surgical Procedures in the First Month of Life
- How necrotising enterocolitis develops
- Cascade of necrotising enterocolitis
- Preparing the necrotising enterocolitis patient
- Outcome after necrotising enterocolitis surgery
- What raises apnoea risk after hernia repair and pyloric stenosis: what happens
- Electrolyte picture in pyloric stenosis
- Resuscitation targets before pyloromyotomy
- Laparoscopic repair of pyloric stenosis
- Patent ductus arteriosus in the preterm
- Newer techniques for closing the ductus
- Access dilemmas and PICC lines
Summary and Key Points
- Key point: the transition period
- Key point: the infant airway
- Key point: the controversial areas and final summary of neonatal anaesthesia
- Closing advice
References
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- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition