Neonatal anaesthesia - Revision history

WikiSysop at 00:22, 3 July 2023

2023-07-03T00:22:37Z

← Older revision		Revision as of 00:22, 3 July 2023
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	=== History ===		=== History ===
	The history should include the gestational age, birth history, current age and weight, and significant peri-natal events such as low APGAR scores, respiratory distress requiring respiratory support, hypoglycaemic episodes, NICU admissions, evidence of sepsis or any antenatal concerns such as maternal illness. The anaesthetist should check whether intramuscular vitamin K has been given to prevent haemorrhagic		The history should include the gestational age, birth history, current age and weight, and significant peri-natal events such as low APGAR scores, respiratory distress requiring respiratory support, hypoglycaemic episodes, NICU admissions, evidence of sepsis or any antenatal concerns such as maternal illness. The anaesthetist should check whether intramuscular vitamin K has been given to prevent haemorrhagic disease of the newborn. The fasting status should be established if the child is receiving feeds - ideally 2 hours for clear fluids, 4 hours for breast milk, 6 hours for formula feed.
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	!DEFINITIONS		!DEFINITIONS
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	\|		\|•Neonate is aged up to 28 days
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	~~disease of the newborn. The fasting status should be established if the child is receiving feeds - ideally 2 hours for clear fluids, 4 hours for breast milk, 6 hours for formula feed.~~

	~~<blockquote>~~


	~~'''DEFINITIONS'''~~

	•Neonate is aged up to 28 days

	•Term neonate is born between 37 to 40 weeks post conception		•Term neonate is born between 37 to 40 weeks post conception

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	• Low birthweight <2.5kg		• Low birthweight <2.5kg

	• Very low birthweight <1.5kg~~</blockquote>~~		• Very low birthweight <1.5kg
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	=== Examination ===		=== Examination ===
	Examine the child carefully. In particular, it is important to look for signs of respiratory distress (respiratory rate, nasal flare, subcostal recession), and cardiovascular compromise (check heart rate, blood pressure, peripheral perfusion and capillary refill). Check the oxygen saturation – low oxygen saturation may be associated with respiratory disease, or in some cases with cyanotic congenital heart disease.		Examine the child carefully. In particular, it is important to look for signs of respiratory distress (respiratory rate, nasal flare, subcostal recession), and cardiovascular compromise (check heart rate, blood pressure, peripheral perfusion and capillary refill). Check the oxygen saturation – low oxygen saturation may be associated with respiratory disease, or in some cases with cyanotic congenital heart disease.
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	* Echocardiogram		* Echocardiogram
	* Cranial/spinal/renal ultrasound		* Cranial/spinal/renal ultrasound


	Finally, the anaesthetic plan, including risks, should be discussed with the parent(s) or guardian(s), and consent taken for anaesthesia including regional anaesthesia and blood transfusion if indicated.		Finally, the anaesthetic plan, including risks, should be discussed with the parent(s) or guardian(s), and consent taken for anaesthesia including regional anaesthesia and blood transfusion if indicated.

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	{\| class="wikitable"		{\| class="wikitable"
	\|+Table 5. ''Suggested transfusion doses for blood and blood products (Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee <nowiki>http://www</nowiki>.''		\|+Table 5. ''Suggested transfusion doses for blood and blood products (Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee [http://www. transfusionguidelines.org/transfusion-handbook/10-effective-transfusion-in-paediatric-practice/10-2-neonatal-transfusion <nowiki>http://www</nowiki>.]''
	''transfusionguidelines.org/transfusion-handbook/10-effective-transfusion-in-paediatric-practice/10-2-neonatal-transfusion)''		[http://www. transfusionguidelines.org/transfusion-handbook/10-effective-transfusion-in-paediatric-practice/10-2-neonatal-transfusion ''transfusionguidelines.org/transfusion-handbook/10-effective-transfusion-in-paediatric-practice/10-2-neonatal-transfusion'']'')''
	!Product		!Product
	!Suggested transfusion dose		!Suggested transfusion dose
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	=== inguinal hernia repair ===		=== inguinal hernia repair ===
	Inguinal hernia is common in premature neonates. The timing of surgery depends on the risk of incarceration, bowel strangulation or testicular atrophy versus the risk of postoperative apnoea and the potential harm to neurodevelopment. The major anaesthetic risk is post- operative apnoea, which has been shown to vary from 4.7% to 49% of patients.<ref name=":0" /><ref>Malviya S, Swartz J, Lerman J. Are all preterm infants younger than 60 weeks postconceptional age a risk for post-anesthetic apnea? Anesthesiology 1993; 78 1076–81.</ref> Some units prefer spinal anaesthesia for inguinal hernia repair, others use a balanced anaesthetic technique using general anaesthesia with intubation, supplemented with a regional technique. There is currently not enough evidence to show whether the incidence of apnoea is lower using spinal anaesthesia, and the choice is usually determined by local preference of the surgeon and anaesthetist.<ref>Craven PD, Badawi N, Henderson-Smart DJ, O’Brien M. Regional (spinal, epidural, caudal) versus general anaesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy. Cochrane Database Syst Rev 2003;3:CD003669.</ref>		Inguinal hernia is common in premature neonates. The timing of surgery depends on the risk of incarceration, bowel strangulation or testicular atrophy versus the risk of postoperative apnoea and the potential harm to neurodevelopment. The major anaesthetic risk is post- operative apnoea, which has been shown to vary from 4.7% to 49% of patients.<ref name=":0" /><ref>Malviya S, Swartz J, Lerman J. Are all preterm infants younger than 60 weeks postconceptional age a risk for post-anesthetic apnea? Anesthesiology 1993; 78 1076–81.</ref> Some units prefer spinal anaesthesia for inguinal hernia repair, others use a balanced anaesthetic technique using general anaesthesia with intubation, supplemented with a regional technique. There is currently not enough evidence to show whether the incidence of apnoea is lower using spinal anaesthesia, and the choice is usually determined by local preference of the surgeon and anaesthetist.<ref>Craven PD, Badawi N, Henderson-Smart DJ, O’Brien M. Regional (spinal, epidural, caudal) versus general anaesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy. Cochrane Database Syst Rev 2003;3:CD003669.</ref>



	''Editors’ note: As this edition of Update goes to press, the editors are aware that the GAS study is reporting its preliminary findings on apnoea comparing GA and spinal in >700 neonates, publication of full results is expected late 2018.''		''Editors’ note: As this edition of Update goes to press, the editors are aware that the GAS study is reporting its preliminary findings on apnoea comparing GA and spinal in >700 neonates, publication of full results is expected late 2018.''


	Caudal anaesthesia using 0.25% bupivacaine 0.75ml.kg<sup>-1</sup> provides excellent supplementary analgesia for inguinal hernia repair under general anaesthesia. Alternatively, an ilioinguinal block can be performed with 0.5-1.0ml.kg<sup>-1</sup> 0.25% bupivacaine. These patients may require post-operative apnoea monitoring dependent on their PCA, as discussed earlier, and some premature infants will require post-operative ventilation or CPAP for treatment of apnoea. Paracetamol (7.5mg.kg<sup>-1</sup> IV or 20mg.kg<sup>-1</sup> rectal suppository) provides adequate post-operative analgesia		Caudal anaesthesia using 0.25% bupivacaine 0.75ml.kg<sup>-1</sup> provides excellent supplementary analgesia for inguinal hernia repair under general anaesthesia. Alternatively, an ilioinguinal block can be performed with 0.5-1.0ml.kg<sup>-1</sup> 0.25% bupivacaine. These patients may require post-operative apnoea monitoring dependent on their PCA, as discussed earlier, and some premature infants will require post-operative ventilation or CPAP for treatment of apnoea. Paracetamol (7.5mg.kg<sup>-1</sup> IV or 20mg.kg<sup>-1</sup> rectal suppository) provides adequate post-operative analgesia

WikiSysop: /* History */

2023-07-03T00:16:07Z

History

@@ Line 20: / Line 20: @@
 === History ===
-The history should include the gestational age, birth history, current age and weight, and significant peri-natal events such as low APGAR scores, respiratory distress requiring respiratory support, hypoglycaemic episodes, NICU admissions, evidence of sepsis or any antenatal concerns such as maternal illness. The anaesthetist should check whether intramuscular vitamin K has been given to prevent haemorrhagic disease of the newborn. The fasting status should be established if the child is receiving feeds - ideally 2 hours for clear fluids, 4 hours for breast milk, 6 hours for formula feed.
+The history should include the gestational age, birth history, current age and weight, and significant peri-natal events such as low APGAR scores, respiratory distress requiring respiratory support, hypoglycaemic episodes, NICU admissions, evidence of sepsis or any antenatal concerns such as maternal illness. The anaesthetist should check whether intramuscular vitamin K has been given to prevent haemorrhagic
-<blockquote>'''DEFINITIONS'''
+<blockquote>
 •Neonate is aged up to 28 days

WikiSysop: /* inguinal hernia repair */

2023-07-03T00:14:15Z

inguinal hernia repair

← Older revision		Revision as of 00:14, 3 July 2023
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	=== inguinal hernia repair ===		=== inguinal hernia repair ===
	Inguinal hernia is common in premature neonates. The timing of surgery depends on the risk of incarceration, bowel strangulation or testicular atrophy versus the risk of postoperative apnoea and the potential harm to neurodevelopment. The major anaesthetic risk is post- operative apnoea, which has been shown to vary from 4.7% to 49% of patients.<ref name=":0" /><ref>Malviya S, Swartz J, Lerman J. Are all preterm infants younger than 60 weeks postconceptional age a risk for post-anesthetic apnea? Anesthesiology 1993; 78 1076–81.</ref>14 Some units prefer spinal anaesthesia for inguinal hernia repair, others use a balanced anaesthetic technique using general anaesthesia with intubation, supplemented with a regional technique. There is currently not enough evidence to show whether the incidence of apnoea is lower using spinal anaesthesia, and the choice is usually determined by local preference of the surgeon and anaesthetist.<ref>Craven PD, Badawi N, Henderson-Smart DJ, O’Brien M. Regional (spinal, epidural, caudal) versus general anaesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy. Cochrane Database Syst Rev 2003;3:CD003669.</ref>		Inguinal hernia is common in premature neonates. The timing of surgery depends on the risk of incarceration, bowel strangulation or testicular atrophy versus the risk of postoperative apnoea and the potential harm to neurodevelopment. The major anaesthetic risk is post- operative apnoea, which has been shown to vary from 4.7% to 49% of patients.<ref name=":0" /><ref>Malviya S, Swartz J, Lerman J. Are all preterm infants younger than 60 weeks postconceptional age a risk for post-anesthetic apnea? Anesthesiology 1993; 78 1076–81.</ref> Some units prefer spinal anaesthesia for inguinal hernia repair, others use a balanced anaesthetic technique using general anaesthesia with intubation, supplemented with a regional technique. There is currently not enough evidence to show whether the incidence of apnoea is lower using spinal anaesthesia, and the choice is usually determined by local preference of the surgeon and anaesthetist.<ref>Craven PD, Badawi N, Henderson-Smart DJ, O’Brien M. Regional (spinal, epidural, caudal) versus general anaesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy. Cochrane Database Syst Rev 2003;3:CD003669.</ref>

WikiSysop: /* Anorectal malformations */

2023-07-03T00:13:28Z

Anorectal malformations

← Older revision		Revision as of 00:13, 3 July 2023
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	=== Anorectal malformations ===		=== Anorectal malformations ===
	Anorectal malformations (ARM) occur in approximately 1:5000 live births. They represent a wide spectrum of disease, from a simple membrane involving the distal rectum and anus to more complex anomalies involving the genital and urinary tract. Spinal anomalies are frequently found in these patients. These include spinal dysraphism, low lying cord (LLC) and tethered cord.<ref>Teo AT, Gan BK, Tung JS, Low Y, Seow WT. Low-lying spinal cord and tethered cord syndrome in children with anorectal malformations. Singapore Med J 2012; 53 570-6.</ref> Plain spinal Xrays and spinal ultrasound are used to screen for these abnormalities although they may be normal in occult dysraphism. Caudal anaesthesia may be beneficial and can be used in ARM if there is certainty that anomalies of the spine and spinal cord have been excluded.<ref>Bozza P, Morini F, Conforti A, Sgrò S. Stress and ano-colorectal surgery in newborn/infant: role of anesthesia. Pediatr Surg Int 2012; 28 821-4.</ref>17 ARM may be associated with other anomalies including Vertebral, Anorectal, Cardiac, Tracheoesophageal, Renal and Limb abnormalities, collectively known as the VACTERL association.		Anorectal malformations (ARM) occur in approximately 1:5000 live births. They represent a wide spectrum of disease, from a simple membrane involving the distal rectum and anus to more complex anomalies involving the genital and urinary tract. Spinal anomalies are frequently found in these patients. These include spinal dysraphism, low lying cord (LLC) and tethered cord.<ref>Teo AT, Gan BK, Tung JS, Low Y, Seow WT. Low-lying spinal cord and tethered cord syndrome in children with anorectal malformations. Singapore Med J 2012; 53 570-6.</ref> Plain spinal Xrays and spinal ultrasound are used to screen for these abnormalities although they may be normal in occult dysraphism. Caudal anaesthesia may be beneficial and can be used in ARM if there is certainty that anomalies of the spine and spinal cord have been excluded.<ref>Bozza P, Morini F, Conforti A, Sgrò S. Stress and ano-colorectal surgery in newborn/infant: role of anesthesia. Pediatr Surg Int 2012; 28 821-4.</ref> ARM may be associated with other anomalies including Vertebral, Anorectal, Cardiac, Tracheoesophageal, Renal and Limb abnormalities, collectively known as the VACTERL association.

	Primary surgical repair can be undertaken in the neonatal period although more commonly a colostomy is performed and a definitive repair is carried out at a later date.		Primary surgical repair can be undertaken in the neonatal period although more commonly a colostomy is performed and a definitive repair is carried out at a later date.

WikiSysop: /* Gastroschisis and exomphalos (omphalocele) */

2023-07-03T00:12:18Z

Gastroschisis and exomphalos (omphalocele)

← Older revision		Revision as of 00:12, 3 July 2023
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	The neonate will require intubation and ventilation for surgery. Expect significant ongoing fluid and heat losses due to the exposed viscera. Peripheral intravenous access may be all that is required, but central venous pressure monitoring and an arterial line are useful to help guide fluid administration. Avoid the femoral vessels as there is a risk of decreased perfusion with the increased abdominal pressures. Placing the post-ductal oxygen saturation probe on either lower limb helps to give an indication if there is poor perfusion. Muscle relaxants will assist the surgeons in reducing the abdominal contents. Reduction of the bowel may cause abdominal compartment syndrome, diaphragmatic splinting and high ventilation pressures. If the intra gastric pressures are >20mmHg or the peak inspiratory pressures exceed 30cm H2O then a staged repair is indicated.<ref>Yaster M, Scherer TL, Stone MM et al. Prediction of successful primary closure of congenital abdominal wall defects using intraoperative measurements. J Pediatr Surg 1989; 24 1217–20.</ref>		The neonate will require intubation and ventilation for surgery. Expect significant ongoing fluid and heat losses due to the exposed viscera. Peripheral intravenous access may be all that is required, but central venous pressure monitoring and an arterial line are useful to help guide fluid administration. Avoid the femoral vessels as there is a risk of decreased perfusion with the increased abdominal pressures. Placing the post-ductal oxygen saturation probe on either lower limb helps to give an indication if there is poor perfusion. Muscle relaxants will assist the surgeons in reducing the abdominal contents. Reduction of the bowel may cause abdominal compartment syndrome, diaphragmatic splinting and high ventilation pressures. If the intra gastric pressures are >20mmHg or the peak inspiratory pressures exceed 30cm H2O then a staged repair is indicated.<ref>Yaster M, Scherer TL, Stone MM et al. Prediction of successful primary closure of congenital abdominal wall defects using intraoperative measurements. J Pediatr Surg 1989; 24 1217–20.</ref>

	Unless there is a very small defect the infant will require post- operative ventilation and a generous opioid-based anaesthetic technique can be used (fentanyl 10-20mcg.kg-1). These patients often require parenteral nutrition and a significant proportion present for further abdominal surgery.		Unless there is a very small defect the infant will require post- operative ventilation and a generous opioid-based anaesthetic technique can be used (fentanyl 10-20mcg.kg<sup>-1</sup>). These patients often require parenteral nutrition and a significant proportion present for further abdominal surgery.

	== CONCLUSION ==		== CONCLUSION ==

WikiSysop: /* inguinal hernia repair */

2023-07-03T00:04:51Z

inguinal hernia repair

← Older revision		Revision as of 00:04, 3 July 2023
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			''Editors’ note: As this edition of Update goes to press, the editors are aware that the GAS study is reporting its preliminary findings on apnoea comparing GA and spinal in >700 neonates, publication of full results is expected late 2018.''


	''Editors’ note: As this edition of Update goes to press, the editors are aware that the GAS study is reporting its preliminary findings on apnoea comparing GA and spinal in >700 neonates, publication of full results is expected late 2018.''

	Caudal anaesthesia using 0.25% bupivacaine 0.75ml.kg<sup>-1</sup> provides excellent supplementary analgesia for inguinal hernia repair under general anaesthesia. Alternatively, an ilioinguinal block can be performed with 0.5-1.0ml.kg<sup>-1</sup> 0.25% bupivacaine. These patients may require post-operative apnoea monitoring dependent on their PCA, as discussed earlier, and some premature infants will require post-operative ventilation or CPAP for treatment of apnoea. Paracetamol (7.5mg.kg<sup>-1</sup> IV or 20mg.kg<sup>-1</sup> rectal suppository) provides adequate post-operative analgesia		Caudal anaesthesia using 0.25% bupivacaine 0.75ml.kg<sup>-1</sup> provides excellent supplementary analgesia for inguinal hernia repair under general anaesthesia. Alternatively, an ilioinguinal block can be performed with 0.5-1.0ml.kg<sup>-1</sup> 0.25% bupivacaine. These patients may require post-operative apnoea monitoring dependent on their PCA, as discussed earlier, and some premature infants will require post-operative ventilation or CPAP for treatment of apnoea. Paracetamol (7.5mg.kg<sup>-1</sup> IV or 20mg.kg<sup>-1</sup> rectal suppository) provides adequate post-operative analgesia

WikiSysop at 23:28, 2 July 2023

2023-07-02T23:28:35Z

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WikiSysop at 23:04, 2 July 2023

2023-07-02T23:04:49Z

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WikiSysop at 22:45, 2 July 2023

2023-07-02T22:45:22Z

← Older revision		Revision as of 22:45, 2 July 2023
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	== GENERAL PRINCIPLES OF ANAESTHESIA IN NEONATES ==		== GENERAL PRINCIPLES OF ANAESTHESIA IN NEONATES ==



	It is important to prepare and check all equipment that may be required, prior to the start of anaesthesia (see Figure 1).		It is important to prepare and check all equipment that may be required, prior to the start of anaesthesia (see Figure 1).
			[[File:Figure 1 Airway an monitoring equipment.jpg\|thumb\|FIGURE 1. ''Airway and monitoring equipment'']]

	FIGURE 1

	=== Monitoring ===		=== Monitoring ===
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	Congenital tracheoesophageal fistula (TOF) occurs in		Congenital tracheoesophageal fistula (TOF) occurs in
	approximately 1:3,000 live births. It arises during foetal development as a result of incomplete separation of the oesophagus from the laryngotracheal tube. It is classified based on the site and presence of the fistula and whether there is oesophageal atresia (Figure 2). There may be other associated VACTERL anomalies.		approximately 1:3,000 live births. It arises during foetal development as a result of incomplete separation of the oesophagus from the laryngotracheal tube. It is classified based on the site and presence of the fistula and whether there is oesophageal atresia (Figure 2). There may be other associated VACTERL anomalies.
			[[File:Figure 2 Incidence and types of EA TEA.jpg\|left\|thumb\|Figure 2. ''Incidence and types of oesophageal atresia/tracheo-oesophageal fistula'']]


	Figure 2. Incidence and types of oesophageal atresia/tracheo-oesophageal fistula


	Neonates with TOF classically present within a few hours of birth with frothy sputum as they are unable to swallow oral secretions; delayed diagnosis is associated with episodes of coughing and choking associated with cyanosis, particularly if feeding is attempted. There may be copious oral secretions and abdominal distension due to gastric insufflation via the fistula. Left untreated the neonate will develop aspiration pneumonia. The diagnosis of oesophageal atresia is confirmed if it is not possible to pass a nasogastric tube and the chest Xray will show the nasogastric tube coiled in the proximal blind-ending oesophagus (Figure 3). There may be an absent gastric bubble in isolated oesophageal atresia without a tracheoesophageal fistula.		Neonates with TOF classically present within a few hours of birth with frothy sputum as they are unable to swallow oral secretions; delayed diagnosis is associated with episodes of coughing and choking associated with cyanosis, particularly if feeding is attempted. There may be copious oral secretions and abdominal distension due to gastric insufflation via the fistula. Left untreated the neonate will develop aspiration pneumonia. The diagnosis of oesophageal atresia is confirmed if it is not possible to pass a nasogastric tube and the chest Xray will show the nasogastric tube coiled in the proximal blind-ending oesophagus (Figure 3). There may be an absent gastric bubble in isolated oesophageal atresia without a tracheoesophageal fistula.

			[[File:Figure 3 CXR NG tube in pouch.jpg\|thumb\|Figure 3. ''Chest Xray showing nasogastric tube curled in the upper oesophageal pouch in a child with oesophageal atresia'']]

	Figure 3. Chest Xray showing nasogastric tube curled in the upper oesophageal pouch in a child with oesophageal atresia




	The goals of pre-operative management are to stabilise the child, minimise respiratory embarrassment and assess for timing of surgery. A nasogastric tube is inserted into the upper oesophageal pouch to drain secretions. The patient		The goals of pre-operative management are to stabilise the child, minimise respiratory embarrassment and assess for timing of surgery. A nasogastric tube is inserted into the upper oesophageal pouch to drain secretions. The patient
	must be nursed head up or on the side to minimise the risk of aspiration. Intravenous fluids and prophylactic antibiotics should be commenced. This allows time for investigations such as an echocardiogram to exclude other associated congenital abnormalities.		must be nursed head up or on the side to minimise the risk of aspiration. Intravenous fluids and prophylactic antibiotics should be commenced. This allows time for investigations such as an echocardiogram to exclude other associated congenital abnormalities.

	Our preferred technique is to induce anaesthesia after pre-oxygenation and to maintain spontaneous ventilation initially with volatile or intravenous anaesthesia. Prior to repair the surgeons may perform flexible or rigid bronchoscopy to assess the level of the fistula and to see if there is a second or proximal fistula. Take note of the distance measured from the cords to the fistula to guide tracheal tube placement; the fistula is mid-tracheal in two thirds of cases, and located at level of the carina in one third of cases. Muscle relaxants and gentle mask ventilation may be given prior to intubation. If possible the tracheal tube is placed distal to the fistula, with the bevel of the tracheal tube facing anteriorly.		Our preferred technique is to induce anaesthesia after pre-oxygenation and to maintain spontaneous ventilation initially with volatile or intravenous anaesthesia. Prior to repair the surgeons may perform flexible or rigid bronchoscopy to assess the level of the fistula and to see if there is a second or proximal fistula. Take note of the distance measured from the cords to the fistula to guide tracheal tube placement; the fistula is mid-tracheal in two thirds of cases, and located at level of the carina in one third of cases. Muscle relaxants and gentle mask ventilation may be given prior to intubation. If possible the tracheal tube is placed distal to the fistula, with the bevel of the tracheal tube facing anteriorly.

WikiSysop at 22:36, 2 July 2023

2023-07-02T22:36:54Z

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