Anaesthetic considerations for the management of very low and extremely low birth weight infants

The opportunities for very low birth weight infants (birth weight <1500 g) and extremely low birth weight infants (birth weight <1000 g) to undergo surgery are increasing. These infants are prone to prematurity-related morbidities including respiratory distress syndrome, intraventricular haemorrhage, periventricular leukomalacia, retinopathy of prematurity, patent ductus arteriosus and necrotising enterocolitis. Evidence is accumulating that preterm infants are also sensitive to pain and stress. The pharmacokinetics of drugs in preterm infants is not fully understood but smaller doses of anaesthetic drugs are usually required in preterm infants compared to term infants and older children and their effects last longer due to low clearance rates and longer elimination half-lives. Key anaesthetic considerations are (i) inspired oxygen concentration that should be adjusted to avoid hyperoxia, (ii) haemodynamic parameters that should be kept stable and (iii) prevention of hypothermia by using adequate measures to keep the infants warm. These precautions must be continuously taken during the operation and the transport to and from the operating theatre.