Neonatal emergencies present unique challenges in anesthesia, requiring specialized knowledge and skills to ensure safe and effective care for these vulnerable patients. This presentation delves into the intricacies of providing anesthesia to neonates in emergency situations, discussing physiological differences, equipment considerations, medication dosages, and monitoring techniques tailored to this population. Explore essential strategies and best practices for managing airway, ventilation, and hemodynamic stability in neonatal emergencies, aiming to optimize outcomes and mitigate risks. Whether you're a seasoned anesthesiologist or a healthcare professional seeking insight into neonatal anesthesia, this presentation offers valuable insights into navigating the complexities of neonatal emergencies with confidence and expertise.

1. ANAESTHETIC CHALLENGES
IN
NEONATAL
EMERGENCIES
Dr Sourav Dash
MKCG MRDICAL COLLEGE
BERHAMPUR, ODISHA

2. AIRWAY CHALLENGES
 Neonatal intubations are difficult (Large tongue, Large occiput,
floppy epiglottis, higher and anterior larynx)

3. AIRWAY :
Obligatory nose breather
Differences from adult airway:
Supraglottic part:
• Short neck.
• Large tongue
• Larynx is more anterior &
cephalad

5. • Long, thin u-shaped epiglottis - needs to be
lifted with straight blade
• Vocal cords angled slightly anterior - ETT stops
at glottic opening
UNDER NEURO-
MUSCULAR
BLOCKADE
•Cricoid cartilage
is the narrowest
portion of the
pediatric airway
Without NMB
•The vocal cords
are the narrowest
part

6. RESPIRATORY PHYSIOLOGY AND CHALLENGES
• O2 CONSUMPTION 5-8 ML/KG/MIN ( V5 ADULT 2-3ml/ kg /MIN)
• Increased RR in neonate - Enhanced CO2 elimination
• ALVEOLAR VENTILATION 130ml/ kg/MIN ( CAUSE OF HIGH RR) VS 60
ML/KG/MIN IN ADULTS
- Induction and emergence from inhalational anaesthesia is rapid
• Alveolar ventilation / FRC - 5:1 (1.5 : 1 in adults)
• TV 7 - 10ml/kg
• ODC IN NEONATE SHIFTED TO LEFT (BECAUSE FETAL Hb HAS HIGH 02 AFFINITY)

7. • Ribs are horizontal (vs vertical in adults)
• Rib cartilages more pliable
• Chest wall collapses with increased negative intrathoracic pressure
• Atelectasis risk is more because of low FRC and less no. of alveoli

8. Upto 20% OF
PREMATURE
INFANTS MAY NEED
ELECTIVE POST OP
VENTILATION
MORE
PRONE TO
APNOEA
1.IMMATURI
TY OF
RESPIRATORY
CENTERS
1.PROLONG
ED ACTION
OF
ANESTHETIC
S (NMB)
FATIGUE
OF
RESPIRATO
RY
MUSCLES
1.OBSTR
UCTIVE
APNEA
HYPOTHERMIA
HYPOGLYCAEMI
A HYPOXIA
SEPSIS
AND
HYPOCAL
CEMIA

9. CARDIOVASCULAR CONCERNS
• Cardiac output is rate dependent
INHALED ANESTHETICS
• Their negative inotropic and chronotropic effects are poorly tolerated
• Baroreceptor reflexes are blunted or obliterated by these agents
• Reflex tachycardia, which is vital in supporting blood pressure and cardiac output, may not
occur
ATROPINE
• Atropine requirements in newborns (0.03
0.05mg/kg intravenous [IV]) are almost three times greater than in adults
• Total doses of less than 0.1 to 0.15 mg may produce paradoxical
bradycardia, further contributing to hypotension

10. RENAL PHYSIOLOGY
↓GFR UPTO 2YRS
↓CONCENTRATING CAPACITY – prone to dehydration and hypothermia
↓Na+ REABSORPTION
↓HCO3- / H+ EXCHANGE
↓FREE H2O CLEARANCE
↓URINARY LOSS OF K, Cl
↓ ABILITY TO EXCRETE VOLUME LOADS - RISK OF FLUID OVERLOAD
Neonates are born with excess Na+
• No Na REQUIRED IN FIRST 72HRS
• Maintenance fluid should be only of hypotonic glucose solution (prevent hypoglycemia)
• Replacement of insensible third space loss and small blood vol. loss - give isotonic fluid
• If more blood loss - PRBC
• MAXIMUM ALLLOWABLE BLOOD LOSS (MABL) = EBV(STARTING HCT – TARGET
HCT)/STARTING HCT

11. TEMPERATURE
 Brown fat metabolism
 MAINTAIN BODY HEAT
 NON SHIVERING THERMOGENESIS
•- INCREASED BODY
SURFACE AREA
•- LOWER HEAT
RESERVES, LESS
INSULATING FAT
•- INABILITY TO SHIVER
•- DECREASED
KERATINISATION OF SKIN
• RADIANT WARMERS,
FLUID WARMERS
• WARMED SURGICAL
SOLUTIONS
• PLASTIC WRAP TO
PREVENT SKIN FROM
GETTING WET
• COVERING HEAD & OTHER
AREAS BY PADDING
VULNERABLE
TO
HYPOTHERMIA
PREVENTION
&
MANAGEMENT
 Brown fat
 Differentiate at 26 – 30wks POG
 Not present sufficiently in preterm
 So more risk of hypothermia

12. NERVOUS SYSTEM
• Increased chances of intra-ventricular hemorrhage
• Pain– neurological, physiological, hormonal and metabolic stress response
is present
NOCICEPTIVE SYSTEM AND STRESS RESPONSE
• Transduction of pain functionally matures by 24 wks POG
• Spinal cord transmission & supraspinal processing and integration mature at 30wks
• But NT which modulate pain do not appear in descending pathway till 1st month of life
• So results in
• Increased intensity of pain
• Increased duration
• Hyperalgesia of injured tissue decrease pain threshold by 30-35%
• Amounts to
• Permanent structural and behavioral changes in neonates’ nervous system and
somatic complaints later on

13. REGIONAL ANAESTHESIA:
 Distal end of spinal cord ends between L2 – L3.
 They have more spinal fluid per body weight, hence require
larger dose , duration of block is short.
 Most common approach for epidural anaesthesia is caudally.

14. Neonatal Pharmacology
• Hepatic function immature.
• Renal tubular function immature.
• Less protein (albumin) ↓PPB & ↑Vd
• Increased volume of distribution (Vd) – larger initial dosage of water soluble drugs
(eg- Sch, antibiotics)
• ↓Fat - slower redistribution in fat - ↑ duration of action eg: Thiopentone
• Fentanyl ; redistributes to muscle ; ↑ duration of action

15. Induction agents
Propofol Moderate-to-severe hypotension, no effect on PVR
Thiopentone Due to high Vd high doses required
Inhalational agents
Sevoflourane Has less effect on hemodynamics
Desflurane Emergence is faster and beneficial in neonates in whom extubation is planned.
Muscle relaxants
Succinylcholine Newborns require higher dose of (2 mg/kg)
Mivacurium, Rocuronium Predictable duration of action, provided the infant is normothermic and no significant
cardiovascular side effects
Opioids
Fentanyl Minimal cardiovascular depression, used in critically ill neonates
Local anaesthetics
Bupivacaine Caudal/epidural-associated with higher blood level in neonates
Chlorprocaine Can be used with greater safety in the newborns.

16.  History - significant events at birth (asphyxia,
meconium aspiration, Apgar score), review NICU care
and ventilatory support
 Examination
 Investigations – CBC, RFT, electrolytes, ECHO, Chest X
ray, blood gases
 Counseling parents and consent
Preoperative considerations

17. Monitoring
 ECG
 Pulse oximeter – pre ductal and post ductal
 Capnograph
 Noninvasive blood pressure
 Precordial stethoscope
 Temperature probe
 Urine output , invasive arterial pressure, central venous pressure in
major surgeries
 CVP catheters in right IJV – monitor CVP & secure iv line in
anticipated blood loss or fluid shift
 PICC line can give fluid but no CVP monitoring

18. • Immediate postoperative extubation
• Post anaesthetic apnoea is high in neonates <40 weeks
• Fluid, electrolytes, glucose monitoring
• Total parenteral nutrition
• Continued NICU care and ventilation
Postoperative considerations

19. SURGICAL EMERGENCIES
• Almost all surgical emergencies in neonates are urgencies & not
emergencies
• Can afford to wait for 24-48 hrs while baby is stabilised & allows for
better foetal to neonatal transition
• Maternal & Perinatal history which could provide important clues to
diagnosis.
• Rule out any associated anomalies especially congenital heart disease.

20. FIRST WEEK OF LIFE :
INTESTINAL
OBSTRUCTION
CONGENITAL
DIAPHRAGMATIC
HERNIA(CDH)
TRACHEO-OESOPHAGEAL
FISTULA(TOF)
OMPHALOCELE &
GASTROCHISIS
MENINGOMYELOCELE
SECOND WEEK OF
LIFE:
Hernia
Necrotising
enterocolitis(NEC)
THIRD TO SIXTH
WEEK OF LIFE :
Pyloric stenosis

21. TRACHEO-OESOPHAGEAL FISTULA(TOF)
Incidence: 1: 3000 live births.
• 50% associated with congenital anomalies.
Associated anomalies:
VATER –
 Vertebral anomalies or ventricular septal defect
 Anal atresia
 TOF
 Oesophageal atresia
 Radial aplasia & renal anomalies
VACTERL
• Also includes Cardiac and limb anomalies.

22. Type: 5 major varieties present
MOST COMMON TYPE - TYPE C ( upper end blind with lower end
communicating)
 Fistula commonly occurs in posterior muscular part of trachea,
just above carina.

23. Embryology:
Division of foregut occurs at 4th & 5th week of development.
Incomplete division leads to FISTULA.
Diagnosis:
• Antenatally: maternal polyhydramnios & absence of
stomach bubble on USG.
• Postnatally: presents with 3 C’s of oesophageal atresia
• choking
• Coughing
• cyanosis
• Passage of NG tube meets with obstruction

24. Clinical presentation:
DEHYDRATION: proximal oesophagus doesn’t
communicate with stomach.
Aspiration pneumonia: reflux of stomach
contents through distal oesophagus into
trachea.
Investigations:
 Chest Xray – coiled catheter in blind
proximal pouch

25. PRE OPERATIVE STABILISATION:
• NPO
• IV access
• Head up position
• Treat dehydration : hydrate
adequately, correct electrolyte
imbalance
• ASPIRATION PNEUMONIA : If reflux
is high , gastrostomy is planned to
protect pulmonary system
• Fistula repair is taken up if neonate
is in good health
ANAESTHETIC MANAGEMENT
INTRAOPERATIVE:
AVOID EXCESSIVE POSITIVE PRESSURE
VENTILATION
INDUCTION & TRACHEAL INTUBATION:
 UNSTABLE PT
• Awake intubation with local
anaesthesia and mild sedation
 STABLE PT
• Rapid sequence IV induction with
muscle paralysis or
• Inhalational induction with
spontaneous ventilation without
muscle relaxant

26. ASSESSMENT OF ETT POSITION :
• Goal: ETT just above the carina & just below the fistula (so that less
gastric insufflation through the fistula)
• Right main stem intubation & withdraw ETT until bilateral breath
sounds.
• Avoid positive pressure ventilation to decrease stomach distension via fistula
• If fistula is too close to carina- selective endobronchial intubation till fistula ligation
• ETT above fistula with spontaneous or gentle assisted ventilation
• If fistula large and PPV needed - do gastrostomy to avoid gastric rupture
• Stethoscope over axilla detects accidental rt. mainstem bronchial ETT
advancement

27. Patient position:
• Lateral decubitus position
• Posterolateral thoracotomy

28. MAINTAINENCE:
• O2 : N2O , Inhalational agent & spontaneous ventilation are used.
• Maintain PaO2 50 – 70 mmHg or SaO2 87 – 92% to avoid
retinopathy of prematurity.
•Spontaneous ventilation
with inhalational agents
before doing
the repair
•controlled ventilation &
muscle relaxant
after doing
the repair

29. POST OPERATIVE:
• Pharynx suctioned with a soft catheter & it must not reach
anastomotic site.
• Prolonged intensive respiratory Care.
• Postop analgesia: epidural catheter, IV narcotics.
•EXTUBATED
Child with a clear
chest who is awake &
moving vigorously
•continue controlled
ventilation
If pulmonary
complication present

30. Congenital diaphragmatic hernia
• Incidence
1:4000-5000, M:F-
2:1
• M/C - POSTEROLAT
- BOCHDALEK TYPE
(90%)
• THROUGH
FORAMEN OF
MORGAGNI – 10%

31. PATHOGENESIS
Herniation of
viscera During
branching of
bronchi and
PAs
Interference with
lung development
Decreased
bronchiolar
branching
Loss of lung mass:
HYPOPLASIA
Dysfunctional
surfactant
system
ATELECTASIS
AND
RESPIRATORY
DISTRESS

32. Associated anomalies
CVS Ductus arteriosus, septal defects, A-V valve defects, aortic
arch hypoplasia,
50%
CNS Neural tube defects, microcephaly 20%
GIT Malrotation & atresia 10%
Genito-
urinary
Hypospadias, renal dysplasia 10%
Musculoskel
etal
Polydactyly, talipes 10%
DELAYED CLOSURE OF PLEURO-PERITONEAL CANALS OR EARLY MIDGUT MIGRATION
OR RESULTS IN CDH

33. Pathophysiology
Visceral herniation
Abnormal lung
development
Abnormal pulmonary
vasculature
Atelectasis of the lung
Systemic hypotension
H
Y
P
O
X
A
E
M
I
A
Pulmonary hypoplasia
Persistent pulmonary
hypertension (PPHN)

34. DIAGNOSIS
USG
• Polyhydramnios on prenatal USG
• Intrathoracic gastric bubble
• Mediastinal shift away from hernia
CLINICAL FEATURES
• ↑HR, ↑RR , CYANOSIS
• Scaphoid (concave) abdomen clause
of herniation
Auscultation - no breath sounds bowel
sounds in chest
X ray - bowel loops in chest (m/c Lt. side)
• NGT in stomach in chest

35. • Initial stabilization with delayed surgery
• Tracheal intubation and mechanical ventilation
• Avoid hypothermia which causes ↑rt→lt shunt ↑ pvr ↑ o2 consumption
• Decompress stomach by ngt
• Avoid bag and mask ventilation (contraindicated)
• Lung protective ventilatory strategy
Low TV, RR high
PIP≤ 25cm H2O
PaCO245-60mm Hg - permissive hypercapina
pH >7.3 (avoid acidosis - pulmonary vasoconstriction and decreases SPO2)
Preductal SpO2 85%-95%
AVOID rt→lt shunt
PRE OP MANAGEMENT

36. • Laboratory studies: CBC, RBS, serum
electrolytes, cross matching, ABG
• CXR: Air filled viscera in the chest,
mediastinal shift
• ECHO : Assessment of myocardial
function, pulmonary hypertension,
concurrent heart defects, R-L
shunting
INVESTIGATIONS

37. Adequate venous access
Gastric decompression
Monitoring
 Pre induction –Standard monitors, preductal & postductal pulse
oximeter, precordial stethoscope
 Post induction - Temperature, capnography, urine output, ±
right radial arterial line, ± central venous access
INTRAOPERATIVE MANAGEMENT

38. • Choice of anaesthesia – Rapid sequence induction with
succinylcholine/rocuronium or awake intubation
• Maintenance- Isoflurane + O2+ air. Avoid N2O
• Volume/ Pressure control ventilation – PIP<30cm H2O,
RR 30-60/min
• Analgesia- IV opioids, epidural
• Active warming measures
INTRAOPERATIVE MANAGEMENT

39. Intraoperative complications
• Acute desaturation- suspect pneumothorax on
unaffected side
• Sudden hypotension - RV failure, kinking of major
blood vessels, abdominal compartment syndrome
• Hypothermia
• Hypoglycemia

40. • Post operative ventilation in large hernia
• Do not hyperventilate
• Aim to maintain PaO2 >150 mmHg with least FiO2
• Slow weaning from oxygen over 48-72 hours
• Abdominal compartment syndrome
• Beware of Honeymoon phenomenon
POSTOPERATIVE MANAGEMENT

41. UPPER GIT LOWER GIT
COMPRISES STOMACH , DUODENUM ,
PROXIMAL ILEUM
TERMINAL ILEUM ,
COLON , RECTUM ,
ANUS
CAUSES 1.Duodenal or ileal atresia.
2.Malrotation of midgut
volvulus.
3.Peritoneal bands.
4.Intra abdominal hernia.
1.Meconium ileus.
2.Intussusception.
3.Imperporate anus
INTESTINAL OBSTRUCTION
Incidence: 1 : 1500 live births

42. UPPER GIT LOWER GIT
CLINICAL
FEATURES
 24 hrs of birth.
Vomiting with initiation of
feeding.
Tender abdomen.
Persistent vomiting leads to
sodium loss, hypochloraemia,
metabolic alkalosis.
 bowel ischaemia – acidosis ,
bloody stools
 2 – 7 days of birth.
Increased
abdominal distention.
No passage of
faeces.
Vomiting is delayed.

43. Anaesthetic management:
• Aggressive correction with fluid & electrolytes, blood products
• Sodium bicarbonate only in severe acidosis (Ph < 7.20)
• Nasogastric tube suctioning and left open
• Rapid sequence intubation is preferred to prevent aspiration
• Procedure: combined general + caudal .
• Advantages : light level of anaesthesia , muscle relaxation & early extubation.
• Post operative ventilation in sick patients till condition stabilises.

44. Abdominal wall defects
• Most common are gastroschisis &
omphalocoele
• Although these conditions are embryologically
unique anaesthetic management is essentially
same

45. Gastroschisis Omphalocoele
Incidence 1:10000 1:4000-7000
Patho-physiology Interruption of
ompalomescentric
artery
Non return of bowel from
extra embryonic coelom
Defect Open with inflamed,
eodematous bowel
Amnion cover outside,
peritoneum inside
Astd anomalies Rare High
Defect size 2-5 cm, lateral 2-15 cm, midline
Umbilical cord Adjacent to defect Apex of sac

46. Surgical management
• Primary closure- for small defects with not much
viscero- abdominal disproportion
• Staged repair- if complete reduction is not possible
• Delayed closure- over weeks to months in very large
omphalocoele

47. Intraoperative management
• Choice of anaesthesia – Modified rapid sequence induction with succinylcholine
/rocuronium, maintenance- isoflurane+O2 + air. Avoid N2O
• Adequate neuromuscular blockade to facilitate
abdominal closure
• Fluid - 10-20ml/kg boluses
• Analgesia- IV opioids, regional techniques
• Active warming

48.  Intragastric <20mm Hg
Intravesical pressures <20mm Hg
PIP prior to abdominal closure < 35 cm H2O
End tidal CO2<50mm Hg
Urine output >0.5ml /kg/hr
Criteria for safe abdominal
closure

49. Complications
• Abdominal compartment syndrome
• Dehydration & electrolyte imbalance
• Hypothermia
• Hypoglycaemia
• B/L lower lobe atelectasis

50. Post operative care
• Continuation of mechanical ventilation for 24-48 hours
• Judicious fluid therapy
• Good analgesia
• Initiating TPN

51. THANK YOU