Neonatal Anesthesia - Indications and Contraindications

Introduction:

Neonates are newborn babies of one month old. Sometimes, these newborns also require surgeries or minor procedures due to suffering or issues after delivery. So, along with the surgery, anesthesia is also necessary to control the pain of the baby patient. Neonatal anesthesia is a good option for newborns under surgery. It is delivered by various means, such as inhalation (through the nose) or intravenous (through the veins). So, this topic elaborates on neonatal anesthesia, its use, and its requirements.

What Is Neonatal Anesthesia?

When the surgery is required in a newborn who is one month older (neonate) or a young or immature baby, to control the pain during the surgery, the baby (patient) is administered anesthesia. Safe and effective anesthesia is a significant concern for the baby patient. Anesthesia can be used in premature babies (babies born before due dates or entire periods of 39 weeks) and neonates.

Why Is Neonatal Anesthesia Used?

The babies do react to pain or stressful conditions. The anesthesia use has benefited the babies by controlling their pain and easing them to sleep or go unconscious during the surgery.

Anesthesia not only benefits the baby by making them unconscious but also supports and favors the doctor to proceed with the surgical procedure with full baby cooperation.

When Is Neonatal Anesthesia Required?

Neonatal anesthesia is required in cases as listed below:

• When the baby is suffering from a congenital (from birth) heart defect condition.

• When some neurological problem involves brain or spinal cord defects.

• When the baby is suffering from airway obstruction.

• When the baby has an abdominal or intestinal condition.

What to Expect Before Going for Neonatal Anesthesia?

Before the surgery, the doctor checks the baby. The check-up involves:

• The baby's medical history, knowing if the baby is premature, underweight, or healthy, or if an individual had a vaginal or cesarean delivery.

• The doctor can ask the parents about the baby's health report in the past few days.

• The doctor can recommend the parents have a few lab tests for the baby.

• The doctor will acknowledge the need and use anesthesia on the baby during surgery.

• The doctor will also inform the parents about the anesthesia risks.

• The doctor will recommend the parents fast the baby before surgery. Particular guidelines for baby fasting have been mentioned below -

  • If the baby is on breast milk, then the doctor recommends fasting for four hours before going to surgery.

  • And if the baby is on formula milk, then the doctor can recommend fasting for about eight hours before going for surgery.

  • And if the baby is on clear liquid, then the doctor recommends fasting for two hours before going for surgery.

What to Expect During Infant Surgery and Anesthesia?

The parents can expect

• The baby is administered anesthesia through masks or injections injected into the veins; then, the baby can go to sleep unconsciously.

• The medical staff, including a doctor, an anesthesiologist (doctor specializing in anesthesia), and nurses, can be present in the surgical room.

• The anesthesiologist monitors the baby's vital signs (temperature, heart rate, blood pressure, and oxygen level). After the surgery, the doctor stops delivering any further anesthetic agents.

• Soon after the surgery, when the baby wakes up, the parents can meet the baby.

What Anesthesia Is Used in Neonates?

General anesthesia and local anesthesia are both used in babies. General anesthesia is mainly preferred in infants during significant surgeries. It makes the patient unconscious. It is delivered by masks, inhaling gasses, or by injection into veins. Local anesthesia is preferred in minor surgeries; it can be delivered by injection or by topically applying it over the skin.

What Are the Contraindications and Side Effects of Neonatal Anesthesia?

Neonatal anesthesia is contraindicated in the following cases:

• If the doctor finds the baby is allergic to anesthetics.

• If the doctor finds any infection over the site of insertion.

• If the baby has any difficulty in breathing.

Side effects of neonatal anesthesia are:

• Nausea.

• Vomiting.

• Dry mouth.

• Itchiness.

• Muscle aches.

• Shivering.

What Are Curious Points Regarding Neonatal Anesthesia Usage?

Some curious points regarding neonatal anesthesia usage are:

• The anesthesia used in babies and adults is the same. There is no such variation in the anesthetic agents and mode of anesthesia delivered to adults or infants.

• Neonatal anesthesia requires the patient to stay overnight in the hospital so that medical attention can be provided. Although parents do get worried about their child, the doctor wants the baby with full medical supervision to overcome the complications.

• Neonatal anesthesia is entirely safe and effective, and surgery can be performed under it. The doctor's anesthetic agents completely fulfill the need for anesthesia to control the patient's pain. It benefits both the baby and the doctor during the surgery. Its safety is measured by the baby's better response or results after the surgery.

• The parents can be with their child in operation theaters after the doctor's allowance. Only one of the parents will be allowed in the operation theater, but the parents can not hold the child in their arms.

• Anesthesia is usually delivered by the doctor not by any other staff or by their own. The doctor or anesthesiologist (one who specializes in anesthesiology) delivers the anesthesia to the patient.

• Anesthesia is delivered by the doctor in such a manner that the baby does not feel much pain while getting anesthetized. Although sometimes, a pinch of pain can be felt by the baby.

What Are the Issues of Concern for Neonatal Anesthesia?

• Thermoregulation in Neonates: It is important to maintain optimal temperature in operating rooms because neonates have less thermogenesis (heat production). Also, their body surface is very small, and a maximum percentage of skin is exposed during the surgeries. In addition, their core body temperature often drops up to one to two degrees during the initial hour of the surgery due to inhibition of thermoregulation by general anesthesia. Therefore, to prevent loss of body heat in neonates, operating rooms are warmed 70 to 80 degrees Fahrenheit before starting the surgery.

• Positioning: Neonates have very little body fat, and the skin is also thin; therefore, checking position regularly is important. During surgical draping, caution should be taken to avoid any red marks or pressure caused by anything touching their skin.

• Glucose Management: Neonates are prone to develop hypoglycemia (low blood glucose) in a short period of ‘nothing by mouth’ or ‘NPO” during surgical procedures due to decreased glycogen stores. Therefore, glucose monitoring should be carefully done in neonates during surgical procedures.

• Intubation and Airway Management: Studies show that neonates are more at risk of developing desaturation and hypoxia (reduced or absence of oxygen in body tissues) during intubation than younger children. Therefore, one must be thoroughly aware of the anatomy (floppy epiglottis, larger head, and position of the larynx) while intubating a neonate.

• Cardiovascular System: The myocardium (heart muscle) of the neonate is less compliant, thus their cardiac output depends on the heart rate. Also, their vasoconstriction is not very responsive to hemorrhage (bleeding), causing a 15 to 30 percent decrease in arterial pressure due to a 10 percent decrease in blood volume. This implies that neonates are less responsive to minimal blood loss, and also their response to blood loss is reduced.

• Respiratory System and Metabolic Oxygen Requirement: There is an incomplete maturation of alveoli (air sacs) in neonates at the time of birth and up to eight to ten years of maturity and development. This causes desaturation quickly as the closing pressure of their airway is slow, thus, causing loss of ventilation.

• Blood Loss and Circulating Blood Volume: The circulating blood volume of neonates is 90 mL/kg (milliliters per kilogram), and in preterm neonates is 100 mL/kg. Therefore, a term baby of 8.4 pounds or 3.8 kg (kilograms) has 342 mL (milliliters) circulating blood volume. Thus, calculating the allowable or safe blood loss levels in neonates is crucial.

• Pharmacology and Drug Metabolism: Pharmacokinetics (what the body does to the drug) of the drugs usually have limited data for neonates as they are a vulnerable population and therefore, drug companies usually do not add them to studies and research. Also, it is essential to note that the liver and renal maturation and normal adult drug metabolism levels reach their peak values after six months of birth.

Conclusion:

Neonatal anesthesia is the medicine delivered to control pain felt by the baby during the operation. The anesthesia is delivered by masks or injection or by applying gel over the area. It is entirely safe and effective for babies. The possible requirements and side effects of neonatal anesthesia are nausea, vomiting, dry mouth, itchiness, or shivering. Neonatal anesthesia is a better option for neonates who require surgery. This anesthesia helps to keep the baby numb and unconscious while the surgical procedure can be performed on them. Although it creates a worrisome situation for a parent, it is quite safe and effective as it is performed under complete medical surveillance.