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KEY POINTS

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KEY POINTS

  1. The cardiopulmonary system of the neonate, particularly that of the preterm neonate, is developmentally immature when compared to the adult. It is imperative that the anesthetist/anesthesiologist understand these differences in order to safely care for neonatal patients as well as to avoid the long-term sequelae of ventilator induced lung injury.

  2. Persistent pulmonary hypertension of the newborn (PPHN) is the failed transition of fetal circulation resulting in sustained elevation of pulmonary vascular resistance. Depending on the presence of various neonatal shunts and the adaptive capability of the right ventricle to high afterload, this can result in profound hypoxemia and right ventricular dysfunction. PPHN may be present in the neonate requiring emergency surgery and require ongoing resuscitation.

  3. Fluid and electrolyte homeostasis during emergency neonatal surgery must consider the delicate requirements of the neonate and narrow therapeutic index, which is directly related to gestational age. Perioperative planning may be categorized into preexisting deficits, hourly requirements, and ongoing losses according to the invasiveness of the surgical procedure.

  4. Children with esophageal atresia and a tracheoesophageal fistula require meticulous care during induction of anesthesia and endotracheal intubation. The anesthesiologist, surgeon, and neonatologist must work in concert to safely position the endotracheal tube distal to the fistulous tract and avoid gastric distention caused by excessive positive-pressure ventilation, which may lead to sudden cardiovascular collapse.

  5. Midgut volvulus is torsion of the intestine around its mesentery that can result in strangulation of the bowel blood supply and infarction. Prompt diagnosis and surgical exploration are paramount to avoid extensive bowel necrosis. The anesthetist/anesthesiologist may be faced with hemodynamic instability from intravascular volume depletion and vasodilation, coagulopathy, and metabolic derangements (hyperglycemia, hyperkalemia).

  6. Anesthetic planning for a neonate presenting for intestinal atresia or abdominal wall defect surgery must consider the great variability seen in this patient population. The anesthesiologist must be thoroughly familiar with the neonate’s coexisting disease as planning for term neonates presenting for relatively simple gastroschisis reduction will differ greatly from staged giant omphalocele repairs in premature children with complex syndromes encompassing congenital heart disease and midface abnormalities.

  7. Necrotizing enterocolitis is a neonatal entity that carries high morbidity/mortality and represents a unique challenge to the anesthesiologist, as patients are often fragile premature neonates that develop sepsis, coagulopathy, and cardiopulmonary instability through the course of the disease process. The anesthesiologist, surgeon, and neonatologist must carefully consider the risks and benefits of proceeding with emergency surgery versus continued medical management.

  8. Early surgical correction of congenital diaphragmatic hernia has given way to aggressive medical management as predictors of survival depend on initial stabilization, reduction in ventilator associated lung injury, and management of secondary organ dysfunction. Neonates with congenital diaphragmatic hernia often require advanced pediatric life support systems such as inhaled nitric oxide, extracorporeal membrane oxygenation, and high-frequency ventilation to manage physiologic derangements.

  9. The Management of Myelomeningocele Study (MOMS Study), a multiple-institute, prospective, randomized trial comparing prenatal surgical repair before 26 weeks of gestation to standard postnatal repair, demonstrated a lower rate of ...

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