Major neonatal surgery under local anesthesia: a cohort study from Bangladesh

Surgeons and anesthetists must respond to the perioperative mortality associated with general anesthesia in developing countries. The safety of performing major neonatal surgery under local anesthesia is one pragmatic response. This study describes and evaluates such practice in a tertiary pediatric surgery center in Bangladesh.

Seven hundred and twenty neonates were admitted for major surgery during a 3.5-year study period. Hundred and fifty two neonates died pre-operatively, and 568 underwent major neonatal surgery. 352 (62.0%) neonates were operated under general anesthesia, while the 216 most fragile neonates (38.0%) were operated with local infiltrative anesthesia alone. Medical files were reviewed; data were collected prospectively; mortality risk factors were assessed by univariate and multivariate analysis.

Two hundred and sixteen procedures were performed under local anesthesia: sigmoid colostomies (37.5%), laparotomies with anastomosis (21.3%), anoplasties (18.1%), laparotomies with enterostomy (8.3%), closures of abdominal wall defects (6.9%), fixations of silastic bags (3.7%), peritoneal tube drainage (2.3%), and gastrostomies (1.9%). Median weight was 2,400 g (2,200-2,460), median gestational age was 37.0 weeks (36.0-38.0), and median age at surgery was 5.0 days (3.0-14.7). In-hospital postoperative mortality was 10.6% among those selected for local anesthesia, and 11.4% among neonates operated under general anesthesia. Low birth weight was an independent risk factor for mortality on multivariate analysis (OR 1.002 g(-1), 95% CI [1.000-1.004], p = 0.029).

Local anesthesia is an established option for the most fragile neonates with major surgical disease. Safe anesthesia ought to be accessible to all children of the world. The global pandemic of perioperative mortality needs to be addressed.