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Neonatal anaesthesia: Difference between revisions
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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. | ||
{| class="wikitable" | {| class="wikitable" | ||
|+ | |+ | ||
!DEFINITIONS | !DEFINITIONS | ||
|- | |- | ||
| | |•Neonate is aged up to 28 days | ||
•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 | • Very low birthweight <1.5kg | ||
|} | |||
=== 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 | ||