Here, we present the anesthetic management of a 2.5 kg, 1-day-old neonate with high anorectal malformation (ARM) posted for colostomy in October, 2020. The neonate had an oxygen saturation of 98% on room air, respiratory rate of 40/min and bilateral equal air entry on auscultation with a heart rate of 160/min, loud S1, and no murmurs. On examination, a distended abdomen, penile duplication, pigmented anal dimples, and a sacrococcygeal mass were found as shown in Figs. 1 and 2, respectively. Invertogram revealed distended bowel loops and pubic symphysis diasthesis. Ultrasound examination confirmed the presence of true diphallia along with two distinct urethra and a single bladder. Family and antenatal history were insignificant. Baseline investigations (complete blood count, renal function tests, liver function tests) were within normal limits. The American Society of Anaesthesiologists (ASA) fasting guidelines were followed.

The neonate was shifted to the prewarmed operating room after obtaining informed consent. Standard monitoring devices—oxygen saturation and temperature probes, electrocardiogram (ECG), noninvasive blood pressure (NIBP), and end-tidal carbon dioxide (e.g., CO2), were attached, and baseline vitals were recorded and monitored continuously. Premedication with glycopyrrolate 0.04 mcg/kg intravenous (IV) and fentanyl 1 mcg/kg (IV) was given via an already secured 26-gauge IV cannula. Following preoxygenation, intravenous (IV) induction was done using propofol 2.5 mg/kg and atracurium 0.5 mg/kg, and the child was intubated after 3 min of gentle bag mask ventilation with a 3.0-mm uncuffed endotracheal tube under direct laryngoscopy using Miller’s Blade 0. Anesthesia was maintained using a mixture of oxygen + air + sevoflurane at 0.75 minimum alveolar concentration (MAC). Paracetamol 10 mg/kg IV was given at end of surgery for postoperative analgesia. Lactated Ringer’s solution (10 ml/kg) with 1% dextrose was infused via burette set. The neonate remained hemodynamically stable. Following surgery (colostomy performed 24 h after birth), he was reversed with neostigmine 0.05 mg/kg IV and glycopyrrolate 10 mcg/kg IV and extubated and shifted to the nursery on 99% saturation.