36 Neonatal Emergencies
ADVANCES IN PERINATAL CARE have greatly reduced the morbidity and mortality of critically ill neonates. Anesthesiologists have contributed to the improvement in neonatal outcome by applying advanced principles of developmental biology and pharmacology to the care of critically ill neonates undergoing surgical procedures. The goal of this chapter is to describe developmental processes in neonates and how they affect the anesthetic management of neonatal emergencies.
The cardiopulmonary system of the neonate is driven by the need to deliver sufficient oxygen (O2) to maintain a high metabolic rate. The O2 consumption of an average neonate is 5 to 8 mL/kg/min, whereas that of an adult is 2 to 3 mL/kg/min (Table 36-1). It is this high rate of O2 consumption that primarily leads to the rapid decrease in blood O2 partial pressures in the neonate during periods of hypoventilation. Although ventilatory gas exchange volume is nearly 10-fold greater in adults than in neonates, the tidal volume relative to body weight for both is approximately equal (6 mL/kg). In neonates, increasing the respiratory rate facilitates the elimination of carbon dioxide (CO2) generated by their relatively high metabolic processes; alveolar ventilation is approximately 130 mL/kg/min in the perinatal period, compared with 60 mL/kg/min in adulthood. In neonates, the thoracic gas volume on a weight basis is similar to that in adults. These metabolic and volume changes are consistent with those predicted by allometric scaling (see Chapter 6).1
Preterm neonates may have abnormalities in lung surfactant activity. Surfactant production by type II alveolar pneumocytes occurs predominantly after 32 weeks of gestation. Infants born prematurely may develop respiratory distress syndrome (RDS) because of surfactant deficiency. However, infants of mothers with gestational diabetes may develop RDS even when born near term. RDS is characterized by grunting respirations, nasal flaring, and chest retractions, developing soon after birth. Radiographic examination demonstrates decreased lung volume resulting from widespread atelectasis. The resultant intrapulmonary shunting of blood through atelectatic lung units causes intrapulmonary shunt and systemic hypoxemia and reduces O2 delivery to the tissues. Judicious application of positive end-expiratory pressure (PEEP) and treatment with exogenous surfactant may reduce intrapulmonary shunting in RDS and decrease hypoxemia.2–6 In addition, the incidence and severity of RDS has been decreased by the now routine treatment of mothers who are in preterm labor with glucocorticoids.
Atelectasis in neonates also might be caused by anatomic forces that decrease lung volume. For example, the relatively large abdomen in a neonate displaces the diaphragm cephalad, placing the lungs’ closing capacity within the expiratory reserve volume. Moreover, increases in intraabdominal pressure from gastric distention associated with overzealous assisted ventilation with a facemask, replacement of bowel in the abdomen during repair of gastroschisis or omphalocele, or surgical retraction or manipulation of the abdominal contents also might shift the closing capacity to within the infant’s expiratory reserve volume. The resulting atelectasis and intrapulmonary shunting may require controlled ventilation with PEEP to recruit closed lung units and improve oxygenation, emptying of the stomach, or changes in surgical maneuvers.
In the neonate, apnea decreases pulmonary gas exchange and can lead to hypoxemia and bradycardia. Conceptually, apnea is differentiated in terms of its cause: (1) central apnea, resulting from immaturity or depression of the respiratory drive; (2) obstructive apnea, caused by an infant’s inability to maintain a patent airway; and (3) mixed apnea, a combination of both central and obstructive apnea.7
Apnea of central origin may be secondary to the poor organization and integration of input from proprioceptive receptors, which are located in the diaphragm and intercostal muscles, and from medullary and peripheral chemoreceptors. Preterm infants are at greater risk for central apnea because chemoreceptor signaling is incompletely developed. Exaggerated responses to chemoreceptor signaling during periods of mild hypercarbia and hypoxia can cause apnea in preterm infants, in whom it might stimulate the respiratory rate in those born at term. Susceptibility to central apnea is also exacerbated by metabolic disturbances such as hypothermia, hypoglycemia, and hypocalcemia, even in full-term neonates. For these reasons, central apnea may be associated with anemia and sepsis in babies. Blood transfusions may decrease the incidence of apnea in preterm infants with a hematocrit less than 27%8,9; however, data suggest a poor correlation between anemia and the incidence of apnea or bradycardia episodes.10 Central apnea resulting from immaturity of the respiratory drive center is often treated with xanthine derivatives, such as caffeine and theophylline (Table 36-2).11–14 Of particular importance to the anesthesiologist is that central apnea in neonates can be exacerbated by opioids. In some cases, apnea in neonates exposed to opioids may be alleviated by treatment with naloxone. Because of these reasons, all neonates require careful continuous monitoring of blood O2 saturations and heart rate in the postoperative period.
Apnea of an obstructive or mixed origin is responsible for the majority of apneic episodes in preterm infants.15–17 Obstructive apnea may be due to incomplete maturation and poor coordination of upper airway musculature. These forms of apnea often respond to changes in head position, insertion of an oral or nasal airway, or placing the infant in a prone position. Application of continuous positive airway pressure (CPAP) also may reduce obstructive apnea.18
Postoperative apnea is a common morbidity associated with anesthesia in neonates with a history of prematurity, apnea, or chronic lung disease.19 Nearly 20% of such infants have apnea exacerbated by anesthesia or surgery in the postoperative period. Apnea may result from prolonged action of anesthetic agents, a shift of CO2 response curve, immaturity of respiratory control, or fatigue of respiratory muscles.20 Early studies suggested that preterm infants who were younger than 46 weeks postconceptional age (PCA*) at the time of general anesthesia require continuous cardiopulmonary monitoring in the hospital afterward until they are apnea-free.15 Kurth and colleagues21 extended these recommendations to include monitoring for premature infants younger than 60 weeks PCA for at least 12 apnea-free hours after surgery. Although several studies suggest that regional anesthesia techniques reduce the incidence of postoperative apnea, others reported that apnea may still occur if the regional technique is supplemented with a sedative (e.g., ketamine).22–25 An analysis of several hundred former preterm infants studied prospectively from four centers over 6 years revealed the following26:
The incidence of postoperative apnea is inversely and independently related to PCA and gestational age; for example, the younger a preterm infant was born and the earlier after birth that the preterm infant undergoes surgery, the greater the incidence of apnea.
Apnea also might be associated with nasal obstruction in infants. Although most neonates prefer to breathe through their nose, a few are obligate nasal breathers and do not overcome nasal airway obstruction by changing to mouth breathing.32,33 In such neonates, nasal obstruction caused by choanal stenosis or atresia or a nasogastric tube may lead to apnea and cyanosis. Obstruction resulting from nasal edema may be relieved by instillation of saline or phenylephrine nose drops.
The work of breathing comprises compliance and resistive components. Although the work of breathing from compliance is 20- to 40-fold greater in the adult than in the neonate, the compliance work relative to tidal volume is nearly the same. However, the resistive work of breathing in the neonate is nearly 6 times greater than in the adult because of the relatively small airways in the neonate. Breathing through a tracheal tube especially increases resistive work in neonates because the airway resistance is inversely proportional to the fifth power of the radius of the tube and directly proportional to the length of the tracheal tube. The relatively narrow and long tracheal tubes through which neonates breathe can greatly increase their work of breathing (see Fig. 12-7). The work is also increased when a neonate breathes spontaneously through a circle system because of the inspiratory force required to open the one-way valves in the system. Although valveless ventilatory circuits, such as the Mapleson D systems, are recommended for spontaneously breathing neonates, studies suggest that a circle system may be used in these patients provided compensation is arranged for the problems associated with this circuit; that is, a neonate requires assisted ventilation and adequate inflation pressures to reduce the work of breathing and ensure adequate ventilation (see Chapter 51).34–36
Bronchopulmonary dysplasia (BPD) is an important chronic lung disease of neonates born prematurely.37 Although the use of antenatal steroids, exogenous surfactant treatment, and advanced ventilator therapies has decreased the incidence of BPD, it still afflicts nearly 10,000 premature infants in the United States every year and is a significant contributor to infant morbidity and mortality. BPD is identified in preterm infants with abnormal chest radiographs that require supplemental O2 at 36 weeks postmenstrual age (PMA). Other factors that increase the risk for developing BPD include chorioamnionitis and the persistence of a patent ductus arteriosus (PDA).38 Lung injury in the preterm infant decreases pulmonary maturation; infants who have died from BPD have impaired pulmonary alveolar and disrupted microvascular development.39 BPD is most often seen in preterm infants who are subjected to high levels of O2 and ventilation therapy and may be caused by lung injury–induced increase in cytokine activation.40 Decreased lung development in infants with BPD diminishes the surface area for pulmonary gas exchange that increases O2 requirements. Moreover, some infants with BPD have reduced lung compliance and increased airway resistance and hence have prolonged pulmonary time constants. Some infants with severe BPD have abnormal muscularization of the vessels in the periphery of their lungs, pulmonary hypertension, and right ventricular hypertrophy.
Pulmonary disease in infants with BPD is associated with abnormal pulmonary function tests and chest radiograph findings (small radiolucent cysts and hyperexpanded lungs), hypercarbia, chronic hypoxemia, and reactive airway disease.41–46 Nitric oxide (NO) is a free radical gas formed in endothelial cells and diffuses into subjacent smooth muscle cells, where it stimulates cyclic guanosine monophosphate (cGMP) production and mediates vasorelaxation (Fig. 36-1). Inhaled NO decreases abnormal cell proliferation in the injured developing lung47,48 and improves alveolar development in preterm animal models of BPD.49,50 Given the biologic plausibility and the results from animal studies, clinical trials have examined whether preterm neonates would benefit from NO. However, 14 randomized controlled trials of inhaled NO in preterm infants 34 weeks gestational age or younger failed to demonstrate benefit in survival or pulmonary or neurodevelopmental outcomes.51 It is likely that decreased NO signaling enzyme activity in the injured newborn lung reduces the effectiveness of inhaled NO in protecting pulmonary development. Emerging laboratory studies suggest that modulating cytokine signaling might improve the development of the injured lung and decrease BPD. For example, investigations in newborn animal models suggest that lung injury increases cytokine signaling. Moreover, in a mouse pup model of BPD, antibody-mediated inhibition of excess transforming growth factor-beta (TGF-β) activity was observed to improve NO signaling and pulmonary alveolar and microvascular development.52 Studies are under way to examine the mechanisms through which TGF-β modulates injured lung development.
FIGURE 36-1 Nitric oxide (NO) produced by nitric oxide synthase (NOS) in endothelial cells (EC) diffuses into subjacent smooth muscle cells (SMC), interacts with soluble guanylate cyclase (sGC ), and increases the concentration of cyclic guanosine monophosphate (cGMP) to cause vascular relaxation. The effect of NO is decreased by metabolism of cGMP by specific phosphodiesterases (PDE). l-arg, l-Arginine.
The treatment of BPD in neonates often requires ventilatory and medical therapies.53 Early and aggressive CPAP may eliminate the need for positive-pressure ventilation. Air trapping during assisted ventilation is associated with the long lung time constants in babies with BPD and may be reduced by using a prolonged expiratory time. Respiratory infection (e.g., Ureaplasma urealyticum) may contribute to the inflammatory response. Bronchodilators such as aminophylline, albuterol, or ipratropium may be beneficial in reducing airway resistance in some infants with BPD.
Infants with BPD are often treated with diuretics. As a result of chronic furosemide treatment, metabolic abnormalities may exist. Hypercalciuria may occur from the action of furosemide on the ascending loop of Henle, leading to secondary hyperparathyroidism and nephrocalcinosis in some infants. Hydrochlorothiazide and spironolactone produce less severe metabolic abnormalities. Finally, large doses of steroids, especially dexamethasone, have been shown to provide relief for some infants with severe BPD that is refractory to other medical and ventilator therapies.54,55 However, dexamethasone treatment may result in systemic hypertension, hyperglycemia, hypertrophic cardiomyopathy, and alteration of neurologic and pulmonary development in some children.56,57 Preoperative evaluation of infants with BPD requires a very careful history and physical examination, particularly focused on the pulmonary and cardiovascular systems.
Uptake of O2 in the pulmonary microvasculature of neonates is facilitated by the greater hemoglobin concentration in the neonate and the increased amount of fetal hemoglobin. Fetal hemoglobin has a reduced affinity for 2,3-diphosphoglycerate and hence a greater affinity for O2. Although this affinity facilitates fetal hemoglobin O2 uptake in the placenta, it can reduce O2 release from hemoglobin to the tissues. Red blood cells containing fetal hemoglobin have an average life span of 100 days, compared with 120 days for those containing adult hemoglobin. The higher hematocrit in neonates causes an increased bilirubin load for an immature hepatic clearance pathway. However, preterm infants frequently experience anemia of prematurity, a normocytic, normochromic hypoproliferative anemia with the hallmark of inadequate production of erythropoietin.58
The O2 delivery to systemic tissues in neonates is facilitated by a cardiac output greater than in adults on a per–kilogram body-weight basis. The relationships among myocardial preload, contractility, afterload, and heart rate determine cardiac output. Passive myocardial fiber tension is reflective of myocardial compliance, which is significantly reduced in the perinatal period.59 Active myocardial tension, reflecting contractility, is also significantly reduced in the neonate.59 At smaller end-diastolic volumes, mild increases in preload in the neonate are associated with increased cardiac output. At greater end-diastolic volumes, as a result of poor ventricular compliance in the neonatal heart, this positive effect is soon overcome and cardiac output becomes more dependent on heart rate (see Chapters 14 and 16).60–62 The heart rate of a term neonate is approximately 120 beats/min; it increases to 160 beats/min by 1 month of age.63 Parasympathetic control of heart rate in lambs, and probably in developing humans, matures earlier in gestation and to a greater extent than β-adrenergic control.64,65 For this reason, neonates tend not to respond to adrenergic signaling associated with hypovolemia or an inadequate depth of anesthesia with tachycardia. Additionally, the vagotonic response caused by succinylcholine or its metabolites (succinylmonocholine) and synthetic opioids may lead to bradycardia. These cardiac reflexes can be offset by the vagolytic effects of pancuronium or atropine.66,67
Preterm infants may have pulmonary hypertension. In utero, the lungs are not required for gas exchange; the placenta performs this function. Thus the fetal circulatory pattern consists of atria and ventricles working as units in parallel (see Fig. 16-1). As little as 10% of the fetal right ventricular output may circulate through the lungs.68 Most of the blood returned from the lower extremities and a portion of the umbilical venous blood supply passes into the pulmonary arteries and subsequently through the PDA into the systemic circulation (see Chapters 14 and 16). The superior vena caval blood supply circulates through the patent foramen ovale (PFO) into the left atria and subsequently into the systemic circulation. With expansion of the lungs during the first breath, pulmonary vascular resistance decreases and blood flow to the lungs increases, matching perfusion with new ventilation.68,69 Any factor that increases pulmonary vascular resistance, (e.g., hypoxia, hypercarbia, or acidosis) may cause the circulation to revert to a fetal circulatory pattern with shunting of deoxygenated blood from the right to the left side of the heart via the PFO or PDA. This right-to-left shunting of blood explains in part why some infants remain hypoxemic despite ventilation with 100% O2 after severe desaturation.
The ductus arteriosus may remain patent in neonates, especially in those born prematurely.70 Bounding peripheral pulses, a harsh systolic ejection murmur at the left sternal border, and widened pulse–pressure difference, suggest the presence of a PDA. The presence of a PDA and of right-to-left shunting of blood may contribute to ventilation-perfusion () mismatch as deoxygenated blood is shunted from the pulmonary arteries to the systemic circulation through the PDA and differential upper and lower extremity O2 saturations result. Later, as the pulmonary vascular resistance decreases, left-to-right shunting of blood from the systemic to pulmonary circulation across the PDA may cause flow-mediated endothelial cell injury and abnormal pulmonary artery remodeling and hypertension. Infants with a PDA often require increased ventilatory support.
A PDA in the neonate may be treated with indomethacin or ibuprofen. If the PDA persists despite medical treatment, surgical ligation may be required.71–73 Treatment with indomethacin is associated with renal and platelet dysfunction. Although experience suggests that infants who have received large volumes of intravascular fluid have a greater incidence of PDA,74 the mechanism behind this is unknown, and the relationship may not be causal. In fact, if the PDA is associated with ventricular dysfunction and poor organ perfusion, it is imperative to provide adequate intravascular volume and to improve cardiac output rather than expose the infant to hypotension mediated by left-to-right shunting across the PDA. Occasionally, systemic perfusion in infants with PDA may be improved with a dopamine infusion and judicious intravenous fluid administration.
In neonates, increased pulmonary vascular resistance causes shunting of desaturated blood through the PFO and PDA and thereby causes severe systemic hypoxemia. Although the cause of persistent pulmonary hypertension of the newborn (PPHN) is incompletely understood, it is associated with increased muscularization of pulmonary arterial vessels75 and sepsis and aspiration syndromes.76 PPHN is suspected in severely hypoxic neonates who do not have a significant increase in postductal O2 saturation when they breathe 100% O2. A difference in preductal and postductal O2 saturations supports the diagnosis because it reflects the extrapulmonary right-to-left shunting of deoxygenated blood via the PDA. PPHN is diagnosed when pulmonary hypertension and no other structural heart lesions are observed by cardiac ultrasound.
Treatment of PPHN is directed at decreasing pulmonary vascular resistance and the extrapulmonary shunting of deoxygenated blood. In cases of pneumonia and aspiration syndromes, in which airway disease can lead to atelectasis and intrapulmonary shunt, PEEP and exogenous surfactant are sometimes used to recruit alveoli. To treat the pulmonary vasoconstriction that is pathognomonic of PPHN, hyperoxia and alkalosis therapies have been used. Although inspired O2 is a potent vasodilator, maximum dilation of the pulmonary vasculature is achieved by relatively low levels of O2. For this reason, increasing the Fio2 often does not improve gas exchange in PPHN. Through a mechanism that is incompletely understood, alkalosis causes pulmonary vasodilation. In many infants with PPHN, alkalosis induced by hyperventilation or the infusion of base decreases pulmonary vascular resistance and increases systemic O2 partial pressures. In general, the vasodilation induced by alkalosis occurs when the arterial pH is 7.55 or greater. With the advent of inhaled NO, alkalosis has been largely replaced with avoiding acidemia, but not inducing marked alkalosis. Intravenous vasodilator drugs cause inconsistent vasodilation in infants with pulmonary hypertension.77 Unfortunately, because these agents dilate the systemic as well as the pulmonary vasculature, they often cause severe systemic hypotension.
Inhaled NO selectively decreases pulmonary vascular resistance and increases systemic O2 partial pressures in infants with PPHN.78–80 NO is a gas that is synthesized by NO synthase from l-arginine and O2 in endothelial cells and diffuses into subjacent smooth muscle cells, where it stimulates soluble guanylate cyclase to increase cGMP levels. It is probably through cGMP’s stimulation of cGMP-dependent protein kinase I and the phosphorylation of several cytoplasmic targets that regulate intracellular calcium levels and vasomotor protein function that NO causes vascular relaxation (see Fig. 36-1). Inhaling small concentrations of NO caused selective pulmonary vasodilation, decreased right-to-left shunting of blood, and increased systemic O2 partial pressures in neonate animals and infants with pulmonary hypertension.81–83 Acutely breathing up to 80 parts per million (ppm) by volume of NO rapidly and selectively decreases pulmonary vascular resistance and increases systemic O2 partial pressures by decreasing extrapulmonary shunting of deoxygenated blood. Although methemoglobin is produced during the metabolism of NO, no important increases in methemoglobin were observed in infants breathing low concentrations of NO. Large multicenter studies suggest that breathing 20 ppm NO decreases the requirement for extracorporeal membrane oxygenation (ECMO). Although ECMO can be lifesaving for severely hypoxemic neonates,84–86 it is expensive and invasive, sometimes causes important complications, and is not available at most hospitals. For these reasons, inhaled NO is used in most intensive care nurseries to treat the severe hypoxemia associated with PPHN.
Studies also suggest that chronic NO inhalation protects the neonatal lung from injury.47 In cell cultures, NO has been observed to decrease pulmonary smooth muscle cell proliferation and increase programmed cell death (apoptosis). Inhaled NO has been observed to decrease pulmonary artery neomuscularization in animals with lungs injured by breathing gases with low concentrations of inspired O2. Although inhaled NO may decrease lung artery remodeling by preventing hypoxic pulmonary vasoconstriction, studies suggest that it prevents abnormal pulmonary artery remodeling in injured lungs without hypertension.78 Although the protective mechanism of inhaled NO is unknown, it does decrease smooth muscle cell proliferation in vitro,87 possibly by altering the expression of transcriptional regulators and the progression of the cell cycle.88–90 It is likely that studies that identify the protective mechanisms of NO/cGMP signaling will guide the development of novel therapies to prevent pulmonary disease in the injured lung.
Appreciation has been increasing of the potential harmful effects of even brief periods of hyperoxia.91 Six randomized controlled clinical studies have shown no apparent advantage of initiating resuscitation of neonates with 100% supplemental O2 instead of 21% O2. In fact, some studies suggest slightly greater mortality rates with 100% O2. In light of these findings, the 2010 Neonatal Resuscitation Program has been updated to recommend initiating resuscitation of full-term neonates with 21% O2 and that pulse oximetry be used if supplemental O2 is needed.92
The neonatal body habitus favors heat loss. The large surface area of the head relative to that of the body of neonates increases heat dissipation. A head cover may significantly reduce temperature loss.93,94 Neonates do not shiver or sweat effectively to maintain body temperature and rely primarily on brown fat metabolism to maintain body heat. Brown fat cells begin to differentiate at 26 to 30 weeks of gestation and hence are not available in extremely preterm infants to provide fat for metabolism and heat generation.95 Warming the operating room to 85° F (30° C), using radiant warming units, forced-air heating pads, and adding humidity to the inspired gases in the ventilator circuits help maintain the neonate’s temperature in the neutral thermal range.96–98 The sources of heat loss in infants is 39% radiation, 37% convection, 21% evaporation, and 3% conduction. Warming intravenous and irrigation fluids before they are used may also be beneficial.
The placenta acts as an excretory organ for the fetus. A neonate’s kidneys are not fully developed at birth, and development is closely related to PCA.98,99 At full-term birth, the glomerular filtration rate (GFR) is only 30% of normal adult rates (see Chapter 6).100 The GFR reaches adult values at approximately 1 year of age (see Figs. 6-10 and 6-11). The kidneys’ tubular function, and hence sodium-retaining ability, does not develop until about 32 weeks of gestation.101,102 The immaturity of the kidney at birth also affects the metabolism of many drugs in the neonate The renal excretion of medications such as penicillin, gentamicin, and some neuromuscular blocking drugs (NMBDs), such as pancuronium, may be prolonged, resulting in increased duration of action or the development of excessive blood concentrations. This effect is particularly important when administering medications to an extremely preterm infant. Thus the use of NMBDs that do not require renal function are most advantageous (e.g., cisatracurium).
The total body water content in neonates is greater than it is in infants, children, or adults. In the preterm infant 75% to 85% of body weight is water; in general, the less the PCA of the neonate, the greater the percentage of water. In a term infant, 70% of body weight is water.103 By 6 to 12 months of age, 50% to 60% of body weight is water (see also Figs. 6-7 and 6-8). Differences between the total body water, renal maturity, and serum protein concentrations (see also Fig. 6-6) in a neonate affect the volume of distribution of many medications. Because of the increase in the volume of distribution of drugs confined to the extracellular fluid, the initial doses of some medications (e.g., NMBDs, aminoglycosides) may be greater on a weight basis in neonates than for adults to achieve the desired blood concentration. In contrast, because of immaturity of renal function, the interval between doses of these drugs may be increased (see also E-Fig. 6-4).
The basic principles of fluid maintenance in neonates are similar to those in older children and adults. The highly variable body fluid composition, degree of renal maturity,104 neuroendocrine control of intravascular fluid status, and insensible fluid loss with age105 make precise estimates of fluid requirements in neonates very difficult (see Chapter 8). Urine volume and concentration may be difficult to determine intraoperatively and may not always correlate with volume status. Moreover, blood pressure and heart rate may not correlate with intravascular volume status in preterm infants, and anesthetics may mask subtle cardiovascular changes that occur with changes in intravascular volume. Increased insensible fluid loss, which often occurs in the operating room environment, requires judicious titration of intravenous fluids. Congenital abnormalities (e.g., gastroschisis, omphalocele) may markedly increase insensible fluid loss through exposure of large mucosal surfaces. The use of humidified gas mixtures reduces insensible fluid loss through the respiratory tract. However, overzealous intraoperative administration of fluids can result in pulmonary complications and worsened third-spacing of fluids.
Infants who are dehydrated after a prolonged period of fasting or vomiting or because of increased insensible fluid losses may require special procedures for intravenous access. With severe hypovolemia, scalp and peripheral veins may be difficult to cannulate. Many of the superficial veins may be thrombosed from prior use. Fiberoptic light sources or ultrasound may help visualize deeper veins and peripheral arteries. Femoral and axillary veins may be accessed percutaneously or via a surgical approach for the delivery of fluids and medications.106–108 Knowledge of femoral artery and vein anatomy decreases the incidence of accidental injury of the femoral head joint and possible septic arthritis (see Fig. 48-5).109 The external or internal jugular veins can also provide alternative sites for venous access.
In neonates, fluids and many medications may be infused through the umbilical vessels. The tip of umbilical arterial lines should be placed either in a “low” position, at the level of the bifurcation of the femoral arteries (L3-4), or in a “high” position, in the descending aorta above the diaphragm (T6-9). The catheter tip of the umbilical artery catheter should not be left in the descending aorta in the area of the renal or mesenteric arteries (L1-2) because renal or mesenteric artery thrombosis might result (see Figs. 48-8 and 48-9). Aortic thrombosis occurs in approximately 1% of umbilical artery catheterizations, although thrombi can be detected with radiologic techniques in 20% to 95% of infants.110–112 Infants with renal artery thrombosis may present with hypertension, oliguria, hematuria, and elevated blood creatinine concentrations. The tip of an umbilical venous catheter should rest in the inferior vena cava above the level of the ductus venosus and hepatic veins so that solutions are not directly infused into the liver parenchyma. The delivery of hypertonic solutions into the liver might result in liver damage and portal cirrhosis. Aspiration of arterial oxygenated blood suggests that the venous catheter has entered the left atrium through the foramen ovale. Catheters in the left atrium should be pulled back to the level described earlier.
Some drugs may be delivered through the tracheal tube. Rapid uptake and minimal effects on gas exchange or the pulmonary parenchyma occur with epinephrine, atropine, and lidocaine (see Chapter 39). The doses of some drugs administered through the tracheal tube are increased in comparison with that delivered intravenously (e.g., epinephrine 0.05 to 0.1 mg/kg via the tracheal tube versus 0.01 to 0.03 mg/kg intravenously).92 It is important to understand that administration of solutions via the endotracheal tube can cause adverse effects. For example, complications associated with the tracheal administration of exogenous surfactant include occasional transient hypoxia and bradycardia and are likely due to the relatively large volume of fluid (2.5 to 6 mL/kg) associated with the proper dose of surfactant.
Intraosseous cannulation of the tibia with a special intraosseous infusion needle (e.g., Easy-IO, Vidacare, San Antonio, Tex.) or a styleted spinal needle provides a rapid route for emergency fluid and drug administration and can be lifesaving (see Fig. 48-6 and E-Fig. 48-1, A through E).
Although the placenta allows the delivery of glucose from the maternal circulation to the fetus, the development of significant glycogen stores does not occur until late in gestation. Various conditions may lead to hypoglycemia in a neonate. Preterm and small-for-gestational-age (SGA) infants have very high glucose requirements; they require glucose infusion rates of 8 to 10 mg/kg/min. In full-term infants, a glucose infusion rate of 5 to 8 mg/kg/min prevents hypoglycemia. Full-term infants who have been excessively fasted, SGA infants, and infants of diabetic mothers are all prone to develop hypoglycemia. Although hypoglycemia may result in respiratory distress, apnea, cyanosis, seizures, tremors, high-pitched cry, irritability, limpness, lethargy, eye-rolling, poor feeding, temperature instability, and sweating, the signs and symptoms in infants are often blunted and nonspecific.113,114 In infants younger than 24 hours old, a plasma glucose concentration of less than 40 mg/dL is a cause for concern and should be treated.115 After 24 hours of life, plasma glucose values less than 45 mg/dL should be considered abnormally low. Although hypertonic glucose administration has been used to treat hypoglycemia in neonates, studies reveal that administration of hypertonic sodium bicarbonate solutions increases the incidence of intraventricular hemorrhage in preterm infants.116 For this reason, it is prudent to avoid bolus administration of hypertonic glucose to treat hypoglycemia to prevent sudden changes in blood tonicity and hyperglycemia. A bolus of 2 to 4 mL/kg of D10W (0.2 to 0.4 g/kg of glucose) and an increase in the basal glucose infusion are prudent measures to treat hypoglycemia. It is extremely important to reassess the blood glucose concentration after these treatments to determine the effectiveness of the therapy.
Infants undergoing surgical procedures often require less glucose supplementation.117 This reduced need may be attributed to hormonal responses that decrease glucose uptake as a result of catecholamine release in excess of insulin activity, as well as a decrease in metabolic demand from the effects of the anesthetic agents.118–120 Nevertheless, it is important to administer glucose-containing solutions using a constant-infusion device to avoid large fluctuations in blood glucose values and monitor blood glucose values in critically ill neonates. All other fluids (e.g., to replace third-space losses, blood loss, and fluid deficits) should be glucose-free to avoid hyperglycemia.117 Infants treated with high levels of glucose via total parental nutrition (TPN) may develop severe hypoglycemia if the infusion rate is abruptly lowered; thus it is important to continue these infusions (possibly at a slightly reduced rate) during surgery and to check the serum glucose concentrations.
Calcium exists in the serum in three fractions: (1) protein bound; (2) chelated to bicarbonate, phosphate, and citrate; and (3) free or ionized calcium (iCa2+). The ionized fraction is the physiologically active component. The serum calcium concentration is mainly regulated by the action of parathyroid hormone (PTH) and vitamin D metabolites. PTH acts directly in the bone and kidneys and indirectly through calciferol in the gut.121
Hypocalcemia has been observed in nearly 40% of critically ill neonates.122 Causes of hypocalcemia include (1) PTH insufficiency and peripheral resistance to PTH, (2) inadequate calcium supplementation, and (3) altered calcium metabolism caused by transfusion with citrated blood products (see also Fig. 10-9), bicarbonate administration, or diuretics (furosemide). Hypocalcemia may be asymptomatic or accompanied by nonspecific symptoms (e.g., seizures and tremors). Thus the diagnosis rests on the determination of total and iCa2+ levels. In critically ill children, total calcium concentrations do not accurately reflect the iCa2+ concentrations; therefore the diagnosis of hypocalcemia in these infants should be determined by direct measurement of iCa2+ with an ion-specific electrode.123 Neonatal hypocalcemia may be defined as a serum iCa2+ less than 1 mmol/L in full-term infants and less than 0.75 mmol/L in preterm infants. Persistent hypocalcemia necessitates determination of magnesium, phosphorus, PTH, and vitamin D concentrations.
Treatment of hypocalcemia is not effective in the presence of hypomagnesemia. In this situation, administration of supplemental magnesium and calcium and treatment of the underlying cause of hypocalcemia are necessary.122 Symptomatic hypocalcemia is treated with 100 mg/kg calcium gluconate (10%) by slow intravenous infusion (5 minutes) in a patent intravenous line. Thereafter, maintenance calcium is administered at 100 to 200 mg/kg/day elemental calcium and the clinical response and serum iCa2+ levels are carefully monitored.
The fetal gut is not functionally developed until late in gestation. In full-term neonates, the maturation of esophageal function occurs soon after birth. However, in comparison with adults, gastric emptying in neonates is prolonged and lower esophageal sphincters are incompetent, making reflux of stomach contents common. Early feeding of hypertonic formulas in preterm infants increases intestinal energy demands and is associated with bowel ischemia and necrotizing enterocolitis.124 On the other hand, the use of hypocaloric or trophic feeds in preterm infants is associated with subsequent feeding intolerance, indirect hyperbilirubinemia, cholestatic jaundice, and metabolic bone disease.125,126
After birth, increased concentrations of unbound serum bilirubin introduce the risk of kernicterus, particularly in infants who are preterm, hypoxemic, and acidotic and have low serum protein concentrations.127 Highly protein-bound agents such as furosemide, sulfonamides, ceftriaxone, and benzyl alcohol (found as a preservative in many drugs such as diazepam) may displace bilirubin and increase the possibility of kernicterus.128 Hepatic metabolism is immature in neonates and particularly in preterm infants. Drug metabolism may be prolonged as a result of both immaturity of enzymatic processes and a relatively low hepatic perfusion (less drug delivered to the liver). Any factor that further compromises hepatic blood flow (e.g., increased intraabdominal pressure) may have profound adverse effects on drugs with perfusion-limited hepatic clearance.129 Therefore careful titration of these drugs (e.g., opioids, propofol) is required to optimize therapeutic effects and prevent toxicity. Just as consideration is given to immature renal function, the use of NMBDs that do not require hepatic metabolism can be advantageous, (e.g., cisatracurium). The use of remifentanil during the procedure followed by a low dose of longer-acting opioid or regional block at the end of the procedure might facilitate early extubation.
The central nervous system is incompletely developed at birth. However, early in gestation, the pain pathways are integrated with the somatic, neuroendocrine, and autonomic systems. The hormonal responses to pain and stress may be exaggerated in neonates,118,119 although the clinical significance of this has not been defined. The potential lack of autoregulation of cerebral blood flow and an infant’s fragile cerebral blood vessels may be important factors in the development of intraventricular hemorrhage.130,131 Although an association has been noted between the incidence of intraventricular hemorrhage and fluctuations in blood pressure,130,132 it is difficult to confirm any causal relationship. This association has been a concern during “awake” or nonanesthetized laryngoscopy and intubation of neonates; however, one study reported no significant change in blood pressure or heart rate in neonates even after awake intubation.133 In addition, another study questioned the lack of autoregulation of cerebral blood flow in preterm infants. Using near infrared spectroscopy, investigators found that preterm infants could maintain adequate cerebral perfusion at a mean arterial blood pressure in the range of 23 to 39 mm Hg.134
In neonates, the spinal cord extends to a lower segment of the spine than in older children and adults (see E-Fig. 41-3). The volume of cerebrospinal fluid and the spinal surface area are proportionally larger in neonates (see also E-Fig. 41-4), whereas the amount of myelination is less than in older children and adults.135,136 These factors may account in part for the increased amount of local anesthetics (milligram per kilogram) required for successful spinal anesthesia in infants.
Hyperoxia has been associated with retinopathy of prematurity (ROP).137–139 Although two case reports of ROP associated with anesthesia in preterm infants implicated hyperoxia as a primary etiologic factor, the cause of ROP appears to be multifactorial140–149; the association between arterial O2 tension and ROP is unclear (see also Chapter 32). ROP begins as retinal vascular narrowing and obliteration followed by increased vascularity (neovascularization), hemorrhage, and, in the most severe cases, retinal detachment and blindness (see also Fig. 32-1). In two clinical trials (the SUPPORT150 and BOOST II151 trials) infants born at less than 28 weeks gestation were randomized to saturation ranges of either 85% to 89% or 91% to 95%. In the SUPPORT trial, for every 11 infants treated in the lower saturation range, one case of severe ROP was prevented (results for the BOOST II trial are not yet available). However, in both the SUPPORT and BOOST II trials, the latter of which was terminated early, the mortality was greater in infants who were randomized to the 85% to 89% range than those in the 91% to 95% range. Although the optimal saturation range has not been defined in preterm infants, it seems prudent to target the O2 saturation in the range of 91% to 95% and avoid a saturation less than 89%.
Conditions that require emergency surgery in neonates are often accompanied by medical problems, and, as a consequence, management and monitoring considerations can be complex. Routine standard monitoring equipment includes an electrocardiograph, chest or esophageal stethoscope, blood pressure monitor, temperature probe, pulse oximeter and a CO2 analyzer. Rapid decreases in arterial O2 content in neonates after brief periods of ventilatory compromise, coupled with the possible risk of ROP as a result of hyperoxia, dictate the need for continuous O2 saturation monitoring. A pulse oximeter probe placed in a preductal position (right hand) can be compared with one placed in a postductal position (foot or left hand ) to determine the severity of extrapulmonary shunting of deoxygenated blood via the PDA. Pulse oximetry may prove to be particularly useful for infants in whom the risk of intraarterial monitoring cannot be justified.152 This device can diagnose hypoxemia but not hyperoxia; however, maintaining the O2 saturation at 91% to 95% (preductal) places most infants on the steep portion of the O2 hemoglobin dissociation curve and avoids severe hyperoxia.153
Expired CO2 can be measured using capnography. However, dilution of the exhaled gases with those of the dead space of the tracheal tube or by the fresh gas may underestimate the true alveolar CO2 partial pressure. If desired, a more accurate estimate of expired CO2 concentration may be obtained by using a special tracheal tube with a sample port located at its tip, by inserting a narrow catheter through the CO2 sampling port in the elbow and into the lumen of the tracheal tube or by using a needle introduced through the side wall of the tracheal tube 2 to 3 cm distal to the 15-mm tube connector (see Chapter 51).154,155 Using a circle system provides a reasonably accurate measurement of expired CO2 concentrations because the fresh gas flows are small and less mixing of exhaled and inhaled gases occurs. However, regardless of the circuit configuration, the value obtained by the capnograph may not accurately reflect Paco2 in the presence of congenital heart disease (e.g., cyanotic heart disease or a mixing shunt) or significant intrapulmonary shunting.156
In neonates, changes in blood pressure, heart rate, and the intensity of heart sounds are excellent indicators of cardiac function, intravascular volume status, and depth of anesthesia. Under most circumstances, a urinary catheter permits adequate determination of urine output and aids in the monitoring of fluid balance during prolonged operations. In cases in which major blood or fluid losses are expected, or the physiology is complicated by the presence of cardiac disease, a central venous catheter is warranted. Any neonate with significant underlying cardiovascular instability should have an arterial catheter placed for continuous monitoring of blood pressure and to provide the means to obtain arterial blood samples for determination of blood pH and gas levels and serum glucose and electrolyte concentrations. Many neonates arrive in the operating room from the intensive care unit (ICU) with an umbilical artery line in place. Because of the risk of renal artery thrombosis with these lines, it is important to verify the location of the tip of the umbilical artery catheter. Infrahepatic umbilical venous lines may not be reliable under operative conditions because they may become wedged in the liver. In this position, infusion of hypertonic solutions may lead to parenchymal necrosis and ultimately fibrosis.157,158
Nonrebreathing (open) circuits are simple and effective for delivering anesthetic agents to infants weighing less than 10 kg. The system must have provisions for a humidifier to warm and hydrate the cold, dry anesthetic gases. However, a trend exists away from the use of nonrebreathing circuits to save money and reduce air pollution.34–3659 With the increasing need for cost savings there appears to be no significant disadvantage to using circle systems, which allow the use of small fresh gas flows. This substitution should only be made if the provider has a clear understanding of the marked increase in compression volume/compliance volume losses (see also Fig. 51-7) compared with nonrebreathing circuits.159 The anesthesia machine should also provide compressed air in addition to O2 and NO. The use of air allows regulation of inspired O2 concentrations during cases in which NO treatment is contraindicated and a high Pao2 is not desired. Table 36-3 lists basic equipment for conducting emergency anesthesia on a neonate.