Clinical Anesthesia for the Newborn and the Neonate

Foreword
Foreword
Foreword
Preface
Neonatal Mortality and Bearing on Anesthesia and Surgical Risk and Outcome
Contents
Part I: Basic: General Aspects of Newborn Diseases and Care
1: Neonatal Mortality and Morbidity: The Burden
1.1 Causes of Neonatal Morbidity and Mortality
1.2 Causes of Neonatal Mortality (Table 1.1)
1.3 Interventions
1.4 Conclusion
References
2: Impact of Maternal Health and Disease on Neonatal Outcome
2.1 Introduction
2.2 Undernutrition in Pregnancy
2.2.1 Micronutrients [7–10]
2.3 Assessment of Fetal Health
2.3.1 EFW [11–14]
2.3.1.1 Fetal Growth Restriction (FGR/IUGR) [15–18]
2.3.2 Birth Weight [19–22]
2.4 Maternal Diseases Affecting Neonatal Health
2.4.1 Anaemia [23–28]
2.4.2 Haematological Disorders in Pregnancy
2.4.2.1 Thalassemia
2.4.2.2 Pregnancy in Women with Sickle Cell Disease
2.4.3 Obesity and Pregnancy
2.4.4 Antiphospholipid Syndrome
2.4.5 Diabetes Mellitus in Pregnancy [31, 32]
2.4.5.1 Effects Maternal GDM on the Baby
2.4.6 Pregnancy and Infectious Diseases [33–35]
2.4.6.1 Rubella (German Measles) [36–39]
2.4.7 Liver Disease [40–42]
2.4.8 Renal Disease [43–46]
2.4.9 Maternal Malignancy and the Fetus [47–49]
2.4.10 Epilepsy in Pregnancy [50–55]
2.5 Multiple Pregnancy
2.6 COVID in Pregnancy
2.7 Conclusion
References
3: Changes in the Newborn at Birth: Fetal-to-Newborn Transition
3.1 Introduction
3.2 Placenta
3.2.1 Feto-placental Maternal Circulation
3.2.2 Functions of Placenta
3.3 Lung Development
3.4 Surfactant [5]
3.4.1 Surfactant Production
3.4.2 Role of Surfactant
3.4.3 Clinical Effects of Surfactant
3.5 Fetal Circulation
3.6 Transition from Fetus to Newborn (Fig. 3.1)
3.7 Other Adaptations
3.7.1 Respiratory Adaptaions
3.7.2 Pulmonary Changes at Birth:
3.7.3 Endocrine Adaptations
3.7.4 Metabolic Adaptations
3.7.5 Thermal Adaptation and Thermogenesis
3.7.6 Hepatic Adaptation
3.8 Normal Transitional Findings
3.9 Abnormalities of Transitional Changes at Birth
3.9.1 Apnea at Birth
3.9.2 Vaginal vs Cesaritan Delivery
3.9.3 Persistence of Fetal Circulation (PFC)/Persistent Pulmonary Hypertension of Newborn (PPHN)
3.9.4 Patent Foramen Ovale PFO/Patent Ductus Arteriosus PDA
3.9.5 Reversal of Shunt
3.9.6 Pulmonary Consequences of Lung Fluid Retention
3.10 Key Points
References
4: Common Medical Conditions in the Neonates
4.1 Introduction
4.2 Definitions Terminologies
4.2.1 As Per Gestational Age (GA)
4.2.2 As Per Birth Weight (BW)
4.3 Special Considerations [3]
4.3.1 Prematurity
4.3.2 Fetal Growth Restriction (FGR)
4.3.3 Large for Gestational Age (LGA)
4.3.4 Hypothermia/Hyperthermia
4.3.5 Birth Injuries (BI) [4–8]
4.3.6 Neonatal Asphyxia (Includes Birth Asphyxia and Perinatal Asphyxia) [9–13]
4.3.7 Hypoxic Ischemic Encephalopathy (HIE) [4]
4.3.8 Birth Defects
4.3.9 Hematological Disorders and Bleeding
4.3.10 Perinatal Infections [36–41]
4.3.11 Cutaneous Manifestations [42, 43]
4.3.12 Central Nervous System
4.3.13 Cardiovascular System
4.3.14 Respiratory System
4.3.15 Liver and GIT
4.4 Conclusion
References
5: Neonatal Screening for Metabolic Diseases
5.1 Introduction
5.2 Congenital Hypothyroidism (CH) and Its Anaesthetic Implications
5.2.1 Preanaesthetic Evaluation of a Neonate Presenting with CH
5.2.2 Perioperative Care of a Neonate with CH
5.3 Congenital Galactosemia (CG) and Its Anesthetic Implications
5.3.1 Clinical Features of CG
5.4 Congenital Phenylketonuria (PKU) and Its Anesthetic Implications
5.4.1 Clinical Features
5.4.2 Perioperative Management of PKU
5.5 Maple Syrup Urine Disease (MSUD) and Anesthetic Implications
5.6 Congenital Adrenal Hyperplasia (CAH) and Anesthetic Implications
5.7 Conclusion
References
6: Ophthalmological Surgical Conditions in the Newborn and Neonate
6.1 Introduction
6.1.1 Ophthalmic Conditions of Importance in the Neonatal Period that Require Anesthetic Attention, Include
6.2 Congenital Cataract
6.2.1 Management
6.3 Congenital Glaucoma
6.3.1 Management
6.4 Retinopathy of Prematurity (ROP)
6.4.1 Indications for Screening
6.4.2 Management
6.5 Retinoblastoma
6.5.1 Management
6.6 Child Abuse and Shaken Baby Syndrome
6.6.1 Management
6.7 Coloboma of the Eyelid
6.7.1 Management
6.8 Congenital Dacryocystocele
6.9 Cryptophthalmos and Ankyloblehpheron
6.9.1 Management
6.10 Congenital Entropion
6.11 Keratomalacia, Corneal Ulceration
6.11.1 Management
6.12 Trauma
6.13 Conclusion
References
7: Neonatal Transfusion
7.1 Introduction
7.2 Pretransfusion Factors
7.3 Red Cell Transfusion in Neonates
7.3.1 Small Volume (TOP UP) Transfusions in Neonatal Anemia
7.3.2 Goal of Blood Transfusion
7.3.3 Neonatal Red Cell Exchange Transfusion (EBT)
7.4 Surgery and Large Volume Neonatal Red Cell Transfusion
7.5 Bleeding in Neonates
7.5.1 Neonatal Platelet Transfusions
7.5.2 Neonatal FFP and Cryoprecipitate Transfusion
7.6 Neonatal Granulocyte Transfusion
7.7 Erythropoietin (EPO)
7.8 Hb Triggers as Per Ventilation Status [14]
7.9 Intrauterine Transfusion (IUT)
7.10 Post-transfusion Complications
7.11 Special Care During Surgery
7.12 Conclusion
References
8: Effect of Anaesthesia on Developing Brain
8.1 Introduction
8.2 Brain Growth and Development
8.3 Suspected Pathways of Neurotoxicity
8.4 Human Studies vs Preclinical Studies
8.5 Effect of Drugs in Utero and Maternal Exposure
8.5.1 Anaesthesia and Pregnant Mother
8.5.2 Anaesthesia and Fetus
8.6 Factors Affecting Neurotoxicity
8.6.1 Drug Type
8.6.2 Exposure Time
8.6.3 Number of Exposures
8.7 Age of Exposure
8.7.1 Window of Vulnerability
8.8 Clinical Implications of Potential Anesthesia-Related Neurotoxicity
8.9 Future Direction
8.10 Conclusion
References
9: Neonatal Rehabilitation and Outcome
9.1 Introduction
9.2 Growing Brain and Neural Plasticity
9.3 Development Process of a Child
9.4 History Taking
9.5 Examination
9.6 Posture and Movement Patterns
9.7 Muscle Tone
9.8 Neonatal Rehabilitation - Early Interventions
9.9 Outcome
9.10 Pearls of Wisdom
References
Part II: Developmental Anatomical and Physiological Aspects
10: General Anatomical and Physiological Considerations in the Newborn and Neonates
10.1 Introduction
10.2 Categorization (Table 10.1)
10.2.1 As Per Gestational Age (GA)
10.2.2 As Per Birthweight (BW)
10.2.3 The Ballard Maturational Assessment
10.2.4 APGAR Score
10.2.5 Anesthesia Risk
10.3 Anatomical and Physiological Considerations
10.3.1 General Features at Birth
10.3.2 Common Medical and Conditions
10.3.3 Common Surgical Conditions
10.4 The Airway Anatomy and Respiratory Physiology in Newborns
10.4.1 Airway Anatomy
10.4.2 Respiratory Physiology
10.4.3 Airway Management
10.5 Respiratory Abnormalities at Birth
10.5.1 Apnea of the Newborn
10.5.1.1 Risk Factors for Apnea in Neonates
10.5.1.2 Neonatal Apnea and the Anesthesiologist
10.5.1.3 Premature Neonates are at Extreme Risk of Perioperative Hypoxemia, Due to
10.5.1.4 Care During Anesthesia Management to Prevent Hypoxemia
10.5.2 Transient Tachypnea of the Newborn (TTN)
10.5.3 Respiratory Distress Syndrome (RDS)
10.5.3.1 Pathophysiology
10.5.3.2 Presentation—Clinical Features Appear Soon After Birth
10.5.3.3 Management—Aims at Improving Oxygenation and Correcting Hypoxemia. Preventive/Prophylactic
10.6 Cardiovascular System (CVS)
10.7 Central Nervous System
10.7.1 Anatomy
10.7.2 Blood–Brain Barrier (BBB)
10.7.3 Cerebral Blood Flow (CBF)
10.7.4 Neonatal Brain Is Protected from Hypoxic Insults by Four Mechanisms
10.7.5 Intraventricular Hemorrhage (IVH)
10.7.6 Spine and Spinal Cord
10.8 Thermoregulation, Endocrine, and Metabolic Functions
10.8.1 Thermoregulation
10.8.2 Brown Fat Metabolism and Thermogenesis
10.8.3 Hypothermia - Causes
10.8.4 Hyperthermia
10.9 Endocrine Physiology
10.9.1 Hypothalamic–Pituitary Axis
10.9.2 Growth Hormone
10.9.3 Gonadotrophins and Gonads
10.9.4 ACTH and Adrenocortical Hormone Function
10.9.5 Catecholamines and Other Vasoactive Substances
10.9.6 Thyroid Hormones
10.10 Metabolism
10.10.1 Carbohydrate Metabolism
10.10.2 Protein Metabolism
10.10.3 Calcium Metabolism, Neonatal Hypocalcemia, and Osteopenia of Prematurity
10.10.4 Magnesium Metabolism
10.11 Hepatic Anatomy and Physiology
10.11.1 Anatomy
10.11.2 Functions of Liver-Fetal Liver Has Two Important Roles Besides Other Functions, Mainly Cardiovascular and Hemopoietic [38–40]
10.12 Neonatal Renal Physiology and Excretory Function
10.13 Total Body Water, Body Water Distribution, and Blood Volume
10.14 Hematopoiesis and Coagulation
10.14.1 Hematopoietic System
10.14.2 Hemoglobin
10.14.3 Oxygen Dissociation Curve (ODC)
10.14.4 Physiologic Anemia
10.14.5 Neonatal Homeostasis
10.14.6 Anesthetic implications
10.15 Neuromuscular System
10.15.1 NM Transmission
10.15.2 Features of NM Transmission (NMT) in Neonates
10.15.3 Depolarizing Block and Muscle Relaxants (DMR)
10.15.4 Nondepolarizing Block and Drugs (NMB/NDMR)
10.15.5 Features of NMB in Newborns
10.15.6 Advantages of Using Muscle Relaxants in Neonates
10.15.7 Antagonism of NM Blocking Drugs
10.15.8 Recovery
10.16 Pharmacology of Drugs in Neonates
10.16.1 Clinical Implications of Altered Pharmacokinetics in the Neonate
10.16.2 Pharmacodynamics
10.16.3 Inhaled Anesthetic Agents (IAA)
10.16.4 Minimum Alveolar Concentration (MAC)
10.16.5 Intravenous Agents (IVA)
10.17 Pain Pathways and Development
10.17.1 Reasons for Poor Pain Management in Neonates
10.17.2 Development of Pain Pathways
10.17.3 Anesthetic Implications
10.17.4 Pain Assessment in Neonates
10.17.5 Clinical Implications During Anesthesia
10.18 Intestinal Physiology and Feeding
10.19 Immune System
10.20 VII. Ophthalmic Effects
10.21 Skin Physiology and Adaptations After Birth
10.21.1 Functions of the Newborn Skin
10.21.2 Physiologic Changes
10.21.3 Clinical Applications—Care and Precautions During Anesthesia and Clinical Care
10.22 Prematurity
References
11: The Respiratory System: Development and Physiology in the Neonate
11.1 Introduction
11.2 Respiratory System
11.2.1 Anatomical and Physiological Development
11.2.1.1 Anatomical Development
11.2.1.2 Physiological Development
11.2.2 Anatomical Fundamentals of the Neonatal Respiratory Tract and Airways
11.2.3 Upper Airway Muscles and Anesthesia
11.2.4 Controlling the Respiratory Process
11.2.5 Response to Hypoxemia
11.2.6 Response to CO2
11.3 Patterns of Breathing in Neonates
11.3.1 Clinical Importance of Severe Forms of Apnea in Neonates
11.3.1.1 Apnea is defined as cessation of respiration for more than 15 s, or less than 15 s if associated with bradycardia (HR<100/min), cyanosis or pallor [5]
11.3.1.2 Postoperative Apnea
11.4 Respiratory Mechanics
11.4.1 Characteristics of Neonatal Lungs and Thorax
11.4.2 Compliance of Lungs
11.4.3 Compliance of Neonatal Thorax (Chest Wall)
11.4.4 Clinical Implications
11.5 Surface Activity and Pulmonary Surfactant
11.6 Pulmonary compliance
11.7 Pulmonary Volumes
11.8 Airway Size and Resistance to Flow
11.9 Oxygen Requirements
11.10 Functional Residual Capacity (FRC) and Anesthesia
11.11 Mechanical Modes of Ventilation
11.11.1 Volume Control Mode (VCM)
11.11.2 Synchronized Intermittent Mandatory Ventilation (SIMV)
11.11.3 Pressure Controlled Ventilation (PCV)
11.11.4 Clinical Implications
11.12 Considerations in Neonatal Respiratory Diseases
11.12.1 Clinical Presentation
11.12.2 Laboratory Studies
11.12.3 Hyperoxia Test Methodology
11.13 Respiratory Distress Syndrome (RDS)
11.13.1 Pathophysiology
11.13.2 Initial Treatment
11.14 Pneumothorax
11.14.1 Causes of Pneumothorax
11.14.2 Clinical Features
11.14.3 Laboratory Studies
11.14.4 Treatment
11.15 Conclusion
References
Further Reading
12: The Neonatal Airway
12.1 Introduction
12.2 Anatomical and Physiological Considerations
12.2.1 Anatomical Considerations
12.2.2 Physiological Considerations
12.3 Airway Assessment
12.3.1 History
12.3.2 Physical Examination
12.3.3 Diagnostic imaging
12.4 Neonatal Airway Management: Procedures and Equipment
12.4.1 MASK Ventilation (MV)
12.4.1.1 Technique of Mask Ventilation:
12.4.2 Oropharyngeal Airways (OPA)
12.4.3 Supraglottic Airway (SGA) Devices
12.4.4 Endotracheal Intubation
12.4.4.1 Microcuff ETT
12.4.5 Video Laryngoscopy (VL)
12.4.6 Fibreoptic bronchoscope (FOB)
12.4.7 Rapid Sequence Induction (RSI) and Intubation (RSII) in Neonate
12.5 The Difficult Neonatal Airway
12.5.1 Definition
12.5.2 Identifying of Difficult Airway
12.5.3 Approach to Difficult Airway
12.5.4 Management Nonsurgical
12.6 Anesthetic Considerations of Difficult Airway
12.6.1 Choanal Atresia (CA)
12.6.2 Laryngomalacia
12.7 Summary
12.8 Conclusion
References
13: Autonomic Nervous System in the Neonate
13.1 Introduction
13.2 Developmental Neuroanatomy of the ANS
13.2.1 The Limbic System Includes the Amygdala, Thalamus, Fornix, Olfactory Cortex, Hippocampus, Hypothalamus, and Cingulate Gyrus
13.2.2 Amygdala
13.2.3 Hippocampus
13.2.4 Primitive Unmyelinated Vagal Nerve
13.2.5 Sympathetic System
13.2.6 Development Milestones of the ANS: [1]
13.3 Evaluation of the ANS Using HR
13.4 Impaired Vagal Balance: Polyvagal Theory
13.5 Impact of Maternal Factors on ANS Maturation
13.6 Adrenergic and Cholinergic Receptors
13.6.1 Adrenergic Receptors [11]
13.6.2 Muscarinic Receptors [6]
13.7 Stress Response in Neonates
13.8 Key Features of Autonomic Nervous System
13.9 Clinical Implications of Stress-Related Hyperglycemia in Neonates
13.10 Separation Anxiety
13.11 Pain Stress
13.12 ANS Concerns During Surgery and Anaesthesia
13.13 Conclusion
References
14: Ventilation and Ventilatory Modes in Neonates
14.1 Introduction
14.2 Relevant Terminologies
14.3 Major Indications for Mechanical Ventilation
14.4 Potential Risks of Mechanical Ventilation
14.5 Broad Principles of Neonatal Ventilation
14.6 Modes of Mechanical Ventilation (MV)
14.7 Selection of Mode
14.8 Non-invasive Ventilation (NIV)
14.8.1 Nasal Continuous Positive Airway Pressure (nCPAP) (Fig. 14.2)
14.8.2 Nasal High Flow Therapy (nHFT)
14.9 Neonatal Resuscitation
14.10 Mechanical Ventilation
14.10.1 How to Initiate Invasive Mechanical Ventilation (MV)
14.10.2 How to Assess Adequacy of MV
14.11 Weaning Off Mechanical Ventilation
14.11.1 How to Wean
14.11.2 Criteria for Weaning
14.11.3 Weaning Protocol Principles
14.11.4 Weaning Failure
14.12 Surfactant Administration
14.12.1 In Case a Newborn is Initially Treated with NIV–Intubation and Surfactant May Be Required If:
14.12.2 Required Interventions Before Surfactant Delivery
14.12.3 Risk of Surfactant Administration
14.13 High-Frequency Oscillatory Ventilation (HFOV)
14.13.1 Working Principle
14.13.2 Clinical Applications
14.13.3 How to Set
14.13.4 How to Wean:
14.13.5 Troubleshooting Situations with Possible Solutions
14.13.6 Limitations
14.14 Significance of Humidification and Flow Sensor Location
14.15 Choice of Endotracheal Tube: Cuffed vs Uncuffed ETT
14.16 Concerns During Transport
14.17 Ventilatory Considerations in the Operation Room (OR)
14.17.1 Management Strategies
14.18 Inhaled Nitric Oxide (iNO)
14.19 Conclusion
References
15: Hematological Diseases and Syndromes in the Neonate: Haemoglobin, Haemoglobinopathies, and Oxygen Therapy
15.1 Introduction
15.2 Haemoglobin
15.2.1 Oxygen Dissociation Curves (ODC)
15.2.2 O2 Affinity
15.2.3 HbA2
15.2.4 Fetal Hb (HbF) [11]
15.2.5 Embryonic Haemoglobins [15]
15.3 Sickle Cell Disease (SCD)
15.3.1 Pathophysiology of SCD
15.3.2 Clinical Presentation
15.3.3 Medical Management of SCD
15.3.4 Anesthesia Considerations and Management
15.3.5 Intraoperative Management
15.3.6 Postoperative Care
15.4 Thalassaemia
15.4.1 Pathophysiology
15.4.2 Clinical Presentation of α-Thalassemia Varies
15.4.3 Perioperative Management
15.4.4 Monitoring and Care
15.4.5 Mutant Haemoglobins and Anesthesia
15.5 Oxygen Therapy for Preterm and Term Neonates
15.5.1 O2 Delivery Devices
15.5.2 Oxygen Toxicity
15.5.3 Retinopathy of Prematurity (ROP)
15.5.4 Bronchopulmonary Dysplasia (BPD)
References
16: Thermoregulation in Newborns, Neonates, and Premature
16.1 Introduction
16.2 Physiology of Brown Fat Metabolism and Thermogenesis
16.3 Mechanisms of Heat Loss
16.4 Preterm Neonates
16.5 Complications of Hypothermia (Cold Injury)
16.6 Temperature Monitoring
16.6.1 Core Versus Peripheral Temperature Monitoring
16.7 Hyperthermia
16.8 Effects of Anaesthesia
16.8.1 General Anesthesia (GA):
16.8.2 Regional anaesthesia (RA)
16.9 Mechanism to Maintain Normothermia in the Perioperative Area
16.10 Conclusion
References
17: Clinical Pharmacology of Anesthetic Drugs in Neonates
17.1 Introduction
17.2 General Pharmacological Definitions and Terms
17.2.1 Pharmacology
17.2.2 Clinical pharmacology
17.2.3 Therapeutic index
17.2.4 Drug approvals
17.3 Developmental Pharmacology
17.4 Pharmacokinetics
17.4.1 Drug Absorption
17.4.1.1 Oral
17.4.1.2 Rectal
17.4.1.3 External Application
17.4.1.4 Inhalation Route
17.4.1.5 Intravenous Route
17.4.2 Drug Distribution
17.4.2.1 Body Composition
17.4.3 Plasma Proteins and Protein Binding
17.4.3.1 Regional Blood Flow
17.4.4 Drug Elimination
17.4.4.1 Hepatic Elimination
17.4.4.2 Extrahepatic Drug Elimination
17.4.4.2.1 Renal Elimination
17.4.4.2.2 Pulmonary Elimination
17.4.4.2.3 Enzymatic Metabolism/Hydrolysis
17.5 Pharmacodynamics
17.6 Anesthetic Agents
17.6.1 Inhaled Anesthetic Agents
17.6.2 Intravenous Anesthetic Agents
17.6.3 Analgesics
17.6.3.1 Alpha 2 Agonists
17.6.3.2 Opioids (Table 17.3)
17.6.3.3 Other Analgesics
17.6.4 Muscle Relaxants
17.6.5 Sedatives
17.6.6 Anticholinergic Drugs
17.6.7 Local Anesthetics (Table 17.4)
17.6.8 Miscellaneous Drugs
17.7 Anesthetic Implications of Clinical Pharmacology in Neonates
17.8 Conclusion
References
For Further Reading
18: Neuromuscular Disorders in Neonate
18.1 Introduction
18.2 Neuromuscular Disorders
18.2.1 Motor Neuron Disorders
18.2.1.1 Anesthesia Considerations
18.2.2 Peripheral Neuropathies
18.2.3 Neuromuscular Junction (NMJ) Disorders
18.2.3.1 Anesthesia Considerations
18.2.4 Muscle Disorders
18.2.4.1 Congenital Muscular Dystrophies (CMD)
18.2.4.1.1 Anesthesia Considerations
18.2.4.2 Congenital Myopathies
18.2.4.3 Mitochondrial Myopathies
18.2.4.3.1 Anesthesia Considerations in Congenital and Mitochondrial Myopathies
18.3 Malignant Hyperthermia
18.4 Approach to Neonatal NM Disorders
18.5 Conclusion
References
Part III: Special Aspects of Neonatal Anesthesia
19: Preoperative Workup, Perioperative NPO, and ERAS
19.1 Introduction
19.2 Terminology
19.3 Prematurity and Its Implications
19.4 Understanding a Newborn
19.4.1 Newborn Apnoea
19.5 Upper Airway Assessment
19.6 Lower Respiratory System
19.7 Cardiovascular System (CVS)
19.8 Other Systems at a Glance
19.9 Fluid and Electrolytes [11, 12]
19.9.1 Assessment of Fluid and Electrolyte Status
19.9.2 Investigations
19.9.3 Special Considerations
19.9.4 Three Pillars of Fluid Administration [13, 14]
19.10 Glucose Homeostasis
19.11 Electrolytes
19.11.1 Sodium
19.11.2 Potassium
19.11.3 Calcium
19.12 Acid–Base Balance
19.13 The Perioperative Workup
19.13.1 Preparing the Parent or Caregiver
19.13.2 Preparing the Baby
19.13.3 History and Physical Examination
19.13.4 Fasting Guidelines
19.13.5 Preoperative Investigations
19.13.6 Intravenous Access
19.13.7 Skin and Eye Care
19.14 Preparing the Environment
19.14.1 Transportation
19.14.2 The Operation Theatre
19.14.2.1 Personnel
19.14.2.2 Temperature Regulation
19.14.2.3 Equipment
19.14.2.4 Drugs and Blood Products
19.14.2.5 Monitors
19.15 Enhanced Recovery After Surgery (ERAS) [21, 22]
19.16 Conclusion
References
20: Central Venous and Peripheral Arterial Access in Neonates
20.1 Introduction
20.2 Central Venous Cannulation (CVC)
20.2.1 Site for Central Venous Canulation
20.2.2 The Size and Length of Catheter
20.2.3 Technique
20.3 Umbilical Vein Cannulation
20.4 Intraosseous/Intramedullary Access (IO)
20.5 Complications
20.5.1 Complications of CVC
20.5.2 Complications of UVC
20.5.3 Complications of IO
20.6 Arterial Cannulation (IA)
20.6.1 Special Considerations in Newborns and Neonates
20.6.2 Contraindications [20]
20.6.3 Technique of Radial Artery Cannulation
20.6.4 Complications of Arterial Cannulation: [20, 26]
20.7 Precautions and Care at Insertion and Maintenance of Vascular Lines:
20.8 Anesthesia for Vascular Cannulation
20.8.1 Anesthesia Techniques
References
21: Ultrasound Guided Vascular Access in Neonates
21.1 Basic Principle of US Guided Vascular Access
21.1.1 Advantages of Ultrasound Over Traditional Landmark Insertion:
21.1.2 Disadvantages of Ultrasound
21.1.3 Possible Vascular Access Sites
21.2 Arterial Cannulation
21.3 Peripheral Venous Cannulation
21.4 Determination of Optimal Catheter Size
21.5 Central Venous Access
21.5.1 Internal Jugular Vein (IJV)
21.5.2 Femoral Vein (FV)
21.5.3 Subclavian Vein (SCV)
21.6 USG Guided Vascular Access Technique and Approaches
21.6.1 LAX-IP Approach
21.6.2 SAX-OOP Approach
21.6.3 Dynamic Needle Tip Positioning (DNTP)
21.6.4 Techniques Aiding USG Vascular Access
21.7 Complications
21.8 Conclusion
References
22: Monitoring During Anaesthesia in the Newborn and Neonate
22.1 Introduction
22.2 Various Monitoring Modalities Are as Follows
22.2.1 General Examination
22.2.2 Systemic Arterial Pressure Monitoring
22.2.3 Central Venous Pressure (CVP)
22.2.4 CO2 Monitoring
22.2.4.1 End-Tidal CO2 (EtCO2)
22.2.4.1.1 Mainstream Analyzers vs Side Stream Analyzers
22.2.4.1.2 Advantages of Capnography
22.2.4.2 Transcutaneous Partial Pressure of CO2 (TcPCO2)
22.2.5 Pulse Oximetry (SpO2)
22.2.6 ECG
22.2.7 Temperature
22.2.8 Near-Infrared Spectroscopy (NIRS)
22.2.9 Neurophysiological Monitoring
22.2.9.1 Electroencephalography (EEG)
22.2.9.1.1 How EEG is Evaluated:
22.2.9.2 Evoked potentials
22.2.9.2.1 Anesthesia, Neonate and Evoked Potential Monitoring
22.2.9.3 Bispectral Index (BIS)
22.2.10 Neuromuscular Transmission (NMT) Monitoring
22.2.11 Urine Output Monitoring
22.2.12 Arterial Blood Gases (ABG)
22.3 Conclusion
References
23: Perioperative Fluid Management and Blood Transfusion in Newborns and Neonates
23.1 Introduction
23.2 Anatomical and Physiological Developmental Changes at Birth
23.3 Nutrition Requirements
23.4 Components of Perioperative Fluid Therapy
23.4.1 Intraoperative Fluid Requirement
23.4.2 Postoperative Fluid Therapy
23.4.3 How to Measure Fluid Responsiveness in Neonates
23.4.4 Care During IV Fluids Administration
23.5 Blood Transfusion
23.6 Fresh Frozen Plasma
23.7 Cryoprecipitate
23.8 Conclusion
Appendix 1: Composition of Crystalloids and Colloids
Further Readings
24: Central Neuraxial Blocks in Neonates
24.1 Introduction
24.2 Anatomy
24.3 Spinal Anesthesia (SAB)
24.3.1 Indications of Spinal Anaesthesia
24.3.2 Technique for SAB in Neonates
24.3.3 Assessment of Block
24.3.4 Adverse Effects
24.3.5 Local Anaesthetics and adjuvants
24.3.6 Contraindications
24.4 Epidural Block
24.4.1 Caudal Epidural Block
24.4.2 Care During Awake Caudal Block in Ex-Premature Neonates
24.4.3 Anatomical Considerations
24.4.4 Technique and position for Caudal Block
24.4.5 Local Anesthetics and Adjuvants
24.4.6 Complications
24.5 Some Technical Aspects of Epidural Block in Neonates
24.5.1 Site of Epidural Insertion
24.5.2 Loss-of-resistance (LOR)
24.5.3 Test Dose
24.5.4 Nerve Stimulation-guided Technique: ‘Tsui-technique’
24.5.5 Ultrasound Guided (USG) Caudal Epidural Catheter Placement
24.5.6 Technique of Caudal Placement Using USG
24.6 Conclusion
Suggested Readings
25: Anaesthesia or Sedation for Procedures Outside the Operation Theatre
25.1 Introduction
25.2 The Context and the Challenges
25.3 General Considerations
25.3.1 Infrastructure and Resources
25.3.2 Clinicians’ Skill and Training
25.3.3 The ‘3-P’s: Physical, Psychological, and Pharmacological
25.3.4 Selection and Screening
25.3.5 Specific Procedures
25.4 Pre-sedation Screening
25.5 Cannulations
25.6 Radiological Procedures
25.7 Cardiac Procedures
25.7.1 Echocardiogram (ECHO)
25.7.2 Cardiac Catheterization
25.8 Other miscellaneous procedures included are as follows:
25.9 Radiotherapy, EEG, Evoked Potentials
25.10 Gastrointestinal Procedures: Insertion of Ryle’s Tube, Esophago-Gastroscopy, and Colonoscopy
25.11 Specific Issues for Different Levels of Sedation
25.12 Scope of Regional Anesthesia/Analgesia
25.13 Some Specific Complications of High Concern
25.13.1 Airway Obstruction
25.13.2 Apnea
25.13.3 Laryngospasm
25.13.4 Local Anesthetic Systemic Toxicity (LAST)
25.14 Conclusion
References
26: Pain Management in Neonates
26.1 Introduction
26.2 Pain Pathways in Neonates
26.3 Neonatal Pain Control Program
26.4 Importance of Understanding Neonatal Pain
26.5 Measuring Pain
26.5.1 Pain Assessment Tools
26.5.2 Method and Interpretation
26.5.3 Frequency of Pain Assessment
26.6 Neonatal Pain Management
26.6.1 Approach to Pain Management in Neonates
26.6.2 Recommendations
26.6.3 Step 1: Nonpharmacologic Interventions
26.6.4 Pharmacologic Treatment Strategies
26.6.4.1 Step 2: Topical Anesthetics
26.6.4.2 Step 3: Acetaminophen
26.6.4.3 Step 4: LA Infiltration, Peripheral Nerve Blocks, Neuraxial Blocks
26.6.4.4 Step 5: Opioids and Adjuvant Drugs
26.7 Alternative/Adjuvant Medications
26.8 Regional Anesthesia in Neonates
26.8.1 Caudal Block
26.8.2 Epidural Analgesia
26.8.3 Spinal Anesthesia
26.8.4 Peripheral Nerve Blocks
26.9 Family-Centered Care
26.10 Training
26.11 Conclusion
References
27: Perioperative Complications and Critical Incidents During Anesthesia in a Surgical Neonate
27.1 Introduction
27.2 Special Concern in Neonates
27.2.1 What Makes Neonates at Greater Risk of Anesthesia Related Adverse Events (CIs)?
27.2.2 Definition
27.3 History and Development of CI Reporting
27.3.1 Utility of CI Reporting in Anesthesia
27.3.2 Limitations of CI Reporting
27.4 Classification of Critical Incidents
27.5 Risk Factors for CIs
27.6 Literature Search
27.7 List of Possible Critical Incidents
27.7.1 Critical Incidents Related to the Pulmonary System are the Most Common
27.7.2 Medication-Related CIs Include Anaphylaxis, LA Toxicity, Wrong Drug, and Wrong Dose
27.7.3 Surgery Related
27.7.4 Transfusion Reactions
27.7.5 Unplanned ICU Admission
27.7.6 Vascular Access-Related CIs
27.7.7 Neuraxial Block Related
27.7.8 Regional Anesthesia Related
27.7.9 Delayed Recovery
27.7.10 Hypothermia
27.7.11 Equipment Related
27.7.12 Malignant Hyperthermia
27.7.13 Cardiac Arrest
27.7.14 Others
27.8 Key Points and Recommendations for Prevention of CIs in Surgical Neonates (Table 27.2)
Further Reading
Part IV: Case-Based Anesthesia Management: Common Procedures
28: Tracheoesophageal Fistula in the Neonates
28.1 Introduction
28.2 Tracheoesophagea Fistula (TEF) [5–7]
28.2.1 History
28.2.2 Development
28.2.3 Etiology
28.2.4 Pathophysiology
28.2.5 Classification
28.2.6 Associated Anomalies
28.3 Prognosis and Risk Stratification
28.4 Diagnosis
28.5 Preoperative Care
28.6 Treatment
28.7 Anesthetic Management
28.7.1 Preoperative Evaluation
28.7.2 Investigations
28.7.3 Optimization and Preoperative Preparation
28.7.4 An Informed Consent
28.7.5 Monitoring
28.7.6 Induction and Intubation
28.7.7 Care During Ventilation
28.7.8 Maintenance of Anesthesia
28.7.9 Recovery from Anesthesia
28.8 Postoperative Management
28.8.1 General Care
28.8.2 Pain Management
28.8.3 Nutrition
28.8.4 Postoperative Ventilation is Indicated
28.9 Complications
28.9.1 Intraoperative Complications Include
28.9.2 Postoperative Complications
28.10 Conclusions
References
Further Reading
29: Anesthesia for Congenital Diaphragmatic Hernia
29.1 Introduction
29.2 Classification of CDH
29.3 Etiology
29.4 Embryology
29.5 Associated Congenital Anomalies
29.6 Pathophysiology
29.7 Clinical Presentation
29.8 Diagnosis [12]
29.8.1 Antenatal Diagnosis
29.8.2 Antenatal Management
29.9 Predictors of Survival in the Perinatal Period
29.10 Intrapartum Management—In the Delivery Room
29.11 Ventilation Specifics
29.12 Management of Pulmonary Hypertension (PHT)
29.13 Predictors of Poor Postnatal Survival in Neonates with CDH
29.14 Surgical Management
29.15 Preoperative Assessment of Prognosis
29.15.1 Extracorporeal Membrane Oxygenation (ECMO) [11, 28–30]
29.15.2 Indications of ECMO
29.15.3 Contraindications to ECMO
29.16 Surgical Approach
29.16.1 Timing of Surgery
29.17 Preanesthetic Assessment
29.18 Preoperative Investigations
29.19 Consent Taking
29.20 Preoperative Preparation
29.20.1 Preoperative Optimization
29.20.2 Maintaining Systemic Blood Pressure
29.20.3 Transport from NICU to Operation Theater
29.21 Anesthesia Management
29.21.1 Intraoperative Monitoring
29.21.2 Premedication
29.21.3 Induction and Maintenance
29.21.4 Positioning for Surgery
29.21.5 Ventilatory Strategy-Intraoperative
29.21.6 Laparoscopic Approach
29.21.7 Fluid Therapy
29.21.8 Complications
29.21.9 Extubation and Postoperative Care
29.22 Postoperative Care
29.22.1 Postoperative Pain management
29.23 Long-Term Outcome in CDH
29.24 Conclusion
References
30: Anesthesia for Thoracic Surgery in Neonates
30.1 Introduction
30.2 Physiological Changes in the Lateral Decubitus Position [1–3]
30.3 Preoperative Evaluation [3, 4]
30.4 Fasting Guidelines and Premedication
30.4.1 Investigations
30.4.2 Blood Products and Vascular Access
30.4.3 Operation Room (OR) Preparation
30.4.4 Induction of Anesthesia
30.5 Airway Management for Thoracotomy
30.5.1 Indications for Lung Isolation and One-Lung Ventilation (OLV)
30.5.2 Techniques of OLV
30.6 Single Lung Ventilation (SLV) by Endobronchial Intubation
30.6.1 Bronchial Blockers
30.6.2 Varieties of Bronchial Blockers (Fig. 30.3)
30.6.3 Technique of Placement of BB (Fig. 30.4)
30.6.4 Marraro Bilumen Tube [9] (Fig. 30.5)
30.7 Pain Management for Thoracotomy
30.7.1 Epidural Analgesia
30.7.2 Erector Spinae Plane Block (ESPB) [17, 18]
30.8 Special Surgical Conditions and Concerns
30.8.1 Congenital Cystic Adenomatoid Malformations (CCAM) [17, 19–22]
30.8.2 Congenital Lobar Emphysema (CLE) [8, 23–29]
30.8.3 Congenital Broncho-Biliary Fistula (CBBF) [30]
30.9 Conclusion
References for Further Reading
31: Abdominal Wall Defects in Newborns and Neonates: Exomphalos and Gastrochisis
31.1 Introduction
31.2 Exomphalos (Omphalocele) and Gastrochisis
31.2.1 Embryology
31.2.2 Etiopathology
31.2.3 Epidemiology
31.2.4 Associated Anomalies
31.3 Diagnosis
31.4 Post-Delivery Management
31.5 Preoperative Management
31.6 Surgical Management
31.7 Anaesthetic Management - Gastroschisis/Exomphalos
31.7.1 Preoperative Assessment
31.7.2 Investigations
31.7.3 Readiness for Anesthesia and Surgery
31.7.4 Induction on Anesthesia
31.8 Postoperative Care
31.9 Complications
31.10 Prognosis
31.11 Conclusion
Further Readings
32: Anesthesia for Gastrointestinal Surgical Conditions in Neonates
32.1 Introduction
32.2 Common Congenital GI Abnormalities
32.3 Anesthesia Considerations in Major GI Surgery (Table 32.2)
32.4 Anesthestic Management
32.4.1 Preoperative Assessment
32.4.2 Perioperative Management
32.4.3 Induction of Anesthesia
32.4.4 Airway Management
32.4.5 Ventilation Strategy
32.4.6 Cardiovascular Stability and Fluid Therapy
32.5 Postoperative Care
32.6 Anesthetic Consideration for Individual Surgical Conditions – NEC, IHPS, Hirschsprung’s Disease, ARM, Intestinal Obstruction. Biliary Atresia, Gastroschisis, CDH, Omphalocele, EA/TEF- are Discussed in Separate Chapters
32.6.1 Necrotizing Enterocolitis (NEC)
32.6.1.1 Clinical Presentation
32.6.1.2 Pathophysiology
32.6.1.3 Management
32.6.1.4 Anesthetic Management of NEC
32.6.1.5 Postoperative Management
32.6.1.6 Outcome
32.6.2 Congenital/Infantile Hypertrophic Pyloric Stenosis (IHPS)
32.6.2.1 Epidemiology and Etiology
32.6.2.2 Pathophysiology
32.6.2.3 Presentation
32.6.2.4 Management
32.6.2.5 Anesthetic Management
32.6.3 Congenital Aganglionic Colon (Hirschsprung’s Disease) (HD)
32.6.3.1 Etiopathogenesis
32.6.3.2 Presentation
32.6.3.3 Surgical Management
32.6.3.4 Perioperative Considerations
32.6.4 Anorectal Malformations (ARM)
32.6.4.1 Epidemiology
32.6.4.2 Etiopathogenesis
32.6.4.3 Presentation
32.6.4.4 Anesthetic Management
32.6.5 Intestinal Obstruction
32.6.5.1 Bowel Atresia
32.6.5.2 Malrotation/Volvulus
32.7 Conclusion
Further Reading
33: Anesthesia for Genitourinary Surgery in the Neonate
33.1 Introduction
33.2 Embryology
33.2.1 Excretory System
33.2.2 Genital System and Gonads
33.3 General Considerations
33.4 Preanesthetic Evaluation
33.4.1 Preanesthetic Evaluation
33.4.2 Preoperative Investigations
33.5 Anesthetic Management
33.5.1 General Anesthesia
33.5.2 Epidural Anesthesia
33.5.3 Spinal Anesthesia
33.5.4 Intraoperative Positioning
33.6 Anesthesia Management of Individual Surgeries
33.6.1 Circumcision
33.6.2 Posterior Urethral Valves (PUV)
33.6.3 Hypospadias/Epispadias
33.6.4 Ureterocele
33.6.5 Prune Belly Syndrome
33.6.6 Cryptorchidism
33.6.7 Testicular Torsion
33.6.8 Hydrocele
33.6.9 Renal Masses
33.6.9.1 Cystic Masses
33.6.9.2 Solid Renal Masses
33.6.10 Anesthesia for Urological Disorders of the Urinary Tract
33.6.11 Gonadal Masses [50]
33.7 Conclusion
References
34: Anesthesia for Ophthalmic Procedures in the Newborn, Neonate, and Premature
34.1 Introduction
34.2 Physiology of IOP (Intraocular Pressure) and Factors Affecting
34.3 Aqueous Humor [6, 7]
34.4 Anesthetic Implications of Drugs Used in Ophthalmology
34.4.1 Oculocardiac Reflex (OCR)
34.5 Anesthesia Considerations
34.5.1 Goals of Anesthesia for Ophthalmic Surgery
34.5.2 Preoperative Evaluation (PAE)
34.5.3 Special Attention Must Be Paid to
34.5.4 Laboratory Investigations
34.5.5 Preoperative Fasting
34.6 Anesthesia Techniques
34.7 Examination Under Anesthesia (EUA)
34.7.1 General Principles
34.7.2 Special Care During EUA and IOP Measurement
34.7.3 Anesthesia Considerations
34.8 Anesthesia for Surgical Procedures
34.8.1 General Principles
34.8.2 Airway Management
34.8.3 Neuromuscular Block (NMB)
34.8.4 Pain Relief
34.9 Regional Anesthesia Techniques
34.10 Monitoring
34.11 Extubation
34.12 Postoperative Care
34.13 Complications
34.14 Common Ophthalmic Surgeries in Neonates
References
35: Neural Tube Development and Defects: Meningocele, Encephalocele, Hydrocephalus
35.1 Introduction
35.2 Neuro-Embryology
35.2.1 Primary Neurulation
35.2.2 Secondary Neurulation
35.3 Etiopathogenesis
35.4 Spinal Dysraphism
35.4.1 Meningomyelocele
35.4.1.1 Pathophysiology
35.4.1.2 Clinical Presentation
35.4.1.3 Diagnosis Prenatal Diagnosis A
35.4.1.4 Management
35.4.1.5 Perioperative Considerations
35.4.1.6 Preanesthetic Preparation
35.4.1.7 Surgical Procedure
35.4.1.8 Anaesthetic Management
35.4.1.9 Monitoring
35.4.1.10 Positioning
35.4.1.11 Allergic Reactions
35.4.1.12 Maintenance of Anaesthesia
35.4.1.13 Intraoperative Concerns
35.4.1.14 Emergence from Anaesthesia
35.4.1.15 Postoperative Care
35.4.2 Occult Spinal Dysraphism
35.4.3 Cranial Dysraphism - Encephalocele
35.4.3.1 Pathogenesis
35.4.3.2 Perioperative Management
35.4.3.3 Conduct of Anaesthesia
35.4.3.4 Major Complications are Related to Location of Encephalocele
35.5 Hydrocephalus
35.5.1 Presentation
35.5.2 Etiology
35.5.3 Treatment
35.5.4 Anaesthetic Management for VP Shunt Surgery
35.6 Special Concerns during Endoscopic Third Ventriculostomy (ETV)
35.7 Conclusion
References
36: Anesthesia for Short Procedures
36.1 Introduction
36.2 Anesthetic Concerns for Short Procedures in Neonates
36.3 Anesthetic management – General Considerations
36.4 Specific Short Procedures
36.4.1 Lower Abdominal and Perineal Procedures
36.4.1.1 Umbilical Hernias
36.4.1.2 Inguinal Hernia and Hydrocele Repair: Herniorrhaphy
36.4.1.3 Undescended Testis: Orchidopexy
36.4.1.4 Torsion Testis
36.4.1.5 Circumcision
36.4.1.6 Cystoscopy and Fulguration for PUV (Posterior Urethral Valves)
36.4.2 Gastro Abdominal Procedures: Gastrostomy, Colostomy, Intraperitoneal Drain Placement
36.4.2.1 Gastrostomy
36.4.2.2 Colostomy
36.4.2.3 Intraperitoneal Drain (PD) Placement
36.4.3 Tracheostomy
36.4.4 Infective (Drainage, Debridement): Necrotizing Fasciitis (NF), Septic Arthritis
36.4.4.1 Necrotizing Fasciitis (NF)
36.4.4.2 Septic Arthritis
36.4.5 Birth Injuries (BI) and Neonatal Care Injuries (NCI)
36.4.5.1 Birth Injuries (BI)
36.4.5.2 Neonatal Care Injuries (NCI)
36.4.6 Ventriculoperitoneal (VP) Shunt Placement
36.4.6.1 Neuroanatomy and Physiology
36.5 Conclusion
References
37: Anesthetic Consideration in a Neonate with Congenital Heart Disease for Noncardiac Surgery
37.1 Introduction
37.2 Fetal Circulation and Changes at Birth
37.3 Etiology of CHD
37.4 CHDs are Classified
37.5 Understanding of Hemodynamics in CHD
37.6 Individual CHD
37.6.1 Patent Foramen Ovale (PFO)/Atrial Septal Defect (ASD) (L → R Shunt)
37.6.2 Ventricular Septal Defect (VSD) (L → R Shunt)
37.6.3 Patent Ductus Arteriosus (PDA) (L → R Shunt)
37.6.4 Tetralogy of Fallot (TOF) (R → L Shunt)
37.7 Complications of CHD
37.7.1 PLSVC (Persistent Left Superior Vena Cava)
37.7.2 TAPVC (Total Anomalous Pulmonary Venous Connection)
37.7.3 Infective Endocarditis (IE)
37.8 Conduct of Anesthesia in Neonates with CHD for Noncardiac Surgery
37.8.1 Anesthetic Challenges
37.8.2 Preoperative Evaluation Should Include
37.8.3 Investigations
37.8.4 Preoperative Optimization
37.8.5 Preoperative Fasting
37.8.6 Premedication
37.9 Cardiac Shunt and Anesthesia
37.9.1 Goals of Anesthetic Management
37.9.2 Care in Preoperative Period
37.9.3 Monitoring
37.9.4 Preoxygenation
37.9.5 Induction
37.9.6 Airway Management
37.9.7 Maintenance of Anesthesia
37.9.8 Intraoperative Concerns
37.9.9 Extubation
37.9.10 Complications After GA
37.9.11 Role of Regional Anesthesia
37.10 Special Situations
37.11 To Summarize
37.12 Conclusion
References
Further Readings
Part V: Anesthesia for Advanced Procedures and Uncommon Surgeries
38: Anaesthesia for Laparoscopic Surgery in Neonates
38.1 Introduction
38.2 Laparoscopic Surgery in Neonates
38.2.1 Benefits of Laparoscopy
38.2.2 Limitations and Harmful Effects of Laparoscopy
38.3 Surgical Equipment and Techniques
38.4 Effects of Laparoscopy on Neonatal Physiology
38.4.1 Cardiovascular System
38.4.1.1 Mechanism
38.4.2 Respiratory System
38.4.2.1 Mechanism
38.4.3 Central Nervous System (CNS)
38.4.4 Renal System
38.4.5 Other Systems
38.5 Selection of Patients
38.5.1 Preterm Neonates
38.5.2 Congenital Heart Disease
38.6 Preoperative Assessment and Preparation
38.7 Monitoring
38.8 Conduct of Anaesthesia
38.8.1 Induction and Maintenance of Anaesthesia
38.8.2 Airway and Ventilatory Management
38.8.3 Hemodynamic Management
38.8.4 Emergence
38.9 Intraoperative Adverse Events
38.9.1 Respiratory and Cardiovascular Events
38.9.2 Hypo- and Hyperthermia
38.9.3 Gas Embolism
38.9.4 Other Complications
38.10 Postoperative Management
38.11 Conclusions
References
39: Anesthesia for Bronchoscopy in Neonates
39.1 Introduction
39.2 Fiberoptic Bronchoscopy in Neonates
39.3 Indications for Neonatal FOB
39.4 Technique of FOB
39.5 Fiberoptic Bronchoscope
39.6 Contraindications
39.7 Limitation and Complications
39.8 FOB and the Role of the Anesthetist
39.8.1 Pre-Procedure Assessment
39.8.2 Pre-Procedure Instructions
39.8.3 Pre-Procedure Preparations
39.8.4 Before Use, Bronchoscope Should be Checked for the Following
39.8.5 Other Important Preparations
39.8.6 FOB under Sedation
39.8.7 The Procedure
39.8.8 Pathologies Visualized
39.9 Practical Trouble-Shooters
39.10 Rigid Bronchoscopy in Neonates
39.11 Conclusion
References
40: Anaesthesia for Neurosurgical Procedures in Neonates
40.1 Introduction
40.2 Neonatal Neurology
40.2.1 Cerebral Blood Flow and Perfusion Pressure
40.2.2 Cerebral Autoregulation
40.2.3 Intracranial Pressure (ICP)
40.2.4 Blood-Brain Barrier
40.2.5 Spinal Cord
40.3 Neurosurgical Conditions in the Neonate
40.4 Neuroembryology and Pathogenesis of Diseases of the CNS
40.4.1 Embryology and Pathogenesis of Neural Tube Defects (NTDs)
40.4.1.1 Types of Neural Tube Defects
40.4.2 Embryology and Pathogenesis of Arnold Chiari Malformation (ACM)
40.4.3 Embryology and Pathogenesis of Congenital Hydrocephalus
40.5 Preoperative Assessment as per the Neurosurgical Condition
40.5.1 Hydrocephalus
40.5.2 Intracranial Cystic Spaces
40.5.3 Neural Tube Defects
40.5.4 Craniosynostosis
40.5.5 Large Cerebral Arteriovenous Shunts
40.6 Anesthetic Concerns in a Neonate Undergoing Neurosurgery
40.6.1 Anesthetic Concerns Due to Neonatal Age
40.6.1.1 Airway and Respiratory System
40.6.1.2 Cardiovascular System (CVS)
40.6.1.3 Hepatorenal System
40.6.1.4 Thermoregulation
40.6.2 Anesthetic Concerns Due to Neurological Pathology
40.6.3 Anesthetic Concerns Due to Neurosurgical Intervention
40.7 Effects of Anaesthetic Agents on Cerebral Perfusion
40.7.1 Intravenous Agents
40.7.2 Volatile Anaesthetic Agents
40.7.3 Opioids and Sedatives
40.7.4 Muscle Relaxants
40.8 Anesthesia Technique: Basic Principles
40.8.1 Preoperative Fasting
40.8.2 Premedication
40.8.3 OT Preparation
40.8.4 Induction of Anesthesia
40.8.5 Inhalational induction
40.8.6 Bag-mask Ventilation
40.8.7 Laryngoscopy and Intubation
40.8.8 Anesthesia Maintenance
40.8.9 Prevention of Hypothermia
40.8.10 Analgesia
40.8.11 Intraoperative Monitoring
40.8.12 Lowering ICP
40.8.13 Prevention of VAE
40.8.14 Extubation
40.8.15 Delayed Awakening
40.8.16 Postoperative Management
40.9 Some Special Concerns in Particular Neurosurgical Procedures
40.9.1 Ventriculoperitoneal (VP) Shunt Insertion
40.9.2 Neonatal Brain Tumour Resection
40.9.3 Encephaloceles Repair
40.9.4 Meningomyeloceles Repair
40.9.5 ACM Correction
40.9.6 Craniosynostosis Surgery
40.10 Neuroendoscopic Procedures
40.11 Conclusion
References
41: Exstrophy Bladder or Ectopia Vesicae
41.1 Introduction
41.2 Embryology
41.3 Pathophysiology
41.3.1 Bone Defect
41.3.2 Anorectal Displacement
41.3.3 Genitalia
41.4 Diagnosis and Postnatal Care
41.5 Surgical Management
41.5.1 Surgical Approaches Include
41.5.2 Other Surgical Approaches Described are
41.5.3 Postoperatively
41.5.4 Preoperative Care
41.6 Preanesthetic Assessment
41.7 Anesthesia Concerns
41.8 Anesthesia Management
41.9 Postoperative Management
41.10 Conclusion
References
42: Biliary Atresia and Anesthetic Considerations
42.1 Introduction
42.2 Classification
42.3 Pathogenesis
42.4 Pathophysiology
42.4.1 Bilirubin Metabolism
42.4.2 Pathophysiology
42.5 Signs and Symptoms
42.6 Diagnosis
42.6.1 Laboratory Investigations [14]
42.6.2 Imaging Studies
42.7 Management
42.7.1 Medical Management Includes Supportive Treatment Like [14, 17]
42.7.2 Surgery is the Definitive Treatment for Biliary Atresia
42.8 Anesthetic Management
42.9 Anesthetic Management of a Child Coming for Kasai Porto Enterostomy
42.9.1 Preoperative Preparation
42.9.2 Intraoperative Management
42.9.3 Intraoperative Anesthetic Goals
42.9.4 Postoperative Analgesia
42.9.4.1 Epidural Block (Fig. 42.3)
42.9.4.2 Peripheral Nerve Blocks
42.9.4.3 Intravenous Paracetamol
42.9.4.4 Systemic Opioids
42.10 Conclusion
References
43: Craniosynostosis: A Congenital Anomaly
43.1 Introduction
43.2 Classification of Craniosynostosis
43.3 Etiology
43.4 Diagnosis
43.5 Complications
43.6 Management
43.7 Anesthetic Management
43.8 Conclusion
Further Readings
44: Cystic Hygroma
44.1 Cystic Hygroma
44.2 Lymphatic Circulation
44.3 Prevalence
44.4 Location
44.5 Etiology (Table 44.1)
44.6 Various Syndromes (Table 44.1)
44.7 Detection/Diagnosis
44.7.1 Prenatal Diagnosis
44.7.2 Postnatal investigations
44.7.3 Presentation
44.7.4 Examination
44.8 Treatment OF CH
44.9 Overall Role of Anesthesiologist
44.10 Indications for Surgery in Neonates
44.11 Anesthetic Management
44.11.1 The Airway
44.11.2 Problems Frequently Encountered are Because of
44.11.3 Preoperative Preparation
44.11.4 Premedication
44.11.5 Intraoperative Monitoring
44.11.6 Induction and Intubation
44.11.6.1 Awake Intubation (AI)
44.11.6.2 Surgical Airway
44.11.6.3 Fixing of the ETT
44.11.7 Maintenance of Anesthesia
44.11.8 Fluids and Blood Transfusion (Ref Chapter on IV Fluid Therapy)
44.11.9 Extubation
44.12 Postoperative Complications
44.12.1 Respiratory Obstruction
44.13 Conclusion
Further Readings
45: Nesidioblastoma (Congenital Hyperinsulinism - CHI)
45.1 Introduction
45.2 Incidence
45.3 Etiopathogenesis
45.4 Clinical Presentation
45.5 Diagnosis (Box 45.1)
45.6 Management
45.6.1 Correction of Symptomatic Hypoglycemia
45.6.2 Drug Management
45.6.3 Surgical Resection
45.7 Anaesthetic Management
45.7.1 Main Goal
45.7.2 Anesthesia Technique
45.7.3 Postoperative Care
45.8 Conclusion
Further Readings
46: Congenital Broncho-Biliary Fistula (CBBF)
46.1 Introduction
46.2 Congenital BBF (CBBF)
46.3 Clinical Presentation
46.4 Pathophysiology
46.5 Diagnosis
46.6 Treatment
46.7 Surgery
46.8 Preoperative Care
46.9 Ventilation Specifics in CBBF
46.10 Anesthetic Management
46.11 Conclusion
References
47: Neonatal Malignancy and Anaesthesia
47.1 Introduction
47.2 Epidemiology of Neonatal Neoplasms
47.3 Clinical Implications of Neoplasia in the Newborn
47.4 Common Malignant Lesions Seen in Neonates
47.4.1 Neuroblastoma
47.4.1.1 Anesthetic Implications of Neuroblastoma Resection in Neonates [14–16]
47.4.2 Germ Cell Tumors or Teratomas (GCT)
47.4.2.1 Anesthetic Implications of GCT
47.4.2.2 Intraoperative Management [19, 20]
47.4.3 Renal Tumours
47.4.3.1 Perioperative Management of Radical Nephrectomy [19]
47.4.4 Liver Tumours in Neonates [9]
47.4.4.1 Perioperative Management [21, 22]
47.4.5 CNS Tumours in Neonates
47.4.5.1 Anaesthetic Implications [23]
47.4.6 Leukaemias
47.5 Summary
References
48: Neonatal Palliative Care: A Paradigm of Care
48.1 Preamble
48.2 When to Refer to Palliative Care?
48.3 Developing a Palliative Care Plan
48.4 Key Components of a Neonatal Palliative Care Plan
48.4.1 Early Integration of Palliative Care and Offering a Flexible Care Plan
48.4.2 Communication with the Parents and Shared Decision-Making
48.4.2.1 Communication and Shared Decision-Making
48.4.2.2 Making an Advance Care Planning
48.4.3 Ensuring Adequate Symptom Control and Comfort Care
48.4.3.1 Basic Care
48.4.3.2 Nutrition and Feeding
48.4.3.3 Pain and Symptom Management
48.4.4 End of Life Care and Withdraw or Withhold Life-Sustaining Treatment
48.4.5 After Death Plan
48.4.6 Team Support
48.4.7 Bereavement
48.5 Conclusion
Appendix
Further Readings
49: COVID-19 and The Surgical Neonate
49.1 Introduction
49.2 COVID and Anesthesia for Neonates
49.3 Tests Available for COVID Detection [3, 11]
49.4 Treatment in Pediatric Age Group [9, 13, 14]
49.5 Indications for ICU Admission in Neonates [13]
49.6 COVID-19 Recommendations for Healthcare Workers (HCWs) (Minnesota 2021) [15]
49.7 COVID in Neonates and Anesthesia
49.7.1 Elective Surgery
49.7.2 Emergency Surgery
49.8 Special OT Requirements for all COVID-Positive Patients
49.9 Anesthetic Management
49.9.1 Choice of Anesthesia
49.9.2 Monitoring
49.9.3 Induction
49.9.4 Maintenance
49.9.5 Emergence
49.9.6 OT Equipment after Care
49.10 Conclusion
References
50: Ethics in Neonatal Anesthesia and Research
50.1 Introduction
50.2 Ethics in Clinical Practice and Neonatal Anesthesia
50.2.1 Clinical Ethics [2–5]
50.2.2 Anesthesiologist’s Dilemma
50.2.3 Ethics in Neonatal Anesthesia
50.2.4 Communication with Parents
50.2.5 Informed Consent
50.2.6 Anesthetic Drug Use in Neonates [8–12]
50.2.7 Legality and Neonatal Anesthesia
50.2.8 Pain Management
50.2.9 Anesthetic drugs that have been used in the past, in the surgical neonates, include the following
50.3 Ethics in Neonatal Research
50.3.1 Development of Ethics in Human Research
50.3.2 Ethics in Human Research - Historical Facts
50.3.3 Conduct of Biomedical Research in Children
50.3.4 Guidelines for Research in Human
50.3.5 Consent
50.3.5.1 Informed consent
50.3.5.2 Validity of the Consent Process in Neonatal Research
50.3.6 Risks and Benefits
50.3.6.1 Classification of Risks [29]
50.3.6.2 Assessment of Risks and Benefits
50.3.6.3 Guidelines for Ethical Approval Based on Degree of Risk
50.3.6.4 Vulnerability
50.3.7 Safeguard for All Studies in Humans
50.3.8 Guidelines for Research in Neonates [29]
50.3.9 Suggestions So That Neonates Can Benefit from Research
50.3.10 Status in India [29]
50.4 Key Points
References
Index