Chapter 86

1470 PART 5 ■ Anesthetic, Surgical, and Interventional Procedures: Considerations
TABLE 86-27. Typical Anesthetic Management of a Neonate Presenting With Bladder Exstrophy
Symptoms
Preoperative investigations
Monitoring
Suggested anesthetic and
recommendations
Recommended Examinations and Management
Obvious from looking at the baby
1. Routine laboratory panel
2. Cardiac echocardiography
3. Blood type and screen
4. Order 1 unit blood and 1 unit plasma
5. Check that adequate antibiotic prophylaxis/treatment is started immediately and that the defect is
covered by wet sponges
1. Routine monitoring
2. Invasive blood pressure monitoring
1. Make sure the patient is not exposed to latex
2. No premedication, I.V. atropine (10 g/kg), preoxygenation
3. Intravenous or inhalational induction appropriate. Tracheal intubation is indicated due to
prolong surgery. No special requirement for maintenance.
4. Due to extensive surgical reconstruction and postoperative need for some immobility of the
lower limbs, a lumbar epidural block should be considered.
5. Hemodynamically stable and normothermic patients can be extubated following emergence from
anesthesia.
Retinopathy of the Premature (ROP)
The cause for this condition was previously believed to be hypero -
xia secondary to overenthusiastic administration of oxygen during
the early neonatal period. Increasing degrees of prematurity and
repeated sepsis episodes are currently seen as more fundamental
predisposing factors for the development of ROP than hyperoxia.
Briefer episodes of hyperoxia, as often happens during anesthesia
of these infants, is currently not believed to be so dangerous in
this regard. The retinal lesions will be treated with a laser or with
a cryothermic probe (or a combination). The ophthalmologists
will need free access to the patients eyes and will, thus, interfere
with the anesthesiologists possibilities to handle the airway. Thus,
face mask ventilation is usually not practical since the anesthe -
siologists hands need to be out of the operating field. Despite the
often small size of these infants (1–2 kg body weight) the use of the
laryngeal mask airway will often avert the need for tracheal
intubation. 122 Crucial for the successful return to the previous level
of respiratory support prior to the anesthetic, is to expose the
patient to as few medications as possible and to use only drugs
with a very short effect duration. 122 The use for example of
thiopental should be considered contraindicated since the halflife
is excessively long in these babies. 117
Inguinal Hernia Repair
Awake caudal or spinal anesthesia can successfully be performed
in the ex-premature infant 210–212 and will circumvent the problem
of general anesthesia and tracheal intubation. The risk for
postoperative apnea will also be reduced with these methods
compared to general anesthesia. However, supplementation of
these blocks by any sedative drugs, including ketamine, 213 will
TABLE 86-28. Typical Anesthetic Management of a Neonate Presenting With Myelomeningocele
Symptoms
Preoperative investigations
Monitoring
Suggested anesthetic
and recommendations
Recommended examinations and management
Obvious from routine inspection of the patient
1. Routine laboratory panel.
2. Blood type and screen. Order 1 units of blood and 1 units of plasma.
3. Check that adequate antibiotic prophylaxis/treatment is started immediately and that the
defect is covered by wet sponges
1. Routine monitoring
2. If large undermining of the skin needed for closure, invasive blood pressure monitoring
might be indicated.
1. Make sure the patient is not exposed to latex
2. No premedication, IV atropine (10 g/kg) and preoxygenation
3. Intravenous or inhalational induction and maintenance per choice
4. If general anesthesia is used tracheal intubation is mandatory because of the duration of
surgery and the prone position. To minimize the risk for accidental dislodgment of the
tracheal tube nasal intubation is recommended. To avoid pressure damage of the nervous
structures within the MMC, tracheal intubation can be performed in the lateral position.
Custom made support pads with a hole cut for the MMC can also be used for tracheal
intubation in the supine position.
5. Most patient will be extubated at the end of the procedure.