Significant advances in perinatal and neonatal medicine over the last 20 years and the recent emergence of fetal surgery has resulted in anesthesia providers caring for a growing number of infants born at the margin of viability. Anesthetic management in this patient population has to take into consideration the immature function of many vital organ systems as well as the effects of the underlying disease processes, which can frequently lead to severe physiological derangements. Accordingly, premature infants presenting for major surgeries early in life can represent a significant anesthetic challenge. However, even with advanced anesthetic and surgical management and optimal intensive care, extremely premature infants face substantial postoperative morbidity and mortality, as well as prolonged hospital courses. In this article, we will discuss the following questions: How far have we come in improving outcomes of extreme prematurity? And what will the future medical and societal challenges be, as we continue to redefine the limits of viability?
[Show abstract][Hide abstract] ABSTRACT: Acute surgical pain management in children is best addressed by a dedicated pain management team. Although PCA with opioids forms the main modality of analgesia, regional techniques have gained popularity. PCA by proxy and PCA basal infusions enhance analgesia but carry a risk for respiratory depression and sedation. Efficient prevention of opioid-induced respiratory depression requires the use of appropriate monitoring including pulsoximetry and respiratory rate, clinical sedation scoring system, repeated assessment by the pain team, early intervention protocols, and use of nonopioid adjuncts like IV or oral acetaminophen and ketorolac/NSAIDs. Thalamocortical connections underpinning the neuroanatomy of pain appear between 20 and 30 weeks of gestational age, and the physiological mechanisms for pain perception become established by early second trimester. There are long-lasting effects of pain experienced in early life underscoring the need to treat surgical pain in fetuses, premature infants, and neonates. In contrast, there is a growing body of evidence in animal models implicating opioids in adversely altering neuronal proliferation in the developing brain and clinical studies wherein morphine sedation in the neonatal period was found to decrease visual motor integration in childhood, suggesting a potential for neurocognitive sequelae. Ongoing research provides hope that future integration of pharmacogenetics, metabolomics, and proteomics in clinical decision and analgesic selection/dosing processes will maximize analgesia and minimize adverse effects.
International anesthesiology clinics 10/2012; 50(4):66-82. DOI:10.1097/AIA.0b013e31826f3284
[Show abstract][Hide abstract] ABSTRACT: Evidence-based guidelines do not indicate when ventricular reservoirs should be placed in children with neonatal hydrocephalus, and delayed intervention is common. We hypothesize that delayed ventricular drainage has adverse effects on structural development and functional outcomes.
Using a well-established animal model of kaolin-induced obstructive hydrocephalus, we evaluated neurologic deficit after early (~1 week post-kaolin) or late (~2 weeks post-kaolin) placement of ventricular reservoirs which were tapped according to strict neurologic criteria.
Progressive ventriculomegaly was similar in early- and late-reservoir implantation groups. The average neurologic deficit scores (NDSs) over the experimental period were 0 (n = 6), 2.74 (n = 5), and 2.01 (n = 3) for the control, early-, and late-reservoir groups, respectively. At reservoir placement, early-group animals displayed enlarged ventricles without neurologic deficits (mean NDS = 0.17), while the late group displayed ventriculomegaly with clinical signs of hydrocephalus (mean NDS = 3.13). The correlation between ventriculomegaly severity and NDS in the early group was strongly positive in the acute (before surgery to 3 weeks post-reservoir placement) (R (2) = 0.65) and chronic (6 to 12 weeks post-reservoir placement) (R (2) = 0.65) phases, while the late group was less correlated (acute R (2) = 0.51; chronic R (2) = 0.19).
Current practice favors delaying reservoir implantation until signs of elevated intracranial pressure and neurologic deficit appear. Our results demonstrate that animals in early and late groups undergo the same course of ventriculomegaly. The findings also show that tapping reservoirs in these neonatal hydrocephalic animals based on neurologic deficit does not halt progressive ventricular enlargement and that neurologic deficit correlates strongly with ventricular enlargement.
Child s Nervous System 07/2012; 28(11):1849-61. DOI:10.1007/s00381-012-1848-z · 1.11 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aim:
To compare causes and rates of mortality among infants admitted to 10 Australian neonatal intensive care units (NICUs) between 1995 and 2006.
De-identified perinatal data from the Neonatal Intensive Care Units' (NICUS) Data Collection for 24 131 infants were examined for causes and rates of death. The study period was divided into two epochs: I (1995-2000, n = 11 185 infants) and II (2001-2006, n = 12 946 infants).
A total of 2224 (9.2%) infants died in hospital. Mortality decreased from 10.3% (1152/11 185) in epoch I to 8.3% (1072/12 946) in epoch II (p < 0.001) due to improved survival in term infants. Extreme prematurity also decreased as a primary cause of death (118 (10.2%) vs 76 (7.1%), p = 0.008). No infant >42-week gestation was admitted in epoch II. Congenital abnormalities were the most common cause of death (>20%) in both epochs, mostly in term rather than preterm infants (40.7% vs 13.9%, p < 0.001). Age of death was unchanged between the two epochs (median 4, 1st, 3rd quartiles: 1,16 days).
Mortality rates have continued to decrease but improvement is predominantly due to improved survival of term infants and prevention of postdate deliveries. Congenital abnormalities continue to be the most common cause of death.
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