1. Inguinal Hernia of Premature Infants

2. Brief History 2 months old male infant G3P1AA2 GA: 28 weeks+6
Birth body weight: 1302gm

3. Brief History Maternal APH, PPROM, placental abruptio
C/S on 2004/11/11
Apgar score: 7→8

4. Brief History
Frequent apnea episodes on 11/13-14 and aminophylline was given
Abscess and osteomyelitis in 2005/12
Pre-op: BW: 2644gm
Herniorraphy for umbilical and right inguinal hernia on 2005/1/21

5. Aminophylin
Atropine 0.1mg
Sevoflurane

6. Discussion 1. When should repair of inguinal hernia be done?
2. Anesthetic risks for surgery of premature infants
3. What kind of anesthetic technique is better?

7. Inguinal Hernia in Prematurity
Incidence: 14-30%(children: 2%)
Higher incidence of incarceration in infants
Hernia repair when ready for discharge has be accepted
Pediatr Surg Int (1999) 15: 36-39

8. Inguinal Hernia in Prematurity
VLBW infants had a longer operation time and a longer waiting period
Preoperative medical complication: RDS, sepsis, and cardiac failure→ considered to delay surgery
The shorting waiting group had shorter operation time
No correlation between operation time and body weight at surgery

9. Inguinal Hernia in Prematurity
For long waits for surgery in VLBW infants: hernia sac may grow large and thick, and fibrous adhesions may develop
Difficult surgical repair and the risk of gonadal ischemia may be increased

10. The Most Common Medical Problems in Prematurity
Respiratory distress syndrome (RDS)
Apnea of prematurity
Anemia of prematurity
Patent ductus arteriosus
Intraventricular hemorrhage

11. The Formerly Premature Infant
Bronchopulmonary dysplasia (BPD):
1. the sequelae of RDS
2. the leading cause of chronic lung disease during infancy
3. periodic episodes of bronchospasm, especially during URI

12. Anesthetic Management of Infants with BPD
Optimization of respiratory status
Deep extubation to avoid bronchospasm
Regional analgesia in abdominal procedures for pain control

13. Laryngeal and Tracheal Injury
Prolonged intubation and mechanical ventilation
Subglottic stenosis
Smaller ET tube when intubation
Stridor following extubation

14. Postoperative Apnea May be accompanied by bradycardia
Probably related to the effects of general anesthetic agents on the immature respiratory control center
Low gestational age, low postconceptional age, preoperative apnea of prematurity

15. General VS Spinal Anesthesia
GA<36wks and post-conceptual age (PCA)<46wks
Exclude preexisting cardiac, neuromuscular or metabolic diseases
Preoperative hemoglobin and a history of preexisting abnormal respiratory function
British Journal of Anaesthesia 86 (3): (2001)

16. General Anesthesia (Group 1)
Induction: 2 MAC sevoflurane and atracurium 0.5 mg/kg
Maintenance: MAC sevoflurane until completion of skin closure
Reversed with neostigmine 50 μg/kg and glycopyrrolate 10 μg/kg
Caudal epidural injection with 0.25% bupivacaine 2 mg/kg

17. Spinal Anesthesia (Group 2)
0.5% bupivacaine 1 mg/kg
Caudal epidural injection with 0.25% bupivacaine 2 mg/kg

18. Results
Spinal anesthesia was attempted unsuccessfully in four patients in group 2
5 patients in group 1 demonstrated an excess number of episodes of postoperative cardiopulmonary complications
3 patients had preexisting abnormal respiratory function and accounted for 80% of the episodes

19. Prevention of Postoperative Apnea
Performing a regional anesthetic instead of a general anesthetic
Perioperative administration of caffeine
Selection of general anesthetic agents or opoids that are characterized by their limited duration of action

20. Regional Anesthesia
Lower incidence (not complete absence) of postoperative apnea
The risk is similar to general anesthesia hen adding systemic sedatives
Potentially stressful for the infant and associated with a clinically significant failure rate

21. Thanks for Your Attention!!