Careful attention to airway management, assisted ventilation, and titration of oxygen therapy with specified goals are essential for success. In mechanically ventilated preterm infants, the anesthesiologist should confirm the position of the tube, transport the infant safely to the operating room, and limit the exposure to high concentration of oxygen. Attention should be taken not to develop hypercarbia and hypoxia, occurring commonly as a result of apnea and hypoventilation during emergency and recovery from anesthesia, since both can lead to increase in choroidal blood volume and intraocular pressure [11].

Perioperative apnea in preterm infant is widely described and can occur in 7% of neonates born at 34–35 weeks gestation, 15% at 32–33 weeks, more than 50% at 30–31 weeks, and as high as almost 100% of micropremie (less than 1000 kg) [14]. Preoperative assessment should determine in advance the occurrence, pattern, and frequency of apnea. Those factors should be considered whether the child is still an inpatient or an outpatient. Should the child be discharged, the current use of respiratory stimulants, oxygen, and/or the use or continuation of an apnea monitor must be determined. Perioperative apnea may preclude tracheal extubation or require close postoperative monitoring after anesthesia [10].

Preterm and small infants rapidly loose heat when anesthetized. Therefore, prevention of hypothermia is essential in the perioperative environment. Hypothermia can decrease metabolism of most drugs and depresses respiratory drive in preterm infants. Additionally, infants with extremely low birth weight require many weeks to grow and develop to a weight of approximately 1800 g and to maintain normothermia without special environmental control [8]. Apnea may also be a complication of hypothermia, leading to unnecessary postprocedural mechanical ventilation, exposing the patient to new complications or to worsen previous basal cerebral and pulmonary conditions.