Anaesthetic management of an extremely low birth weight preterm neonate undergoing surgery for midgut malrotation: A case report

Nagesh R*, Mohan N, Nadir Abbas Malvia, Ashok M, Hemanth Kamath, Rajesh K C, Madhushree, Karthik, Monika, Vijay Sai

Department of Anaesthesiology and Critical Care, Kauvery Hospital, Electronic City, Bengaluru, India

Abstract

Background: Anaesthesia in extremely low birth weight (ELBW) neonates (<1000 g) is particularly challenging because of physiological immaturity, limited reserves, and susceptibility to hypothermia and cardiorespiratory instability. Literature on neonates under 800 g undergoing laparotomy remains scarce.

Case Presentation: We report the anaesthetic management of an 11-day-old, 29-week preterm neonate weighing 735 g who underwent exploratory laparotomy for midgut malrotation. The baby was managed on the same incubator bed used in the neonatal intensive care unit (NICU) to minimise transfer risks. Propofol infusion and epinephrine support were used for maintenance and haemodynamic stability, while invasive monitoring, thermal regulation, and neonatal ventilator support ensured safe intraoperative management. Postoperatively, the neonate remained ventilated for 48 hours and was successfully extubated in the NICU.

Conclusion: This case highlights that with meticulous preparation, neonatal-specific ventilatory strategies, and multidisciplinary collaboration, safe anaesthesia is achievable even in ELBW neonates undergoing major abdominal surgery.

Keywords: Anaesthesia; Extremely low birth weight; Neonate; Midgut malrotation; Neonatal laparotomy.

Introduction

Anaesthetic management in ELBW neonates represents one of the most demanding areas of paediatric anaesthesia. These neonates exhibit profound physiological immaturity, altered pharmacokinetics, and high susceptibility to hypothermia, hypoglycaemia, and respiratory failure. Despite technological advances in neonatal intensive care, anaesthetic data for infants <800 g remain limited [1,2].

We present an 11-day-old, 29-week preterm neonate weighing 735 g who underwent exploratory laparotomy for correction of midgut malrotation. The case underscores the value of NICU–operating theatre integration, multidisciplinary teamwork, and neonatal-specific strategies to improve perioperative outcomes.

Case Presentation

An 11-day-old male, gestational age 29 weeks, birth weight 720 g (current 735 g), born via emergency caesarean for abruptio placenta, presented with bilious aspirates and abdominal distension. Contrast-enhanced upper GI study revealed midgut malrotation. The neonate had prior respiratory distress syndrome managed with surfactant therapy, mechanical ventilation, and bubble CPAP. He was on total parenteral nutrition, with sepsis being treated using broad-spectrum antibiotics.

After counselling and informed consent, surgery was planned under general anaesthesia. The neonate was transported in an incubator with active warming, invasive lines, and ventilatory support. Operating room temperature was maintained at 26°C. The baby was operated on the same incubator bed to minimise hypothermia and dislodgement risks. Padding and wrapping with cotton rolls prevented heat loss.

Monitoring included ECG, invasive blood pressure, capnography, pulse oximetry, and temperature. Anaesthesia was induced with fentanyl 2 µg/kg, midazolam 0.05 mg/kg, and propofol infusion (1 mg/kg/hr). Muscle relaxation was achieved with atracurium 0.5 mg/kg. Maintenance was achieved with propofol infusion in air-oxygen mixture using a neonatal ventilator with warm humidification. Epinephrine (0.05 µg/kg/min) maintained perfusion, and dextrose 5% infusion (7 ml/kg/hr) maintained glucose homeostasis. EtCO₂ was 35–45 mmHg, SpO₂ 90–95%, HR 150–170/min, and mean arterial pressure 25–35 mmHg. Blood loss was <10 ml. The procedure lasted 60 minutes without major instability.

Postoperatively, the neonate remained intubated for elective ventilation due to prematurity and risk of apnoea. Extubation was performed on postoperative day 2; the neonate was discharged in stable condition on day 3.

Discussion

Extremely low birth weight (ELBW) neonates are physiologically fragile due to incomplete organ maturation and limited metabolic reserves [1]. Survival rates decline steeply below 800 g, with recent studies indicating 80–85% survival at tertiary centres using advanced neonatal care [2,3]. Malrotation requiring laparotomy in ELBW infants adds complexity because of sepsis, hypothermia risk, and ventilation–perfusion instability [4].

Maintaining normothermia is critical as even a 1°C drop increases oxygen consumption by 10% [1]. Active warming using incubator beds, forced-air warmers, and preheated fluids is recommended [5]. The use of the same NICU incubator as the operative platform, as in our case, minimised handling and temperature loss—a strategy increasingly adopted in resource-constrained environments [6].

Ventilation in these neonates requires lung-protective strategies with low tidal volumes (4–6 ml/kg) and permissive hypercapnia (PaCO₂ 45–55 mmHg) to reduce barotrauma and bronchopulmonary dysplasia risk [7]. Target SpO₂ 90–95% avoids both retinopathy of prematurity and hypoxia-induced pulmonary hypertension. Dedicated neonatal ventilators with heated humidification should be preferred over anaesthesia workstations [8].

Cardiovascular management must address poor myocardial compliance, blunted baroreflex, and dependence on heart rate for cardiac output. Vasopressors such as norepinephrine or low-dose epinephrine are preferred for maintaining perfusion without excessive tachycardia. Glucose levels must be maintained between 70–150 mg/dL; both hypoglycaemia and hyperglycaemia are associated with neurodevelopmental harm [9].

Intraoperative monitoring accuracy is essential: invasive arterial lines improve perfusion assessment and allow frequent blood gas sampling [1]. Pharmacological dosing should reflect reduced hepatic metabolism and renal clearance; dose intervals for sedatives and opioids must be extended [5]. Etomidate and propofol can be safely titrated in small infusions under direct haemodynamic monitoring [10].

Analgesia and anaesthetic depth are vital to prevent stress-induced intraventricular haemorrhage. Postoperative ventilation reduces risk of apnoea, particularly when sepsis or anaemia coexists. Prophylactic caffeine (5–10 mg/kg) reduces apnoea and facilitates earlier extubation [11].

In recent years, performing surgery within the NICU has gained traction, as it mitigates hypothermia, transport-related dislodgement, and ventilator-related complications. A 2020 Indian series reported successful neonatal surgeries performed in NICU environments with improved survival in ELBW infants [12]. Our case demonstrates that with proper multidisciplinary preparation and neonatal-focused perioperative protocols, safe anaesthesia and positive outcomes are attainable.

Conclusion

Anaesthesia in ELBW neonates requires meticulous preparation, experienced multidisciplinary collaboration, and neonatal-specific perioperative strategies. Temperature control, tailored ventilation, cautious fluid and glucose management, and elective postoperative ventilation remain the cornerstones for safe outcomes in this fragile population.

Declaration of Patient Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient’s parents have given consent for clinical information to be reported in the journal. The parents understand that names and initials will not be published, and efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial Support and Sponsorship

Nil

Conflicts of Interest

There are no conflicts of interest.

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