POST-ANAESTHETIC MANAGEMENT OF TERM AND EX
PRETERM INFANTS AT RISK OF APNOEA
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Definitions
Background
Post-Anaesthetic Management Ex-Preterm Infants
Post-Anesthetic Management of Term Infants
References
Definitions
1. Premature Infant: Infant born at less than 37 weeks gestation.
2. Apnoea: Absent breathing for 15 seconds or more, or less than 15 seconds if associated with
bradycardia (heart rate < 100 bpm) or oxygen saturation < 90%.
3. Post Conceptual Age (PCA): Gestational age plus post natal age in weeks.
Background
1. Ex premature infants are known to be at risk of idiopathic apnoea after anaesthesia. The incidence
reported may be as high as 30%. Studies suggest that in up to one third of ex preterms may
experience transient desaturations even with no anaesthesia in any twelve hour period.
2. Term infants < 44 weeks PCA may have a 1-3% incidence of post-anaesthesia apnoea. This is
based on extrapolated data by Cote et al.
3. The incidence of post anaesthetic apnoea is inversely related to PCA.
4. A poor post natal history (apnoea, bronchopulmonary dysplasia, anaemia or neurological disease)
may also be associated with increased incidence of apnoea, although the evidence is not as strong as
for 3.1
5. Ex premature Infants less than 44 weeks PCA are particularly at risk, however post anaesthetic
apnoea has been described in infants of up to 60 weeks PCA.
6. In all series reported to date, the first apnoea has always occurred within 12 hours of the
anaesthetic.
7. Post anaesthetic apnoea can occur after spinal anaesthesia/caudal/local anesthesia, though may be
less likely than after general anaesthesia.2 3 4 5
Custodian (developed by): Dr. Simon Parsons, Paediatric Intensivist
Authorised by (departmental areas): Division of Critical Care, ACH
Effective Date: June 2013
Review Date: June 2015
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POST-ANAESTHETIC MANAGEMENT OF TERM AND EX
PRETERM INFANTS AT RISK OF APNOEA
Post-Anaesthetic Management of Term Infants
All healthy Term infants < 44 PCA weeks of age can be admitted to Units 1- 4 after a general or
regional anaesthetic for a minor surgical procedure, and be monitored as per below.
The definition of a "minor" surgical or other interventional procedure is to be determined by the
responsible surgeon/interventionalist and the anesthesiologist. Examples might be infants after inguinal
hernia or cystoscopy. The definition of "healthy" rests primarily with the anesthesiologist. The indication
for a PICU admission includes other factors beyond the gestational and postconceptual age.
Acetaminophen (15 mg/kg q6h PO/PR) and/or Ibuprofen (5-10 mg/kg q6h PO) are effective pain
medications for infants after minor surgical procedures. If an infant’s pain is not responsive to regular
acetaminophen and/or Ibuprofen, the reason for ongoing pain or suspected pain should be reviewed
and considered.
Treatment of pain with low dose opioids may place the infant at further increased risk of apnoea. 6 7 If
low dose opioids are required for pain management (in healthy term infants < 44 PCA) within 24 hours
of an anaesthetic, the suggested monitoring within this guideline may not be sufficient. Narcotics
(even low dose) should be used with caution and appropriate monitoring in this patient
population.
Routine monitoring of these infants on inpatient units should include:
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In addition to regular vital signs, centrally displayed continuous cardio-respiratory
monitoring (CRM - monitoring of oxygen saturation, heart rate, and impedance pneumography
for respiratory rate) should occur for a minimum of 24 hours following the anaesthetic.
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Continuous monitoring must be continued for an additional 12 hours after any episode of
apnoea, bradycardia, or desaturation.
In addition to the above, all infants monitored on units other than PICU require the following:
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Patient:nurse ratio assignment of 3:1 is recommended (lower patient:nurse ratios can be
ordered as deemed appropriate on a case by case basis). The patient:nurse ratio may
increase for short time periods as a result of staff coverage, but patient care will continue to
emphasize response to the patient/monitor in a timely fashion.
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Placement of patients in rooms across from or close to the nursing station during the 24hour continuous monitoring period is recommended to increase visual and audible contact with
the patient and their monitor. The door of the room should remain open whenever possible
during the 24-hour continuous monitoring period.
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Equipment:
Custodian (developed by): Dr. Simon Parsons, Paediatric Intensivist
Authorised by (departmental areas): Division of Critical Care, ACH
Effective Date: June 2013
Review Date: June 2015
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POST-ANAESTHETIC MANAGEMENT OF TERM AND EX
PRETERM INFANTS AT RISK OF APNOEA
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An auto-inflating bag, appropriately sized masks, and suction equipment are easily
accessible in every patient room. All healthcare providers should review the equipment
and its use regularly.
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A physician or nurse may order or choose to have the equipment set up at the bedside.
“Educational STEP consult” for all infants:
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Order: MD to nurse clinical communication to be entered by the most responsible
physician (MRP) or delegate in SCM as: “Educational STEP Consult” upon patient
arrival on the unit. The “Educational STEP Consult” can also be requested by nursing
staff without an MD to nurse clinical communication order.
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The receiving unit (bedside/charge RN or unit clerk) will need to text page the STEP
Team to initiate the “Educational STEP Consult” (i.e. education consult pt.---- on Unit--).
NB: An SCM MD to nurse clinical communication order will NOT result in notification of
the STEP Team of the consult.
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The consult will offer “on-the-spot” staff education about apnoea monitoring and
management, as well as equipment setup. The MRP will be text paged by the charge
nurse or delegate of the receiving unit with "STEP education call on pt. ---", to let them
know the educational consult was initiated.
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Once the consult is complete, unless there are clinical concerns (in which case, the
STEP team will remain involved and liaise with the MRP), the STEP team will sign off.
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For any patient concerns/deterioration, standard processes including notification of
MRP/delegate (Resident or Fellow), activation of STEP, and/or calling a Code Blue
should be followed.
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The in-house hospital paediatrician on-call (pager # 01652) is available for urgent or non-urgent
(general paediatric) consults at all times.
Post-Anaesthetic Management of Ex Preterm Infants
Assessment of infants must include birth history including gestational age and calculation of PCA.
Some very premature infants may be as old as 7 months and still be at risk (i.e. still < 50 weeks PCA).
Where possible, procedures requiring anaesthesia should be delayed until the Ex Premature infant is
older than 50 weeks PCA.
All ex Premature infants less than 50 weeks PCA must be admitted to PICU for overnight stay post
anaesthesia. Some studies do suggest infants are at significant risk of apnoea up to 60 weeks PCA.8
Custodian (developed by): Dr. Simon Parsons, Paediatric Intensivist
Authorised by (departmental areas): Division of Critical Care, ACH
Effective Date: June 2013
Review Date: June 2015
Page 3 of 5
POST-ANAESTHETIC MANAGEMENT OF TERM AND EX
PRETERM INFANTS AT RISK OF APNOEA
Cote et al found that 35 weekers were susceptible (95% confidence limits for ≤ 1% o apnoea risk) up to
54 weeks whilst 32 weekers were susceptible up to 56 weeks.
All Ex Premature infants less than 50 weeks PCA must be continuously monitored for apnoea for
24(?12) hours following anaesthesia of any type.
Monitoring must be continued for 12 hours after any episode of apnoea.
Monitoring should include oxygen saturation, heart rate and impedance pneumography. A staff
member must be in visual and audible contact with the patient’s monitor at all times.
Ex premature infants > 50 weeks PCA may require monitoring on inpatient Units or PICU at the
discretion of the Surgeon, Anaesthetist, and/or Paediatrician.
References
1
Postoperative apnea in former preterm infants after inguinal herniorrhaphy. A combined analysis.
Coté CJ, Zaslavsky A, Downes JJ, Kurth CD, Welborn LG, Warner LO, Malviya SV.
Anesthesiology. 1995 Apr;82(4):809-22.
2
Regional (spinal, epidural, caudal) versus general anaesthesia in preterm infants undergoing inguinal
herniorrhaphy in early infancy. Craven PD, Badawi N, Henderson-Smart DJ, O'Brien M.Cochrane
Database Syst Rev. 2003;(3):CD003669. Review.
3
Apnea following spinal anaesthesia in two former pre-term infants. Tobias JD, Burd RS, Helikson MA.
Can J Anaesth. 1998 Oct;45(10):985-9.
4
Post-operative recovery after inguinal herniotomy in ex-premature infants: comparison between
sevoflurane and spinal anaesthesia. William JM, Stoddart PA, Williams SA, Wolf AR. Br J Anaesth.
2001 Mar;86(3):366-71.
5
Caudal block and light sevoflurane mask anesthesia in high-risk infants: an audit of 98 cases.
Lacrosse D, Pirotte T, Veyckemans F. Ann Fr Anesth Reanim. 2012 Jan;31(1):29-33. doi:
10.1016/j.annfar.2011.08.018. Epub 2011 Dec 16.
6
Safety profile of morphine following surgery in neonates. El Sayed MF, Taddio A, Fallah S, De Silva
N, Moore AM. J Perinatol. 2007 Jul;27(7):444-7.
7
Predictive factors of PACU stay after herniorraphy in infant: a classification and regression tree
analysis. Silins V, Julien F, Brasher C, Nivoche Y, Mantz J, Dahmani S. Paediatr Anaesth. 2012
Mar;22(3):230-8. doi: 10.1111/j.1460-9592.2011.03726.x. Epub 2011 Nov 21.
Custodian (developed by): Dr. Simon Parsons, Paediatric Intensivist
Authorised by (departmental areas): Division of Critical Care, ACH
Effective Date: June 2013
Review Date: June 2015
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POST-ANAESTHETIC MANAGEMENT OF TERM AND EX
PRETERM INFANTS AT RISK OF APNOEA
8
The former preterm infant and risk of post-operative apnoea: recommendations for management.
Walther-Larsen S, Rasmussen LS. Acta Anaesthesiol Scand. 2006 Aug;50(7):888-93. Review.
Custodian (developed by): Dr. Simon Parsons, Paediatric Intensivist
Authorised by (departmental areas): Division of Critical Care, ACH
Effective Date: June 2013
Review Date: June 2015
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