BACKGROUND: Dogma established by Millard in 1976 regarding the ideal timing of elective surgery in infants has long centered on the Rule of 10s (>10 weeks of age, >10 pounds, >10 g hemoglobin, and <10 white cell count).1 These guidelines were built upon archaic anesthetic protocols and do not accurately represent safety profile of modern day agents.2 Opposition to neonatal anesthesia cite concerns regarding GABA-agonists and NMDA-receptor antagonists being associated with a degree of neural apoptosis. Opioids and low-dose dexmedetomidine, a highly selective alpha-2 agonist, remain among the few agents used for anesthesia that have not shown pro-apoptotic activity.4 As such, the divisions of plastics and craniofacial surgery and anesthesiology at Children’s Hospital of Los Angeles created a neonatal neuroprotective anesthetic protocol (NPP) designed with dexmedetomidine as the dominant agent in early cleft lip repair (ECLR).
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