Anesthesia for fetal surgery

Fetal surgery is a rapidly growing and evolving area. Fetal surgery is based on years of animal and clinical research. In contrast, anesthesia techniques for fetal surgery are based on clinical experience. The techniques that have emerged are safe for mother and fetus. In this review, the authors describe current techniques for anesthetic management of fetal surgery patients. General anesthesia is the primary technique used for hysterotomy based surgical correction of midgestation fetuses and ex utero interpartum corrections of end-gestation fetuses. Epidural analgesia, with general anesthesia as back-up, is the primary technique used for fetoscopic cases in which anesthetic care is required. Because of the myriad of anesthetic and surgical issues these cases generate, it is essential to have good communication and cooperation between surgeons and anesthesiologists from the preoperative period to the postoperative period. This will allow development of a cohesive anesthetic and surgical plan that can be used for the safe perioperative management of the fetal surgery patient.     

Anesthesia for pediatric outpatient surgery

Children are ideal patients for outpatient surgery. Thorough preoperative medical evaluation and selection of appropriate surgical and anesthetic procedures allow most pediatric surgery to be performed safely on an outpatient basis. Psychological preparation, the presence of parents whenever possible, and the appropriate use of premedication minimize the emotional trauma inherent in having anesthesia and surgery. Good anesthetic management consists of selecting anesthetic agents and techniques to promote safety, minimize complications, reduce postoperative nausea, vomiting and pain, and facilitate recovery and discharge. Most importantly, the outpatient setting permits minimal disruption of a child's life and provides an opportunity for the pediatric patient and family to have a positive health-care experience while receiving necessary surgical care.     

Emergency neonatal surgery in a developing country

 With better understanding of neonatal physiology and improvements in diagnostic facilities and neonatal intensive care units (NICU), the outcome of neonatal surgery has improved in developed countries. In developing countries, however, neonatal surgery is problematic, particularly in the emergency setting, but there are few reports from these countries. A retrospective analysis of 154 neonates who had emergency surgery over a 10-year period at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria, was undertaken. Emergency surgery represented 40% of surgical procedures in neonates in the hospital. The majority of the patients (94.8%) were delivered at home or in rural health centers. The median weight was 2.7 kg (range 2.0–3.7 kg). In 89 cases (58%) the indications for surgery were intestinal obstruction, anorectal malformations in 60(67%) and in 33(21%) complicated exomphalos or gastroschisis. Nine patients (6%) required surgery for ruptured neural-tube defects. A colostomy was the commonest procedure (51, 33%), 27(53%) of which were performed using a local anesthetic without adverse effects. Thirty-three abdominal-wall defects were closed by various methods (fascial closure 23, skin closure 6, improvised silo 4). Overall, 37 (24%) procedures were performed using local anesthesia. Fifty-nine patients (38%) developed postoperative complications (infections 33, respiratory insufficiency 16, colostomy complications 8, anastomotic leak 2). The mortality was 30.5%, 66% due to overwhelming infection, 28% to respiratory insufficiency, and 4.3% to multiple anomalies. Other factors considered to have contributed to morbidity and mortality were late referral and presentation and a lack of NICUs. Thus, emergency neonatal surgery is attended by high morbidity and mortality in our environment at the present time. Early referral and presentation and provision of NICUs should improve the outcome. Accepted: 3 August 2000     

General Anesthesia for Children With Severe Heart Failure

Severe heart failure in children is uncommon. The anesthetic management of children with this condition is challenging. The authors aimed to identify the frequency with which anesthesia for short noncardiac surgical procedures or investigations was complicated by life-threatening hemodynamic instability and to describe the anesthetic techniques used. This study retrospectively reviewed the anesthetic charts and notes of children admitted acutely with a diagnosis of severe heart failure (fractional shortening of 15% or less) who received general anesthesia for noncardiac surgical or diagnostic interventions during the 3-year period from September 2005 to September 2008. In this study, 21 children received a total of 28 general anesthetics. Two patients (10%) experienced a cardiac arrest, and both required unplanned admission to the authors’ pediatric intensive care unit (PICU) postoperatively. A variety of anesthetic techniques was used. In 27 (96%) of the 28 cases, perioperative inotropic support was required. General anesthesia for children with severe heart failure is associated with a significant complication rate and should be administered by anesthetists familiar with managing all aspects of circulatory support for children in an appropriate setting.     

Regional block via continuous caudal infusion as sole anesthetic for inguinal hernia repair in conscious neonates

Purpose

The use of general anesthesia in young children has come under increasing scrutiny due to its potential long-term neurotoxic effects. Meanwhile, regional anesthesia for surgical procedures in neonates has many advantages, including preservation of respiratory status and faster return to feeding. We describe the successful use of 3% 2-chloroprocaine administered via continuous caudal infusion as the sole anesthetic agent during elective surgical procedures in infants.

Methods

A retrospective chart review of all patients who underwent elective surgical procedures under continuous caudal regional anesthetic at a single institution was performed. Thirty patients (27 males, three females) were identified: 28 patients underwent inguinal hernia repairs. Caudal anesthesia was established via continuous infusion of 3% 2-chloroprocaine through an indwelling catheter.

Results

Successful analgesia by regional block alone was achieved in all patients for the duration of each surgical procedure without need for rescue anesthesia. Mean operative time was 49 min. Patients were able to return to feeding immediately after surgery and were ready for discharge home within that day.

Conclusion

Continuous caudal infusion of chloroprocaine is a safe and effective way to maintain adequate analgesia for elective surgeries in infants. This successful regional approach obviates the use of general anesthetic which reduces post-operative recovery time and avoids concerns for neurotoxicity.

     

Regional anesthesia in the preterm neonate.

The physiologic immaturity of respiratory musculature and central respiratory control centers leads to an increased risk of apnea and respiratory complications following general anesthesia in the neonate. Regional anesthetic techniques, such as spinal and caudal epidural anesthesia, may obviate the need for general anesthesia and lessen the risks of perioperative morbidity. Although these techniques have been previously described in infants, most reports focus on regional anesthesia in the former preterm infant outside the actual neonatal period. There is relatively little or no information concerning regional anesthesia in neonates during the first week of life. We present four neonates (weight, 1.07 to 2.8 kg; gestational age, 27 to 35 weeks) who required anesthetic care during the first week of life for various surgical procedures, including vesicostomy placement, gastroschisis closure, and debridement of a lower-extremity wound. Either caudal epidural or spinal anesthesia was successfully used in the four neonates. Regional anesthesia was used as the sole technique without supplementation with intravenous or inhalational agents in three of the four neonates. The advantages, risks, and applications of regional anesthesia in the neonate are discussed.     

Postoperative analgesia. Use of intrathecal morphine in children

The identification of opiate receptors in the spinal cord gave rise to the suggestion that the use of intrathecal and epidural narcotics may provide effective and safe postoperative analgesia. The authors retrospectively reviewed the records of ten children who received intrathecal morphine as part of their anesthetic care over the last 2 years. Preservative-free morphine (Duramorph) in a dose of 0.02 mg/kg was administered to all patients in the lumbar intrathecal space before the start of the surgical procedure. Adequate postoperative analgesia was achieved in the ten children. No patient required supplemental analgesic agents for the initial 15-hour postoperative period. Surgical procedures included exploratory laparotomy, laryngotracheoplasty, and craniofacial reconstruction. As with narcotics administered by any route, intrathecal morphine can cause respiratory depression, and such depression may be delayed for up to 24 hours after the dose. Therefore, the postoperative respiratory status of these children should be monitored for 24 hours after the dose, preferably in an intensive care unit. With this caveat, the use of intrathecal morphine provides safe and effective postoperative analgesia in children undergoing major surgery.     

Anaesthesia for urgent and emergency surgery

The general principles that guide a pediatric anesthesiologist in the care of a newborn needing urgent and emergent neonatal surgery are reviewed. These include careful evaluation and assessment of the newborn including a detailed prenatal history. A brief review of neonatal physiology including the development of the autonomic nervous system and the development of nociceptive pathways is discussed and how important it is to suppress the stress response to surgical intervention in order to improve surgical outcomes. Most of the current general anesthetics have been associated with anesthetic neurotoxicity in juvenile mammals and several epidemiologic studies in human infants and toddlers have linked surgery occurring in the first 3 years of life with neurocognitive delays in school age children. These concerns are discussed in this paper. Practical considerations about neonatal intubation, line placement and intraoperative fluid management are also reviewed. And the anesthetic management of specific neonatal conditions such as congenital diaphragmatic hernias, transesophageal fistulas, gastroschisis and omphaloceles, necrotizing enterocolitis and meningomyeloceles is examined.     

How do I do it: Continuous local anesthetic infusion for children with spinal dysraphism undergoing major reconstruction of the lower urinary tract

Postoperative pain control is a fundamental aspect of contemporary pediatric surgery. While many options for analgesia are available to the general patient population, choices are limited for individuals with spinal dysraphism who undergo major urologic procedures. Continuous infusion of local anesthetics has been shown to improve postoperative pain scores and decreases the need for systemic analgesia. We present our technique for continuous local anesthetic infusion utilizing readily available equipment with limited additional cost.     

Cost-effectiveness of neonatal surgery: first greeted with scepticism,now increasingly accepted

Mortality rates in neonatal surgery have dropped markedly, illustrating the enormous progress made. Yet, new questions have arisen. To mention one, health care budgets have tightened. It follows that the effects of medical interventions should be weighted against their costs. As evidence was particularly sparse, we set out to analyse cost-effectiveness of neonatal surgery. The purpose of this article is to summarise our findings and to review recent studies. Moreover, this article explains the relevance of cost-effectiveness analysis and explores how cost-effectiveness interacts with other determinants of health care priority setting. Our research revealed that treatments for two common diagnostic categories in neonatal surgery (congenital anorectal malformations and congenital diaphragmatic hernia) produce good cost-effectiveness. Other groups also published cost-effectiveness studies in the field of neonatal surgery, although their number is still small. Contemporaneously, the economic aspects of health care have captured the interest of policy makers. Importantly, this is not to say that there are no other factors playing a role in priority setting, foremost among which are ethical questions and arguments of equity. This article concludes that, according to present evidence, neonatal surgery yields good value for money and contributes to equity in health.     

Exposure to invasive procedures in neonatal intensive care unit admissions.

The nature and numbers of invasive procedures were studied in 54 consecutive infants admitted to a neonatal intensive care unit. Over 3000 procedures were recorded, 74% in infants below 31 weeks of gestation. One infant (23 weeks'' gestation, birth weight 560 g) underwent 488 procedures. Heel prick blood sampling was the most common procedure (56%), followed by endotracheal suction (26%) and intravenous cannula insertion (8%). Invasive procedures which would cause pain or distress to a child are frequently performed on infants admitted to the neonatal intensive care unit. A reduction in the number of procedures, modifying them, or providing adequate analgesia could relieve some of this pain and distress.     

Pain relief for neonates in Australian hospitals: a need to improve evidence-based practice

OBJECTIVE: To ascertain the extent to which neonatal analgesia was used in Australia for minor invasive procedures as an indicator of evidence-based practice in neonatology. METHODS: A cross-sectional telephone survey of hospitals in all Australian states and territories with more than 200 deliveries per year was carried out. Questions were asked regarding awareness of the benefits and the use of analgesia for minor invasive procedures in term and near term neonates. Analysis was undertaken according to state and territory, annual birth numbers and the level of neonatal nursery care available. RESULTS: Data were available from 212 of 214 eligible hospitals. Of the total respondents, 51% and 70% respectively were aware of the benefits of sucrose and breast-feeding for neonatal analgesia. Eleven per cent of units administered sucrose before venepuncture and 25% of units used breast-feeding. Ten per cent of units used sucrose before heel prick with 49% utilizing breast-feeding. Expressed breast milk was used in 10% of units. Analgesia was given less frequently before intravenous cannulation compared to venepuncture and heel prick. Awareness and implementation of neonatal analgesia varied widely in the states and territories. There was a trend for hospitals providing a higher level of neonatal care to have a greater awareness of sucrose as an analgesic (P < 0.0001) and the use of sucrose for venepuncture (P = 0.029), heel prick (P = 0.025) and intravenous catheter insertion (P = 0.013). Similar trends were found on analysis according to birth number of the maternity units. Smaller units had a greater usage of breast-feeding as an analgesic for heel prick (P = 0.017). CONCLUSION: Despite good evidence for the administration of sucrose and breast milk in providing effective analgesia for newborn infants, it is not widely used in Australia. It is imperative that the gap between research findings and clinical practice with regard to neonatal analgesia be addressed.     

Current status of nitrous oxide use in pediatric patients

Nitrous oxide is one of the most commonly used inhalational anesthetic agents used in practice. It is a cost-effective, pleasant, safe, and versatile anesthetic agent with many desirable properties like good quality analgesia, decreased awareness, accelerated induction and recovery from anesthesia, and reduced utilization of other expensive inhalational agents with potential cost savings. The use of nitrous oxide has been questioned by a lot of studies and case reports perceiving its adverse systemic, hematological, immune, and neurologic adverse effects. However, the literature in the recent past has tried to resolve the controversies related to its use. The concerns over an increase in cardiovascular complications and mortality following nitrous oxide use have been negated by recent data. However, its use in certain vulnerable populations like children with cobalamin and folate deficiency or defects in their metabolic pathways remains a cause of concern for its toxic effects. In this narrative review, we aim to discuss the pharmacological properties of nitrous oxide, the potential advantages and drawbacks of the use of nitrous oxide in children, address the neurodevelopmental and other systemic effects, and throw light on the evidence regarding the safety of nitrous oxide use and its current role in pediatric procedural sedation and anesthesia practice. The literature related to its use in the pediatric population for painful procedures and surgeries has been summarized.     

Preanesthesia Considerations for the Nurse Practitioner

With increases in pediatric ambulatory surgery, primary health care providers such as nurse practitioners are being called upon to provide input about patients preoperatively or prior to other procedures requiring anesthesia. Because the anesthesia team may not meet the patient and family until the day of surgery; a thorough evaluation done by the primary care provider can supply the anesthesia team with the information required for optimal care. Such information includes a detailed history, including the patient's birth history, medical diagnoses, medications, allergies, recent laboratory test values, and the results of a recent physical examination. The purpose of this article is to provide primary care nurse practitioners with guidelines and information to consider when seeing their patient for a preprocedural visit.     

Pain relief for neonatal circumcision: a follow-up of residency training practices.

OBJECTIVE: To assess current training practices regarding the provision of effective analgesia for routine newborn circumcision. METHODS: All family practice (FP), obstetric and gynecologic (OB/GYN), and pediatric (PED) residency program directors in the United States received a mailed survey in 2003 (N = 940). RESULTS: Survey responses were received from 86% (811/940) of the programs (FP 88%, OB/GYN 82%, and PED 87%). Eighty-two percent (669/811) of all programs surveyed taught circumcision (FP 95%, OB/GYN 89%, and PED 49%). Of programs that taught circumcision, 97% (648/669) taught the administration of an anesthetic, either locally or topically. This proportion is significantly higher than that reported in 1998 (71%, 374/527; P < .001). However, of these same programs that taught circumcision, the anesthetic techniques were used frequently or always in only 84%. CONCLUSIONS: The percentage of training programs that teach effective analgesia for neonatal circumcision increased dramatically since the time of the previous data collection. Despite this improvement in teaching practices, some training programs may not consistently use effective analgesia for neonatal circumcision.     

Anesthesia for the newborn and ex-preterm infant.

This article addresses the pertinent aspects of neonatal physiology and pharmacology, general considerations in the anesthetic care of surgical neonates, management details of selected neonatal surgical lesions, and anesthetic considerations for the ex-preterm infant.     

Anesthesia for minimally invasive surgery

Minimally invasive surgery has become the surgical approach of choice for a number of operative procedures in adults, but remains a challenge in children, especially the youngest, due to the physiologic changes that occur during the procedure as well as limitations posed by equipment. These surgical techniques can present unique problems to the pediatric anesthesiologist in designing and implementing the anesthetic management plan. In this article, we will outline the physiologic impact, anesthetic management, and potential challenges and complications associated with minimally invasive surgery in children.     

Prospective pricing system for tertiary neonatal intensive care

This study assessed the potential impact of the federal neonatal diagnosis-related group (DRG) pricing system upon reimbursement to a state neonatal intensive care program. Data for length of intensive care unit stay, procedures, hospital charges, and audited cost reports from the state of Florida's ten regional neonatal intensive care centers were analyzed for 8,492 neonates whose charges totaled $118 million. Mean lengths of stay in these tertiary care centers were substantially longer than those reported for the federal DRGs, which were based on community hospital data. If federal DRG-based reimbursement to hospitals were implemented in Florida's perinatal intensive care program, compensation would range from 9% to 56% of actual hospital care charges. Federal DRG price rates were not predictive of hospital charges. Only 16% of the total variation in hospital charges was explained by differences among federal DRG rates (R2 = .16). Analysis of data by major determinants of resource consumption provided groups more homogeneous with respect to hospital charges and, hence, cost. Therefore, we developed a prospective pricing system that used modifications of federal newborn DRG system. These modifications resulted in a threefold increase in R2 (.52). Our proposed system permits prediction of cost and reimbursement for infants by three criteria: birth weight, need for mechanical ventilation and/or major surgery, and survival status and length of survival for those who die.     

Experience with an anesthesiologist interventional model for endoscopy in a pediatric hospital

BACKGROUND: Endoscopy is now a routine part of the work-up for many patients with gastrointestinal symptoms. Adults tolerate these procedures well, with either no sedation or a relatively light level. In contrast, children often require deep sedation or a general anesthetic to successfully perform these procedures. Therefore, pediatric endoscopies may require more time, personnel, and monitoring equipment to provide optimal conditions for the patient. The goals of this retrospective case series were to describe the anesthesia times and recovery duration of the different procedures, the types and amounts of medications commonly used, and the types and rates of complications experienced. METHODS: Patients (2,306) who underwent endoscopy in the Arkansas Children's Hospital endoscopy suite during a 4-year period were identified. A random sample of 720 charts was reviewed retrospectively. RESULTS: Patients ranged in age from younger than 1 year to 29 years. Patients most often had abdominal pain or multiple gastrointestinal symptoms. Sixty-eight percent of patients underwent esophagogastroduodenoscopies; 30% colonoscopy or a combination of the two. Ninety-five percent of patients received a propofol-based anesthetic. Midazolam, fentanyl, and alfentanil were frequently used as supplemental agents. Complications occurred infrequently and were airway related. All complications were easily treated, with no adverse sequelae. CONCLUSIONS: This model of anesthesiologist-provided sedation/anesthesia for gastrointestinal endoscopy procedures has been extremely successful in the Arkansas Children's Hospital and has served to heighten awareness of many issues surrounding sedation and anesthesia outside of the operating room, while ensuring a high level of care is provided.