Introduction
Pediatric anesthesia for neonates and infants encompasses a distinct and high-risk practice within anesthesiology, requiring specialized expertise, clinical environments, equipment, resources, and teams to deliver safe, effective, and high-quality care. Neonates and infants are the most vulnerable patient population undergoing anesthesia – with more perioperative adverse events and mortality than adults.[1] Severe complications in pediatric anesthesia have a 10 times increased risk of mortality than adults.[2] Furthermore, neonates and infants have several times more anesthesia-related cardiac arrests than older children undergoing anesthesia.[3] The mortality of cardiac arrest in neonates receiving anesthesia is 72%.[4] Clinically, neonates and infants are at heighted risk for complications due to their immature and developing organ systems, wide spectrum of congenital defects, small body size, and dynamic metabolic profiles. Consequently, delivering anesthesia for this population presents its own challenges, ranging from large variations in pharmacokinetics and pharmacodynamic, need for specialized care environments and equipment, need for precise delivery of medications and ventilation, and need for experienced clinicians. Operationally, neonatal and infant anesthesia is distinct from adult practices due to the interplay of smaller case volumes, varied care delivery settings and types of procedures that require anesthesia. Therefore, a focus on optimizing the delivery of anesthesia care for neonates and infants - the smallest, youngest, and highest risk patient population – is a necessary opportunity to deliver safe, effective, and high-quality care. Innovating care pathways, systems, and technology for neonates and infants by delivering more precise and personalized anesthesia care with expert teams will lead to improved safety and quality for all children.
The highest perioperative risk population: neonates and infants
Each year, millions of neonates and young infants worldwide undergo surgery requiring general anesthesia,[5] highlighting the critical role of pediatric anesthesia in modern healthcare. In the United States alone, approximately six million children, including 1.5 million infants, undergo surgical procedures under general anesthesia annually, with many requiring multiple procedures and anesthetics.[6],[7],[8] This substantial patient population underscores the importance of advancing safe and effective anesthesia practices tailored to the unique needs of these youngest patients. Among this special population, there are two distinct age categories, each with unique physiologic characteristics and stages of development that impact clinical care, anesthetic and perioperative risk. The two categories of patients are neonates and infants.
Neonates are defined as infants up to 28 days old and are the highest risk pediatric population that receive anesthesia. Neonates have more perioperative complications and higher mortality rates than older children [9],[10],[11],[12] and may have adverse outcomes related to the brain development following surgery and anesthesia.[13] Neonates are at increased risk due to a variety of factors including underdeveloped organ systems particularly related to the lungs and heart, higher consumption of oxygen, and immature liver and kidney function affecting drug metabolism. Neonates can have higher sensitivity to anesthesia medications, increased risk of postoperative apnea, greater susceptibility to hypothermia, and are more technically demanding for anesthesia clinicians to manage the airway, obtain vascular access, and other perform other invasive procedures.[14] Premature neonates represent the highest-risk population among all neonates, and the rising global incidence of premature births[15] further amplifies the challenges associated with their care.
Infants are defined as aged 1 month to 12 months and have different anesthetic considerations and risks than neonates. While infants face less perioperative risks than neonates, the risks are still significantly greater than in children. Since the early 1960s, studies comparing outcomes across difference age groups have consistently demonstrated higher perioperative morbidity and mortality rates in infants under 1 year of age.[16],[17] Infants can be considered on a similar continuum of perioperative risk as neonates.
Self-assessment: the highest risk population
How do I currently assess the perioperative risks specific to neonates and infants in my practice? Am I familiar with the physiological differences between neonates and infants, and how these differences influence my anesthetic management? What strategies do I employ to mitigate the challenges associated with managing neonatal airways and obtaining vascular access? Do I appropriately adjust anesthetic drug dosages for these age groups? What specific areas of my practice could benefit from further education or training to enhance the care of this vulnerable patient population?
The current landscape of pediatric anesthesia care
Anesthesia for children is common and a large part of routine clinical practice. Almost 30% of all general anesthesia procedures are for children less than 15 years of age.[18] In high-income countries, one out of seven children have had at least one anesthetic before the age of 4 years.[19] In children less than 8 years, over 80% of anesthetics are in relatively healthy children with American Society of Anesthesiologists (ASA) Physical Status (PS) class of I and II and are performed mostly in community hospitals and ambulatory surgical centers. While a smaller proportion of children are more complex or critically ill, the anesthetic care for the youngest and most complex children are more often cared for in large health care systems, academic medical centers, and children’s hospitals. In a pattern markedly different than adults, general anesthesia is the primary type of anesthetic in 93% of pediatric cases. In addition, unlike adults, a notable 21% of all pediatric anesthetics are for diagnostic procedures with 79% of anesthetics for surgery.[20] In some pediatric health systems, non-operating room anesthesia (NORA) can constitute up to 40% of anesthesia cases. The higher proportion in children requiring anesthesia for diagnostic procedures is due to the limited ability of young children to be still during radiologic procedures such as MRIs.
Congenital heart disease in neonates and infants
Approximately 40,000 infants around the world are born with congenital heart disease every year and are among the most complex to care for. The landscape of congenital heart disease (CHD) management has undergone a remarkable transformation in recent decades, giving rise to a novel demographic of survivors. Advancements in medical, surgical, and anesthetic care have significantly improved the outcomes for neonates and infants with CHD, resulting in a growing population of patients who are now surviving into adulthood.[21],[22] This emerging cohort, previously non-existent, presents unique challenges and opportunities. The epidemiology of CHD survivors has shifted dramatically, with approximately 81% of children born with CHD now expected to survive to at least 35 years of age.[23] This survival rate is attributed to several factors, including refined surgical techniques, improved anesthesia and perioperative management, and innovations in cardiopulmonary bypass for neonatal and infant cardiac surgery.[24] The increasing prevalence of CHD survivors has led to a paradigm shift in care focus, moving from survival to optimizing long-term outcomes and quality of life. As this population continues to grow and age, healthcare systems must adapt to address the complex, lifelong needs of these patients, encompassing both cardiac and non-cardiac comorbidities. Key areas of focus include determining the type of anesthesia expertise and healthcare systems are best equipped to manage the increasing population of young adults with a history of complex congenital heart defects.
Optimizing neonatal and infant outcomes with expertise in pediatric anesthesia
The question of what level of anesthesia expertise is necessary to provide optimal safety and outcomes for neonates and infants undergoing surgery is both timely and critical. Pediatric anesthesiology, as a subspecialty of anesthesiology, has evolved to address the unique physiological and developmental needs of this highly vulnerable and high-risk patient population. Across the United States, the division of care responsibilities reflects these complexities. Some general anesthesiologists may manage children aged 2 years and older undergoing routine surgical procedures, provided these children are relatively healthy and classified as American Society of Anesthesiologists (ASA) Physical Class I or II. As children remain healthy and become older children, there are more general anesthesiologists that are likely to be involved in their care. However, according to the American College of Surgeons Task Force for Children’s Surgical Care, children under the age of 2, neonates and those classified as ASA Class III or higher are most often cared for by board-certified pediatric anesthesiologists.[25] Pediatric anesthesiologists undergo advanced training and certification to ensure they can meet the specialized needs of these high-risk patients effectively.
The correlation between pediatric-specific anesthesia training and reduced anesthesia-related morbidity has been well-documented. Studies demonstrate that anesthesiologists with higher pediatric case volumes, specifically, those performing more than 200 pediatric cases annually report five times fewer complications, including failed intubation, inadequate ventilation, anesthetic overdose, cardiac arrest, pulmonary aspiration, and other perioperative events.[26] These findings underscore the importance of experience and specialization in improving outcomes for pediatric patients, particularly neonates and infants who are at the highest risk of perioperative complications.
In recognition of the importance of pediatric specialization and expert care teams to care for young children, including neonates and infants, the American College of Surgeons (ACS) created the Children’s Surgery Verification (CSV) standards. The ACS CSV guidelines emphasize that younger children and those with significant comorbidities should be cared for by board-certified or board-eligible pediatric anesthesiologists. In recognition of the importance of this expertise, the American Board of Anesthesiology introduced subspecialty board certification for pediatric anesthesiology in 2012. Since its inception, the number of certified pediatric anesthesiologists has grown significantly, with over 4,000 physicians certified as of 2015 and fellowship training positions increasing by 162% between 2002 and 2015. Projections suggest that by 2035, over 7,000 pediatric anesthesiologists will be practicing in the United States.[27]
The value of pediatric-specific expertise extends to health systems and facilities. Studies consistently demonstrate that children undergoing surgery at hospitals with robust pediatric resources experience better outcomes compared to those treated at less well-resourced facilities. The management of complex surgical conditions in centers with specialized expertise and resources reduces adverse events and improves overall clinical outcomes. The ACS CSV task force which included pediatric anesthesiologists, worked to develop a consensus approach to better align resources with the surgical needs of children. Their efforts culminated in the establishment of the ACS CSV Program, which collaborates with other national initiatives from the Society for Pediatric Anesthesia and the American Academy of Pediatrics.[28] These efforts highlight the critical need for specialized pediatric anesthesia care to optimize safety and outcomes for neonates and infants. Continued investments in training, certification, and the development of comprehensive pediatric surgical verification programs will be essential in advancing the quality of care for neonates and infants requiring surgery.
Self-assessment: current landscape of pediatric anesthesia care
How often do I care for high-risk pediatric patients, including neonates and infants, in my practice? Do I feel confident managing perioperative complications in neonates and infants? What additional resources or training might I need to strengthen my clinical skill and experience in neonatal and infant anesthesia? What steps do I take to remain current with pediatric-specific anesthesia training, certification, and emerging guidelines? What role do I play in advocating for or contributing to the development of specialized pediatric anesthesia care within my practice and hospital?
Key clinical challenges, opportunities and advancements
Neonatal and infant anesthesia presents unique challenges and opportunities for advancing safe care in this vulnerable population. Emerging clinical opportunities emphasize the need for precision and personalization to address the varying physiological immaturity and diverse needs of these youngest patients. The following sections explores current clinical challenges and key opportunities in optimizing anesthesia care for neonates and infants.
Precise and personalized anesthesia drug delivery improves safety and quality
Optimizing the dosing and delivery of anesthesia medications for neonatal and infant patients is a key opportunity to advance safety and quality. Although anesthesia medications have their activity on the central nervous system, including the brain and spinal cord, the brain is not routinely monitored during anesthesia.
Traditional approaches to anesthetic dosing, which rely on population pharmacokinetic models based on a patient’s age and weight, falls short of precision and personalization. Such methods fail to incorporate crucial individual factors, including organ development and function, pharmacogenomics, and medication interactions. These limitations are particularly concerning in neonates and infants, who are more vulnerable to the effects of anesthetic agents. Furthermore, while the long-term consequences of anesthesia exposure in neonates and infants remain inconclusive, the need for a precise and individualized dosing approach has become increasingly evident.
The advent of processed electroencephalogram monitors for clinical use offers anesthesia clinicians a powerful tool to directly observe the brain’s response to anesthetic drugs. This technology enables real-time monitoring and titration of anesthetic doses according to changes in states of consciousness.[29] When integrated into routine anesthetic care and monitoring, intraoperative EEG guidance complements established cardiopulmonary monitoring practices and enhances anesthesia delivery. The benefits of this approach include improved patient safety, optimized medication administration, and a better perioperative experience.
Evidence supports the utility of EEG guidance in reducing anesthetic requirements for agents such as sevoflurane and propofol, leading to faster recovery and fewer episodes of oversedation.[30],[31] Moreover, EEG-guided anesthesia has been associated with a reduced incidence of adverse events, including respiratory complications and emergence delirium (ED), and has demonstrated a shorter time to discharge.[32],[33] These benefits are especially significant in neonates and infants where anesthetic needs can be highly variable due to developing physiology, in critically ill children, those with atypical neurodevelopment, or individuals undergoing total intravenous anesthesia.
Several studies have examined the occurrence of isoelectric EEG patterns during anesthesia in young children. For instance, research has revealed that up to 51% of children under three years of age experience isoelectric EEG or discontinuity patterns during sevoflurane anesthesia, particularly within the first 30 minutes of induction. Additional studies have shown varying rates of isoelectric EEG occurrences across age groups and anesthetic practices, with younger children and those with greater illness severity exhibiting higher susceptibility.[34] These findings underscore the risk of over-reliance on traditional population-based dosing, which may inadvertently result in administering unnecessary medication to the brain.
The implementation of intraoperative EEG monitoring provides a means to directly visualize and interpret the patient’s brain activity, allowing for precise, individualized anesthesia care. Key outcomes of EEG-guided approaches include:
- Prevention of burst suppression: By monitoring brain activity, anesthesiologists can minimize the occurrence of burst suppression, a state linked to adverse neurological outcomes.
- Reduction in anesthetic dosage: EEG-guided anesthesia has been shown to reduce the required doses of sevoflurane and propofol. This reduction minimizes potential drug-related side effects.
- Improved perioperative outcomes: Intraoperative EEG monitoring reduces the incidence of respiratory complications and emergence delirium, contributing to safer and more predictable recoveries.
Overall, EEG-guided anesthesia represents a significant advancement in pediatric care. It enhances the current standard of care by offering precision anesthesia tailored to the unique needs of each child. As EEG technology continues to develop and educational programs are implemented, more widespread use and adoption of EEG guided anesthesia in neonates and infants will be realized. Accelerating the use of EEG-guided anesthesia dosing will require large scale educational programs and research demonstrating the economic benefit of using a new monitor to improve anesthesia safety, outcomes, and operations.
Self-assessment: personalized anesthesia drug delivery using EEG
How do I currently determine anesthetic dosages for neonates and infants? How familiar am I with the principles and clinical applications of intraoperative EEG monitoring in neonates and infants? Should I incorporate EEG-guided anesthesia into my practice? What additional training or education do I need to confidently use EEG-guided anesthesia in my practice? What steps can I take to prepare for the wider adoption of precision anesthesia technologies in my practice?
Precise and personalized ventilation improves neonatal and infant anesthesia care
Effective ventilation management during anesthesia is crucial for neonates and infants due to their small and fragile lung physiology. Premature and term neonates possess developing lungs that are structurally and functionally distinct from those of older children and adults. These distinctions include smaller airway diameters, fewer alveoli, and a highly compliant chest wall, which collectively increase the risk of atelectasis, ventilation-perfusion mismatch, and respiratory fatigue.[35] Additionally, immature respiratory control mechanisms often lead to periodic breathing or apnea, further complicating perioperative care.[36]
In neonates, precise and protective ventilation is critical to minimize the risks of lung injury and long-term complications. This challenge is particularly pronounced in extremely small neonates, often weighing as little as 1 to 3 kilograms, where even minor deviations in tidal volume can have significant physiological consequences.[37] Lung-protective strategies, which emphasize tidal volumes target between 6-7 mL/kg and adequate positive end-expiratory pressure (PEEP), have become standard to mitigate the risk of post operative complications. These strategies must be tailored to each patient's weight, lung compliance, and clinical status, highlighting the necessity for anesthesia teams caring for neonates and infants to utilize modern ventilators capable of delivering precision at small scales.
Before the advances of modern anesthesia ventilators, traditional anesthesia ventilators were challenged when attempting to deliver small tidal volumes with the accuracy needed for neonates. Circuit compliance, fresh gas flow variability, and the influence of uncuffed endotracheal tubes can significantly affect delivered volumes, potentially leading to hypo- or hyperventilation. However, advances in modern anesthesia ventilator technology, such as compliance compensation and fresh gas flow compensation, have enabled more accurate delivery of set tidal volumes, even in the smallest patients.[38]
The precise delivery of ventilation in neonates and infants requires advanced, specialized equipment. Anesthesia teams caring for neonates and infants can now deliver more precise and personalized ventilation when using modern anesthesia ventilators equipped with compliance compensation, accurate tidal volume controls, and sophisticated respiratory monitoring systems. In addition to ventilator advancements, minimizing apparatus dead space, carefully selecting endotracheal tubes, and ensuring appropriate humidification are critical for maintaining effective ventilation. Monitoring tools, such as continuous capnography and pulse oximetry, further support individualized ventilation strategies by enabling real-time assessment of gas exchange and lung mechanics.
Self-assessment: precision ventilation for neonates and infants
Do I consistently apply lung-protective ventilation strategies? Am I proficient in the use of modern anesthesia ventilators equipped with compliance compensation and fresh gas flow compensation for neonatal and infant care? What protocols or interventions do I employ to ensure adequate ventilation in neonates with compromised respiratory function? Do I adjust ventilation parameters in real-time based on the feedback provided by monitoring tools to optimize patient outcomes? Have I received adequate training in the use of modern ventilators and advanced respiratory monitoring systems for neonatal and infant patients? What role can I play in advocating for or implementation modern ventilator technology within my healthcare facility?
Optimizing neonatal and infant care in non-operating room anesthesia (NORA)
Non-operating room anesthesia (NORA) for neonates and infants has emerged as an important and rapidly growing area within pediatric anesthesiology. NORA is more common in children than in adults due to their unique procedural needs, diseases, and need for anesthesia to facilitate high quality radiological imaging studies.[39] NORA for neonates and infants may include MRI suites, Interventional Radiology, Cardiac Catheterization Labs, GI suites, Radiation Oncology, procedure rooms, and intensive care unit bedside procedures. In recent years, there has been a substantial increase in pediatric NORA cases.[40] This trend is likely to continue as technological advancements enable more non-invasive procedures to be performed outside the traditional OR setting on more medically complex patients. This shift in practice necessitates a comprehensive understanding of the differences between NORA and main operating room environments, as well as the specific considerations for neonates and infants.
Included in NORA are bedside procedures in the neonatal intensive care unit
(NICU) which is almost always an emergency procedure with an extremely high risk for morbidity or mortality.[41] Neonates that require a bedside procedure are considered too unstable to transport to the operating room, due to multiple factors including significant hemodynamic instability, respiratory failure requiring high flow oscillatory ventilation, or extremely premature neonates. In some clinical situations, neonates cared for at the bedside by the pediatric anesthesia team could weigh less than 1 kg. During bedside procedures, pediatric anesthesiologists need to deliver high quality care in a high-risk environment that is away from the main operating room, with limited availability to their standard equipment, setup, and other anesthesia colleagues. Depending on the NICU resources, anesthesia teams may be dependent on bringing the necessary equipment to the bedside to deliver safe and effective care.
The NORA environment presents distinct challenges for pediatric anesthesia teams, particularly when caring for neonates and infants. Unlike the controlled setting of an operating room, NORA locations often lack the full range of resources and equipment readily available in the main OR to contend with the already higher risk neonatal and infant patient population. Anesthesiologists must contend with unfamiliar environments, remote locations, limited access to pediatric specific rescue equipment, and potential difficulties in room layout and machine placement.[42] These factors necessitate advanced planning, system-based improvements, and standardization in equipment, medications, and resource availability.
Resource limitations in NORA settings can be significant. Without advanced planning and standardization of the care environment, these locations may lack adequate anesthesia equipment for complex pediatric patients and emergencies, comprehensive monitoring devices, trained support staff familiar with neonates and infants, and familiar workspace. Such limitations require anesthesiologists to be adaptable and resourceful, often managing more medically complex patients with fewer resources than in the main OR. This scenario demands a high level of expertise and the ability to improvise, when necessary, all while maintaining the highest standards of patient care and safety.
The management of NORA for neonates and infants across a hospital presents significant logistical challenges. The geographic spread of NORA procedures across diverse locations within a healthcare facility can strain anesthesia team staffing, requiring them to cover multiple remote locations simultaneously. Effective communication becomes crucial yet more challenging in NORA settings. Anesthesia clinicians must coordinate with proceduralists, nursing staff, technicians, and support personnel outside the immediate vicinity. Establishing clear lines of communication, especially for emergent situations, is essential to ensure patient safety and procedural success.[43]
To address these challenges, several solutions can be implemented to improve the safety and efficacy of NORA for neonates and infants. Enhanced communication systems that allow real-time interaction between the anesthesia team and support staff outside the procedure room are crucial. Developing and implementing remote monitoring technologies, such as centralized monitoring stations for vital signs, real-time data streaming from anesthesia machines and ventilators, and mobile applications for anesthesiologists to access patient data remotely, can significantly improve patient safety, quality, and operational efficiency. Creating standardized practice guidelines, checklists, and equipment setup for neonates and infants specific to NORA locations can help ensure consistency and safety across different settings,[44] especially among clinical teams that do not care for neonates and infants regularly. Multidisciplinary team communication, pre-procedural huddle, and team simulations can improve the competency and preparedness for caring for high-risk neonates and infants in remote locations.
As the demand for pediatric NORA continues to grow, it is essential to develop and implement solutions that address the specific challenges of this area of practice. The future of pediatric NORA lies in the seamless integration of advanced technologies, multidisciplinary collaboration, and standardization of practice for neonates and infants. This ongoing evolution in pediatric anesthesiology will undoubtedly lead to improved outcomes and safer procedures for neonates and infants in non-operating room settings.
Self-assessment: optimizing neonatal and infant safety in NORA
How effectively do I plan and prepare for anesthesia care in NORA environments to ensure the necessary equipment and medications are available? What steps do I take to ensure preparedness for emergencies during bedside procedures? What strategies does my team use to overcome communication challenges inherent to geographically remote NORA locations? Do I regularly participate in multidisciplinary pre-procedural huddles or team simulations to improve readiness and teamwork for NORA procedures? How do I contribute to fostering a collaborative culture among clinical teams that may not routinely care for neonates and infants? What role can I play in advocating for the adoption of innovative solutions, such as remote monitoring or standardized equipment setups, to improve NORA outcomes?
Optimizing neonatal and infant anesthesia with effective team coordination, communication, and preparation
Care team coordination, communication, and preparation are foundational aspects of optimizing pediatric anesthesia care for neonates and infants. This patient population is uniquely vulnerable, requiring a highly specialized approach that integrates expertise from pediatric anesthesiologists and clinicians, surgeons, neonatologists/intensivists, pediatricians, and nursing staff. The experience, coordination and preparedness of clinical teams and health systems, directly influence the safety for neonates and infants undergoing anesthesia for invasive and non-invasive procedures.
Effective multidisciplinary team training is critical for improving outcomes in neonatal and infant anesthesia. This population poses unique challenges due to the combination of their physiologic vulnerability, surgical stress, and the technical and cognitive demands on clinicians. Experience is a key factor in successful management; however, gaining such experience is challenging due to the lower volume of neonatal and infant procedures and the wide variability in disease complexity. This highlights the importance of structured team training that prepares all members for high-risk scenarios.
Simulation-based training is particularly valuable in neonatal and infant anesthesia, where low procedural volumes and high complexity necessitate deliberate practice.[45] Simulation-based training, especially high-fidelity simulation, plays an essential role in fostering technical and non-technical skills.[46] It allows care teams to practice in a controlled environment, improving communication, decision-making, and the management of critical events.[47] For instance, practicing infant airway management in simulations can prepare clinicians for the challenges of rapid oxygen desaturation and limited time for corrective actions, both of which are common during neonatal and infant intubation. Just-in-time (JIT) training, has shown promise in equipping inexperienced clinicians to perform high-stakes procedures shortly before they occur, thus enhancing confidence and competence. In a single center randomized clinical trial, JIT for inexperienced clinicians increased first attempt success in infant intubations, thereby demonstrating an improvement in patient safety.[48]
Clearly defined roles and responsibilities are essential for optimizing team dynamics during neonatal and infant anesthesia. Structured communication protocols, such as preoperative briefings and postoperative debriefings, ensure that every team member understands their duties and contributes effectively to the perioperative process. Standardized management pathways and equipment setup tailored to neonates and infants further streamline care and reduce variability in outcomes.
Emergency response preparedness is equally important. The use of evidence-based guidelines and emergency response checklists in pediatric anesthesia ensures that critical steps are not overlooked during high-pressure situations.[49] These tools improve coordination, reduce errors, and enhance the team’s ability to respond swiftly and effectively.[50] Some hospitals have integrated emergency checklists for rare but high-risk clinical scenarios into the electronic health record and wall mounted operating room monitors for easy access during crisis management. Used around the world, a mobile application to assist clinicians in responding to pediatric perioperative life-threatening events was created for the purposes of training and to be used in real time during actual critical events.[51],[52] Simulation exercises should include practicing these emergency checklists for perioperative crisis management to ensure seamless implementation in real-life scenarios.
Optimizing pediatric anesthesia care for neonates and infants requires a multifaceted approach that prioritizes care team coordination, communication, and preparedness. A commitment to continuous improvement and dedication to prepare will pave the way for safer, more effective anesthesia care for neonates and infants.
Self-assessment: effective team coordination, communication, and preparedness
How often do I participate in preoperative briefings and postoperative debriefings to enhance communication and team dynamics? Have I participated in simulation-based training to prepare for high-stakes scenarios in neonatal and infant anesthesia? What steps do I take to enhance my preparedness for low-frequency, high-complexity neonatal cases? How frequently do I engage in simulation exercises to refine my skills in neonatal and infant care, including airway management and crisis response? Have I utilized just-in-time (JIT) training to prepare for specific high-risk procedures? What role do I play in fostering a culture of continuous improvement and preparedness within my team or institution?
Optimizing neonatal and infant anesthesia airway management
Neonates and infants are among the most vulnerable populations requiring airway management during anesthesia. Their unique anatomical and physiological characteristics place them at an increased risk of severe hypoxemia leading to significant morbidity and mortality.[53] This vulnerability arises from their high metabolic oxygen consumption, reduced cardiopulmonary reserves, and distinct anatomical challenges, which together make airway management for neonates and infants a critical focus for pediatric anesthesiologists.[54]
Respiratory complications are the leading cause of anesthetic-related adverse events in children, and neonates and infants are disproportionately affected. Hypoxemia, bradycardia, and cardiac arrest occur more frequently in these populations, underscoring the importance of meticulous airway management. Neonates, in particular, face unique challenges due to their limited functional residual capacity, highly compliant chest walls, and immature sympathetic responses. These characteristics exacerbate the rapid onset of hypoxemia during periods of apnea or respiratory compromise. Anatomical factors such as a relatively large occiput, a large tongue, an omega-shaped epiglottis, and a narrow cricoid cartilage further complicate airway management in these patients. Additionally, the small diameter of their tracheas increases the risk of trauma, highlighting the need for precision and careful planning.
Effective airway management in neonates and infants begins with thorough anticipation and preparation. Pediatric anesthesiologists and anesthesia teams must assess each patient’s unique anatomical and physiological traits while considering specific risk factors for difficult airways. This proactive approach is especially important for patients with craniofacial abnormalities, congenital syndromes, or extremely low birth weights, as these conditions often predict more challenging airway scenarios.
The use of high-flow nasal oxygenation (HFNO) has emerged as a pivotal advancement in airway management for this population. Techniques such as transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) have been shown to prolong apnea time by delaying the onset of hypoxemia, thereby providing a critical buffer during intubation attempts. Studies have demonstrated that HFNO can double the time to desaturation in neonates and infants, significantly enhancing safety margins during airway intubation.[55]
The use of video laryngoscopy (VL) has revolutionized pediatric airway management by improving visualization and increasing the success rate of intubations. VL devices, equipped with camera-enabled blades, facilitate indirect laryngoscopy, making them particularly useful in cases where direct visualization is challenging due to anatomical factors. Specialized blades, such as hyperangulated designs, and the integration of VL with flexible bronchoscopes have further enhanced the ability of clinicians to manage both routine and difficult airways. These advancements have reduced the risk of repeated intubation attempts, which are known to increase the likelihood of airway trauma and hypoxemia, especially in neonates and infants.[56]
Airway management for neonates and infants also benefits from a system-based approach that emphasizes standardization, teamwork, and preparedness. Simulation-based training has proven invaluable for preparing clinicians to manage neonatal and infant airways. High-fidelity simulations allow healthcare teams to practice both technical and non-technical skills in a controlled environment, fostering improved communication, decision-making, and crisis management. This deliberate practice is particularly critical for rare but high-risk scenarios, such as managing rapidly desaturating infants during intubation.
The safe management of neonatal and infant airways requires a multifaceted approach that integrates clinical expertise, advanced technology, and robust systems of care.[57] Pediatric anesthesiologists must continuously refine their skills and adopt evidence-based practices to minimize airway-related morbidity and mortality. The application of high-flow nasal oxygenation, video laryngoscopy, and simulation-based training, combined with a commitment to teamwork and preparedness, underscores the critical steps taken to safeguard this vulnerable population.
Self-assessment: neonatal and infant airway management
What steps do I take to ensure I am fully prepared to manage both expected and unexpected airway challenges in neonates and infants? How familiar am I with the principles and application of high-flow nasal oxygenation techniques in prolonging apnea time during intubation? Do I consistently use high-flow nasal oxygenation when managing neonatal and infant airways? Am I proficient in integrating specialized airway equipment, such as video laryngoscopes and flexible bronchoscopes, to improve visualization and intubation success? Do I participate in team-based simulation training to refine both technical and non-technical skills required for managing neonatal airways? What measures do I take to minimize the risk of airway-related morbidity and mortality in neonates and infants?
The road ahead for optimizing neonatal and infant anesthesia
Neonatal and infant anesthesia faces several pressing challenges that reflect the evolving demands of the healthcare sector and the unique needs of the youngest, smallest and highest risk patients. Economic considerations are at the forefront, with funding mechanisms and reimbursement structures for children presenting persistent issues. Pediatric anesthesia operates within a distinct framework compared to adult practices, with lower case volumes and more heterogeneous patient populations, which further complicates funding and resource allocation. Staffing and workforce shortages, in a subspecialized practice, exacerbate these challenges, as healthcare systems grapple with increasing patient complexity, workforce shortages, burnout, and the rising costs of care. These issues are particularly pronounced in geographic areas with limited access to specialized pediatric anesthesia expertise. Furthermore, research and development for advancing new procedures and creating specialized medical devices for neonates and infants can be challenging. The relatively lower volumes of patients, compared to adults, and large heterogeneity of congenital diseases among neonates and infants create natural barriers to robust data collection often required for medical device development and new transformative technologies such as artificial intelligent devices.
Conclusion
In conclusion, optimizing anesthesia care for neonates and infants requires a deliberate focus on precision, personalization, and collaboration to address the unique challenges of this high-risk population. By advancing care pathways through innovations in precision drug dosing using EEG, refining ventilation strategies tailored to their dynamic physiology, enhancing safety in NORA environments, prioritizing effective team communication, coordination, and preparation, and optimizing airway management, anesthesia teams can significantly improve outcomes for these vulnerable patients. As the smallest, youngest, and most fragile patients, neonates and infants require a relentless commitment to advancing pediatric anesthesia practices.
Disclaimer: Dr. Jonathan Tan is a paid consultant for GE HealthCare. The statements by Dr. Tan here are based on his own opinions on results that were achieved in his unique setting. Since there is no “typical” hospital/clinical setting and many variables exist, i.e. hospital size, case mix, staff expertise, etc. there can be no guarantee that others will achieve the same results.
Nothing in this material should be used to diagnose or treat any disease or condition. The reader must consult with a healthcare professional. Not all products or features are available in all markets. Contact your GE HealthCare representative for further details.
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