Best practice & research. Clinical anaesthesiology
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Postoperative apnoea in ex-premature infants is inversely proportional to gestational age at birth and postmenstrual age (PMA). Spinal anaesthesia is an important technique in ex-premature infants as it reduces the risk of postoperative apnoea, provided intra-operative sedation is avoided. ⋯ There are a variety of reasons why awake regional is not the preferred technique for ex-premature infants undergoing lower abdominal surgery in many centres, and there is also controversy over the appropriate anaesthetic technique for outpatient surgery in infants <60 weeks PMA. A pragmatic decision analysis on the selection of anaesthetic techniques for inguinal hernia repair in infants is presented.
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Best Pract Res Clin Anaesthesiol · Sep 2010
ReviewEvidence for the need for anaesthesia in the neonate.
Neonates are both capable of experiencing pain and memory formation, albeit implicit memory. During surgical procedures, insufficient ablation of the stress response and possible implicit memory formation of intra-operative events might result in adverse early and long-term outcomes. ⋯ It is thus the responsibility of the anaesthetist to provide sufficient anaesthesia for neonates undergoing surgery. A critical approach in weighing the risks and benefits of exposing a neonate to anaesthesia is prudent, and truly elective surgery should be delayed.
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Best Pract Res Clin Anaesthesiol · Sep 2010
ReviewUse of pharmaceuticals 'off-label' in the neonate.
Neonates are frequently not studied in the development of a novel pharmacological agent. With lack of data to support safe and effective use of a new agent in this population, sponsors will not receive approval for labelling the agent for use in this age group from the United States Food and Drug Administration (USFDA). This causes a significant conundrum for the clinician. ⋯ This article provides the clinician with an introductory understanding of the approval process of pharmaceuticals in the United States by USFDA. Models of clinical trial design are noted. Examples of anaesthetic and non-anaesthetic agents and their development and use are discussed as either 'labelled' or 'off-label' indications.
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Premature infants have immature respiratory control that predisposes them to apnoea, haemoglobin oxygen desaturation and bradycardia. Apnoeas are loosely classified, according to the presence or absence of respiratory effort, into central, obstructive or mixed. There are a variety of conditions, in the perioperative period, that predispose an infant to apnoea, including: central nervous system (CNS) lesions, infections and sepsis, ambient temperature fluctuations, cardiac abnormalities, metabolic derangements, anaemia, upper airway structural abnormalities, necrotising enterocolitis, drug administration (including opiates and general anaesthetics) and possibly gastro-oesophageal reflux. ⋯ There is some evidence of both short- and long-term complications of repeated apnoeas in the neonatal period, but the causal relationship is difficult to establish. Continuous positive airway pressure and caffeine therapy (up to 10 mg kg(-1)) are the most common treatments of neonatal apnoea. The less soluble volatile agents and regional anaesthetic techniques (without concurrent sedation) are associated with a lower incident of postoperative apnoea.
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Best Pract Res Clin Anaesthesiol · Sep 2010
ReviewTracheo-oesophageal fistula (TOF) and oesophageal atresia (OA).
Tracheo-oesophageal fistula (TOF) and oesophageal atresia (OA) represent a series of anatomical abnormalities presenting for emergency surgery in the neonatal period. They present the anaesthetist with cardio-respiratory challenges in the preoperative, intra-operative and postoperative phases. ⋯ The basic science, anatomy and genetics are discussed as well as the clinical presentation, perioperative management, controversies and complications. The evidence for optimum management is based mostly on expert opinion; there are very few large randomised controlled trials concerning many areas of perioperative management.