Chapter 19

1. It is our belief that, except for extraordinary circumstances, all newborns require anesthesia for surgery.

2. Maternal factors associated with increased perinatal risk include hypertension, diabetes, prolonged rupture of membranes, drug abuse (tobacco, alcohol, opioids, amphetamines) and use (antipsychotics, antidepressants, anticonvulsants), collagen vascular disease, and maternal infection (prolonged rupture of membranes) or inflammation.

3. Small for gestational age and large for gestational age babies often have glucose homeostatic instability and require 10% glucose infusions to maintain normoglycemia (45-100 mg/dL).

4. The definition of prematurity is an infant born at less than 37 weeks of gestation.

5. The younger the infant, the more fragile the neurologic, pulmonary, and gastrointestinal systems and the more likely the severity of complications.

6. The presence of 1 congenital anomaly should always alert the anesthesiologist to the potential for others.

7. It is always a good idea to check this site (http://www.ncbi.nlm.nih.gov/omim) before the induction of anesthesia, particularly if you are unfamiliar with the syndrome, defect, or malformation and/or its anesthetic implications.

8. A good rule of thumb to remember is that the presence of any midline defect is almost always associated with another defect.

9. The newborn is an obligate nose breather.

10. The narrowest part of the infant's airway is at the level of the cricoid ring and not the vocal cords.

11. The weight in kilograms + 6 is where the endotracheal tube in centimeters should be taped at the lip.

12. Increasingly, cuffed endotracheal tubes are being used even in the newborn, particularly in situations in which aspiration of gastric content or poor lung compliance makes ventilation with an uncuffed endotracheal tube difficult.

13. Oxygen consumption in the newborn is 2 to 3 times that of older children and adults.

14. A history of prematurity (ie, <37 weeks postconceptual age) or apnea must alert the anesthesiologist to possible respiratory compromise in the postoperative period, particularly if an opioid, vapor, or ketamine are used during anesthesia. Indeed, premature infants are at risk of developing postanesthetic apnea for weeks after birth (48-60 weeks postconceptual age) and require overnight admission to a high-surveillance in-hospital care unit regardless of the surgical procedure performed.

15. Arterial hypoxemia, hypercarbia, hypothermia, pain, or acidosis will reverse this transitional circulation and restore the fetal circulatory pattern and is referred to as persistent fetal circulation or persistent pulmonary hypertension of the newborn.

16. An intravenous infusion of prostaglandin E1 to maintain the patency of the ductus arteriosus may be life-sustaining in these ductal-dependent patients.

17. The newborn's myocardium is less compliant than that of the adult or older child, and cardiac output is primarily heart rate dependent.

18. The most common cause of bradycardia in the newborn is hypoxia, and in the operating room, unexplained bradycardia should always be considered to be due to hypoxia until proven otherwise.

19. The central nervous system is the least mature major organ system at birth. This structural immaturity predisposes the newborn to certain risks, including intraventricular hemorrhages, seizures, respiratory depression, hypoxic–ischemic injury, and retinopathy of the premature.

20. Intraventricular hemorrhage, in which subependymal hemorrhage occurs, is now the leading cause of death and morbidity in premature infants.

21. Evaporative heat loss is the major source of heat loss in the perioperative period.

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