Anemia of Prematurity - Portal Neonatal

PREOPERATIVE ASSESSMENT AND PREPARATION Section 3 of 10
Suffering can be minimized during the preoperative visit when physicians avoid unnecessary
laboratory studies, especially those that require phlebotomy. Furthermore, inappropriately long NPO
(ie, nothing by mouth) periods can be eliminated, thereby avoiding unwarranted patient agitation.
Postoperative pain management should be discussed when the surgical neonate and family are seen
preoperatively. Issues that may eventually affect decisions about postoperative pain management,
and should therefore be addressed, include coexisting disease states, surgical site, postoperative
disposition, and family consent for pain management techniques that are being considered.
Neonates who are unstable, septic, or likely to remain intubated postoperatively are frequently
managed with narcotic administration intraoperatively and are continued on narcotics as needed
postoperatively. Narcotic administration is pursued more cautiously in neonates who will be in a non-
ICU setting postoperatively. Neonates undergoing outpatient surgery or surgery associated with minor
postoperative pain are frequently managed postoperatively with acetaminophen with regional or local
anesthetic infiltration. Neonates who undergo lower extremity, abdominal, or thoracic surgery are
excellent candidates for regional anesthesia, whether undergoing inpatient or outpatient surgery. As in
adults, coexisting pulmonary disease in neonates may be an excellent reason to consider regional
anesthesia for postoperative pain management. Finally, anxiety among family members concerning a
pain control strategy should be thoroughly addressed and considered in postoperative pain
management decision-making.
THE PAIN RESPONSE IN NEONATES Section 4 of 10
After extensive work in the 1980s and 1990s, the fact that neonates experience pain and mount a
stress response has been established and appreciated. Metabolic and hormonal indicators of the
degree of stress a surgical patient experiences have been monitored during and after surgery. These
indicators are, in fact, elevated in neonates perioperatively. Even premature neonates undergoing
surgery are capable of mounting a significant stress response, as measured by hormonal and
metabolic indicators. Stress indicators include plasma adrenaline, noradrenaline, glucagon, insulin,
and cortisol as well as blood glucose, lactate, pyruvate, and alanine.
The mounting of a surgical stress response results in catabolic responses, including glycogenolysis,
gluconeogenesis, and lipolysis during the perioperative period. These catabolic responses, when
unmodulated by medical intervention, may have a detrimental effect on the clinical course of a
neonatal surgical patient. Adverse circulatory and respiratory events are also more likely during the
postoperative course of neonates who have had inadequate interventions to minimize stress
response. Tachycardia, systemic hypertension, pulmonary hypertension, respiratory embarrassment,
and intraventricular hemorrhage may be associated with inadequate pain control in neonates.
Furthermore, inadequate treatment of pain in neonates may have implications that extend beyond the
neonatal period, including hypersensitivity to noxious stimuli later in life.
INTRAOPERATIVE PAIN MANAGEMENT Section 5 of 10
To a large extent, management of the surgical stress response in neonates can be accomplished with
the same pharmacologic interventions that characterize anesthetic care of other surgical patients.
Volatile anesthetic agents remain the most common means of providing anesthesia and analgesia
intraoperatively. This is probably because they meet, at least to some degree, each of the criteria
required for a complete anesthetic, including some degree of hypnosis, amnesia, analgesia, and
muscle relaxation. Anand demonstrated that blood levels of hormonal and metabolic indicators of the
stress response were lower in neonates who received volatile anesthetics during surgery. Furthermore,
clinical stability of neonates during and after surgery was improved by adequate administration of
volatile anesthetic agents intraoperatively.