Complex Challenges in Perioperative Care of a Preterm Neonate: A Case Report

Complex Challenges in Perioperative Care of a Preterm Neonate: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Complex Challenges in Perioperative Care of a Preterm Neonate: A Case Report Anand K, Agathiyan A, Mohammed Arshad N, yuvaraj p This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7702782/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Perioperative management of extremely preterm neonates presents significant challenges due to their fragile physiological status, including respiratory instability, cardiovascular vulnerability, and metabolic immaturity. This case report details the complex perioperative care of a 22-day-old male neonate, born at 27 weeks of gestation, who required surgical intervention for an incarcerated inguinoscrotal hernia. Case Presentation The neonate with post conception age of 30 weeks, born weighing 1.225 kg, presented with a right scrotal swelling diagnosed as an incarcerated inguinoscrotal hernia. His early postnatal course was complicated by respiratory distress syndrome (RDS), necessitating mechanical ventilation and surfactant therapy. A multimodal, opioid-free anaesthesia regimen was conceived to minimize the risk of postoperative apnoea. Intraoperative care focused on maintaining stable oxygenation, normothermia, and hemodynamic parameters. Anaesthesia was induced using ketamine and maintained with mixture of air/Oxygen and Sevoflurane. Ultrasound guided caudal block with Levo bupivacaine was administered to address perioperative pain. The neonate was ventilated intraoperatively in pressure-controlled mode and postoperatively in P-SIMV mode, with a smooth transition to CPAP and then to room air. The patient recovered without complications, demonstrating the effectiveness of the anaesthetic strategy employed. Conclusion This case highlights the complexities of perioperative management in extremely preterm neonates, emphasizing the importance of an individualized, multidisciplinary approach. The successful outcome underscores the efficacy of opioid-sparing anaesthesia and meticulous perioperative care in mitigating the risks associated with surgery in these vulnerable preterm neonates. This report contributes to the growing body of knowledge on optimizing perioperative strategies for preterm neonates. Preterm neonate perioperative management opioid-free anesthesia caudal block neonatal surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction The perioperative management of extremely preterm neonates represents one of the most challenging role in paediatric anaesthesia due to their immature physiology and increased susceptibility to a spectrum of perioperative complications. Preterm neonates—particularly those born before 28 weeks of gestation—are characterized by underdeveloped organ systems, including incomplete pulmonary surfactant synthesis, fragile cardiovascular regulation, and metabolic immaturity, leading to elevated risks of respiratory distress syndrome, cardiovascular instability, hypoglycaemia, and temperature dysregulation. [ 1 , 2 , 3 ]. These physiological vulnerabilities the anaesthetic management more complex and necessitate careful and evidence-based strategies focused to the unique needs of the neonate. This case report presents the perioperative management of a 22-day-old male neonate born at 27 weeks of gestation (Post conception age of 30weeks + 1day). The neonate, classified as very preterm with a very low birth weight of 1.225 kg, was diagnosed with a right incarcerated inguinoscrotal hernia. The management of such a high-risk neonate required careful consideration of the unique physiological challenges associated with prematurity, including respiratory, cardiovascular, and metabolic instability. Case presentation A 22-day old male neonate presented with a right scrotal swelling whose antenatal history was marked by oligohydramnios detected during the third trimester, necessitating close monitoring. The mother had an uneventful first and second trimester. The neonate was delivered via emergency lower segment caesarean section (LSCS) due to spontaneous labour and oligohydramnios at 27 weeks of gestation. The baby had a birth weight of 1.225 kg, an Apgar score of 7 at 1 minute and 8 at 5 minutes, and required immediate NICU admission due to respiratory distress syndrome (RDS) for which the neonate was initially intubated and received surfactant therapy. He was managed on synchronized intermittent mandatory ventilation (SIMV) for 4 days, followed by continuous positive airway pressure (CPAP) until day 11 of life, when he was successfully weaned to room air. On general and systemic examination, the neonate was alert, with good hydration and no signs of respiratory distress or cardiovascular instability. Blood investigations were within normal limits. Ultrasound abdomen revealed an incarcerated inguinoscrotal hernia. The herniated bowel loop showed no signs of peristalsis but maintained normal vascularity. Emergency right open herniotomy was planned. The neonate was kept nil per oral (NPO) for 4 hours prior to surgery, with maintenance fluid isolyte-p at 6ml/hr provided via an infusion pump. The operating room was pre-warmed to 35–37°C, and warmed fluids were used to prevent hypothermia. Due to the difficult airway anticipated from the neonate’s anatomy (larger head, narrow nasal passage, larger tongue, floppy epiglottis), airway cart to manage difficult airway including, video laryngoscope (VDL) was kept on standby Hemodynamic monitoring was carefully conducted during the transfer to the operating theatre. The neonate was preoxygenated ( Fig. 1 ) and premedicated with Inj.Atropine and Inj.Ondansetron. An opioid-free, multimodal anaesthesia approach was selected to prevent the risk of apnoea. Inj.Ketamine was used for induction, followed by Inj.Cisatracurium for muscle relaxation to secure the airway with a cuffed endotracheal tube. The baby was ventilated with pressure-controlled ventilation ( Fig. 2 ) with minimal tidal volume of 8ml/kg and the plane was maintained with air/oxygen and Inh.Sevoflurane. The ventilation parameters were carefully adjusted to maintain oxygen saturation between 88–92%, avoiding the use of Inh.Nitrous oxide to prevent bowel distension. Caudal analgesia was administered using 1ml of Inj.0.25% Bupivacaine, guided by ultrasound to locate the caudal space accurately ( Fig. 3 ,4). Intraoperative fluids were maintained at 6 ml/hr using an infusion pump, and strict monitoring of blood glucose and core temperature was performed throughout the surgery. Intraoperatively, a very rare finding of a perforated appendix within the hernial sac was encountered, necessitating immediate surgical intervention to prevent further complications. Postoperatively, the neonate was shifted back to the NICU for elective mechanical ventilation in SIMV mode, later transitioning to nasal CPAP(Fig. 5 ). Hemodynamic monitoring continued postoperatively to ensure stability. Antibiotics were administered as per the neonatologist orders to prevent infection. The neonate was successfully weaned off from mechanical ventilation within 6 hours post-surgery following adequate respiratory function without signs of apnoea. Baby recovered well, gained weight and was eventually discharged in good health. Discussion The case illustrates the significant perioperative challenges in managing a very preterm neonate, including the risk of difficult airway, respiratory depression, cardiovascular instability, hypoglycaemia, hypothermia, and postoperative apnoea. Careful fluid management is critical and the individualized fluid therapy in necessary in neonates due to their limited physiological reserves and higher vulnerability.[ 4 ] Caudal blockade is a effective and safe technique for postoperative pain management in paediatric patients. The technical difficulty of administering caudal analgesia in a neonate with immature anatomy was successfully managed with ultrasound guidance. Ultrasound guidance improves the success rate of caudal blockade and reduces the risk of complications compared to landmark-based techniques.[ 5 , 6 ] The decision to use opioid-free anaesthesia was crucial in minimizing the risk of postoperative apnoea, a common complication in preterm infants.[ 7 , 8 ] Macrae et al, highlighted that the premature neonates require specialized anaesthetic care due to their immature physiology. Anaesthetic techniques should be tailored to minimize risks and optimize outcomes. Additionally, attention to fluid management and thermoregulation is critical in the perioperative period.[ 9 ] Subramaniam et al, supports and expands on the anaesthetic considerations and provides additional information on the physiological differences between preterm and term neonates and how these differences impact anaesthetic management.[ 10 ] Taneja B et al, discussed the unique physiological characteristics of preterm neonates, such as Immature organ systems, limited cardiovascular reserve, increased sensitivity to anaesthetic agents.[ 11 ] This case highlights the importance of a multidisciplinary approach, involving anaesthesiologists, surgeons and neonatologists to address the unique needs of preterm neonates during surgery. Conclusion This case underscores the complexity of perioperative care in extremely preterm neonates, emphasizing the need for careful planning, specialized monitoring, specialized techniques, and vigilant postoperative management to ensure favourable outcomes. The successful management of this case demonstrates the critical role of a tailored anaesthesia plan and close interdisciplinary collaboration in addressing the multifaceted challenges presented by such high-risk patients. Declarations Clinical Trial Number Not applicable. Consent for Publication: Written informed consent was obtained from the patient’s parents for publication of this case report and accompanying images. Consent for human ethics and participation Not applicable. Consent for publication was obtained from patient’s parents. Competing interests The authors declare that there is no conflict of interest regarding the publication of this case report. Funding The authors received instutional funding for the publication of this case report. Author Contribution DR.Anand K, review and editing.DR.Agathiyan A, writing—original draft.DR.Mohammed Arshad N, review.DR.Yuvaraj P, review. Acknowledgements We acknowledge the support of the Surgical team in the successful management of this case. We are also grateful to our institution for providing the necessary facilities and finally we sincerely thank the patient and their family for their cooperation and consent. Data Availability No datasets were generated or analysed during the current study. References Morniroli D, Tiraferri V, Maiocco G, De Rose DU, Cresi F, Coscia A, Mosca F, Giannì ML. Beyond survival: the lasting effects of premature birth. Front Pead. 2023;11:1–12. 10.3389/fped.2023.1048581 . Doherty TM, Hu A, Salik I, Physiology. Neonatal. [Updated 2023 Apr 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539840/# Party BW. Managing the difficult airway in the neonate A framework for practice. London: British Association of Perinatal Medicine; 2020. Sümpelmann R, Becke K, Brenner S, Breschan C, Eich C, Höhne C, Jöhr M, Kretz FJ, Marx G, Pape L, Schreiber M, Strauss J, Weiss M. Perioperative intravenous fluid therapy in children: guidelines from the Association of the Scientific Medical Societies in Germany. Paediatr Anaesth. 2017;27(1):10–8. 10.1111/pan.13007 . Epub 2016 Oct 17. PMID: 27747968. Willschke H, Bosenberg A, Marhofer P, Willschke J, Schwindt J, Weintraud M, Kapral S, Kettner S. Epidural catheter placement in neonates: sonoanatomy and feasibility of ultrasonographic guidance in term and preterm neonates. Reg Anesth Pain Med. 2007 Jan-Feb;32(1):34–40. 10.1016/j.rapm.2006.10.008 . PMID: 17196490. Opfermann P, Kraft F, Obradovic M, Zadrazil M, Schmid W, Marhofer P. Ultrasound-guided caudal blockade and sedation for paediatric surgery: a retrospective cohort study. Anaesthesia. 2022;77(7):785–94. 10.1111/anae.15738 . Epub 2022 Apr 22. PMID: 35460068; PMCID: PMC9322320. Maheshwari M, Sanwatsarkar S, Katakwar M. Pharmacology related to paediatric anaesthesia. Indian Journal of Anaesthesia 63(9):p 698–706, September 2019. | 10.4103/ija.IJA_487_19 Paul M, Bamba C, Vinay V, Krishna B, Bharani Kumar. B.1. Comparing Opioid with Opioid-free Anesthesia Technique in Neonates Undergoing Tracheoesophageal Fistula Repair. Oman Med J. 2023;38(5):e547. 10.5001/omj.2023.98 . PMID: 38204595; PMCID: PMC10776962. Macrae J, Ng E, Whyte H. Anaesthesia for premature infants. BJA Educ. 2021;21(9):355–63. 10.1016/j.bjae.2021.03.007 . Epub 2021 Jul 6. PMID: 34447582; PMCID: PMC8377236. Subramaniam R. Anaesthetic concerns in preterm and term neonates. Indian Journal of Anaesthesia 63(9):p 771–779, September 2019. | 10.4103/ija.IJA_591_19 Taneja B, Srivastava V, Saxena KN. Physiological and anaesthetic considerations for the preterm neonate undergoing surgery. J Neonatal Surg. 2012;1(1):14. PMID: 26023373; PMCID: PMC4420318. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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4","display":"","copyAsset":false,"role":"figure","size":1315309,"visible":true,"origin":"","legend":"\u003cp\u003eUSG Guided caudal analgesia\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7702782/v1/ec453cb4e80b04f7eec0959b.png"},{"id":95414142,"identity":"a98b72b7-4d7b-4858-a93b-d8520f7af8c3","added_by":"auto","created_at":"2025-11-07 20:15:10","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1528271,"visible":true,"origin":"","legend":"\u003cp\u003eNasal CPAP ventilation\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7702782/v1/fc4ebb1b84e806a131fab839.png"},{"id":95653935,"identity":"801efc30-9310-4569-a48f-0e7867be98a3","added_by":"auto","created_at":"2025-11-11 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Preterm neonates\u0026mdash;particularly those born before 28 weeks of gestation\u0026mdash;are characterized by underdeveloped organ systems, including incomplete pulmonary surfactant synthesis, fragile cardiovascular regulation, and metabolic immaturity, leading to elevated risks of respiratory distress syndrome, cardiovascular instability, hypoglycaemia, and temperature dysregulation. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These physiological vulnerabilities the anaesthetic management more complex and necessitate careful and evidence-based strategies focused to the unique needs of the neonate.\u003c/p\u003e\u003cp\u003eThis case report presents the perioperative management of a 22-day-old male neonate born at 27 weeks of gestation (Post conception age of 30weeks\u0026thinsp;+\u0026thinsp;1day). The neonate, classified as very preterm with a very low birth weight of 1.225 kg, was diagnosed with a right incarcerated inguinoscrotal hernia. The management of such a high-risk neonate required careful consideration of the unique physiological challenges associated with prematurity, including respiratory, cardiovascular, and metabolic instability.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 22-day old male neonate presented with a right scrotal swelling whose antenatal history was marked by oligohydramnios detected during the third trimester, necessitating close monitoring. The mother had an uneventful first and second trimester. The neonate was delivered via emergency lower segment caesarean section (LSCS) due to spontaneous labour and oligohydramnios at 27 weeks of gestation. The baby had a birth weight of 1.225 kg, an Apgar score of 7 at 1 minute and 8 at 5 minutes, and required immediate NICU admission due to respiratory distress syndrome (RDS) for which the neonate was initially intubated and received surfactant therapy. He was managed on synchronized intermittent mandatory ventilation (SIMV) for 4 days, followed by continuous positive airway pressure (CPAP) until day 11 of life, when he was successfully weaned to room air. On general and systemic examination, the neonate was alert, with good hydration and no signs of respiratory distress or cardiovascular instability. Blood investigations were within normal limits. Ultrasound abdomen revealed an incarcerated inguinoscrotal hernia. The herniated bowel loop showed no signs of peristalsis but maintained normal vascularity. Emergency right open herniotomy was planned.\u003c/p\u003e\u003cp\u003eThe neonate was kept nil per oral (NPO) for 4 hours prior to surgery, with maintenance fluid isolyte-p at 6ml/hr provided via an infusion pump. The operating room was pre-warmed to 35\u0026ndash;37\u0026deg;C, and warmed fluids were used to prevent hypothermia. Due to the difficult airway anticipated from the neonate\u0026rsquo;s anatomy (larger head, narrow nasal passage, larger tongue, floppy epiglottis), airway cart to manage difficult airway including, video laryngoscope (VDL) was kept on standby\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eHemodynamic monitoring was carefully conducted during the transfer to the operating theatre. The neonate was preoxygenated \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) and premedicated with Inj.Atropine and Inj.Ondansetron. An opioid-free, multimodal anaesthesia approach was selected to prevent the risk of apnoea. Inj.Ketamine was used for induction, followed by Inj.Cisatracurium for muscle relaxation to secure the airway with a cuffed endotracheal tube. The baby was ventilated with pressure-controlled ventilation\u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) with minimal tidal volume of 8ml/kg and the plane was maintained with air/oxygen and Inh.Sevoflurane. The ventilation parameters were carefully adjusted to maintain oxygen saturation between 88\u0026ndash;92%, avoiding the use of Inh.Nitrous oxide to prevent bowel distension. Caudal analgesia was administered using 1ml of Inj.0.25% Bupivacaine, guided by ultrasound to locate the caudal space accurately\u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e,4).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIntraoperative fluids were maintained at 6 ml/hr using an infusion pump, and strict monitoring of blood glucose and core temperature was performed throughout the surgery. Intraoperatively, a very rare finding of a perforated appendix within the hernial sac was encountered, necessitating immediate surgical intervention to prevent further complications.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003ePostoperatively, the neonate was shifted back to the NICU for elective mechanical ventilation in SIMV mode, later transitioning to nasal CPAP(Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Hemodynamic monitoring continued postoperatively to ensure stability. Antibiotics were administered as per the neonatologist orders to prevent infection. The neonate was successfully weaned off from mechanical ventilation within 6 hours post-surgery following adequate respiratory function without signs of apnoea.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eBaby recovered well, gained weight and was eventually discharged in good health.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe case illustrates the significant perioperative challenges in managing a very preterm neonate, including the risk of difficult airway, respiratory depression, cardiovascular instability, hypoglycaemia, hypothermia, and postoperative apnoea. Careful fluid management is critical and the individualized fluid therapy in necessary in neonates due to their limited physiological reserves and higher vulnerability.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Caudal blockade is a effective and safe technique for postoperative pain management in paediatric patients. The technical difficulty of administering caudal analgesia in a neonate with immature anatomy was successfully managed with ultrasound guidance. Ultrasound guidance improves the success rate of caudal blockade and reduces the risk of complications compared to landmark-based techniques.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] The decision to use opioid-free anaesthesia was crucial in minimizing the risk of postoperative apnoea, a common complication in preterm infants.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eMacrae et al, highlighted that the premature neonates require specialized anaesthetic care due to their immature physiology. Anaesthetic techniques should be tailored to minimize risks and optimize outcomes. Additionally, attention to fluid management and thermoregulation is critical in the perioperative period.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Subramaniam et al, supports and expands on the anaesthetic considerations and provides additional information on the physiological differences between preterm and term neonates and how these differences impact anaesthetic management.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eTaneja B et al, discussed the unique physiological characteristics of preterm neonates, such as Immature organ systems, limited cardiovascular reserve, increased sensitivity to anaesthetic agents.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThis case highlights the importance of a multidisciplinary approach, involving anaesthesiologists, surgeons and neonatologists to address the unique needs of preterm neonates during surgery.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case underscores the complexity of perioperative care in extremely preterm neonates, emphasizing the need for careful planning, specialized monitoring, specialized techniques, and vigilant postoperative management to ensure favourable outcomes. The successful management of this case demonstrates the critical role of a tailored anaesthesia plan and close interdisciplinary collaboration in addressing the multifaceted challenges presented by such high-risk patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eClinical Trial Number\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eConsent for Publication:\u003c/h2\u003e\u003cp\u003eWritten informed consent was obtained from the patient\u0026rsquo;s parents for publication of this case report and accompanying images.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for human ethics and participation\u003c/strong\u003e\u003cp\u003eNot applicable. Consent for publication was obtained from patient\u0026rsquo;s parents.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cp\u003eThe authors declare that there is no conflict of interest regarding the publication of this case report.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThe authors received instutional funding for the publication of this case report.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eDR.Anand K, review and editing.DR.Agathiyan A, writing\u0026mdash;original draft.DR.Mohammed Arshad N, review.DR.Yuvaraj P, review.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eWe acknowledge the support of the Surgical team in the successful management of this case. We are also grateful to our institution for providing the necessary facilities and finally we sincerely thank the patient and their family for their cooperation and consent.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMorniroli D, Tiraferri V, Maiocco G, De Rose DU, Cresi F, Coscia A, Mosca F, Giann\u0026igrave; ML. Beyond survival: the lasting effects of premature birth. Front Pead. 2023;11:1\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fped.2023.1048581\u003c/span\u003e\u003cspan address=\"10.3389/fped.2023.1048581\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDoherty TM, Hu A, Salik I, Physiology. Neonatal. [Updated 2023 Apr 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK539840/#\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/books/NBK539840/#\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eParty BW. Managing the difficult airway in the neonate A framework for practice. London: British Association of Perinatal Medicine; 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eS\u0026uuml;mpelmann R, Becke K, Brenner S, Breschan C, Eich C, H\u0026ouml;hne C, J\u0026ouml;hr M, Kretz FJ, Marx G, Pape L, Schreiber M, Strauss J, Weiss M. Perioperative intravenous fluid therapy in children: guidelines from the Association of the Scientific Medical Societies in Germany. Paediatr Anaesth. 2017;27(1):10\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/pan.13007\u003c/span\u003e\u003cspan address=\"10.1111/pan.13007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2016 Oct 17. PMID: 27747968.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWillschke H, Bosenberg A, Marhofer P, Willschke J, Schwindt J, Weintraud M, Kapral S, Kettner S. Epidural catheter placement in neonates: sonoanatomy and feasibility of ultrasonographic guidance in term and preterm neonates. Reg Anesth Pain Med. 2007 Jan-Feb;32(1):34\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.rapm.2006.10.008\u003c/span\u003e\u003cspan address=\"10.1016/j.rapm.2006.10.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 17196490.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOpfermann P, Kraft F, Obradovic M, Zadrazil M, Schmid W, Marhofer P. Ultrasound-guided caudal blockade and sedation for paediatric surgery: a retrospective cohort study. Anaesthesia. 2022;77(7):785\u0026ndash;94. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/anae.15738\u003c/span\u003e\u003cspan address=\"10.1111/anae.15738\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2022 Apr 22. PMID: 35460068; PMCID: PMC9322320.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMaheshwari M, Sanwatsarkar S, Katakwar M. Pharmacology related to paediatric anaesthesia. Indian Journal of Anaesthesia 63(9):p 698\u0026ndash;706, September 2019. | \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/ija.IJA_487_19\u003c/span\u003e\u003cspan address=\"10.4103/ija.IJA_487_19\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePaul M, Bamba C, Vinay V, Krishna B, Bharani Kumar. B.1. Comparing Opioid with Opioid-free Anesthesia Technique in Neonates Undergoing Tracheoesophageal Fistula Repair. Oman Med J. 2023;38(5):e547. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5001/omj.2023.98\u003c/span\u003e\u003cspan address=\"10.5001/omj.2023.98\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 38204595; PMCID: PMC10776962.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMacrae J, Ng E, Whyte H. Anaesthesia for premature infants. BJA Educ. 2021;21(9):355\u0026ndash;63. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.bjae.2021.03.007\u003c/span\u003e\u003cspan address=\"10.1016/j.bjae.2021.03.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2021 Jul 6. PMID: 34447582; PMCID: PMC8377236.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSubramaniam R. Anaesthetic concerns in preterm and term neonates. Indian Journal of Anaesthesia 63(9):p 771\u0026ndash;779, September 2019. | \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/ija.IJA_591_19\u003c/span\u003e\u003cspan address=\"10.4103/ija.IJA_591_19\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTaneja B, Srivastava V, Saxena KN. Physiological and anaesthetic considerations for the preterm neonate undergoing surgery. J Neonatal Surg. 2012;1(1):14. PMID: 26023373; PMCID: PMC4420318.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Preterm neonate, perioperative management, opioid-free anesthesia, caudal block, neonatal surgery","lastPublishedDoi":"10.21203/rs.3.rs-7702782/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7702782/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePerioperative management of extremely preterm neonates presents significant challenges due to their fragile physiological status, including respiratory instability, cardiovascular vulnerability, and metabolic immaturity. This case report details the complex perioperative care of a 22-day-old male neonate, born at 27 weeks of gestation, who required surgical intervention for an incarcerated inguinoscrotal hernia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe neonate with post conception age of 30 weeks, born weighing 1.225 kg, presented with a right scrotal swelling diagnosed as an incarcerated inguinoscrotal hernia. His early postnatal course was complicated by respiratory distress syndrome (RDS), necessitating mechanical ventilation and surfactant therapy. A multimodal, opioid-free anaesthesia regimen was conceived to minimize the risk of postoperative apnoea. Intraoperative care focused on maintaining stable oxygenation, normothermia, and hemodynamic parameters. Anaesthesia was induced using ketamine and maintained with mixture of air/Oxygen and Sevoflurane. Ultrasound guided caudal block with Levo bupivacaine was administered to address perioperative pain. The neonate was ventilated intraoperatively in pressure-controlled mode and postoperatively in P-SIMV mode, with a smooth transition to CPAP and then to room air. The patient recovered without complications, demonstrating the effectiveness of the anaesthetic strategy employed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case highlights the complexities of perioperative management in extremely preterm neonates, emphasizing the importance of an individualized, multidisciplinary approach. The successful outcome underscores the efficacy of opioid-sparing anaesthesia and meticulous perioperative care in mitigating the risks associated with surgery in these vulnerable preterm neonates. This report contributes to the growing body of knowledge on optimizing perioperative strategies for preterm neonates.\u003c/p\u003e","manuscriptTitle":"Complex Challenges in Perioperative Care of a Preterm Neonate: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-07 20:15:05","doi":"10.21203/rs.3.rs-7702782/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"837cf942-f1e1-421d-bdca-96f1fcc06119","owner":[],"postedDate":"November 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-07T20:15:07+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-07 20:15:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7702782","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7702782","identity":"rs-7702782","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}