ABSTRACT
Perioperative anesthetic management of the neonate with hypoxic respiratory failure (HRF) is a complex undertaking associated with a high risk of morbidity and mortality. Prematurity, more complex surgery, coexisting comorbidities, and the development of pulmonary hypertension are additional factors that increase risk. The challenge for neonatal anesthesia is to mitigate the pain and neurohumoral stress response to surgery and maintain cardiorespiratory function in a population with underlying respiratory instability, immature pharmacologic responses, and limited functional reserve. A rational approach to perioperative management must incorporate a clear understanding of the underlying pathophysiology with current evidence-based recommendations regarding noninjurious ventilation and hemodynamic support during the dynamic alterations in cardiorespiratory function anticipated with transport, anesthesia, and the proposed surgical intervention. This review synthesizes recent literature pertaining to perioperative risk, approaches to intraoperative mechanical ventilation, and options for anesthetic and hemodynamic management in the neonate with HRF during surgery. Concern regarding potential anesthesia-associated neurotoxicity has promoted greater focus on the conduct of safe neonatal anesthesia practice but rigorous evidence regarding optimal anesthetic agent combinations, techniques, perioperative ventilation approaches, and cardiovascular support for the neonate with HRF is limited. Collaborative research efforts combining insights from neonatal intensive care, surgery, and anesthesia will be required to improve outcomes in this highly vulnerable population.
