Anesthesia Practices for Preterm Infants: A Survey in the Nordic Countries and Review of the Literature

Preterm infants are at increased risk of perioperative mortality and are among the most vulnerable patients anesthesiologists can encounter. The literature on anesthesia practice in preterm infants is limited, mainly focusing on their physiological immaturity and related pharmacodynamics and pharmacokinetics.

Our aim was to gather comprehensive data on the current practice of anesthesia management in preterm infants and, when available, to compare these findings with existing literature or guidelines.

A cross-sectional study was conducted using a structured survey distributed to pediatric anesthesiologists across the Nordic countries between June and November 2024. The survey assessed various aspects of anesthesia practice in preterm patients, including agent dosing for induction and maintenance, perioperative monitoring techniques, and respiratory and circulatory management strategies.

A total of 57 surveys were collected from 14 hospitals, with an estimated response rate of 30.4%. For induction, 15 different combinations were reported, with the most common being fentanyl and sodium thiopental (31.6%). For maintenance, 13 combinations were identified, primarily fentanyl and sevoflurane (47.4%). Anesthetic doses exhibited considerable variability, with up to a 20-fold difference between the lowest and highest doses. Rocuronium and atracurium were used almost equally as neuromuscular blocking agents, although significant variation in dosing intervals was noted. Targeted mean SpO₂ levels ranged from 90% to 96%, and EtCO₂ levels from 4.5 to 6.5 kPa, with some outliers. Approximately 86% of respondents used gestational age in weeks as the minimum acceptable mean arterial pressure, with noradrenaline being the first-choice vasopressor (59.6%). Notable differences were observed in transfusion thresholds, fluid resuscitation strategies, and monitoring practices among respondents.

The substantial heterogeneity in anesthesia practice highlighted the need for high-quality research leading to evidence-based protocols and broader consensus to improve safety and quality of care for this vulnerable population. This survey reports on the breadth of practice details for anesthesia management when preterm infants require surgery, from centers in the 5 Nordic countries.