Neonatal Anesthesia

Description

Since publication of the first edition in 2015, neonatal anesthesia and surgery have advanced at lightning speed with many new developments, hence the need to update several essential topics. These include our understanding of neonatal apoptosis, the ever-increasing use of regional anesthesia in neonates, pharmacology of drugs in neonates, the delivery of anesthesia outside the operating room, neonatal resuscitation/guidelines, and perinatal complexities such as the EXIT procedure together with the fundamental principles of developmental physiology, airway management and ventilation as well as perioperative complications and ethical considerations that are unique to this age group.  This comprehensive and well-illustrated book is led by Dr. Jerrold Lerman who brings four decades of research, publication and clinical experience in pediatric and neonatal anesthesia. He has amassed a team of recognized international experts in neonatal anesthesia, surgery, and intensive care to share their knowledge in managing neonates for the challenges they face both within and without the surgical suites. Neonatal Anesthesia, the 2nd edition, is the quintessential clinical reference for perioperative care of these small patients that should be read by trainees as well as experienced clinicians and is certain to become an invaluable resource for every anesthetic and critical care department that serves children. Reviews from the 1st edition: “Lerman’s book stands alone as an up-to-date text dedicated exclusively to the practice of anesthesia in neonates … . The text covers its subject matter in extraordinary breadth and depth. … Throughout the book there are illustrative and clinically relevant diagrams, nicely supporting and summarizing relevant text for the more visual learner. … Neonatal Anesthesia is a sophisticated but approachable text that offers its readers theory-based practical approaches to understanding and managing anesthesia in our youngest, most fragile patient population.” (Stephanie A. Black and Lynne G. Maxwell, Anesthesiology, Vol. 125 (3), 2016) “It is a long-awaited contribution to the literature, filling a gap of over a decade without a neonatal anaesthesia textbook. … textbook should hold an essential and required spot on the bookshelf of any anaesthetist or critical care physician who cares for neonates. … The reference lists are comprehensive and exhaustive. Dr Lerman should be commended for finally presenting the anaesthesia community worldwide with this textbook, which will be able to stand on its own, probably for the next decade.” (K. P. Mason, British Journal of Anaesthesia, Vol. 116 (4), 2016) “This book covers in 400-plus pages and 17 chapters most of what is known about the neonatal airway, physiology, drugs and anesthetics, with separate chapters on each subcategory of neonatal anesthesia. … Certainly pediatric surgeons, anesthesiologists who only occasionally care for children, students, residents, and fellows will appreciate this book. … This is a large book on a narrow topic that has increasing relevance to the field of current pediatric practice. It is well written, well illustrated, and highly useful.” (Robert M. Arensman, Doody’s Book Reviews, April, 2015) “The book has many outstanding chapters that have been thoughtfully crafted by leading researchers in specific fields. … this book is an essential addition to any pediatric anesthesiology library in any organization that provides care to neonates. This book is an excellent resource, not only for anesthesiologists at every level of training and expertise but also for other professionals who provide postoperative care, administer sedative drugs, control the airway, and undertake procedures in newborn infants.” (Carolyne Montgomery and J. Mark Ansermino, Canadian Journal of Anesthesia, Vol. 62, 2015) Foreword Acknowledgments Contents Contributors 1: The History of Neonatal Anesthesia Prelude Early Times The Twentieth Century Endotracheal Intubation of Neonates Neuromuscular Blocking Drugs Anesthesia Circuits and Controlled Ventilation Monitoring Intraoperative Temperature Control Neonatal Anesthesia: Some Landmark Procedures and Their Development Repair of Esophageal Atresia and Tracheoesophageal Fistula Congenital Diaphragmatic Hernia Abdominal Wall Defects Neonatal Cardiovascular Surgery Open Heart Surgery Regional Analgesia Minimally Invasive Neonatal Surgery Ex Utero Intrapartum Treatment: “The EXIT Procedure” Regionalization of Neonatal Services Research in Neonatal Anesthesia Ethical Considerations and Infant Anesthesia References 2: Physiology and Development of the Term and Preterm Neonate Cardiovascular Function The Transitional Circulation The Placenta: In Utero Function and Cord Clamping Myocardial Development Myocardial Compliance: Extracellular Matrix/Cytoskeleton Adrenergic Function The Preterm Infant Clinical Significance and Summary Central Nervous System Function Normal Development of the Central Nervous System Age-Related Patterns of Injury Vulnerable Cell Populations: The Preterm Infant Vulnerable Cell Populations: The Term Infant Congenital Heart Disease Summary Autoregulation of Cerebral Blood Flow Cerebral White Matter Injury Germinal Matrix–Intraventricular Hemorrhage Cerebellar Injury Clinical Significance and Summary The Pulmonary System Embryology The Embryonic Stage (0–7 Weeks’ Gestational Age) Pseudoglandular Stage (7–17 Weeks’ Gestational Age) Canalicular Stage (17–27 Weeks) Saccular Phase (28–36 Weeks’ Gestation) Alveolar Phase (36 Weeks’ Gestation Until ~2–3 Years) Postnatal Development of the Lung Airway Anatomy Anatomy of Chest Wall and Mechanics of Breathing Functional Residual Capacity Pulmonary Function Testing Pulmonary Surfactant Respiratory Distress Syndrome (RDS) Oxygen Toxicity Control of Ventilation Apnea of the Newborn Hepatic Function Anatomy In Utero Development Early Postnatal Hepatic Function: Anatomy Early Postnatal Hepatic Function: Synthesis Early Postnatal Hepatic Function: Metabolism Early Postnatal Hepatic Function: Common Neonatal Hepatic Disorders and Hemorrhagic Disease of the Newborn Early Postnatal Hepatic Function: Common Neonatal Hepatic Disorders, Jaundice, and Hyperbilirubinemia Clinical Significance and Summary Renal Function (also See Chap. 8 Developmental Changes in Distribution of Total Body Water GFR and Blood Flow Renal Tubular Function Development of Sodium-Driven Transport Function Renin–Angiotensin System Clinical Significance and Summary References 3: Anesthesia and Ancillary Drugs and the Neonate Introduction Disentangling Pharmacokinetic Covariates in Neonates Size Maturation Organ Function Neonatal Pharmacokinetic Differences Absorption Distribution Body Composition Plasma Proteins Regional Blood Flows Blood–Brain Barrier (BBB) Elimination Hepatic Metabolic Clearance Extrahepatic Routes of Metabolic Clearance Pulmonary Elimination Renal Elimination Neonatal Pharmacodynamic Differences Pharmacodynamic Measures Induction Agents Propofol Mechanism Pharmacodynamics Pharmacokinetics Adverse Effects Thiopentone Mechanism Pharmacodynamics Pharmacokinetics Adverse Effects Ketamine Mechanism of Action Pharmacodynamics Pharmacokinetics Adverse Effects Inhalation Agents Physicochemical Properties Pharmacokinetics Ventilation Cardiac Output Induction Control of Anesthetic Depth Shunts Metabolism Emergence Pharmacodynamics Central Nervous System Cardiovascular System Respiratory System Renal Hepatic Clinical Effects Induction Techniques Central Neuroexcitation Emergence Emergence Delirium Neuromuscular Junction Malignant Hyperthermia (MH) Stability Analgesic Drugs Acetaminophen (Paracetamol) Mechanism of Action Analgesic Pharmacodynamics Pharmacokinetics Adverse Effects Nonsteroidal Anti-Inflammatory Drugs Mechanism of Action Pharmacodynamics Pharmacokinetics Drug Interactions Adverse Effects Opioid Analgesic Drugs Morphine Pharmacodynamics Pharmacokinetics Adverse Effects Fentanyl Pharmacodynamics Pharmacokinetics Adverse Effects Remifentanil Pharmacodynamics Pharmacokinetics Adverse Effects Alfentanil Sufentanil Codeine Meperidine (Pethidine) Methadone Sedatives Benzodiazepines Mechanism of Action Pharmacodynamics Pharmacokinetics Adverse Effects Alpha-2 agonists Clonidine Pharmacodynamics Pharmacokinetics Dexmedetomidine Pharmacodynamics Pharmacokinetics Adverse Effects Local Anesthetic Agents Mechanism of Action Pharmacodynamics Pharmacokinetics Adverse Effects Neuromuscular Blocking Drugs Neonatal Physiology Pharmacodynamics Pharmacokinetics Antagonism of Neuromuscular Blockade Adverse Effects Anticholinergic Drugs Atropine Scopolomine Glycopyrrolate Adverse Effects References 4: The Selection of Anesthesia Techniques for the Neonate Part 1. General Principles and Aims of Anesthesia in the Neonate First Objective: To Provide Optimal Conditions for Surgery and Maintain Homeostasis. Second Objective: To Avoid the Storage of Unpleasant Implicit Memories Third Objective: To Ensure That the Techniques Employed Minimize the Risk of Cerebral Damage (Hypoxic/Ischemic, metabolic, or neurotoxic) Cerebral Hypoxia/Ischaemia Metabolic, Neurotoxic, and Other Potential Causes of Cerebral Damage. Part 2. Techniques of Anesthesia Spinal Anesthesia Induction of General Anesthesia for Elective Surgery Inhalational Induction Use of Opioid Drugs to Facilitate Anesthesia Induction Intravenous Induction Other Issues During Anesthetic Induction Muscle Relaxants for Tracheal Intubation Nitrous Oxide Tracheal Intubation: Oral or Nasal Route? Rapid Sequence Induction for General Anesthesia Preoxygenation Gastric Emptying Cricoid Pressure Mask Ventilation Anesthetic Agents for RSI Maintenance of Anesthesia Hypnosis Analgesia Muscle Relaxants Conclusion References 5: Airway Management Upper Airway Anatomy Reflexes Airway Management Anesthesia Preanesthetic Assessment Preoperative Preparation Airway Management and Equipment Face Mask Ventilation Laryngeal Mask Airways and Supraglottic Devices Laryngoscopy and Airway Instrumentation Orotracheal Intubation Nasotracheal Intubation Selection of Tracheal Tubes Uncuffed Versus Cuffed Tracheal Tubes Assessing Tracheal Tube Size Positioning the Tip Rapid Sequence Intubation Managing the Difficult Airway Managing the Airway in the Ex Utero Intrapartum Treatment (EXIT) Procedure (See Chap. 14) References 6: Neonatal Ventilation Strategies and Their Practical Application Respiratory System Ventilation Modes Pressure-Controlled Ventilation Volume-Controlled Ventilation Volume-Targeted Ventilation High-Frequency Ventilation Continuous Positive Airway Pressure and Noninvasive Ventilation Nasal High-Flow Oxygenation Application of Ventilation Modes in the Operating Theatre Ventilation Strategy in the Operating Theatre Monitoring of Ventilation Conclusion References 7: Perioperative Monitoring: Methods, Implementation, and Interpretation Introduction Cardiorespiratory Monitoring Precordial Stethoscope Arterial Hemoglobin Oxygen Saturation—Pulse Oximetry Pulse Oximetry Use in Clinical Practice Clinical Application of Pulse Oximetry Electrocardiography (ECG) Advanced Pulse CO-Oximetry and Oxygen Reserve Index (ORI) Oxygen Reserve Index (ORI) Inspired and Expired Gas Analysis Sidestream Capnography Mainstream Capnography Transcutaneous Carbon Dioxide Monitoring (tcpCO2) Apnea Monitors Respiratory Volume Monitor (RVM) Pulmonary Mechanic Monitors Systemic Blood Pressure Monitoring Noninvasive Blood Pressure (NIBP) Invasive Blood Pressure Definition of Hypotension Central Venous Pressure Monitoring Cannulation of the Internal Jugular Vein Cannulating the Brachiocephalic Vein (BCV) Central Venous Access: General Principles The Nervous System EEG and Amplitude-Integrated EEG (aEEG) Near-Infrared Spectroscopy Transcranial Doppler Neurophysiological Monitors Neuromuscular Junction Monitoring Temperature Monitoring Body Temperature Monitoring (see Chap. 8) Monitoring Blood Glucose Renal Function: Monitoring Urine Output References 8: Metabolic Care of the Preterm and Term Infants, Including Control of Body Temperature Neonatal Body Water Distribution and Metabolism Postnatal Changes in Hypothalamic, Endocrine, and Renal Physiology Hypothalamic–Pituitary–Adrenal Axis Renin–Angiotensin–Aldosterone Atrial Natriuretic Peptides (ANPs) Antidiuretic Hormone Neonatal Renal Function Renal Blood Flow (RBF) Glomerular Filtration Rate (GFR) Tubular Function Aquaporin Peptides Maintenance Fluid Therapy Water Requirement Sodium and Electrolyte Requirements Glucose Endocrine Response at Birth Hypoglycemia Hyperglycemia Enteral Nutrition (Trophic Feeding or Minimal Enteral Nutrition) Minimal or Small Volume Enteral Nutrition (Trophic Feeding) Normal Enteral Feeds Total Parenteral Nutrition Fasting and Preoperative Oral Fluids Gastrointestinal Ontogeny Gastric Fluid pH and Volume Gastric Emptying The Ideal Intraoperative Maintenance Fluid Hyponatremia Intravenous Solutions Glucose-Containing Solutions Perioperative Fluid Management General Principles Perioperative Steroids Emergency Surgery Maintenance Fluids The Myth of the Third Space Replacement of Intraoperative Losses Intraoperative Hypotension Colloids Albumin Nonprotein Colloids Transfusion Triggers Postoperative Fluid Maintenance Postoperative Metabolic Needs Special Cases: Cardiac Surgery Temperature Homeostasis Brown Adipose Tissue (BAT) Normothermia and Hypothermia Prevention of Hypothermia in Infants Receiving Anesthesia References 9: General and Thoracoabdominal Surgery Including Management of Conjoined Twins Introduction General Considerations Preoperative Assessment History and Examination Investigations Logistical Issues Emergency Status Surgery in the NICU Team Brief and Preparing the Theater Conduct of Anesthesia Monitoring Induction Vascular Access Temperature Monitoring and Warming Positioning Fluid Management Deficit Maintenance Requirements Perioperative Losses Glucose Transfusions Platelets and Blood Products Point of Care Testing Minimally Invasive Surgery in Neonates Physiological Effects of Laparoscopic Surgery One-Lung Ventilation Postoperative Care Specific Conditions Congenital Thoracic Malformations Congenital Cystic Adenomatoid Malformation (CCAM) Classification Diagnosis Postnatal Management Surgical Considerations Lung Sequestration Classification Diagnosis Management Surgical Considerations Congenital Lobar Emphysema (CLE) Diagnosis Management Anesthetic Implications for the Management of Congenital Thoracic Malformations Esophageal Atresia/Tracheoesophageal Fistula Classification Diagnosis Risk Stratification Medical Management Surgical Considerations Anesthetic Considerations Congenital Diaphragmatic Hernia Embryology Diagnosis Outcomes Antenatal Treatment Medical Management Surgical Considerations Anesthetic Considerations Abdominal Surgery Inguinal Hernia Pathophysiology Diagnosis Surgical Management Anesthetic Management Pyloric Stenosis Diagnosis Medical Management Surgical Management Anesthetic Considerations Intestinal Atresias Pyloric Atresia Duodenal Atresia Embryology Diagnosis Management Outcomes Surgical Considerations Anesthetic Considerations Jejunal/Ileal Atresia Embryology Diagnosis Outcomes Medical Management Surgical Considerations Anesthetic Considerations Colonic Atresia Diagnosis Management Surgical Considerations Meconium Ileus Diagnosis Outcomes Management Surgical Considerations Anesthetic Considerations Malrotation and Volvulus Embryology Diagnosis Outcomes Management Surgical Considerations Anesthetic Considerations Hirschsprung’s Disease Embryology Genetics Diagnosis Management Surgical Procedures Outcomes Surgical Considerations Anesthetic Considerations Anorectal Anomalies Embryology Classification Diagnosis Outcomes Management Surgical Considerations Anesthetic Considerations Cloaca Diagnosis Management Outcomes Surgical Considerations Abdominal Wall Defects Gastroschisis Pathophysiology Diagnosis Management Outcomes Surgical Considerations Anesthetic Considerations Exomphalos (Omphalocele) Pathophysiology Diagnosis Outcomes Management Surgical Considerations Anesthetic Considerations Bladder Exstrophy/Cloacal Exstrophy Outcomes Management Surgical Considerations Anesthetic Considerations Posterior Urethral Valves Diagnosis Management Anesthetic Considerations Sacrococcygeal Teratoma Diagnosis Management Outcomes Surgical Considerations Anesthetic Considerations Biliary Atresia Classification Diagnosis Management Surgical Approach Anesthetic Considerations Necrotizing Enterocolitis Pathogenesis Diagnosis Outcomes Management Surgical Approach Anesthetic Considerations Conjoined Twins Introduction Epidemiology Presentation Management Anesthesia Issues Logistics Airway Vascular Access and Blood Loss Preoperatively Assessment Theater Setup Conduct of Anesthesia Induction Airway Lines Monitoring Fluids and Blood Antibiotics Inotropes and Resuscitation Surgical Considerations Postoperative Care Summary References 10: Neurosurgery and Ophthalmology Introduction Development of the Central Nervous and Visual System Embryology Cerebrovascular Physiology Anatomy of the CNS and Eye Cranium Spine Eye Neurosurgery Congenital Anomalies Cranial Dysraphism Spinal Dysraphisms Anesthetic Management Preanesthetic Evaluation Intraoperative Management Postoperative Management Hydrocephalus Anesthetic Management Tumors Anesthetic Management Vascular Anomalies Perinatal Stroke Vein of Galen Malformation Preoperative Management Intraoperative Management Postoperative Management Ophthalmology Congenital Ophthalmologic Lesions Acquired Lesions Retinopathy of Prematurity Trauma Summary References 11: Cardiac Surgery Introduction Cardiovascular Physiology Types of Circulation Fetal Circulation The Transitional Circulation Postnatal Circulation Cardiac Output and Distribution of Blood Flow Developmental Aspects of the Myocardium Epidemiology of Congenital Heart Disease Clinical Presentation and Diagnosis of Congenital Heart Disease in the Neonate Classification of Congenital Heart Disease Congenital Cardiovascular Anomalies of the Neonate: Anatomy, Pathophysiology, and Management, with Anesthetic Considerations Patent Ductus Arteriosus Anatomic Features Pathophysiology Management Anesthetic Considerations Specific Issues Coarctation of the Aorta Anatomic Features Pathophysiology Management Anesthetic Considerations Specific Issues d-Transposition of the Great Arteries Anatomic Features Pathophysiology Management Anesthetic Considerations Specific Issues Tetralogy of Fallot Anatomic Features Pathophysiology Management Anesthetic Considerations Specific Issues Total Anomalous Pulmonary Venous Return Anatomic Features Pathophysiology Management Anesthetic Considerations Specific Issues Truncus Arteriosus Anatomic Features Pathophysiology Management Anesthetic Considerations Specific Issues Critical Aortic Stenosis Anatomic Features Pathophysiology Management Anesthetic Considerations Specific Issues Hypoplastic Left Heart Syndrome Anatomic Features Pathophysiology Management Anesthetic Considerations Specific Issues Interrupted Aortic Arch Anatomic Features Pathophysiology Management Anesthetic Considerations Specific Issues Critical Pulmonary Stenosis and Pulmonary Atresia with Intact Ventricular Septum Anatomic Features Pathophysiology Management Anesthetic Considerations Specific Issues Aortopulmonary Window Anatomic Features Pathophysiology Management Anesthetic Considerations Specific Issues Ebstein Anomaly Anatomic Features Pathophysiology Management Anesthetic Considerations Specific Issues Preoperative Assessment of the Neonate with Congenital Heart Disease History and Physical Examination Ancillary Studies and Laboratory Data Informed Consent Fasting Period Perioperative Considerations in the Neonate Undergoing Cardiac Surgery Transport to the Operating Room Premedication Intravenous Access Availability of Emergency Medications Physiologic Monitoring Electrocardiography Pulse Oximetry Capnography Temperature Arterial Blood Pressure Noninvasive Monitoring Indwelling Arterial Monitoring Sites for Invasive Monitoring Cutdown for Arterial Cannulation Central Venous Pressure Monitoring Ultrasound Guidance Percutaneous Sites for Central Venous Access Direct Transthoracic Pressure Monitoring Urinary Output Measurements Transesophageal Echocardiography Neurologic Monitoring Near-Infrared Spectroscopy Transcranial Doppler Ultrasound Intraoperative Management of the Neonate Undergoing Cardiac Surgery Induction of Anesthesia Maintenance of Anesthesia Cardiopulmonary Bypass in the Neonate Pre-bypass Period Perfusion Equipment, Tubing, Circuits, and Bypass Prime Heart-Lung Machine [(Pump] Heat Exchanger Unit Membrane Oxygenator Arterial Filter Cannulas and Tubing Venous Reservoir Air/Oxygen Blender, Carbon Dioxide Tank, High−/Low-Flow Meter Cardioplegia Circuit Blood Hemoconcentrator Venous Saturation and Hematocrit Monitor Activated Clotting Time Machine Arterial Blood Gas Machine Cell Saver Miniaturization of Bypass Circuit Pump Prime Stages of Cardiopulmonary Bypass Anticoagulation Cannulation and Initiation of Cardiopulmonary Bypass Cooling and Temperature Management Aortic Cross-Clamping and Myocardial Protection Release of Aortic Clamp and Myocardial Reperfusion Separation from CPB, Reversal of Anticoagulation, and Removal of Cannulas Transport to the Intensive Care Unit Special Cardiopulmonary Bypass Techniques: Deep Hypothermic Circulatory Arrest, Selective Antegrade Cerebral Perfusion, and Others Unique Aspects of Neonatal Cardiopulmonary Bypass and Differences From the Adult Effects of Cardiopulmonary Bypass and Related Strategies Systemic Inflammatory Response Syndrome Effects on Bleeding and Coagulation Neurologic Effects Pulmonary Effects Myocardial Effects Renal and Gastrointestinal Effects Cardiothoracic Surgery Without Cardiopulmonary Bypass in the Neonate Pulmonary Artery Banding Systemic to Pulmonary Artery Shunt Placement Coarctation of the Aorta Repair Vascular Ring Division Mechanical Circulatory Support in the Neonate with Congenital Heart Disease Perioperative Issues and Some Special Considerations in the Neonate Undergoing Cardiac Surgery Pulmonary Hypertension Systemic Hypotension Congestive Heart Failure Cyanosis Ventricular Pressure Overload Ventricular Volume Overload Myocardial Ischemia Altered Respiratory Mechanics Systemic Air Embolization Conduction Disturbances and Arrhythmias Perioperative Stress Response Post-cardiac Transplant Recipients Summary References 12: ECMO for the Neonate Introduction Patient Selection ECMO Circuit Components Gas Exchange on ECMO Modes of ECMO ECMO Management Cannulation and ECMO Initiation Anticoagulation and Homeostatic System in Neonates Mechanical Ventilator Management Sedation and Analgesia Fluid Management Decannulation Complications Survival and Outcome Anesthesia Considerations for a Surgical Procedure on ECMO Intraoperative Conduct of Anesthesia Transfer of Neonates to the Operating Theater Monitoring During ECMO and Surgical Procedure CDH and ECMO Trends in Neonatal ECMO: The Future Conclusion References 13: Anesthesia Outside the Operating Room Neonates Are Not Small Children Benefits of Performing Surgery in the NICU Patient Indications for Surgery in the NICU Logistics of Performing Surgery in the NICU Vascular Access Anesthesia Requirements Sedation and Analgesia for Common Procedures in the NICU High-Frequency Ventilation Transport Specific Conditions Requiring Surgery in the NICU (For Further Details, See Chap. 9 “Thoracoabdominal Surgery”) Closure of PDA NEC SIP Gastroschisis Retinopathy of Prematurity (See Chap. 2) CDH Other Reported NICU Surgical Procedures Sedation for Imaging Procedures (MRI/CT) Cardiac MRI Cardiac Catheterization Laboratory Preanesthetic Assessment of the Neonate in the Cath Lab Anesthetic Technique Complications Interventional Radiology for Neuroimaging Conclusion References 14: Fetal Surgery and the EXIT Procedure Introduction Anesthetic Considerations for Fetal Surgery Preoperative Evaluation of the Fetal Surgery Patient Maternal Physiology Maternal Circulatory System Maternal Airway and Pulmonary Systems Other Maternal Physiologic Changes Uterine and Placental Physiology Fetal Physiology Fetal Pain Perception Anesthetic Neurotoxicity Anesthetic Management for Minimally Invasive Fetal Procedures Anesthetic Management for Open Fetal Surgery Postoperative Considerations Specific Fetal Conditions Amenable to Fetal Treatment Fetal Anemia Twin Reversed Arterial Perfusion (TRAP) Sequence Twin-to-Twin Transfusion Syndrome (TTTS) Congenital Heart Disease Obstructive Uropathy Congenital Diaphragmatic Hernia (CDH) Congenital Pulmonary Lesions SCT MMC The Ex Utero Intrapartum Treatment (EXIT) Procedure Conclusions References 15: Neonatal Pain: Significance, Assessment, and Management Neonatal Pain Mechanisms Significance of Neonatal Pain Effects of Analgesics Assessment of Neonatal Pain Pain Measurement Tools Selecting an Appropriate Pain Assessment Tool Management of Pain Information and Protocols: Pain Management Plans Multimodal or Balanced Analgesia Pharmacological Methods Acetaminophen (Paracetamol) Nonsteroidal Anti-inflammatory Drugs (NSAIDs) Opioids Morphine Fentanyl Remifentanil Hydromorphone Codeine Tramadol Non-opioid Analgesics Clonidine and Dexmedetomidine Ketamine Local Anesthetics Lidocaine, Bupivacaine, Levobupivacaine, Ropivacaine, Chloroprocaine EMLA, Amethocaine Gel, and Other Topical LA Preparations Sucrose Postoperative Pain Management Group 1: Inguinal Hernia Repair, Circumcision, Pyloromyotomy, etc. Group 2: Major Gastrointestinal or Genitourinary Surgery Group 3: Cardiothoracic Surgery or Complex Gastrointestinal/Genitourinary Surgery Analgesia for Neonates in ICU Procedural Pain References 16: Regional Anesthesia for Neonates Introduction Risks and Benefits Anatomical Considerations [80–87] (Table 16.2) Pharmacological Differences Neuraxial Blockade Spinal Caudal Block Caudal Catheter Techniques Lumbar and Thoracic Epidural Sacral Epidural Block Continuous Epidural Infusions Epidural Adjuvants Ultrasound Imaging of the Spinal Cord Peripheral Nerve Blocks Management of Local Anesthetic Toxicity Conclusion References 17: Anesthetic Complications in the Neonate: Incidence, Prevention, and Management Introduction Peri-anesthetic Mortality and Adverse Events Peri-anesthetic Cardiac Arrest Respiratory and Airway Complications Additional Considerations Location of Operative Procedures Transfusion of Blood Products Vascular Access Oxygen Toxicity Prevention of Adverse Events Human Factors Medication Errors Equipment-Related Incidents Addressing Risks and Adverse Events Conclusion References 18: Do Anesthetic Drugs Harm Neonates? A Global Perspective Introduction Animal and Preclinical Data At What Age Are Animals Particularly Vulnerable to or Safe from Neurocognitive Effects of Anesthetics? Does the Duration of Exposure Impact Long-Term Effects? Do All Anesthetic Agents Cause Neurocognitive Dysfunction? Intravenous Anesthetics Intravenous vs. Inhaled Anesthetic Neurocognitive Effects Inhalation Agents Single Inhalational Agents Pairwise Comparisons Comparison of Three Inhalational Anesthetics Is There a Difference Between Single and Multiple Exposures or the Duration of Exposure on Apoptosis? Are There Any Preventative Measures or Treatments That May Attenuate This Insult? Translation and the Effects of Surgery Human Studies Retrospective Cohort Studies Twin and Sibling Studies Large Databases Prospective Human Trials Relevant Human Outcome Measures, Population Migration, and Sample Sizes Age at Exposure, Duration of Surgery/Number of Exposures, and Impact of Surgery Sex, Parenting, and Low Birth Weight Future Studies Other Aspects Important Issues to Consider Conclusion References 19: Neonatal Resuscitation for Anesthesiologists Introduction Equipment Physiology of Transition at Birth (Fig. 19.3) Fetal Circulation (Fig. 19.3a) Transition at Birth and Deferred Cord Clamping (DCC) Asphyxia Physiology of Resuscitation Preparation for Delivery Positioning Temperature Management Stimulation Monitoring Approach to an Infant Born Through Meconium Stained Amniotic Fluid (MSAF—Fig. 19.9) Positive Pressure Ventilation (PPV) Oxygen Intubation Indications for Tracheal Intubation in the DR Size of the ETT Confirmation of Tube Position Depth of Insertion of ETT in Neonates (Fig. 19.16) Deterioration after Intubation Chest Compressions Epinephrine in the DR Volume Expansion Discontinuation of Resuscitation Conclusion References 20: Ethical and Medicolegal Considerations Reasoning About Ethical Concerns The Four Principles Approach to Ethical Reasoning Limitations to the Four Principles Framework Perioperative Applications of the Four Principles Framework Autonomy Non-maleficence Beneficence Justice Perioperative Do-Not-Resuscitate Orders Regulatory Concerns in Perinatal Care The Baby Doe Regulation Controversy Born Alive Infant Protection Act Conclusions References Index