Ex-premature infant for retinopathy laserBoy born at 26 weeks, now 10 weeks old (36 weeks postmenstrual), 1.9 kg
Ex-premature infant: apnoea risk, retinopathy laser and neonatal ventilation
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Know this first
- Ex-premature infants under 50–60 weeks postconceptual age need overnight apnoea monitoring.
- Aim for a stable middle range of saturation, about 89–94%; avoid hyperoxia.
- Chronic lung disease: reactive airways, stiff lungs, possible subglottic stenosis.
- PALS: below 60 and poorly perfused despite ventilation means CPR, then adrenaline 0.01 mg/kg.
- Caffeine 10 mg/kg reduces apnoeic spells after anaesthesia.
The patient
The examiner asks
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Consider
What are your concerns?
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- An ex-26-week infant, now 36 weeks, with chronic lung disease, for retinopathy laser. Patient
- As an ex-prem he risks apnoea, loses heat fast, and needs glucose and careful fluids.
- His lung disease means reactive airways and stiff lungs; furosemide alkalosis can raise his CO2. Disease
- Oxygen cuts both ways: avoid hypoxia, and avoid the hyperoxia that feeds his retinopathy.
- Retinal work can trigger the oculocardiac reflex. Surgery
Prepare
How do you prepare him?
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- Baseline saturation and oxygen need noted; electrolytes checked on his diuretic. Disease
- Caffeine continued; a further 10 mg/kg reduces apnoea afterwards.
- Tube half to one size smaller than predicted, given his ventilation history. Airway
- Theatre warmed, warmed fluids and blankets; he returns to the neonatal unit. Patient
Plan
How do you conduct the anaesthetic?
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- GA with a tube, not sedation, which adds apnoea risk; deep before handling his reactive airway. Airway
- Saturation target 89–94%; oxygen titrated, not 100% by default. Disease
- Higher inflation pressures may be needed; I watch for pneumothorax. Airway
- Dextrose-containing maintenance with regular glucose checks. Patient
- Atropine 10–20 mcg/kg ready for the oculocardiac reflex. Surgery
- Back to the neonatal unit with overnight apnoea monitoring at the least. After surgery
Crisis
During the laser, SpO2 falls to 70% and HR to 50; the chest barely moves and pressures are high. What do you do?
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- PALS bradycardia: at 10 weeks he is past the newborn period; HR 50, poorly perfused. (Crisis)
- Surgeon stops; hand-ventilate; DOPE: displacement, obstruction, pneumothorax, equipment.
- His small tube blocks easily: suction catheter down it; if blocked, replace the tube.
- Rate stays below 60 and he's poorly perfused despite good ventilation: start CPR.
- He's intubated, so compressions run continuously with a breath every 2–3 s; 15:2 applies only without a tube.
- Still bradycardic once oxygenated and ventilated: adrenaline 0.01 mg/kg IV.
Crisis
Back in the neonatal unit his oxygen need climbs to 50% over 2 hours, with apnoeas. What do you do?
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- Post-anaesthetic apnoea on worsening lung disease: reassess airway, chest and gas. Crisis
- Look for pneumothorax, collapse, or fluid overload in his stiff lungs.
- Nasal CPAP for apnoeas; reintubate if they continue.
- Caffeine continued; glucose and temperature checked.
- Saturation target stays 89–94%; no unrestricted oxygen. After surgery
Fatal mistakes
- High oxygen with no saturation target.
- Drugs before ventilation for his bradycardia.
- Extubation to an unmonitored setting.
Checked against: Stoelting 8e · Barash 9e · Miller 10e · AHA and AAP guidelines: pediatric advanced life support (2025) · AHA and AAP guidelines: neonatal resuscitation (2025)
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