Anesthesia for ex-premature infants and children
- Leila M Pang, MD
Leila M Pang, MD
- Ngai-Jubilee Professor of Anesthesiology
- College of Physicians and Surgeons of Columbia University
Prematurity is defined as a birth that occurs before 37 completed weeks (less than 259 days) of gestation. In ex-premature infants and children, there are high rates of long-term neurodevelopment impairment and chronic health problems, and an increase in conditions that require surgery and anesthesia compared with full-term infants.
Ex-premature infants and children include a heterogenous population, ranging from healthy children born at 36 weeks gestation to formerly extremely premature children with significant medical issues that affect anesthetic care.
Outside of the neonatal period, the most common surgical procedures performed in these children are inguinal hernia repair and ophthalmologic procedures (often due to underlying retinopathy of prematurity). After even minor surgical procedures, ex-premature infants are at higher risk for postoperative apnea than infants born at term.
This topic will discuss the anesthetic management of children who undergo surgical procedures outside of the neonatal period. Neonatal management, the acute and chronic complications of prematurity, and medical care of formerly preterm infants are discussed separately. (See "Care of the neonatal intensive care unit graduate" and "Management of bronchopulmonary dysplasia" and "Short-term complications of the preterm infant" and "Long-term complications of the preterm infant".)
In this topic, we follow the American Academy of Pediatrics policy statement on the recommended terminology regarding the length of gestation and age for neonates , as follows:
- Engle WA, American Academy of Pediatrics Committee on Fetus and Newborn. Age terminology during the perinatal period. Pediatrics 2004; 114:1362.
- Coté CJ, Zaslavsky A, Downes JJ, et al. Postoperative apnea in former preterm infants after inguinal herniorrhaphy. A combined analysis. Anesthesiology 1995; 82:809.
- Liu LM, Coté CJ, Goudsouzian NG, et al. Life-threatening apnea in infants recovering from anesthesia. Anesthesiology 1983; 59:506.
- Malviya S, Swartz J, Lerman J. Are all preterm infants younger than 60 weeks postconceptual age at risk for postanesthetic apnea? Anesthesiology 1993; 78:1076.
- Davidson AJ, Morton NS, Arnup SJ, et al. Apnea after Awake Regional and General Anesthesia in Infants: The General Anesthesia Compared to Spinal Anesthesia Study--Comparing Apnea and Neurodevelopmental Outcomes, a Randomized Controlled Trial. Anesthesiology 2015; 123:38.
- Welborn LG, Rice LJ, Hannallah RS, et al. Postoperative apnea in former preterm infants: prospective comparison of spinal and general anesthesia. Anesthesiology 1990; 72:838.
- Murphy JJ, Swanson T, Ansermino M, Milner R. The frequency of apneas in premature infants after inguinal hernia repair: do they need overnight monitoring in the intensive care unit? J Pediatr Surg 2008; 43:865.
- Welborn LG, Hannallah RS, Luban NL, et al. Anemia and postoperative apnea in former preterm infants. Anesthesiology 1991; 74:1003.
- Doyle LW, Anderson PJ. Long-term outcomes of bronchopulmonary dysplasia. Semin Fetal Neonatal Med 2009; 14:391.
- Landry JS, Chan T, Lands L, Menzies D. Long-term impact of bronchopulmonary dysplasia on pulmonary function. Can Respir J 2011; 18:265.
- Gross SJ, Iannuzzi DM, Kveselis DA, Anbar RD. Effect of preterm birth on pulmonary function at school age: a prospective controlled study. J Pediatr 1998; 133:188.
- Sanabria-Carretero P, Ochoa-Osorio C, Martín-Vega A, et al. [Anesthesia-related cardiac arrest in children. Data from a tertiary referral hospital registry]. Rev Esp Anestesiol Reanim 2013; 60:424.
- del Cerro MJ, Sabaté Rotés A, Cartón A, et al. Pulmonary hypertension in bronchopulmonary dysplasia: clinical findings, cardiovascular anomalies and outcomes. Pediatr Pulmonol 2014; 49:49.
- Pike KC, Lucas JS. Respiratory consequences of late preterm birth. Paediatr Respir Rev 2015; 16:182.
- Boucherat O, Morissette MC, Provencher S, et al. Bridging Lung Development with Chronic Obstructive Pulmonary Disease. Relevance of Developmental Pathways in Chronic Obstructive Pulmonary Disease Pathogenesis. Am J Respir Crit Care Med 2016; 193:362.
- O'Reilly M, Sozo F, Harding R. Impact of preterm birth and bronchopulmonary dysplasia on the developing lung: long-term consequences for respiratory health. Clin Exp Pharmacol Physiol 2013; 40:765.
- Silva DM, Nardiello C, Pozarska A, Morty RE. Recent advances in the mechanisms of lung alveolarization and the pathogenesis of bronchopulmonary dysplasia. Am J Physiol Lung Cell Mol Physiol 2015; 309:L1239.
- Islam JY, Keller RL, Aschner JL, et al. Understanding the Short- and Long-Term Respiratory Outcomes of Prematurity and Bronchopulmonary Dysplasia. Am J Respir Crit Care Med 2015; 192:134.
- Northway WH Jr, Moss RB, Carlisle KB, et al. Late pulmonary sequelae of bronchopulmonary dysplasia. N Engl J Med 1990; 323:1793.
- Doyle LW, Faber B, Callanan C, et al. Bronchopulmonary dysplasia in very low birth weight subjects and lung function in late adolescence. Pediatrics 2006; 118:108.
- Halvorsen T, Skadberg BT, Eide GE, et al. Characteristics of asthma and airway hyper-responsiveness after premature birth. Pediatr Allergy Immunol 2005; 16:487.
- Kim DH, Kim HS, Choi CW, et al. Risk factors for pulmonary artery hypertension in preterm infants with moderate or severe bronchopulmonary dysplasia. Neonatology 2012; 101:40.
- Farquhar M, Fitzgerald DA. Pulmonary hypertension in chronic neonatal lung disease. Paediatr Respir Rev 2010; 11:149.
- An HS, Bae EJ, Kim GB, et al. Pulmonary hypertension in preterm infants with bronchopulmonary dysplasia. Korean Circ J 2010; 40:131.
- Collaco JM, Romer LH, Stuart BD, et al. Frontiers in pulmonary hypertension in infants and children with bronchopulmonary dysplasia. Pediatr Pulmonol 2012; 47:1042.
- Check J, Gotteiner N, Liu X, et al. Fetal growth restriction and pulmonary hypertension in premature infants with bronchopulmonary dysplasia. J Perinatol 2013; 33:553.
- Bhat R, Salas AA, Foster C, et al. Prospective analysis of pulmonary hypertension in extremely low birth weight infants. Pediatrics 2012; 129:e682.
- Garg M, Kurzner SI, Bautista DB, Keens TG. Clinically unsuspected hypoxia during sleep and feeding in infants with bronchopulmonary dysplasia. Pediatrics 1988; 81:635.
- Anderson de Moreno LC, Matt BH. The effects of prematurity on incidence of aspiration following supraglottoplasty for laryngomalacia. Laryngoscope 2014; 124:777.
- Gray RF, Indurkhya A, McCormick MC. Prevalence, stability, and predictors of clinically significant behavior problems in low birth weight children at 3, 5, and 8 years of age. Pediatrics 2004; 114:736.
- Saigal S, Doyle LW. An overview of mortality and sequelae of preterm birth from infancy to adulthood. Lancet 2008; 371:261.
- Vohr BR, Wright LL, Dusick AM, et al. Neurodevelopmental and functional outcomes of extremely low birth weight infants in the National Institute of Child Health and Human Development Neonatal Research Network, 1993-1994. Pediatrics 2000; 105:1216.
- Tanner K, Sabrine N, Wren C. Cardiovascular malformations among preterm infants. Pediatrics 2005; 116:e833.
- Maitra S, Baidya DK, Pawar DK, et al. Epidural anesthesia and analgesia in the neonate: a review of current evidences. J Anesth 2014; 28:768.
- William JM, Stoddart PA, Williams SA, Wolf AR. Post-operative recovery after inguinal herniotomy in ex-premature infants: comparison between sevoflurane and spinal anaesthesia. Br J Anaesth 2001; 86:366.
- Jones LJ, Craven PD, Lakkundi A, et al. Regional (spinal, epidural, caudal) versus general anaesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy. Cochrane Database Syst Rev 2015; :CD003669.
- Steward DJ. Preterm infants are more prone to complications following minor surgery than are term infants. Anesthesiology 1982; 56:304.
- Kurth CD, Spitzer AR, Broennle AM, Downes JJ. Postoperative apnea in preterm infants. Anesthesiology 1987; 66:483.
- PREANESTHETIC EVALUATION
- Postoperative apnea
- - Incidence and severity of postoperative apnea
- - Risk factors for postoperative apnea
- - Timing of surgery
- Pulmonary disease
- Neurodevelopmental disabilities
- Gastrointestinal disorders
- Cardiac abnormalities
- ANESTHESIA MANAGEMENT
- Regional versus general anesthesia
- Maintenance of general anesthesia
- POSTOPERATIVE MANAGEMENT
- Pain management
- Postoperative monitoring
- SUMMARY AND RECOMMENDATIONS