The basic principies of anesthesia for the neonate
Keywords:
Infant newborn, Anesthesia general, Pharmacology, Anesthesia conduction, Pharmacokinetics
Abstract
Introduction: There are significant developmental differences in physiology and pharmacology in neonates that make the conduct of a safe anesthetic much more challenging in a neonate.
Objectives: Complete a focused review of the current knowledge of the physiological and pharmacologic differences seen in newborns that impact the safe administration of anesthesia.
Methods: A selective review of literature in developmental changes in physiology and pharmacology was completed.
Results: This knowledge acquired in the review was used to establish common principles for the safe administration of anesthesia to newborn patients.
Conclusion: In spite of the persistence of large gaps in our knowledge in this physiology and pharmacology, common modern anesthetic management principles for neonatal surgery have significantly improved clinical outcomes.
References
1. Richards CC, Bachman L. Lung and chest wall compliance of apneic paralyzed infants. J Clin Invest. 1961;40:273-8.
2. Piedboeuf B. Regulation of alveolar growth. Pediatr Pulmonol. 2001; Suppl. 23:77-9.
3. Mansell A, Bryan C, Levison H. Airway closure in children. J Appl Physiol. 1972;33:711-4.
4. McCoy KS, Castile RG, Allen ED, Filbrum DA, Flucke RL, Bar-Yishay E. Functional residual capacity (FRC) measurements by plethysmography and helium dilution in normal infants. Pediatr Pulm. 1995;19:282-90.
5. Stark AR, Cohlan RA, Waggener TB, Frantz ID III, Kosch PC. Regulation of end-expiratory lung volume during sleep in premature infants. J Appl Physiol. 1987;62:1117-23.
6. Patel R, Lenczyk M, Hannallah RS, McGill WA. Age and onset of desaturation in apnoeic children. Can J Anaesth. 1994;41:771-4.
7. Polgar G, Weng TR. The functional development of the respiratory system from the period of gestation t adulthood. Am Rev Respir Dis. 1979;120:625-95.
8. Sandberg K, Sjoqvist BA, Hjalmarson O, Olsson T. Analysis of alveolar ventilation in the newborn. Arch Dis Child. 1984;59:542-7.
9. Thomas J. Reducing the risk in neonatal anesthesia. Paediatr Anaesth. 2014;24:106-13.
10. Sullivan M, Paliotta J, Saklad M. Endotracheal tube as a factor in measurement of respiratory mechanics. J Appl Physiol. 1976;41:590-2.
11. Rigatto H, Kalapesi Z, Leahy FN, Durand M, MacCallum M, Cates D. Ventilatory response to 100% and 15% O2 during wakefulness and sleep in preterm infants. Early Hum Dev. 1982;7:1-10.
12. Coté CJ, Zaslavsky A, Downes JJ, Kurth CD, Welborn LG, Warner LO, et al. Postoperative apnea in former preterm infants after inguinal herniorrhaphy: a combined analysis. Anesthesiology. 1995;82:809-22.
13. Kurth CD, Spitzer AR, Broennle AM, Downes JJ. Postoperative apnea in former preterm infants. Anesthesiology. 1987;66:483-8.
14. Rudolph AM, Heymann MA. Circulatory changes during growth in the fetal lamb. Circ Res. 1970;26:289-99.
15. Jain A, McNamara PJ. Persistent pulmonary hypertension of the newborn: advances in the diagnosis and treatment. Semin Fetal Neonat Med. 2015;20:262-71.
16. Clark RH, Kueser TJ, Walker MW, Southgate WM, Huckaby JL, Perez JA, et al. Low-dose nitric oxide therapy for persistent pulmonary hypertension of the newborn. N Engl J Med. 2000;342:469-74.
17. Kattan J, González A, Becker P, Faunes M, Estay A, Toso P,et al. Survival of newborn infants with severe respiratory failure before and after establishing an extracorporeal membrane oxygenation program. Pediatr Crit Care Med. 2013;14:876-83.
18. Nassar R, Reedy MC, Anderson PA. Developmenta changes in the ultrastructure and sarcomere shortening of the isolated rabbit ventricular myocyte. Circ Res. 1987;61:465-83.
19. Jarmakani JM, Nakanishi T, George BL, Bers D. Effect of extracellular calcium on myocardial mechanical function in the neonatal rabbit. Dev Pharmacol Ther. 1982;5:1-13.
20. Kaufman TM, Horton JW, White DJ, Mahony L. Age-related changes in myocardial relaxation and sarcoplasmatic reticulum. Am J Physiol. 1990;259:H309-16.
21. Anand KJS, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med. 1987;317:1321-9.
22. Greisen G. Autoregulation of cerebral blood flow in newborn babies. Early Hum Dev. 2005;81:423-8.
23. Cayabyab R, McLean CW, Seri I. Definition of hypotension and assessment of hemodynamics in the preterm neonate. J Perinatol. 2009;29:S58-62.
24. Bada HS, Korones SB, Perry EH, Arheart KL, Ray JD, Pourcyrous M, et al. Mean arterial blood pressure changes in premature infants and those at risk for intraventricular hemorrhage. J Pediatr. 1990;117:607-14.
25. Bossi E, Koerner F. Retinopathy of prematurity. Intensive Care Med. 1995;21:241-6.
26. Ohlson KB, Mohell N, Cannon B, Lindahl SG, Nedergaard J. Thermogenesis in brown adipocytes is inhibited by volatile anesthetic agents: a factor contributing to hypothermia in infants? Anesthesiology. 1994;81:176-83.
27. Plattner O, Semsroth M, Dessler DI, Papousek A, Klasen C, Wagner O. Lack of nonshivering thermogenesis in infants anesthetized with fentanyl and propofol. Anesthesiology. 1997;86:772-7.
28. Soll RF. Heat loss prevention in neonates. J Perinatol. 2008;28 Suppl. 1:S57-9. 2017;45(1):54-61.
29. Friis-Hansen B. Body water compartments in children: changes during growth and related changes in composition. Pediatrics. 1961;28:169.
30. Leelanukrom R, Cunliffe M. Intraoperative fluid and glucose management in children. Paediatr Anaesth. 2000;10:353-9.
31. Siker D. Pediatric fluids, electrolytes, and nutrition. In: Polin RP, Fox WW, editors. Fetal and neonatal physiology. Philadelphia: WB Sanders Company; 1992. p. 83-117.
32. Rhodin MM, Anderson BJ, Peters AM, Coulthard MG, Wilkins B, Cole M, et al. Human renal function maturation: a quantitative description using weight and postmenstrual age. Pediatr Nephrol. 2009;24:67-76.
33. Srinivasan G, Jain R, Pildes RS, Kannan CR. Glucose homeostasis during anesthesia and surgery in infants. J Pediatr Surg. 1986;21:718-21.
34. Anderson BJ. Pharmacology in the very young: anaesthetic implications. Eur J Anaesthesiol. 2012;29:261-70.
35. Kearns GL, Abdel-Rahman SM, Alander SW, Blowey DL, Leeder JS, Kauffman RE. Developmental pharmacology-drug disposition, action, and therapy in infants and children. N Engl J Med. 2003;349:1157-67.
36. Lerman J, Strong HA, LeDez KM, Swartz J, Rieder MJ, Burrows FA. Effects of age on the serum concentration of alpha 1-acid glycoprotein and the binding of lidocaine in pediatric patients. Clin Pharmacol Ther. 1989;46:219-25.
37. Luz G, Wieser C, Innerhofer P, Frischhut B, Ulmer H, Benzer A. Free and total bupivacaine plasma concentrations after continuous epidural anaesthesia in infants and children. Paediatr Anaesth. 1998;8:473-8.
38. Anderson BJ. My child is unique; the pharmacokinetics are universal. Pediatr Anesth. 2012;22:530-8.
39. Kuhls E, Gauntlett IS, Lau M, Brown R, Rudolph CD, Teitel DF, et al. Effect of increased intra-abdominal pressure on hepatic extraction and clearance of fentanyl in neonatal lambs. J Pharmacol Exp Ther. 1995;274:115-9.
40. Lerman J. Pharmacology of inhalational anaesthetics in infants and children. Pediatr Anesth. 1992;2:191-203.
41. LeDez KM, Lerman J. The minimum alveolar concentration (MAC) of isoflurane in preterm neonates. Anesthesiology. 1987;67:301-7.
42. Lerman J, Sikich N, Kleinman S, Yentis S. The pharmacology of sevoflurane in infante and children. Anesthesiology. 1994;80:814-24.
43. Suresh S, Anand KJ. Opioid tolerance in neonates: a state-of-the-art review. Paediatr Anaesth. 2001;11:511-21.
44. Anand KJ, Sippell WG, Aynsley-Green A. Randomised trial of fentanyl anaesthesia in preterm babies undergoing surgery: effects on the stress response. Lancet. 1987;1:62-6.
45. Welzing L, Kribs AQ, Eifinger F, Huenseler C, Oberthuer A, Roth B. Propofol as an induction agent for endotracheal intubation can cause significant arterial hypotension in preterm neonates. Paediatr Anaesth. 2010;20:605-11.
46. Fong JJ, Sylvia L, Ruthazer R, Schumake G, Kcomt M, Devlin JW. Predictors of mortality in patients with suspected propofol infusion syndrome. Crit Care Med. 2008;36:2281-7.
47. Keenan RL, Boyan CP. Cardiac arrest due to anesthesia. A study of incidence and causes. JAMA. 1985;253:2373-7.
48. Morray JP, Geiduschek JM, Caplan RA, Posner KL, Gild WM, Cheney FW. A comparison of pediatric and adult closed malpractice claims. Anesthesiology. 1993;78:461-7.
49. Van der Griend BF, Lister NA, McKenzie IM, Martin N, Ragg PG, Sheppard SJ, et al. Postoperative mortality in children after 101,885 anesthetics at a tertiary pediatric hospital. Anesth Analg. 2011;112:1440-7.
50. Gonzalez LP, Pignaton W, Kusano PS, Modolo NS, Braz JR, Braz LG. Anesthesia-related mortality in pediatric patients: a systematic review. Clinics (Sao Paulo, Brazil). 2012;67:381-7.
51. Bhananker SM, Ramamoorthy C, Geiduschek JM, Posner KL, Domino KB, Haberkern CM, et al. Anesthesia-related cardiac arrest in children: update from the Pediatric Perioperative Cardiac Arrest Registry. Anesth Analg. 2007;105:344-50.
52. Flick RP, Sprung J, Harrison TE, Gleich SJ, Schroeder DR, Hanson AC, et al. Perioperative cardiac arrests in children between 1988 and 2005 at a tertiary referral center: a study of 92,881 patients. Anesthesiology. 2007;106:226-37.
53. McCann ME, Soriano SG. Perioperative central nervous system injury in neonates. Br J Anaesth. 2012;109:i60-7.
54. Bosenberg AT, Johr M, Wolf AR. Pro con debate: the use of regional vs systemic analgesia for neonatal surgery. Paediatr Anaesth. 2011;21:1247-58.
55. Polaner DM, Taenzer AH, Walker BJ, Bosenberg A, Krane EJ, Suresh S, et al. Pediatric Regional Anesthesia Network (PRAN): a multi-institutional study of the use and incidence of complications of pediatric regional anesthesia. Anesth Analg. 2012;115:1353-64.
56. Van der Walt JH. Oxygen - elixir of life or Trojan horse? Part 1: oxygen and neonatal resuscitation. Pediatr Anesth. 2006;16:1107-11.
57. Van der Walt JH. Oxygen - elixir of life or Trojan horse? Part 2: oxygen and neonatal anesthesia. Pediatr Anesth. 2006;16:1205-12.
58. Sola A. Oxygen in neonatal anesthesia: friend or foe? Curr Opin Anaesthesiol. 2008;21:332-9.
2. Piedboeuf B. Regulation of alveolar growth. Pediatr Pulmonol. 2001; Suppl. 23:77-9.
3. Mansell A, Bryan C, Levison H. Airway closure in children. J Appl Physiol. 1972;33:711-4.
4. McCoy KS, Castile RG, Allen ED, Filbrum DA, Flucke RL, Bar-Yishay E. Functional residual capacity (FRC) measurements by plethysmography and helium dilution in normal infants. Pediatr Pulm. 1995;19:282-90.
5. Stark AR, Cohlan RA, Waggener TB, Frantz ID III, Kosch PC. Regulation of end-expiratory lung volume during sleep in premature infants. J Appl Physiol. 1987;62:1117-23.
6. Patel R, Lenczyk M, Hannallah RS, McGill WA. Age and onset of desaturation in apnoeic children. Can J Anaesth. 1994;41:771-4.
7. Polgar G, Weng TR. The functional development of the respiratory system from the period of gestation t adulthood. Am Rev Respir Dis. 1979;120:625-95.
8. Sandberg K, Sjoqvist BA, Hjalmarson O, Olsson T. Analysis of alveolar ventilation in the newborn. Arch Dis Child. 1984;59:542-7.
9. Thomas J. Reducing the risk in neonatal anesthesia. Paediatr Anaesth. 2014;24:106-13.
10. Sullivan M, Paliotta J, Saklad M. Endotracheal tube as a factor in measurement of respiratory mechanics. J Appl Physiol. 1976;41:590-2.
11. Rigatto H, Kalapesi Z, Leahy FN, Durand M, MacCallum M, Cates D. Ventilatory response to 100% and 15% O2 during wakefulness and sleep in preterm infants. Early Hum Dev. 1982;7:1-10.
12. Coté CJ, Zaslavsky A, Downes JJ, Kurth CD, Welborn LG, Warner LO, et al. Postoperative apnea in former preterm infants after inguinal herniorrhaphy: a combined analysis. Anesthesiology. 1995;82:809-22.
13. Kurth CD, Spitzer AR, Broennle AM, Downes JJ. Postoperative apnea in former preterm infants. Anesthesiology. 1987;66:483-8.
14. Rudolph AM, Heymann MA. Circulatory changes during growth in the fetal lamb. Circ Res. 1970;26:289-99.
15. Jain A, McNamara PJ. Persistent pulmonary hypertension of the newborn: advances in the diagnosis and treatment. Semin Fetal Neonat Med. 2015;20:262-71.
16. Clark RH, Kueser TJ, Walker MW, Southgate WM, Huckaby JL, Perez JA, et al. Low-dose nitric oxide therapy for persistent pulmonary hypertension of the newborn. N Engl J Med. 2000;342:469-74.
17. Kattan J, González A, Becker P, Faunes M, Estay A, Toso P,et al. Survival of newborn infants with severe respiratory failure before and after establishing an extracorporeal membrane oxygenation program. Pediatr Crit Care Med. 2013;14:876-83.
18. Nassar R, Reedy MC, Anderson PA. Developmenta changes in the ultrastructure and sarcomere shortening of the isolated rabbit ventricular myocyte. Circ Res. 1987;61:465-83.
19. Jarmakani JM, Nakanishi T, George BL, Bers D. Effect of extracellular calcium on myocardial mechanical function in the neonatal rabbit. Dev Pharmacol Ther. 1982;5:1-13.
20. Kaufman TM, Horton JW, White DJ, Mahony L. Age-related changes in myocardial relaxation and sarcoplasmatic reticulum. Am J Physiol. 1990;259:H309-16.
21. Anand KJS, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med. 1987;317:1321-9.
22. Greisen G. Autoregulation of cerebral blood flow in newborn babies. Early Hum Dev. 2005;81:423-8.
23. Cayabyab R, McLean CW, Seri I. Definition of hypotension and assessment of hemodynamics in the preterm neonate. J Perinatol. 2009;29:S58-62.
24. Bada HS, Korones SB, Perry EH, Arheart KL, Ray JD, Pourcyrous M, et al. Mean arterial blood pressure changes in premature infants and those at risk for intraventricular hemorrhage. J Pediatr. 1990;117:607-14.
25. Bossi E, Koerner F. Retinopathy of prematurity. Intensive Care Med. 1995;21:241-6.
26. Ohlson KB, Mohell N, Cannon B, Lindahl SG, Nedergaard J. Thermogenesis in brown adipocytes is inhibited by volatile anesthetic agents: a factor contributing to hypothermia in infants? Anesthesiology. 1994;81:176-83.
27. Plattner O, Semsroth M, Dessler DI, Papousek A, Klasen C, Wagner O. Lack of nonshivering thermogenesis in infants anesthetized with fentanyl and propofol. Anesthesiology. 1997;86:772-7.
28. Soll RF. Heat loss prevention in neonates. J Perinatol. 2008;28 Suppl. 1:S57-9. 2017;45(1):54-61.
29. Friis-Hansen B. Body water compartments in children: changes during growth and related changes in composition. Pediatrics. 1961;28:169.
30. Leelanukrom R, Cunliffe M. Intraoperative fluid and glucose management in children. Paediatr Anaesth. 2000;10:353-9.
31. Siker D. Pediatric fluids, electrolytes, and nutrition. In: Polin RP, Fox WW, editors. Fetal and neonatal physiology. Philadelphia: WB Sanders Company; 1992. p. 83-117.
32. Rhodin MM, Anderson BJ, Peters AM, Coulthard MG, Wilkins B, Cole M, et al. Human renal function maturation: a quantitative description using weight and postmenstrual age. Pediatr Nephrol. 2009;24:67-76.
33. Srinivasan G, Jain R, Pildes RS, Kannan CR. Glucose homeostasis during anesthesia and surgery in infants. J Pediatr Surg. 1986;21:718-21.
34. Anderson BJ. Pharmacology in the very young: anaesthetic implications. Eur J Anaesthesiol. 2012;29:261-70.
35. Kearns GL, Abdel-Rahman SM, Alander SW, Blowey DL, Leeder JS, Kauffman RE. Developmental pharmacology-drug disposition, action, and therapy in infants and children. N Engl J Med. 2003;349:1157-67.
36. Lerman J, Strong HA, LeDez KM, Swartz J, Rieder MJ, Burrows FA. Effects of age on the serum concentration of alpha 1-acid glycoprotein and the binding of lidocaine in pediatric patients. Clin Pharmacol Ther. 1989;46:219-25.
37. Luz G, Wieser C, Innerhofer P, Frischhut B, Ulmer H, Benzer A. Free and total bupivacaine plasma concentrations after continuous epidural anaesthesia in infants and children. Paediatr Anaesth. 1998;8:473-8.
38. Anderson BJ. My child is unique; the pharmacokinetics are universal. Pediatr Anesth. 2012;22:530-8.
39. Kuhls E, Gauntlett IS, Lau M, Brown R, Rudolph CD, Teitel DF, et al. Effect of increased intra-abdominal pressure on hepatic extraction and clearance of fentanyl in neonatal lambs. J Pharmacol Exp Ther. 1995;274:115-9.
40. Lerman J. Pharmacology of inhalational anaesthetics in infants and children. Pediatr Anesth. 1992;2:191-203.
41. LeDez KM, Lerman J. The minimum alveolar concentration (MAC) of isoflurane in preterm neonates. Anesthesiology. 1987;67:301-7.
42. Lerman J, Sikich N, Kleinman S, Yentis S. The pharmacology of sevoflurane in infante and children. Anesthesiology. 1994;80:814-24.
43. Suresh S, Anand KJ. Opioid tolerance in neonates: a state-of-the-art review. Paediatr Anaesth. 2001;11:511-21.
44. Anand KJ, Sippell WG, Aynsley-Green A. Randomised trial of fentanyl anaesthesia in preterm babies undergoing surgery: effects on the stress response. Lancet. 1987;1:62-6.
45. Welzing L, Kribs AQ, Eifinger F, Huenseler C, Oberthuer A, Roth B. Propofol as an induction agent for endotracheal intubation can cause significant arterial hypotension in preterm neonates. Paediatr Anaesth. 2010;20:605-11.
46. Fong JJ, Sylvia L, Ruthazer R, Schumake G, Kcomt M, Devlin JW. Predictors of mortality in patients with suspected propofol infusion syndrome. Crit Care Med. 2008;36:2281-7.
47. Keenan RL, Boyan CP. Cardiac arrest due to anesthesia. A study of incidence and causes. JAMA. 1985;253:2373-7.
48. Morray JP, Geiduschek JM, Caplan RA, Posner KL, Gild WM, Cheney FW. A comparison of pediatric and adult closed malpractice claims. Anesthesiology. 1993;78:461-7.
49. Van der Griend BF, Lister NA, McKenzie IM, Martin N, Ragg PG, Sheppard SJ, et al. Postoperative mortality in children after 101,885 anesthetics at a tertiary pediatric hospital. Anesth Analg. 2011;112:1440-7.
50. Gonzalez LP, Pignaton W, Kusano PS, Modolo NS, Braz JR, Braz LG. Anesthesia-related mortality in pediatric patients: a systematic review. Clinics (Sao Paulo, Brazil). 2012;67:381-7.
51. Bhananker SM, Ramamoorthy C, Geiduschek JM, Posner KL, Domino KB, Haberkern CM, et al. Anesthesia-related cardiac arrest in children: update from the Pediatric Perioperative Cardiac Arrest Registry. Anesth Analg. 2007;105:344-50.
52. Flick RP, Sprung J, Harrison TE, Gleich SJ, Schroeder DR, Hanson AC, et al. Perioperative cardiac arrests in children between 1988 and 2005 at a tertiary referral center: a study of 92,881 patients. Anesthesiology. 2007;106:226-37.
53. McCann ME, Soriano SG. Perioperative central nervous system injury in neonates. Br J Anaesth. 2012;109:i60-7.
54. Bosenberg AT, Johr M, Wolf AR. Pro con debate: the use of regional vs systemic analgesia for neonatal surgery. Paediatr Anaesth. 2011;21:1247-58.
55. Polaner DM, Taenzer AH, Walker BJ, Bosenberg A, Krane EJ, Suresh S, et al. Pediatric Regional Anesthesia Network (PRAN): a multi-institutional study of the use and incidence of complications of pediatric regional anesthesia. Anesth Analg. 2012;115:1353-64.
56. Van der Walt JH. Oxygen - elixir of life or Trojan horse? Part 1: oxygen and neonatal resuscitation. Pediatr Anesth. 2006;16:1107-11.
57. Van der Walt JH. Oxygen - elixir of life or Trojan horse? Part 2: oxygen and neonatal anesthesia. Pediatr Anesth. 2006;16:1205-12.
58. Sola A. Oxygen in neonatal anesthesia: friend or foe? Curr Opin Anaesthesiol. 2008;21:332-9.
How to Cite
1.
Martin LD. The basic principies of anesthesia for the neonate. Colomb. J. Anesthesiol. [Internet]. 2017 Jan. 1 [cited 2024 Jul. 2];45(1):54-61. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/49
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2017-01-01
How to Cite
1.
Martin LD. The basic principies of anesthesia for the neonate. Colomb. J. Anesthesiol. [Internet]. 2017 Jan. 1 [cited 2024 Jul. 2];45(1):54-61. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/49
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Narrative review
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