Role of the anesthesiologist in preventing return to fetal circulation in pediatric anesthesia: narrative literature review

Abstract

Background: Pediatric anesthesia presents unique physiological and anatomical challenges, particularly in neonates, whose circulatory system undergoes a critical transition from fetal to extrauterine patterns. Failure in this transition may precipitate a return to fetal circulation, with significant hemodynamic instability and high morbidity.

Aim: To analyze the role of the anesthesiologist in preventing reversion to fetal circulation during pediatric anesthetic care, emphasizing physiological principles, risk factors, pharmacological considerations, and perioperative strategies.

Methods: This narrative review was constructed from an extensive analysis of recent literature on neonatal physiology, pulmonary hypertension, anesthetic pharmacology, perioperative management, and the hemodynamic repercussions of fetal circulation persistence. Studies addressing preoperative evaluation, intraoperative management, ventilatory strategies, vasoactive support, and postoperative monitoring were included.

Results: The review highlights that neonates are particularly susceptible to hypoxemia, hypercarbia, acidosis, pain, and agitation—triggers that increase pulmonary vascular resistance and may precipitate right ventricular failure or shunting through fetal channels. Anesthetic agents exert variable effects on pulmonary and systemic vascular resistance, requiring careful selection and titration. Evidence underscores the importance of meticulous control of ventilation, oxygenation, hemodynamics, and nociception. Multidisciplinary planning and early identification of high-risk patients significantly reduce perioperative complications.

Conclusion: Prevention of fetal circulation reversion in pediatric anesthesia demands profound physiological understanding and precise perioperative management. Anesthesiologists play a pivotal role in anticipating triggers, optimizing cardiopulmonary function, and ensuring safe perioperative outcomes in neonates.