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Year : 2019  |  Volume : 63  |  Issue : 9  |  Page : 771-779  

Anaesthetic concerns in preterm and term neonates

Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication12-Sep-2019

Correspondence Address:
Dr. Rajeshwari Subramaniam
Department of Anesthesiology, Pain Medicine and Critical Care, Room 5009, 5th Floor Teaching Block, All India Institute of Medical Sciences, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ija.IJA_591_19

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Anaesthesia for neonates is a composite of good knowledge of neonatal and transitional physiology combined with skill in airway maintenance and vascular access. When the newborn is a preterm, the complexities of management increase due to the small size and accompanying issues such as bronchopulmonary dysplasia and apnoea. World over, the number of survivors of preterm birth is on the increase. We searched Pubmed for “Anesthesia, apnea, neonatal, neonates, physiology, preterm, spinal anesthesia”, as well as cross references from review articles. These babies have a high incidence of conditions warranting surgery (e.g., tracheoesophaeal fistula, congenital diaphragmatic hernia, anorectal malformations, incarcerated hernia, necrotising enterocolitis). The possibility of neurodevelopmental harm by anaesthetics is currently the topic of active research. In parallel, advances in paediatric anaesthesia equipment, use of regional and neuraxial anaesthesia and availability of monitoring have steadily increased the safety of anaesthesia in these tiny patients.

Keywords: Anaesthesia, apnoea, GAS study, neonatal, neonates, neurodevelopmental issues, outcomes, physiology, preterm, spinal anaesthesia

How to cite this article:
Subramaniam R. Anaesthetic concerns in preterm and term neonates. Indian J Anaesth 2019;63:771-9

How to cite this URL:
Subramaniam R. Anaesthetic concerns in preterm and term neonates. Indian J Anaesth [serial online] 2019 [cited 2020 Sep 23];63:771-9. Available from: http://www.ijaweb.org/text.asp?2019/63/9/771/266810

   Introduction Top

The perioperative anaesthetic management of neonates is challenging even for experienced anaesthesiologist. Their small size [Figure 1] calls for skill in vascular access and airway management, and their vulnerability to respiratory and cardiac events and their immature physiological adaptation need vigilance, rapid detection and correction.[1] There are additional problems of the transitional circulation, increased presence of co-morbidities and, importantly, the occurrence of apnoea in preterms. Neonatal surgery is associated with higher mortality than older children.[2] The possible neurotoxic effect of anaesthetics on the developing neonatal brain is the subject of active research (GAS, PANDA).[3],[4]
Figure 1: A 800-g premature infant positioned for tracheoesophaeal fistula repair

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   History of Paediatric Anaesthesia Top

Till the 1980s, it was assumed that neonates feel little or no pain due to immaturity of the nervous system and it was customary to omit the use of narcotics in neonatal anaesthesia. The Liverpool technique popularised by Jackson Rees used oxygen–nitrous oxide, muscle relaxant and volatile agent for even lengthy procedures without narcotics. Seminal research by Anand et al. showed that neonates have dynamic physiologies and feel and respond to noxious stimuli. Perioperative stress has been related to unfavourable postoperative outcomes in neonates undergoing cardiac surgery.[5] Intrauterine exchange transfusions performed through the innervated abdominal wall of the foetus result in a greater neuroendocrine stress response compared with puncture of the non-innervated umbilical cord.[6]

   American Association of Pediatrics (AAP) Definition Top

The postmenstrual age (PMA) which is the sum of the gestational age ( first day of last menstrual period to date of delivery) and chronological age (from date of birth to present) is recommended by the American Association of Pediatrics (AAP)[7] for contemporary use [Figure 2]. The terms 'post-conceptional' age (PCA) and postmenstrual age are often used interchangeably.
Figure 2: AAP definition of age of neonates and preterms

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Premature babies are defined as those born before 37 weeks gestation and account for about 10-13% of total births in Western literature. The terminology of neonates and preterms [Table 1] is based on either gestational age or weight.[8]
Table 1: Nomenclature used for classification of neonates and preterm babies

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Relevant points in the physiology of neonates and preterm infants [9],[10],[11],[12],[13],[14],[15] are outlined in [Table 2].
Table 2: Physiology in the neonate and preterm infant[9],[10],[11],[12],[13],[14],[15]

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Apnoea of the preterm/neonate

Periodic breathing with pauses is common in neonates and preterms. Apnoea is pathological when >20 s, or <20 s with bradycardia (30 beats/min/20% decline from resting heart rate), or with cyanosis, pallor, or hypotonia.[13],[16] The incidence of apnoea varies from 25% in LBW premature to 84% in the VLBW group. Apart from active inhibitory reflexes and anaemia, which is a proven risk factor, other contributory factors are listed in [Table 3].
Table 3: Factors contributing to/associated with apnoea of the newborn

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The incidence of apnoea becomes less than 1% only after PCA of 54-56 weeks is reached, thus necessitating admission and overnight monitoring of infants <60 weeks PMA.[17] The contributing factors related to postoperative apnoea can also be used as indicators of overnight monitoring and admission.[18]

Caffeine and apnoea

Administration of 5/10 mg/kg caffeine IV preoperatively significantly reduces postoperative apnoea.[19] Caffeine stimulates the respiratory center and cardiovascular system, enhances responsiveness to CO2, increases diaphragmatic contractility, minute ventilation oxygen consumption and metabolic rate.[20] A reduction in duration of CPAP has been observed.[21],[22] Neurodevelopmental outcomes may be improved and motor impairment reduced by protection of white matter.[23],[24] However caffeine administration has been seen to result in lower weight gain and increased incidence of death.[25],[26] A recent study advocated its administration to only infants weighing <1250 g.[27]

Preoperative evaluation

It is important to keep the parents of the infant updated regarding the condition of their child and the perioperative plan. The reasons for operation and the risks anticipated should be explained. Appropriate consent should be obtained for invasive procedures, regional anaesthesia (RA), blood transfusion and need of postoperative ventilation.

The history, apart from gestational age, current age and weight, should include salient perinatal history, for example, APGAR scores, birth asphyxia, meconium aspiration, septicaemia, requirement of oxygen therapy, high frequency oscillatory ventilation, mechanical ventilation, hypoglycaemic episodes and seizures. Evidence of congenital cardiac disease, if diagnosed, should be noted. The presence of significant ductal flow/persistent fetal circulation/decompensation should be documented. Intramuscular Vit K should be administered. Fasting status should be confirmed (2 h for clear fluids, 4 h for breast milk and 6 h for formula feed). Surgical colleagues should be consulted for concerns regarding surgery with respect to timing, duration, blood loss and postoperative support. This is especially important when the premature infants are operated upon by specialists other than paediatric surgeons [e.g., ophthalmic surgery for retinopathy of prematurity (ROP)].

The infant should be examined for any obvious syndromic facies which can portend airway difficulties. Careful observation for signs of respiratory distress (alar flaring, intercostal/subcostal recessions/tachypnoea) is important; capillary fill, color and turgor of skin, presence of mottling, moistness of mucosa (tongue) and BP indicate adequacy of volume status. Dehydration, if present, should be aggressively corrected.

Careful auscultation should be performed for cardiac murmurs and lung fields. Airway patency and stability should be ascertained. If the infant is on a ventilator, the settings should be noted, along with a recent arterial blood gas and chest X-ray to verify the tube position. The adequacy of vascular access is very important. The functioning and patency of current IV/arterial access devices should be noted; if vascular access is inadequate for the planned procedure, a plan should be made for central vascular access after induction of anaesthesia. All infusions and rates should be noted. All IV/arterial catheters should be protected as they are notorious to get misplaced.

Laboratory and other investigations: The 'normal' values for a neonate

All preoperative laboratories should be scrutinised. Anaemia should be corrected. Low platelet counts and increased international normalised ratio should prompt evaluation and correction of coagulopathy. The electrolytes and acid base status should be optimised. Special attention is to be paid to the potassium levels to avoid inadvertent hyperkalaemia with transfusion. Hypoglycaemia, hyponatraemia, hypernatraemia, hyperkalaemia, hypocalcaemia and hypomagnesaemia are all common in premature infants.[10] The glucose levels with the current infusion composition and rate should be noted. Packed red blood cells should be arranged for anemic infants and where surgical losses are expected [Figure 3]. Cranial/spinal/renal ultrasound/echocardiography results should be available in specific cases.
Figure 3: Preterm infant with large sacrococcygeal teratoma

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It is extremely important to check whether appropriate airway equipment, with back-up devices, are in place prior to commencing the induction of the neonate or preterm infant.

Facemasks with minimum dead space and oropharyngeal airways should be available. The sizes of the oropharyngeal airways are 000-00 for preterms and 0 for term neonates.

Conventional laryngoscopes, with straight/curved blades of right size, should be ready, as also videolaryngoscopes. Videolaryngoscopes, especially C-MAC have greatly facilitated intubation in preterms and small babies [Figure 4]. Endotracheal tubes with correct sized stylets should be available. Choice of appropriate tube size is provided in [Table 4].
Figure 4: Intubating a preterm infant using C-Mac videolaryngoscope

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Table 4: Endotracheal tube size and length based on weight

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Anaesthesia circuits

Although the paediatric circle system can be used in babies weighing 1 kg (workstations can deliver tidal volumes ≤10 ml), a survey showed that the modified Mapleson E is still the preferred system used by UK members of the APA for smaller children.[28] However, its use has become less now because of concerns of atmospheric pollution and availability of ventilators.

Warming of the operation room

Heat loss is a major concern in the term and preterm neonates. The lack of keratin in the preterm's skin enhances heat loss. The operation room (OR) should be warmed to 27°C before receiving the baby.[12] All exposed parts should be covered with waterproof dressing ('cling wrap' or foil). A warming mattress and forced air warming must be available. IV fluids and inspired gases should be humidified and warmed.


Standard monitoring should be in place. All inotrope infusions, if in use, should be connected, as also glucose-containing fluids, to prevent any deterioration during induction, especially in sick babies coming from the NICU. A pulse oximeter should be applied wherever a satisfactory trace is obtained. When the status of the transitional circulation needs monitoring, both preductal (in the right hand) and post-ductal probes should be applied. A BP cuff is mandatory. A precordial stethoscope is a cheap and minimally invasive method to monitor hypovolaemia by the muffling of heart sounds. If an arterial line is placed, adequate distal perfusion should be ensured. The temperature probes are placed in the oesophagus or rectum, and over the skin.

Drug preparation

A saline flush should be drawn up to flush IV lines and drugs. The doses of induction agent, narcotic and muscle relaxant should be precalculated before the infant arrives in the OR. It is good practice to keep the 'stock' syringes well out of the way so that 1 mL and 2 mL syringes containing the appropriate amount of drugs are available, and overdosing can be avoided. The fluid volumes given with drugs should be recorded. The doses should be double-checked, especially neuraxial drugs and opioids. The emergency drugs should be drawn up in appropriate doses and concentration. These include atropine (20 μg/kg), suxamethonium (1–2 mg/kg) and adrenaline (10 μg/kg, i.e., 0.1 mL/kg of 1:10,000 adrenaline).


In the absence of IV access, sevoflurane is the inhalational agent of choice in neonates, due to the absence of airway irritation and relative cardiostability. It should be remembered that the high cardiac output combined with rapid respiratory rate makes for a rapid induction. Enhanced alveolar ventilation facilitates inhalational agent uptake. The minimum alveolar concentration (MAC) is reduced in preterms and peaks at 1–6 months.[11] Sevoflurane upward of 6% can cause apnoea in the neonate. The term/preterm infant may need assistance during induction, and the inhalational agent concentration should be kept at a lower range (e.g., sevoflurane 2%–3%). The immature myocardium is exquisitely sensitive to the depressant effects of volatile anaesthetic agents. Atropine premedication (20 μg/kg) is advisable to counter bradycardia at induction.

If IV access is present, ketamine 2 mg/kg or thiopentone 3–4 mg/kg may be administered, keeping in mind that the neonate may become apnoeic, and the practitioner should be facile at maintaining the airway. Rapid sequence intubation (RSI) is controversial in small babies and rarely used. Propofol is occasionally used in term babies. Tracheal intubation is usually carried out after administering atracurium (and fentanyl/sufentanil), which makes for a smooth and atraumatic intubation.[29] Smearing the laryngeal inlet and epiglottis with lignocaine gel using the operator's little finger may facilitate an 'awake look' or awake intubation in infants where there is a concern for securing the airway, for example, in syndromic infants. The choice of appropriate tube size is provided in [Table 1].

The tube should be securely taped and note made of the depth of insertion in case it needs to be changed at any time in the perioperative period.

With the availability of paediatric size supraglottic devices, these are now being routinely used for airway management especially during ophthalmologic procedures for ROP.[30],[31] Both sevoflurane and desflurane are useful volatile agents for maintenance of anaesthesia.[32],[33]

Fluid therapy

The prepared fluid lines should be meticulously de-aired. The normal rates of infusion for a preterm are 100 mL/kg/24 h (4–5 mL/kg/h) and should contain dextrose. Operative losses should be replaced with lactated Ringer's or Plasmalyte (i.e., isotonic solutions).[34]

The recommended estimates for replacement are 1–2 mL/kg/h for superficial surgery, 4–7 mL/kg/h for thoracotomy and 5–10 mL/kg/h for abdominal surgery (from the APA consensus Guidelines on Perioperative Fluids Management in Children, 2007).[35] It is important to prevent both hyperglycaemia and hypoglycaemia [36] as both have disastrous consequences. The fluids may need to be restricted to reduce oedema in gastroschisis.[37]

Third-space losses are often difficult to estimate. Tachycardia, diminished heart sounds, hypotension, increased core-peripheral temperature gradient and delayed capillary refill should alert the anaesthesiologist for hypovolemia. Although good urine output is very reassuring, small volumes (0.5–2 mL/kg/h) may be difficult to measure. The position of the dicrotic notch on an arterial trace, pulse pressure variation and area under the arterial trace may be used as approximates of fluid volume and perfusion.

Spinal anaesthesia in the neonate and preterm infants

There has been a revival of interest in spinal anaesthesia [38],[39],[40] since the survival rate of extremely pre-term infants has increased. A significant number (11-40%) of ex-premature infants, develop inguinal hernia and other surgical conditions which can be managed by spinal anaesthesia [Table 5].[41],[42] General anaesthesia (GA) has been associated with high incidence of postoperative apnoea, bradycardia, desaturation and requirement of prolonged post operative mechanical ventilation in premature infants undergoing hernia repair,[42],[43],[44],[45],[46] which may be significantly low with spinal anaesthesia.[47]
Table 5: Indications for spinal anaesthesia

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The preterm and neonatal spines have one primary anterior concave curvature, and the lumbar and cervical lordosis are absent.[48] This 'straight' spine predisposes the neonate and preterm infant to high spinal blockade with small changes in position, for example, lifting the feet up to place the diathermy earthing pad.

The spinal cord ends between L2 and L3 vertebrae in 90% of premature infants and between L1 and L2 vertebrae in 92% of term infants. The dural sac is at the S4 level at birth and reaches the S2 level by the end of the first year [Figure 5]. The intercristal line crosses at the L5–S1 interspace at birth and the L5 vertebra in young children and is a safe landmark to prevent cord injury.[48]
Figure 5: Preterm/neonate spine: cord ends L3, dural sac ends at S4; Spine at 1 year: cord ends at L1, dural sac ends at S2

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The neonate may be kept in the lateral decubitus or sitting position [Figure 6]. The sitting position provides better view of the landmarks and increases CSF pressure. It is important to keep the head extended to prevent airway obstruction. A 450 head-up tilt has also been reported to result in better success and fewer bloody taps especially in infants.[48],[49] Effect of the block can be judged by lack of response to pinch/tetanic stimulus. Absence of hip flexion indicates a block of L1.
Figure 6: Infant held in sitting position for spinal anaesthesia

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Drugs and doses

Infant dose of bupivacaine for inguinal hernia repair is 0.6–1 mg/kg, which is roughly two to three times the adult requirement (0.17–0.2 mg/kg). This is because of the larger volume of circulation (CSF volume in infants is 4 mL/kg, double that of the adult) and rapid drug clearance (high heart rate and cardiac output result in greater flow and turnover).

The various drugs used are hyperbaric bupivacaine (0.75% bupivacaine with 8.75% dextrose at 0.6 mg/kg), isobaric bupivacaine (0.8 mg/kg) with or without epinephrine and 1% tetracaine with 10% dextrose (in equal volume) with the addition of 0.02 mL of 1:1000 epinephrine.[48] Levobupivacaine and ropivacaine are 30%–40% less potent at the ED50 values of bupivacaine. The addition of hyperbaric dextrose increases the success rate and prolongs the duration of the block. Other additives that prolong the duration of action are epinephrine (1:200,000), clonidine (1 μg/kg), fentanyl (0.25–1 μg/kg) and neostigmine (1 μg/kg). Clonidine and fentanyl may result in sedation and respiratory depression necessitating bag-mask ventilation or intubation.

The distance from skin to epidural space is about 6 mm at birth, increasing to 10–12 mm at 1 year. It has also been estimated at 1 mm/kg. Paediatric spinal needles range from 22 to 29 G. Quincke, Sprotte and Whitacre variations are available. It is recommended to use styletted needles to avoid introduction of the epidermal tissue into the spinal canal leading to formation of epidermoid tumors.[48] The effect of the block can be judged by the lack of response to pinch/tetanic stimulus. The absence of hip flexion indicates a block of L1.

Adverse effects of spinal anaesthesia

Haemodynamic depression is uncommon.[50] Reported adverse sequelae include failure, inadvertent high blockade due to the change in position and respiratory depression consequent to the addition of clonidine/fentanyl or IV sedative supplementation. The presence of BPD and leukomalacia may result in apnoea/delayed discharge;[51] some series report significant failures.[52]

The GAS study cohort was also analyzed for failure rates of RA. This analysis noted that RA was sufficient for surgery in more than 80% of cases, spinal having a higher success rate compared with combined spinal–caudal technique.[53] A bloody tap was associated with block failure.

The 'GAS' (GA versus spinal) study

This was a multi-center RCT comparing regional vs. GA for effects on neurodevelopmental outcome and apnoea at 12 hours in 780 premature and ex-premature infants undergoing hernia repair.[3] Although less than 1 h of sevoflurane anaesthesia did not increase the risk of adverse neurodevelopmental outcome at 2 years and at 5 years of age compared with awake-regional anaesthesia, regional anaesthesia was associated with less hypotension than sevoflurane and less early apnoea.[54],[55]


The steady increase in survivors of premature birth has led to an increase in such infants presenting for surgery. The immature cardiovascular system, the predisposition of the respiratory system to BPD and apnoea, and airway issues such as tracheomalacia and stenosis in these small infants call for expertise in management. Neuraxial blocks in preterms and neonates are well-established. Airway management is now easier due to the availability of appropriate size videolaryngoscopes. The effect of GA on the developing brain is still the subject of research, although preliminary reports indicate no neurodevelopmental adverse effect of sevoflurane used for 1–2 h.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Kuratani N. The cutting edge of neonatal anesthesia: The tide is changing. J Anesth 2015;29:1-3.  Back to cited text no. 1
Houck CS, Vinson AE. Anesthetic considerations for surgery in newborns. Arch Dis Child Fetal Neonatal Ed 2017;102:F359-63.  Back to cited text no. 2
Davidson AJ, Morton NS, Arnup AJ, de Graaff JC, Disma N, Withington DE, et al. Apnea after awake regional and general anesthesia in infants: The general anesthesia compared to spinal anesthesia study—Comparing apnea and neurodevelopmental outcomes, a randomized controlled trial. Anesthesiology 2015;123:38-54.  Back to cited text no. 3
Sun LS, Li G, Miller TL, Salorio C, Byrne MW, Bellinger DC, et al. (The Pediatric Anesthesia Neuro Development Assessment (PANDA) study group): Association between a single general anesthesia exposure before age 36 months and neurocognitive outcomes in later childhood. JAMA 2016;315:2312-20.  Back to cited text no. 4
Anand KJ, Hansen DD, Hickey PR. Hormonal-metabolic stress responses in neonates undergoing cardiac surgery. Anesthesiology 1990;73:661-70.  Back to cited text no. 5
Lonnqvist PA. Regional anaesthesia and analgesia in the neonate. Best Pract Res Clin Anaesth 2010;24:309-21.  Back to cited text no. 6
Blackmon LR, Batton DG, Bell EF, Denson SE, Engle WA, Kanto WP, et al. Age terminology during the perinatal period. Pediatrics 2004;114:1362-4.  Back to cited text no. 7
Glass HC, Costarino AT, Stayer SA, Brett CM, Cladis F, Davis PJ. Outcomes for extremely premature infants. Anesth Analg 2015;120:1337-51.  Back to cited text no. 8
Pribul V. Anaesthesia for the pre-term infant. Anaesthesia Tutorial Of The week (Journal on the Internet) 2012 May;259: 1-7. Available from: https://www.frca.co.uk/Documents/259%20Anaesthesia%20for%20the%20Pre-term%20Infant.pdf. [Last cited on 2019 Aug 28].  Back to cited text no. 9
Berg S. Special considerations in the premature and ex-premature infant. Anaesth Int Care Med 2005;6:81-3.  Back to cited text no. 10
Martin LD. The basic principles of anesthesia for the neonate. Rev Columb Anestesiol 2017;45:54-61.  Back to cited text no. 11
Peiris K, Fell D. The prematurely born infant and anaesthesia. CEACCP 2009;9:73-7.  Back to cited text no. 12
Bang SJ. Neonatal anesthesia: How we manage our most vulnerable patients. Korean J Anesthesiol 2015;68:434-41.  Back to cited text no. 13
Wolf AR. Ductal ligation in the very low birth weight infant. Simple anesthesia or extreme art? Pediatr Anesth 2012;22:558-63.  Back to cited text no. 14
Arnold PD. Coagulation and the surgical neonate. Pediatr Anesth 2014;24: 89-97.  Back to cited text no. 15
Liu LM, Cote CJ, Goudsouzian NG, Ryan JF, Firestone S, Dedrick DF, et al. Life-threatening apnea in infants recovering from anesthesia. Anesthesiology 1983;59:506-10.  Back to cited text no. 16
Cote CJ, Zaslavsky A, Downes JJ, Kurth CD, Welborn LG, Warner LO, et al. Post operative apnea in former preterm infants after inguinal herniorraphy. Anesthesiology 1995;82:809-22.  Back to cited text no. 17
Massoud M, Kuhlmann AY, van Dijk M, Staals LM, Wijnen RM, van Rosmalen J, et al. Does the incidence of postoperative complications after inguinal hernia repair justify hospital admission in prematurely and term born infants? Anesth Analg 2019;128:525-32.  Back to cited text no. 18
Welborn LG, de Soto H, Hannallah RS, Fink R, Ruttimann UE, Boeckx R. The use of caffeine in the control of post anesthetic apnea in former premature infants. Anesthesiology 1988;68:796-8.  Back to cited text no. 19
Abdel-Hady H, Nasef N, Shabaan AE, Nour I. Caffeine therapy in preterm infants. World J Clin Pediatr 2015;4:81-93.  Back to cited text no. 20
Schmidt B, Roberts RS, Davis P, Doyle LW, Barrington KJ, Ohlsson A, et al. Caffeine therapy for apnea of prematurity. N Engl J Med 2006;354:2112-21.  Back to cited text no. 21
Henderson–Smart DJ, Subramaniam P, Davis PG. Continuous positive airway pressure versus theophylline for apnea in preterm infants (Review). Cochrane Database Syst Rev 2001:CD001072.  Back to cited text no. 22
Abu-Shaweesh JM, Martin RJ. Caffeine use in the neonatal intensive care unit. Semin Fetal Neonatal Med 2017;22:342-7.  Back to cited text no. 23
Schmidt B, Roberts RS, Anderson PJ, Asztalos EV, Costantini L, Davis PG, et al. Academic performance, motor function, and behavior11 years after neonatal caffeine citrate therapy for apnea of prematurity An 11-Year Follow-up of the CAP randomized clinical trial. JAMA Pediatr 2017;171:564-672.  Back to cited text no. 24
Dobson NR, Patel RM, Smith PB, Kuehn DR, Clark J, Vyas-Read S, et al. Trends in caffeine use and association between clinical outcomes and timing of therapy in very low birth weight infants. J Pediatr 2014;164:992-8.  Back to cited text no. 25
Henderson-Smart DJ, Steer PA. Prophylactic caffeine to prevent postoperative apnoea following general anaesthesia in preterm infants. Cochrane Database Syst Rev. 2001;CD000048.  Back to cited text no. 26
Fakoor Z, Makooie AA, Joudi S, Asl RG. The effect of venous caffeine on the prevention of apnea of prematurity in the very preterm infants in the neonatal intensive care unit of Shahid Motahhari Hospital, Urmia, during a year. J Adv Pharm Technol Res 2019;10:16-19.  Back to cited text no. 27
[PUBMED]  [Full text]  
Marsh DF, Mackie P. National survey of pediatric breathing systems use in the UK. Pediatr Anesth 2009;19: 477-80.  Back to cited text no. 28
Durrmeyer X, Dahan, S Delorme P, Blary S, Dassieu G, Caeymaex L, et al. Assessment of atropine-sufentanil-atracurium anaesthesia for endotracheal intubation: An observational study in very premature infants. BMC Pediatr 2014;14:120-8.  Back to cited text no. 29
Velankar P, Joshi M, Sahu P. Use of laryngeal mask airway in premature infant. Indian J Anaesth 2013;57:634-5.  Back to cited text no. 30
[PUBMED]  [Full text]  
Sinha R, Talawar P, Ramachandran R, Azad RV, Mohan VK. Perioperative management and post operative course in preterm infants undergoing vitreo-retinal surgery for retinopathy of prematurity: A retrospective study. J Anaesth Clin Pharmacol 2014;30:258-62.  Back to cited text no. 31
O'Brien K, Robinson DN, Morton NS. Induction and emergence in infants less than 60 weeks post conceptual age: Comparison of thiopentone, halothane, sevoflurane and desflurane. Br J Anaesth 1998;80:456-9.  Back to cited text no. 32
Sale SM, Read JA, Stoddart PA, Wolf AR. Prospective comparison of sevoflurane and desflurane in formerly premature infants undergoing inguinal herniotomy. Br J Anaesth 2006;96:774-8.  Back to cited text no. 33
Lonnqvist PA. Fluid management in association with neonatal surgery: Even tiny guys need their salt. Br J Anaesth 2014;112:404-6.  Back to cited text no. 34
APA consensus guideline on perioperative fluid management in Children v 1.1 September 2007 © APAGBI Review Date August 2010.  Back to cited text no. 35
Visram AR. Intra operative fluid therapy in neonates. S Afr J Anaesth Analg 2016;22:46-51.  Back to cited text no. 36
Bonasso II PC, Lucke-Wold B, Hobbs GR, Vaughan RA, Shorter NA, Nakayama DK. Excessive post operative fluid administration in infants with gastroschisis. Am Surg 2016;82:704-6.  Back to cited text no. 37
Abajian JC, Mellish RW, Browne AF, Perkins FM, Lambert DH, Mazuzan JE. Spinal anesthesia for surgery in the high risk infant. Anesth Analg 1984;63:359-62.  Back to cited text no. 38
Frumiento C, Abajian JC, Vane DW. Spinal anesthesia for preterm infants undergoing inguinal hernia repair. Arch Surg 2000;135:445-51.  Back to cited text no. 39
Kachko L, Simhi E, Tzeitlin E, Efrat R, Tarabikin E, Peled E, et al. Spinal anesthesia in neonates and infants-a single-centre experience of 505 cases. Pediatr Anesth 2007;17:647-53.  Back to cited text no. 40
Ahmad N, Greenaway S. Anaesthesia for inguinal hernia repair in the newborn or ex-premature infant. BJA Education 2018;18:211-7.  Back to cited text no. 41
Gregory GA, Steward DJ. Life-threatening perioperative apnea in the 'ex-premie'. Anesthesiology 1983;59:495-8.  Back to cited text no. 42
Welborn LG, Rice LJ, Hannallah RS, Broadman LM, Ruttimann UE, Fink R. Post operative apnea in former preterm infants: Prospective comparison of spinal and general anesthesia. Anesthesiology 1990;72:838-42.  Back to cited text no. 43
Somri M, Gaitini L, Vaida S, Collins G, Sabo E, Mogilner G. Postoperative outcome in high-risk infants undergoing herniorrhaphy: Comparison between spinal and general anaesthesia. Anaesthesia 1998;53:762-6.  Back to cited text no. 44
Krane EJ, Haberkern CM, Jacobson LE. Postoperative apnea, bradycardia, and oxygen desaturation in formerly premature infants: Prospective comparison of spinal and general anesthesia. Anesth Analg 1995;80:7-13.  Back to cited text no. 45
Kim GS, Song JG, Gwak MS, Yang M. Postoperative outcome in formerly premature infants undergoing herniorrhaphy: Comparison of spinal and general anesthesia. J Korean Med Sci 2003;18:691-5.  Back to cited text no. 46
Jones LJ, Craven PD, Lakkundi A, Foster JP, Badawi N. Regional (spinal, epidural, caudal) versus general anaesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy (Review). Cochrane Database Syst Rev 2015:CD003669.  Back to cited text no. 47
Frawley G, Ingelmo P. Spinal anaesthesia in the neonate. Best Pract Res Clin Anaesth 2010;24:337-51.  Back to cited text no. 48
Apiliogullari S, Duman A, Gok F, Ogun CO, Akillioglu I. The effects of 45° head up tilt on the lumbar puncture success rate in children undergoing spinal anesthesia. Pediatr Anesth 2008;18:1178-82.  Back to cited text no. 49
Oberlander TF, Berde CB, Lam KH, Rappaport LA, Saul JP. Infants tolerate spinal anesthesia with minimal overall autonomic changes: Analysis of heart rate variability in former premature infants undergoing hernia repair. Anesth Analg 1995;80:20-7.  Back to cited text no. 50
Shenkman Z, Erez I, Freud E, Arnon S. Risk factors for spinal anesthesia in preterm infants undergoing inguinal hernia repair. J Pediatr (Rio J) 2012;88:222-6.  Back to cited text no. 51
Williams JM, Stoddart PA, Williams SA, Wolf AR. Post-operative recovery after inguinal herniotomy in ex-premature infants: Comparison between sevoflurane and spinal anaesthesia. Br J Anaesth 2001;86:366-71.  Back to cited text no. 52
Frawley G, Bell G, Disma N, Withington DE, deGraaff JC, Morton NS, et al. Predictors of failure of awake regional anesthesia for neonatal hernia repair: Data from the General Anesthesia compared to Spinal anesthesia (GAS) study: Comparing apnoea and neurodevelopmental outcomes. Anesthesiology 2015;123:55-65.  Back to cited text no. 53
McCann ME, Withington DE, Arnup SJ, Davidson AJ, Disma N, Frawley G, et al. Differences in blood pressure in infants after general anesthesia compared to awake regional anesthesia (GAS study-a prospective randomized trial). Anesth Analg 2017;125:837-45.  Back to cited text no. 54
McCann ME, de Graaff JC, Dorris L, Disma N, Withington D, Bell G, et al. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): An international, multicentre, randomised, controlled equivalence trial. Lancet 2019;393:664-77.  Back to cited text no. 55


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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