Neonatal Anesthesia

  • Chris Johnson
  • Dan Durack


A neonate is a baby in the first 4 weeks of life, and preterm neonates are those born at less than 37 weeks gestation. Based on weight, neonates have twice the metabolic rate, twice the minute ventilation and twice the cardiac output of adults. A neonate’s larynx in high in the neck to allow feeding while breathing. Because it is so high, flexing the neck during intubation (the sniffing position) does not improve the view of the larynx. Intubation is usually straightforward however, and videolaryngoscopes are now often used routinely. The control of respiration is poorly developed in preterm neonates, and they are prone to apnea after anesthesia. Neonates are also prone to hypoglycemia and usually receive 10% glucose with 0.2% saline while fasting. Additional isotonic fluid is given to replace losses of salt-rich body fluids. Fetal hemoglobin is the predominant type of hemoglobin at birth, falling to less than 1% of the total by 1 year of age. The high proportion of fetal hemoglobin is one reason a higher transfusion threshold is used in neonates. Most metabolic enzyme systems are immature at birth, affecting the doses of morphine, paracetamol and muscle relaxants among others, and increasing side effects from others, including propofol. Anesthesia is required for many different surgical procedures in neonates. Dealing with significantly smaller anatomy and more extreme proportions requires skill and appropriately sized equipment. Less robust physiology demands more care and attention to detail before during and after anesthesia. This cohort can also present with some unique pathology requiring equally specific surgery.


Endotracheal intubation, neonate Tracheo-esophageal fistula, anesthesia Neonatal apnea and anesthesia Neonatal pharmacology Neonatal laparotomy anesthesia 

Further Reading

  1. American Academy of Pediatrics. Age terminology during the perinatal period. Pediatrics. 2004;114:1362–4.CrossRefGoogle Scholar
  2. Davidson AJ. Apnea after awake regional and general anesthesia in infants. Anesthesiology. 2015;123:38–54.CrossRefGoogle Scholar
  3. de Graff JC. Intraoperative blood pressure levels in young and anaesthetised children: are we getting any closer to the truth? Curr Opin Anesthesiol. 2018;31:313–9.CrossRefGoogle Scholar
  4. Frawley G, Ingelmo P. Spinal anaesthesia in the neonate. Best Pract Res Clin Anaesthesiol. 2010;24:337–51.CrossRefGoogle Scholar
  5. Glass HC, et al. Outcomes for extremely premature infants. Anesthesiology. 2015;120:1337–51. An interesting article about what happens to the 10% of babies born preterm in the longer term.Google Scholar
  6. Jones LJ, et al. Regional (spinal, epidural, caudal) versus general anaesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy. Cochrane Database Syst Rev. 2015;6.
  7. Kair LR, et al. Bronchopulmonary dysplasia. Pediatr Rev. 2012;33:255–61.CrossRefGoogle Scholar
  8. Kurth CD, Cote CJ. Postoperative apnea in former preterm infants. Anesthesiology. 2015;123:15–7. This editorial nicely summarizes the postop apnea findings from the GAS study that compared the effect on neurodevelopment of general and spinal anesthesia.CrossRefGoogle Scholar
  9. Lissauer T, et al. Neonatology at a glance. 3rd ed. Massachusetts: Wiley-Blackwell; 2015.Google Scholar
  10. Lonnqvist P. A different perspective: anesthesia for extreme premature infants: is there an age limitation or how low should we go? Curr Opin Anesthesiol. 2018;31:308–12. An interesting discussion about ethics of caring for extremely sick infants, and some advance tips about anesthesia of neonates with NEC.CrossRefGoogle Scholar
  11. Sale SM. Neonatal apnoea. Best Pract Res Clin Anaesthesiol. 2010;24:323–36.CrossRefGoogle Scholar
  12. Vutskits L, Skowno J. Perioperative hypotension in infants: insights from the GAS study. Anesth Analg. 2017;125:719–20. An editorial discussing links between BP and cerebral oximetry.CrossRefGoogle Scholar
  13. Wolf AR, Humphry AT. Limitations and vulnerabilities of the neonatal cardiovascular system: considerations for anesthetic management. Pediatr Anesth. 2014;24:5–9. A detailed discussion of the cardiovascular system and physiology in neonates.CrossRefGoogle Scholar

Surgical Conditions

  1. King H, Booker PD. Congenital diaphragmatic hernia in the neonate. Contin Educ Anaesth Crit Care Pain. 2005;5:171–4.CrossRefGoogle Scholar
  2. Poddar R, Hartley L. Exomphalos and gastroschisis. Contin Educ Anaesth Crit Care Pain. 2009;9:48–51.CrossRefGoogle Scholar
  3. Rich BS, Dolgin SE. Necrotizing enterocolitis. Pediatr Rev. 2017;38:552–7. A good review article of medical aspects of NEC.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Chris Johnson
    • 1
  • Dan Durack
    • 2
  1. 1.Formerly Department of Anaesthesia and Pain ManagementPrincess Margaret Hospital for ChildrenSubiacoAustralia
  2. 2.Department of Anaesthesia and Pain ManagementPerth Children’s HospitalNedlandsAustralia

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