Recovery Characteristics in Neonates Following General Anesthesia: A Retrospective Chart Review.

Introduction Preterm babies increasingly survive the neonatal period as a result of advanced care practices. Accordingly, anesthesiologists are likely to encounter these patients with greater frequency. Ex-premature infants and term neonates are known to have an increased risk of post-operative apneas following surgery and anaesthesia. Methods Following approval from the Institutional Review Board, we performed a retrospective chart review of neonates 0-28 days of age who underwent general anaesthesia procedures over two years. Data collected included age days, sex, weight, gestational age, American Society of Anaesthesiologists (ASA) physical status, type of anaesthetic (general/regional/spinal), airway management, surgical procedure, intraoperative adverse events, duration of anaesthesia, medications administered, post-operative recovery location, the occurrence of apneic events, medical co-morbidities, duration of post anaesthesia care unit (PACU) admission, a requirement for neonatal intensive care unit (NICU) admission, and duration of hospital admission. Results A total of 239 charts were reviewed from January 1, 2015, to December 31, 2016. Ninety-five cases were excluded for required postoperative mechanical ventilation. For the remaining 144 cases, the mean age was 12.8 days, 65% male, 35% female, mean gestational age 38.6 weeks, mean post-menstrual age 40.5 weeks, mean ASA status 3.5, and mean weight 3.46 kg. Post-operative apnea was observed in two neonates (1.4%). Risk factors for postoperative apnea included lower gestational age at birth (median 37.5 vs. 39.1 weeks, p=0.26), lower post-menstrual age (median 38.5 vs. 41.0 weeks, p=0.18), and lower weight (median 2.8 vs. 3.5kg, p=0.27), respectively. ASA classification, preoperative anaemia, and known pathology were all significant risk factors for apnea (p<0.05). Significant factors from the bivariate analysis were preoperative anaemia, known pathology, age, duration of anaesthesia, weight, intraoperative fentanyl, and amount of neuromuscular blocker. Age and preoperative anaemia were significant predictors for recovery location. The odds of going to PACU vs NICU/PICU for post-operative recovery were 7.4 times greater for every two weeks greater age (95% CI=(2.80-19.31), p<0.001).  Conclusion This study corroborates previous findings of predictive risk factors for post-anaesthesia apnea in preterm and term neonates. Previously reported risk factors, including low gestational/post-menstrual age, lower weight, and intraoperative narcotic use, were likely contributors to one of the apneic events in our study. A larger sample size is warranted to confirm a valid predictive model. Standardized universal guidelines would be useful in eliminating local variation in PACU monitoring and discharge criteria in this vulnerable age group.

Low Body Weight Predicted Bradycardia and Desaturation in Retinopathy of Prematurity Surgeries: A Retrospective Cohort Study.

Background: As a leading cause of childhood blindness, the epidemic of retinopathy of prematurity (ROP) in China is characterized by advanced stage of ROP in more mature infants than those in the West. More advanced stage of disease necessitates more complicated surgical procedures and consequently exposure to general anesthesia. These ex-prematurely born infants are at risk of developing desaturation especially after surgery under general anesthesia. Physical status, anesthetic management and surgical profile are three main facets of perioperative setting and need to be investigated to identify useful predictors for perioperative adverse events in this population of fragile infants. Methods: In this retrospective cohort study, we enrolled all infants undergoing ROP surgeries at Peking University People's Hospital, Beijing, China from November 1, 2016 to October 31, 2017. Physical status, anesthesia and surgical management were analyzed by exploratory factor analysis and component matrix to explore risk factors for adverse events. Results: During the 12 months, 267 cases were included, among whom 61 infants underwent two surgeries required by their ophthalmological conditions. The median postconceptual age at the time of surgery was 46 (40, 53) weeks, and median body weight was 4.0 (3.0, 6.5) kg. None of the infants was dependent on caffeine, oxygen or ventilator before surgery. Bradycardia (29/267, 10.9%) and postoperative desaturation (34/267, 13.4%) were identified as major cardiac and respiratory adverse events. Preoperative atropine, intubation and bigger body weight would prevent patients suffering from bradycardia. Infants with a body weight less than 3.15 kg had a significantly higher chance of desaturation and neonatal intensive care unit admission after ROP surgeries than those who weighed more than 3.15 kg (27.8 vs. 5.1%, OR 5.46 (95% CI 2.66-11.21), P = 0.000). Conclusion: This study found that preoperative atropine and intubation would prevent bradycardia and low body weight was a predictor for both bradycardia and postoperative desaturation in preterm infants undergoing ROP surgeries.

Apnea 6 h after a cesarean section.

Intrathecal narcotics have proven to be invaluable in providing pain relief following a cesarean section. They also aid in earlier mobilization. Unfortunately, they come at the risk of delayed apnea requiring close monitoring for a prolonged period of time. Physicians may sometimes underestimate the risk of these delayed complications. This especially a big concern in hospitals that cannot provide the necessary postoperative monitoring required for these women. I present a case where it took more than 6 h after injection of narcotics before the complication occurred.

Fatores de risco para raquianestesia em recém-nascidos pré-termo submetidos a herniorrafia inguinal / Risk factors for spinal anesthesia in preterm infants undergoing inguinal hernia repair

OBJETIVOS: Investigar os fatores de risco e a incidência de efeitos adversos perioperatórios advindos da raquianestesia não suplementada em recém-nascidos pré-termo. Também foi avaliado o tempo decorrido até o reinício da alimentação oral e até a alta hospitalar. MÉTODOS: Foram coletados prospectivamente os dados perioperatórios de todos os recém-nascidos prematuros e ex-prematuros submetidos a herniorrafia inguinal com raquianestesia em um centro médico terciário. RESULTADOS: O grupo de estudo consistiu em 144 recém-nascidos com uma idade gestacional mediana de 30 semanas, idade concepcional de 37 semanas, peso de nascimento de 1.420 g, e peso de 2.140 g no momento da cirurgia. No total, seis (4,2%) recém-nascidos apresentaram complicações intraoperatórias, que incluíram apneia (2/1,4%), bradicardia (2/1,4%) e hipoxemia (4/2,8%). Complicações pós-operatórias ocorreram em 15 (10,4%) recém-nascidos, principalmente hipoxemia (3/2,1%), bradicardia (8/5,5%) e apneia (6/4,1%). Os fatores preditivos de desfecho desfavorável (apneia, alimentação oral > 6 h de pós-operatório, ou alta > 30 h de pós-operatório) foram displasia broncopulmonar [razão de chances (OR) = 3,2, intervalo de confiança de 95% (IC95%) 2,8-5,3; p = 0,01] e leucomalácia periventricular (OR = 2,8, IC95% 2,1-4,9; p = 0,03). CONCLUSÕES: A raquianestesia é segura e eficaz na herniorrafia inguinal em recém-nascidos pré-termo, levando a um reinício precoce da alimentação oral e a um menor período de hospitalização. Displasia broncopulmonar e leucomalácia periventricular podem acarretar risco de desfecho desfavorável.

OBJECTIVES: To investigate the risk factors and incidence of perioperative adverse effects from unsupplemented spinal anesthesia in preterm infants. Times to resumption of oral feeding and to home discharge were also evaluated. METHODS: Perioperative data were collected prospectively for all preterm and former preterm infants who underwent inguinal hernia repair with spinal anesthesia at a tertiary medical center. RESULTS: The study group consisted of 144 infants with a median gestational age of 30 weeks, postmenstrual age of 37 weeks, birth weight of 1,420 g, and weight at surgery of 2,140 g. Overall, six (4.2%) infants had intraoperative complications, which included apnea (2/1.4%), bradycardia (2/1.4%), and hypoxemia (4/2.8%). Postoperative complications occurred in 15 (10.4%) infants, mainly hypoxemia (3/2.1%), bradycardia (8/5.5%), and apnea (6/4.1%). Predictive factors of an unfavorable outcome (apnea, resumption of oral feeding > 6 h postoperatively, or discharge > 30 h postoperatively) were bronchopulmonary dysplasia (odds ratio [OR] = 3.2, 95% confidence interval [95%CI] 2.8-5.3; p = 0.01) and periventricular leukomalacia (OR = 2.8, 95%CI 2.1-4.9; p = 0.03). CONCLUSIONS: Spinal anesthesia is safe and effective for inguinal hernia repair in preterm infants, with early resumption of oral feeding and short hospitalization. Bronchopulmonary dysplasia and periventricular leukomalacia may pose risks for an unfavorable outcome.