Paediatric Anaesthesia Department

Guidelines for the Post-Anaesthetic Management of Ex-Premature Infants and Neonates

1.0 Definitions:

1.1 Premature Infant: Infant born at less than 37 weeks gestation.

1.2 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%.

1.3 Post Conceptual Age (PCA): Gestational age plus post natal age in weeks.

2.0 Ex Premature Infants in the Post Anaesthetic period:

2.1 Ex premature infants are known to be at risk of idiopathic apnoea after anaesthesia. The incidence reported is around 30%.

2.2 The incidence of post anaesthetic apnoea is inversely related to PCA.

2.3 A poor post natal history ( apnoea, bronchpulmonary dysplasia, anaemia or neurological disease) may also be associated with increased incidence of apnoea, although the evidence is not as strong as for 2.2.

2.4 Ex premature Infants less than 44 weeks PCA are particularly at risk, however post anaesthetic apnoea has been described in infants of up to 52 weeks PCA.

2.5 In all series reported to date, the first apnoea has always occurred within 12 hours of the anaesthetic.

2.6 Post anaesthetic apnoea is probably less likely after spinal anaesthesia than general anaesthesia, but only if no sedation or supplementation is used.

3.0 Post Anaesthetic Management of Ex Premature Infants:

3.1 Where possible, procedures requiring anaesthesia should be delayed until the ex premature infant is older than 52 weeks PCA.

3.2 All Ex Premature infants less than 52 weeks PCA must be admitted for overnight stay post anaesthesia. Note: Assessment of infants must include birth history including gestational age and calculation of PCA. Some ex premature infants may be as old as 7 months and still be at risk (ie <52 weeks PCA).

3.3 All Ex premature infants less than 52 weeks PCA must be continuously monitored for apnoea for at least 12 hours following anaesthesia of any type.

3.4 Monitoring must be continued for 12 hours after any episode of apnoea.

3.5 Monitoring should include oxygen saturation, heart rate and impedance pneumography. In this hospital, this monitoring can occur in Rose ward, HDU and PICU. Any infant after anaesthesia on Rose ward has a staff ratio of 3:1. If a staff ratio of 2:1 is required, infants should be admitted to HDU. If medical supervision is required, infants should be admitted to PICU.

3.6 Ex premature infants less than 44 weeks PCA are particularly at risk of post anaesthetic apnoea and should be admitted to PICU or NICU after any anaesthesia.

3.7 Ex premature infants 44 - 52 weeks PCA who have a poor post natal history (apnoea, bronchopulmonary dysplasia, anaemia or neurological disease) may also be at high risk of post anaesthetic apnoea and should be admitted to PICU.

3.8 Ex premature infants of 44 - 52 weeks PCA with a good post natal history but who are having major or prolonged surgery, or who require opioid analgesia, should be admitted to HDU.

3.9 Ex premature infants of 44 – 52 weeks PCA with a good post natal history who are having minor surgery and do not require opioid analgesia may be admitted to Rose ward.

3.10 Any apnoea or bradycardia should be reported to a Medical Officer. Prolonged or recurrent apnoea, and apnoea associated with bradycardia or desaturation requires admission of the infant to PICU.

3.11 Requirements for monitoring and staff ratio should be clearly detailed by the anaesthetist in the patient’s notes.

3.12 The PICU, HDU or Rose ward admission should be arranged prior to the procedure requiring anaesthesia, preferably when the procedure is booked

References:

Review:

Sims C, Johnson CM Postoperative Apnoea in infants. Anaesthesia and Intensive Care. 22(1):40-5,1994 Feb.

Original research:

Liu LM, Cote CJ GoudsouzianNG et al. Life Threatening apnea in infants recovering from anesthesia. Anesthesiology. 59(6):506-10, 1983 Dec

Kurth CD, Spitzer AR, Broennle AM, Downes JJ. "Postoperative Apnoea in preterm infants." Anesthesiology. 66(4): 483-8, 1987 Apr.

Welborn LG, Rice LJ, Hannallah RS, Broadman LM, Ruttimann UE, Fink R. "Postoperative apnoea in former preterm infants: prospective comparison of spinal and general anesthesia." Anesthesiology. 72(50): 838-42, 1990 May.

Cox RG Goresky GV "Life threatening apnea following spinal anesthesia in former preterm infants." Anesthesiology. 73(2): 345-7, 1990 Aug.

Gunter JB. Watcha MF. Forestner JE. Hirshberg GE. Dunn CM. Connor MT Ternberg JL. Caudal epidural anesthesia in conscious premature and high risk infants. Journal of pediatric surgery. 26(1): 9-14, 1991 Jan.

Kurth CD. LeBard SE. Association of postoperative apnoea, airway obstruction, and hypoxaemia in former premature infants. Anesthesiology. 75(1): 22-6, 1991 Jul.

Warner LO, Teitelbaum DH Caniano DA et al. Inguinal herniorrhaphy in young infants: perianesthetic complications and associated preanesthetic risk factors. Journal of Clinical Anesthesia. 4(6):445-61, 1992 Nov-Dec

Webster AC McKishnie JD. Kenyon CF Marshall DG. Spinal anaesthesia for inguinal hernia repair in high-risk neonates. Canadian Journal of Anaesthesia. 38(3): 281-6, 1991 Apr.

Sartorelli KH. Abajian JC Kreutz JM Vane DW. Improved outcame utilizing spinal anesthesia in high risk infants. Journal of Pediatric Surgery. 27(8): 1022-5, 1992 Aug.

Puetrell JM Hughes DG. Epidural anaesthesia through caudal catheters for inguinal herniotomies in awake ex premature babies. Anaesthesia. 48(2):128-31 1993 Feb.

Gerber ACH Spinal Anaesthesia in former preterm infants. Paediatric Anaesthesia. 1993, (3): 153-156

Krane EJ Haberkern CM Jacobson LE Postoperative apnea, bradycardia and oxygen desaturation on formerly premature infants: prospective comparison of spinal and general anesthesia. Anesthesia and analgesia. 80(1): 7-13, 1995 Jan.

Cote CJ. Postoperative Apnea in former preterm infants after inguinal herniorrhaphy. A combined analysis. Anesthesiology. 1995, 82;809-822.

Somri M et al. Postoperative outcome in high risk infants undergoing herniorrhaphy:comparison between spinal and general anaesthesia. 1998. 53; 762-766

Kunst G. The proportion of high risk preterm infants with postoperative apnoea and bradycardia is the same after general and spinal anesthesia. CJA. 1999 Jan 46(1): 94-5.

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