Anatomical & Physiological

Concerns In Neonatal
Anaesthesia
Ranju Singh
Director Professor
Department of Anaesthesiology
Lady Hardinge Medical College & Associated Hospitals
New Delhi
 Why This Is Important ?
• Newborn period is defined as the 1st 24 hrs after birth & the neonatal period
is defined as the 1st 30 days

• Anesthesia-related morbidity & mortality is higher in children than adults &

more in younger compared to older children

• Infants & young children ARE NOT SMALL ADULTS

• "ONE SIZE FITS ALL" does not apply

• Successful & safe anaesthetic management depends on appreciation & clear

understanding of the anatomical & physiologic differences
 Learning Objectives

• To enumerate the anatomical & physiological characteristics of a neonate

• To understand the difference from an adult

• To describe how these changes are clinically relevant

• To describe how these influence the conduct of anesthesia

 Neonatal Airway

Different & Complex

 Difference Between Neonatal & Adult Airway
Head Large head, short neck & a prominent occiput
Tongue Larger in proportion to the oral cavity than in adult
Epiglottis Longer, narrower, stiff, U-Shaped, flops posteriorly
Larynx High & anterior at level of C3-C4 (C5-C6 in adult)
Cricoid More conically shaped, narrowest at cricoid ring whereas in
adult it is at level of VCs
Trachea Deviated posteriorly & downwards

Large tongue causes obstruction to ventilation, obscures DL &

can make ETT placement more difficult
‘Sniffing the morning air’ position will not help BMV or to visualise glottis
Head needs to be in
a neutral position

Ideal manoeuvre
is combination
of jaw thrust &
chin lift, keeping
the mouth open
Larynx in the neonate with
the long epiglottis (A) &
the vocal cords (B)

Larynx in a 2-year-old with

a shorter epiglottis (C) &
the vocal cords (D)

Straight blade
laryngoscope reqd
 Neonatal Airway Contd…
• Airway is funnel shaped

• Narrowest at cricoid rather than VCs

• ETT may be small enough to pass through

VCs but not cricoid

• Larynx is funnel shaped, so secretions

accumulate in retro-pharangeal space

• Shorter length of trachea → endo-

bronchial intubation & accidental
extubation common with head movement
 Neonatal Airway Contd…
• Neonates obligate nasal breathers

• Nasal passages narrow - easily blocked by secretions, damaged by a NGT or a

nasally placed ETT

• Clinical significance - Difficulty breathing

- ↑ed airway resistance from blocked nasal passages

• Epithelium loosely bound to underlying tissue, trauma easily results in oedema

• Leak be present around ETT to prevent trauma → subglottic oedema →

subsequent post-extubation stridor
 Respiratory System
• Neonate have limited respiratory reserve

• Horizontal ribs prevent ‘bucket handle’

action seen in adults → CSA of thoracic
cage remains fairly constant & limits an
increase in TV

• Chest wall significantly more compliant →

noncalcified cartilage, poorly developed ms,
the ribs are incompletely calcified

• Ventilation is primarily diaphragmatic,

WOB increases to approx three times of the
adult
 Respiratory System contd…

Poor BMV - stomach filled with gases can impinge on contents of chest
& splint the diaphragm, reducing ability to ventilate adequately

• Diaphragmatic strength depends on adequate no of type I (slow twitch, high

oxidative capacity) ms fibres to respond to ↑ed workload → less no → easily
subject to fatigue

• Alveoli are thick walled at birth, only 10% of total no found in adults

• Physiological dead space = 30%, is increased by anaesthetic equipment

 Respiratory System contd…
• FRC is relatively low - apneic kid has a disproportionately smaller reserve of
intrapulmonary O2 on which to draw than an adult

• FRC ↓es further with apnoea & anaesthesia causing lung collapse

• ↑ed metabolic rate (O2 consumption 7 ml/kg) contributes to rapid

development of hypoxemia if airway compromised

• MV is rate dependant as there is little means to increase TV (7ml/kg)

• CV is larger than FRC → an increased tendency for airway closure at end

expiration → small changes in lung volume can l/t shunting & desaturation

• Neonates generally need IPPV during anaes & benefit from a higher RR & use
of PEEP
 Regulation of Breathing
• Maturation of neuronal respiratory control is related to postconceptional age
rather than postnatal age

• In neonates as in adults, PaO2, PaCO2, & pH control ventilation

• In contrast to adult, neonate’s response to hypercapnia is not potentiated by

hypoxia, but actually depress the hypercapnic ventilatory response

• Hypoxic response inconsistent, initially, hypoxia restores respiration to

baseline but thereafter it depresses it

• Periodic breathing & central apnea in the majority of premature infants

• Immature respiratory control + ↑ susceptibility to fatigue of resp muscles →

↑ed risk of postop apnea in preterm infants
 Postoperative Apnea
• Apnea occur mostly within 12 hours postoperatively

• Are significant if they last longer than 15 seconds, associated with desaturation
or bradycardia

• Compounding factors associated with development of postop apnea are

ØExtent of surgery
ØAnaesthetic techniques (d/t residual depressant effect of anaesthetics,
opioids or sedatives
ØAnemia (HCT < 30%) - regardless of post-conceptional age
ØPostoperative hypoxemia

• Caffeine (10-20 mg/Kg oral or IV) & theophylline effective in ↓ incidence,

strengthen muscle contractility, prevent fatigue & stimulate respiration
 Cardiovascular
System
• Transformation to neonatal
circulation occurs with first
few breaths

• Neonatal pulmonary
vasculature reacts to ↑ in
Pa02 & pH & the ↓ in PaCO2
at birth

• Marked increase in SVR

• Marked decrease in PVR

 Cardiovascular System Contd…
• LA pressure increases above RA pressure, leading to closure of foramen ovale
on 1st day of life but may reopen within the next 5 yrs

• Increased arterial O2 tension causes constriction of ductus arteriosus in 1st

few days of life & it fibroses within 2-4 weeks

• Ductus venosus & the umbilical arteries also constrict over several days

• Reversion to transitional circulation may occur in first few weeks after birth
• Increase in PVR (eg: acidosis, hypoxia, hypercapnia)
• In response to decrease in SVR (eg: most anaesthetics)

• Risk factors include prematurity, infection, acidosis, pulmonary diseases

resulting in hypercarbia or hypoxemia, hypothermia & CHD
 Cardiovascular System Contd…
• Myocardium is less contractile causing ventricles to be less compliant → less
able to generate tension during contraction
• Limits size of SV
• CO (200 ml/kg/min) is thus rate dependent, increase possible by about 30%
• Infant behaves as with a fixed CO state

• Vagal parasympathetic tone is dominant, makes neonates more prone to

bradycardias
• Associated with reduced CO
• Hypoxia can ppt brady, should be vigorously avoided
• Cardiac compression will be required in neonate with HR ≤ 60
 Cardiovascular System Contd…

• D/t right sided predominance of fetal

heart, neonatal ECG shows a marked RAD
(+300 to +1800) compared to adults (-300
to +1050)

• Also seen are tall ‘R’ waves in right leads,

deep ‘S’ waves in left leads, shorter QRS
duration, shorter PR interval, T waves
inverted toward left

• Innocent systolic murmurs - Stills M, basal

systolic ejection M, murmurs heard only
during diastole are pathologic

ABL = Weight X EBV X (Ho-H1)/Ha
BP is low at birth
(approx. 80/50)
secondary to a low SVR
Neonate has reduced
catecholamine stores &
blunted responses to
exogenous catecholamines
→ vasoconstriction in
response to hypotension is
less manifested &
HYPOTENSION WITHOUT
TACHYCARDIA is hallmark of
intravascular fluid depletion
 Renal System
• RBF and GFR are low in first 2 years of life d/t high renal vascular resistance

• Tubular function is immature → unable to excrete a large Na load

• ↓ concentrating capacity - UO 1-2 ml/Kg/hr - dehydration is poorly tolerated

• Premature infants have ↑ed insensible losses as have large SA relative to wt

• Larger proportion of ECF in children (40% BW as compared to 20% in adult)

Newborn kidneys has limited capacity to compensate Meticulous attention

for volume EXCESS or volume DEPLETION in fluid administration
 Hepatic System
• At birth, the functional maturity of the liver is incomplete

• Most enzyme systems for drug metabolism although developed, are not yet
induced (stimulated) by agents they metabolise

• Conjugation reactions are often impaired in the neonates, resulting in jaundice,

decreased degradation reaction leading to long drug half lives

• Barbiturates & opioids for example have a longer duration of action

• Also minimal glycogen stores (tendency to hypoglycaemia), inability to handle

large protein loads, lower levels of plasma albumin (contribute to neonatal
coagulopathy) & other drug binding proteins (higher levels of free drug)
 Glucose Metabolism
• Hypoglycaemia is common in the stressed neonate, inadequate glycogen
stores & immature gluconeogenesis are important risk factors

• SG < 30–40 mg/dL in term infants during 1st 72 hrs & < 40 mg/dL thereafter

• CNS signs of hypoglycemia – seizures/apnea/lethargy/mottling & pallor

• Neurological damage may result from hypoglycaemia, glucose levels should be

monitored regularly, treat hypoglycaemia promptly

• Infants & older children maintain BG better, rarely need glucose infusions

• Hyperglycaemia is usually iatrogenic

 Haematology
• At birth, 70-90% of Hb is HbF, within 3 mths HbF ↓es to approx 5% & HbA
predominates

• Hb level in a newborn around 15-20 g/dl, ≈ haematocrit of 0.6

• Hb drop over 3-6 mths to 9-12 g/dl, nadir b/w 8th – 10th week of life→
circulating volume increases more rapidly than bone marrow function

• HbF - allows O2 extraction from maternal Hb

even at relatively low venous O2 tension
- released less readily as less 2,3-DPG
- protective against red cell sickling
ODC In A Neonate
 Haematology Contd…

• 0DC shifted to left in neonate (P50 19 mm Hg) shifts to right as levels of HbA
& 2,3-DPG rise

• Vitamin K dependent clotting factors (II, VII, IX, X) & platelet function are
deficient in the first few months

• Vitamin K is given at birth to prevent haemorrhagic disease of the newborn

• Transfusion is generally recommended when 15% of the circulating BV lost

• Maintain neonate’s Hct closer to 40% than 30%

 Temperature Control
• Large surface area to weight ratio with minimal subcutaneous fat

• Poorly developed shivering, sweating & vasoconstriction mechanisms

Prone to hypothermia
• Non-shivering thermogenesis → brown fat metabolism is required, comprises
2-6% of neonatal body weight

• More O2 is required for metabolism of brown fat – O2 consumption increases

• Heat lost during anaesthesia is mostly via radiation but may also by
conduction, convection & evaporation
Poikilothermic → Severe hypothermia
 Hypothermia
• Optimal ambient temp to prevent heat loss is 34ºC for premature infant, 32ºC
for neonates & 28ºC in adolescents

• Low body temperature causes

ØRespiratory depression
ØAcidosis
ØDecreased cardiac output
ØIncreases the duration of action of drugs
ØDecreases platelet function
ØIncreases the risk of surgical wound infections
ØProlonged hospitalization

• Incubators for transport, warming mattresses, warm IV fluids & blood,

warming anaesthetic gases, over head radiant heaters, plastic wrap to ↓
evaporative loss, warming prep solution, increasing OT temp
 Central Nervous System
• Neonates can appreciate pain → associated with increased HR, BP & a neuro-
endocrine response → administer sufficient analgesia

• BBB is poorly formed → drugs cross BBB easily causing a prolonged & variable
duration of action
Ø Barbiturates
Ø Opioids
Ø Antibiotics
Ø Bilirubin

• At birth, SC extends to L3, by 1 year of age

SC ends at L1 - lower intervertebral approaches
to epidural/SA spaces recommended to avoid
any inadvertent neurologic damage
 Central Nervous System Contd…
• Lack of myelin, ↓ size of nerve fibres, shorter distance b/w successive nodes of
Ranvier favour LA penetration & rapid onset of nerve blockade with dilute LA

• Cerebral autoregulation is present & functional from birth

• Glucose reqmt (6.8 mg/100 mg/min in child vs 5.5 mg/100 mg/min in adult

• CMRO2 - 5.5 ml O2/100 g/min in child vs 3.5 ml O2/100 g/min in adult

• Cerebral vessels in preterm infant thin walled, fragile → prone to IVH→ risk ↑
ØHypoxia, hypercarbia
ØHypernatremia
ØLow haematocrit
ØAwake airway manipulations
ØRapid bicarbonate administration
ØFluctuations in BP & CBF
 Take Home Message
• The differences in anatomical & physiological characteristics makes
anaesthetic management different & challenging for the anaesthesiologist

• It is imperative to have a good knowledge of the anatomic & physiologic

difference between an adult & a paediatric patient for safe conduct of
anaesthesia