Anesthesia and Pain Management

  • Aidan Magee
  • Suzanne CroweEmail author
Living reference work entry


Due to developments in surgical techniques and equipment, surgical repairs in smaller infants and young children became feasible in the last decades. This has been linked to new anesthetic drugs and new anesthesia modalities such as regional anesthesia. Increased operative intervention in preterm and low birth-weight infants has led to increased demand for postoperative high dependency and intensive care.

The success of major pediatric and neonatal surgery depends on the cooperation between surgeon, anesthetist, and nursing and allied professions to optimize anesthetic and surgical management. Basic techniques for maintaining a favorable physiologic milieu in the face of surgical intervention while at the same time ensuring adequate analgesia and anesthesia is essential. Besides intraoperative management, adequate postoperative care is crucial for the surgical pediatric patient. The best postoperative care should take place in an environment where the healthcare staff are skilled and trained to manage the challenges presented by neonatal and pediatric physiology in the perioperative period.


Anesthesia Analgesia Cardiovascular monitoring Cardiovascular monitoring Perioperative care Respiratory management Preterm infant 


  1. Abu Elvazed MM, Mostafa SF, Abdullah MA, Eid GM. The effect of ultrasound-guided transversus abdominis plane (TAP) block on postoperative analgesia and neuroendocrine stress response in pediatric patients undergoing elective open inguinal hernia repair. Paediatr Anaesth. 2016;26(12):1165–71.CrossRefGoogle Scholar
  2. Adler AC, Schwartz DA, Begley A, Friderici J, Connelly NR. Heart rate response to a caudal block in children anesthetized with sevoflurane after ultrasound confirmation of placement. Paediatr Anaesth. 2015;25(12):1274–9.CrossRefPubMedGoogle Scholar
  3. American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health; Task Force on Pain in Infants, Children, and Adolescents. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2001;108(3):793–7.Google Scholar
  4. Anand KJ, Hansen DD, Hickey PR. Hormonal-metabolic stress responses in neonates undergoing cardiac surgery. Anesthesiology. 1990;73:661–70.CrossRefPubMedGoogle Scholar
  5. Atzori P, Iacobelli BD, Bottero S, Spirydakis J, Laviani R, Trucchi A, et al. Preoperative tracheobronchoscopy in newborns with esophageal atresia: does it matter? J Pediatr Surg. 2006;41:1054–7.CrossRefPubMedGoogle Scholar
  6. Boerlage AA, Ista E, Duivenvoorden HJ, de Wildt SN, Tibboel D, van Dijk M. The COMFORT behaviour scale detects clinically meaningful effects of analgesic and sedative treatment. Eur J Pain. 2015;19(4):473–9.CrossRefPubMedGoogle Scholar
  7. Bosenberg AT. Epidural analgesia for major neonatal surgery. Paediatr Anaesth. 1998;8:479–8310.CrossRefPubMedGoogle Scholar
  8. Bosenberg AT, Hadley GP, Wiersma R. Oesophageal atresia: caudo-thoracic epidural anaesthesia reduces the need for postoperative ventilatory support. Pediatr Surg Int. 1992;7:289–91.CrossRefGoogle Scholar
  9. Bouwmeester NJ, Anand KJ, van Dijk M, Hop WC, Boomsma F, Tibboel D. Hormonal and metabolic stress responses after major surgery in children aged 0–3 years: a double-blind, randomized trial comparing the effects of continuous versus intermittent morphine. Br J Anaesth. 2001;87:390–9.CrossRefPubMedGoogle Scholar
  10. Bradley AE, White MC, Engelhardt T, Bayley G, Beringer RM. Current UK practice of pediatric supraglottic airway devices – a survey of members of the Association of Paediatric Anaesthetists of great Britain and Ireland. Paediatr Anaesth. 2013;23(11):1006–9.CrossRefPubMedGoogle Scholar
  11. Brady M, Kinn S, O’Rourke K, Randhawa N, Stuart P. Preoperative fasting for preventing perioperative complications in children. Cochrane Database Syst Rev. 2005;18(2):CD005285.Google Scholar
  12. Brusseau R, Koka B. Manual of neonatal surgical intensive care. 2nd ed. Shelton: People’s Medical Publishing House; 2009. Anesthesia for Neonatal Surgical Emergencies; pp. 563–87.Google Scholar
  13. Calder A, Hegarty M, Davies K, von Ungern-Sternberg BS. The difficult airway trolley in pediatric anesthesia: an international survey of experience and training. Paediatr Anaesth. 2012;22(12):1150–4.CrossRefPubMedGoogle Scholar
  14. Choong K, Kho ME, Menon K, Bohn D. Hypotonic versus isotonic saline in hospitalised children: a systematic review. Arch Dis Child. 2006;91(10):828–35.CrossRefPubMedPubMedCentralGoogle Scholar
  15. Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T, Carter T, Cassidy CL, Chittenden EH, Degenhardt E, Griffith S, Manworren R, McCarberg B, Montgomery R, Murphy J, Perkal MF, Suresh S, Sluka K, Strassels S, Thirlby R, Viscusi E, Walco GA, Warner L, Weisman SJ, Wu CL. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ committee on regional anesthesia, executive committee, and administrative council. J Pain. 2016;17(2):131–57.CrossRefPubMedGoogle Scholar
  16. Crellin DJ, Harrison D, Santamaria N, Babl FE. Systematic review of the face, legs, activity, cry and consolability scale for assessing pain in infants and children: is it reliable, valid and feasible for use? Pain. 2015;156(11):2132–51.CrossRefPubMedGoogle Scholar
  17. Czarnecki ML, Hainsworth K, Simpson PM, Arca MJ, Uhing MR, Varadarajan J, Weisman SJ. Is there an alternative to continuous opioid infusion for neonatal pain control? A preliminary report of parent/nurse-controlled analgesia in the neonatal intensive care unit. Paediatr Anaesth. 2014;24(4):377–85.CrossRefPubMedPubMedCentralGoogle Scholar
  18. Davidson AJ, Morton NS, Arnup SJ, de Graaff JC, Disma N, Withington DE, Frawley G, et al. Apnea after awake regional and general anesthesia in infants: the general anesthesia compared to spinal anesthesia study – comparing apnea and neurodevelopmental outcomes, a randomized controlled trial. Anesthesiology. 2015a;123(1):38–54.CrossRefPubMedPubMedCentralGoogle Scholar
  19. Davidson AJ, Morton NS, Arnup SJ, de Graaff JC, Disma N, Withingotn DE, Frawley G, Hunt RW, Hardy P, Khotcholava M, von Ungern-Sternberg BS, Wilton N, Tyo P, Salvo I, Ormond G, Stargatt R, Locatelli BG, ME MC, General Anesthesia compared to spinal anesthesia (GAS) Consortium. Apnea after awake regional and general anesthesia in infants: the general anesthesia compared to spinal anesthesia study – comparing apnea and neurodevelopmental outcomes, a randomized controlled trial. Anesthesiology. 2015b;123(1):38–54.CrossRefPubMedPubMedCentralGoogle Scholar
  20. Davidson AJ, Disma N, de Graaff JC, Withington DE, Dorris L, Bell G, Stargatt R, Bellinger DC, Schuster T, Arnup SJ, Hardy P, Hunt RW, Takagi MJ, Giribaldi G, Hartmann PL, Salvo I, Morton NS, von Ungern-Sternberg BS, Locatelli BG, Wilton N, Lynn A, Thomas JJ, Polaner D, Bagshaw O, Szmuk P, Absalom AR, Frawley G, Berde C, Ormond GD, Marmor J, ME MC, GAS Consortium. Neurodevelopmental outcome at 2 years of age after general anesthesia and awake-regional anesthesia in infancy (GAS): an international multicentre, randomized controlled trial. Lancet. 2016;387(10015):239–50.CrossRefPubMedGoogle Scholar
  21. Eicher C, Seitz G, Bevot A, Moll M, Goelz R, Arand J, Poets C, Fuchs J. Surgical management of extremely low birth weight infants with neonatal bowel perforation: a single-center experience and a review of the literature. Neonatology. 2012;101(4):285–92.CrossRefPubMedGoogle Scholar
  22. Goeller JK, Bhalla T, Tobias JD. Combined use of neuraxial and general anesthesia during major abdominal procedures in neonates and infants. Paediatr Anaesth. 2014;24(6):553–60.CrossRefPubMedGoogle Scholar
  23. Greenough A, Dimitriou G, Prendergast M, Milner AD. Synchronized mechanical ventilation for respiratory support in newborn infants. Cochrane Database Syst Rev. 2008;1(1):CD000456. doi:10.1002/14651858Google Scholar
  24. Gunter JB. Benefit and risks of local anesthetics in infants and children. Paediatr Drugs. 2002;4(10):649–72.CrossRefPubMedGoogle Scholar
  25. Hamill JK, Rahiri JL, Liley A, Hill AG. Rectus sheath and transversus abdominis plane blocks in children: a systematic review and meta-analysis of randomized controlled trials. Paediatr Anaesth. 2016;26(4):363–71.CrossRefPubMedGoogle Scholar
  26. Hiller SC, Krishna G. Neonatal anesthesia. Semin Pediatr Surg. 2004;3:142–51.CrossRefGoogle Scholar
  27. Johnson SA, Young C, Olney JW. Isoflurane-induced neuroapoptosis in the developing brain of nonhypoglycemic mice. J Neurosurg Anesthesiol. 2008;20(1):21–8.CrossRefPubMedGoogle Scholar
  28. Jones LJ, Craven PD, Lakkundi A, Foster JP, Badawi N. Regional (spinal, epidural, caudal) versus general anesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy. Cochrane Database Syst Rev. 2015;9(6):CD003669.Google Scholar
  29. Kearns GL, Abdel-Rahman SM, Alander SW, Blowey DL, Leeder JS, Kauffman RE. Developmental pharmacology – drug disposition, action, and therapy in infants and children. N Engl J Med. 2003;349:1157–67.CrossRefPubMedGoogle Scholar
  30. Kinottenbelt G, Skinner A, Seefelder C. Tracheo-oesophageal fistula (TOF) and oesophageal atresia (OA). Best Pract Res Clin Anaesthesiol. 2010;24:387–401.CrossRefPubMedGoogle Scholar
  31. Lak M, Araghizadeh H, Shayeghi S, Khatibi B. Addition of clonidine in caudal anesthesia in children increases duration of post-operative analgesia. Trauma Mon. 2012;16(4):170–4.CrossRefPubMedPubMedCentralGoogle Scholar
  32. Lerman J, Nolan J, Eyres R, Schily M, Stoddart P, Bolton CM, Mazzeo F, Wolf AR. Efficacy, safety, and pharmacokinetics of levobupivacaine with and without fentanyl after continuous epidural infusion in children: a multicenter trial. Anesthesiology. 2003;99(5):1166–74.CrossRefPubMedGoogle Scholar
  33. Lingappan K, Arnold JL, Shaw TL, Fernandes CJ, Pammi M. Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates. Cochrane Database Syst Rev. 2015;18(2):CD009975.Google Scholar
  34. Millar C. Anaesthesia and intensive care medicine. vol. 6. The Medicine Publishing Company Limited; 2005. London: Principles of Anesthesia for Neonates; p. 92–6.Google Scholar
  35. Mueller CM, Sinclair TJ, Stevens M, Esquivel M, Gordon N. Regional block via continuous caudal infusion as sole anesthetic for inguinal hernia repair in conscious neonates. Pediatr Surg Int. 2016; 33:341–5 (Epub ahead of print).Google Scholar
  36. Nesher N, Wolf T, Uretzky G, Oppenheim-Eden A, Yussim E, Kushnir I, et al. A novel thermoregulatory system maintains perioperative normothermia in children undergoing elective surgery. Paediatr Anaesth. 2001;11:555–60.CrossRefPubMedGoogle Scholar
  37. Nose S, Sasaki T, Saka R, Minagawa K, Okuyama H. A sutureless technique using cyanoacrylate adhesives when creating a stoma for extremely low birth weight infants. Springerplus. 2016;5:189 (eCollection 2016-10-3).Google Scholar
  38. Padda GS, Cruz OA, Krock JL. Comparison of postoperative emesis, recovery profile, and analgesia in pediatric strabismus repair. Rectal acetaminophen versus intravenous fentanyl-droperidol. Ophthalmology. 1997;104(3):419–24.CrossRefPubMedGoogle Scholar
  39. Sale SM, Read JA, Stoddart PA, Wolf AR. Prospective comparison of sevoflurane and desflurane in formerly premature infants undergoing inguinal herniotomy. Br J Anaesth. 2006;96(6):774–8.CrossRefPubMedGoogle Scholar
  40. Sammartino M, Garra R, Sbaraglia F, De Riso M, Continolo N, Papacci P. Experience of remifentanil in extremely low-birth-weight babies undergoing laparotomy. Pediatr Neonatol. 2011;52(3):176–9.CrossRefPubMedGoogle Scholar
  41. Sathiyamurthy S, Banerjee J, Godambe SV. Antiseptic use in the neonatal intensive care unit – a dilemma in clinical practice: an evidence based review. World J Clin Pediatr. 2016;5(2):159–71.CrossRefPubMedPubMedCentralGoogle Scholar
  42. Smithers CJ, Hamilton TE, Manfredi MA, Rhein L, Ngo P, Gallagher D, Foker JE, Jennings RW. Categorization and repair of recurrent and acquired tracheoesophageal fistulae occurring after esophageal atresia repair. J Pediatr Surg. 2017;52(3):424–430.Google Scholar
  43. Spitzer AT, Sims KM. A comparison of the impact of cuffed versus uncuffed endotracheal tubes on the incidence of tracheal tube exchange and on post-extubation airway morbidity in pediatric patients undergoing general anesthesia. JBI Database System Rev Implement Rep. 2016;14(5):10–7.CrossRefPubMedGoogle Scholar
  44. Taddio A, Katz J. The effects of early pain experience in neonates on pain responses in infancy and childhood. Paediatr Drugs. 2005;7:245–57.CrossRefPubMedGoogle Scholar
  45. Tan Z, Lee SY. Pulmonary aspiration under GA: a 13-year audit in a tertiary pediatric unit. Pediatr Anesth. 2016; 26(5):547–52 (Epub 2016 Mar 17).Google Scholar
  46. Taneja B, Srivastava V, Saxena KN. Physiological and anesthetic considerations for the preterm neonate undergoing surgery. J Neonatal Surg. 2012;1:14.PubMedPubMedCentralGoogle Scholar
  47. Uyasal HY, Takmaz SA, Yaman F, Baltaci B, Basar H. The efficacy of intravenous paracetamol versus tramadol for postoperative analgesia after adenotonsillectomy in children. J Clin Anesth. 2011;23(1):53–7.CrossRefGoogle Scholar
  48. Van de Putte P, Perlas A. Ultrasound assessment of gastric content and volume. Br J Anaesth. 2014;113(1):12–22.CrossRefPubMedGoogle Scholar
  49. Vutskits L. Anesthetic-related neurotoxicity and the developing brain: shall we change practice? Paediatr Drugs. 2012;14(1):13–21.CrossRefPubMedGoogle Scholar
  50. Zgleszewski SE, Graham DA, Hickey PR, Brustowicz RM, Odegard KC, Koka R, Seefelder C, Navedo AT, Randolph AG. Anesthesiologist- and system-related risk factors for risk-adjusted pediatric anesthesia-related cardiac arrest. Anesth Analg. 2016;122(2):482–9.CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  1. 1.Our Lady’s Children’s Hospital CrumlinDublinIreland

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