Introduction

Apnoeas in infants following anaesthesia and sedation can be potentially life threatening. Apnoeas are defined as a cessation of airflow for greater than 20 seconds or greater than 15 seconds if associated with bradycardia. The aetiology of postoperative apnoea may involve a complex interplay of residual anaesthetic suppression of an immature central respiratory drive, stress from the surgery, airway obstruction, poor respiratory reserve or infection and sepsis. 

Infants are most at risk of having an apnoea during the first 2 hours of the post-operative period; however, apnoea’s can occur within 12 hours following surgery. Regional anaesthesia has shown to decrease the risk of apnoea in the early postoperative period (less than30 minutes), however in late postoperative apnoea (30 minutes – 12 hours) a regional anaesthesia has same risk as general anaesthesia. An apnoea could be central, obstructive or mixed. Apnoea monitoring should begin immediately in the Post Anaesthetic Care Unit (PACU) and continue until the patient has had 12 hours of apnoea-free monitoring.  

Aim 

This guideline was created to have a clear understanding of the specific patients that require admission for apnoea monitoring post operatively and to standardise the care these patients receive. The aim is to define the age that patients require apnoea monitoring as well as the causes of post-operative apnoea and how to minimise risk. It also outlines the nursing roles and responsibilities when caring for these patients including the acute management of an apnoea.

Definition of Terms 

• Apnoea (post-operatively) – Cessation of respiration. Considered significant if one or more of the following:
  
  • Cessation of airflow for greater than 20 seconds
  • Or greater than 15 seconds with bradycardia (HR less than 100/min when awake or less than 80/min whilst asleep) and with oxygen desaturation (less than 90%)
  • Apnoea may be classified as central (cessation of breathing effort), obstructive (airflow obstruction usually at the pharyngeal level) or mixed.
    
• Cardiorespiratory monitoring – Saturation probe and 3 lead ECG monitoring. Measures oxygen saturations, heart rate, respirations, cardiac rhythm and apnoeas.
  
• Chronological age – is the time elapsed since birth. Usually described in days/weeks/months/years.
  
• Corrected age – the age of the child from the expected date of delivery in weeks/months. (Chronological age minus the number of weeks born premature). For example, if the infant was born at 30 weeks gestation and is now 12 weeks post birth the infant
  would be considered a corrected age of 2 weeks rather than 12 weeks old.
• Gestational age – is the time elapsed between the first day of the mothers last normal menstrual period and birth.
• Neonate – A child aged less than 28 days (for preterm infants, use the expected date of delivery plus 28 days).
  
• Postmenstrual age (PMA = Gestational age + chronological age) – Total time elapsed from the first day of the mothers last menstrual period to birth plus the time elapsed after birth.
  
• Preterm infant – a child born less than 37 weeks gestational age.
  
• Regional anaesthesia – a block or infusion that are used to provide local anaesthesia to a specific area of the body for example a caudal, spinal or epidural.  

Pre-Operative Assessment  

Nursing staff should take a detailed history including comorbidities (e.g. chronic lung disease), degree of prematurity, gestational age, duration and degree of respiratory support, history of apnoea’s, need for caffeine and/or oxygen therapy.  
Nursing staff should assess the patient pre-operatively for any signs of respiratory distress.  

The Anaesthetist, in consultation with Surgeons determine the need for overnight admission or extended stay for post-operative apnoea monitoring based on the patients gestational age and postmenstrual age on the day of surgery and any other existing risk factors they feel may increase the risk of an apnoea. 

An extended period of stay allows the patient to receive post-operative apnoea monitoring in Day of Surgery for a shorter period than 12 hours. This enables the patient to have several sleep wake cycles while receiving apnoea monitoring. The Anaesthetist will review the patient later in the day and determine to send the patient home if there have been no episodes of apnoea or any other post operative issues.  

For more information, please see  Apnoea Risk in Infants Following Anaesthesia and Sedation 

Risk Factors 

The relatively immature respiratory centre among infants, particularly the preterm infants, makes them vulnerable to apnoeic episodes post operatively. Postmenstrual age (PMA)

• Apnoea of prematurity (idiopathic) 

• Anaemia  

• Glucose or electrolyte imbalance  

• Presence of a patent ductus arteriosus with a large shunt  

• Medications including opioid analgesics, muscle relaxants and magnesium sulfate  

• Gastroesophageal reflux   

• Abnormal body temperature, hyperthermia or hypothermia 

• Chronic lung disease or airway obstruction  

• Anaesthetic technique 

• Stress response from surgery including pain 

• Sepsis 

• Other risk factors may include however are not limited to patients with a history of congenital cardiac disease, prostin infusion, chronic respiratory disease, metabolic disorders, neurological disorders or hypotonia.   

Minimizing Risk Intraoperatively

Regional anaesthesia 

• Awake, regional anaesthesia in neonates and infants is challenging and is only appropriate for selected procedures. E.g. elective inguinal hernia repair, orchidopexy, cystoscopy or circumcision. 

• Use of spinal anaesthesia and avoidance of general anaesthesia reduces the risk of postoperative apnoea in preterm infants undergoing minor surgeries in the immediate postoperative period. 

• Supplementation with sedation of any kind (e.g. ketamine or midazolam) abolishes this apnoea risk benefit. 

• Adding clonidine to spinal or caudal injections is useful for prolonging the block and for its opioid sparing effect.  

 Opioid analgesia 

• The use of any opioid analgesia increases the risk of postoperative apnoea in neonates. 

• If a neonate patient is administered opioid analgesia, monitor cardiorespiratory status closely, as these patients are more susceptible to opioid induced respiratory depression. Consider the need for weaning dose. 

For neonatal pain management see Neonatal Pain Management Nursing Guideline and Management of Paediatric Patients Receiving Opioids Nursing Guideline.  

Supplemental oxygen 

• Higher-risk infants who have been on oxygen at home or on the ward should continue this postoperatively. 

• If a patient requires supplemental oxygen in the immediate post operative period (PACU), the anaesthetist should be notified. Oxygen order and MET modification if required. 
  

• See oxygen saturation SpO2 level targeting in neonates nursing guideline for more information. 

Other measures 

• Careful positioning to avoid upper airway obstruction should include placing the patient supine with their head in a neutral position. 

• Appropriate environmental temperature control should be implemented to ensure that the patient stays warm. Consider forced air warming if necessary. 

• Higher risk infants may be required to be admitted to the HDU in Butterfly or Rosella (PICU) if they are aged less than 6 months old and have significant comorbidities +/- if they have an opioid infusion. 

• Other high-risk infants that may require Butterfly (NICU) or Rosella (ICU) admission postoperatively include infants who weigh less than 2.5kg or who may be dependent on respiratory support such as CPAP. 

• In collaboration with the nursing team, it is at the discretion of the Surgeons and, Anaesthetist and the bed management team to determine the need for a HDU or ICU bed for these high-risk infants. Request for HDU or ICU beds should be escalated to the bed management team. 

• Patients who are admitted to an inpatient ward need should be assessed and allocated HDU status if clinically necessary.

Management of an Apnoea's in the PACU/Recovery

Apnoea monitoring should commence immediately in the Post Anaesthetic Care Unit (PACU).

• Ensure patient is monitored with a 3 lead ECG 

• Assess airway and breathing of the patient immediately  

• Observe for  desaturation and apnoeas 

• In the first instance provide tactile stimulation to manage apnoea 

• Provide oxygen, PEEP via face mask and T-piece 

• Provide rescue breaths if patient remains apnoeic  
  

• If spontaneous ventilation has not resumed, consider airway (guedel) insertion 

• If apnoea is associated with bradycardia consider commencement of CPR and adrenaline administration 

• Initiate internal PACU Emergency Response (Press red emergency buzzer). Ensure PACU AUM, Anaesthesia team and PICU outreach have been notified and or are in attendance 

• Document apnoea event and interventions 

• The PACU nurse in collaboration with AUM will ensure the patient will be discharged with apnoea monitoring order, MET modification and or PICU outreach involvement if deemed necessary. 

Any infant who has had an apnoea in the immediate postoperative period should be considered for overnight admission and apnoea monitoring. 

Overnight Admission and Monitoring 

Handover from PACU- Assess patient on discharge from PACU and ensure that apnoeas and interventions have been clearly handed over and documented. 

Line of Sight Nursing- Patients should be placed in a room closest to the nurse’s station – this allows for visualisation for the monitor from a distance and quick access should an apnoea occur. 

Apnoea monitoring should continue for a minimum of 12 hours.  

Apnoea monitoring includes: 

• Continuous cardiorespiratory monitoring (Saturation probe and 3 lead ECG monitoring) regardless of whether the patient is awake or asleep. 

• Ensure the monitors alarms are selected to the age-appropriate parameters and that the apnoea alarm is set to 20 seconds. . 

• Routine Post Anaesthetic Observations (RPAO) should be completed once transferred to a ward according to RCH Nursing Guideline: Routine post anaesthetic observation.  

• Due to a small risk of delayed toxicity, if regional anaesthesia was used, patients should receive observations every 30 minutes for 2 hours, in recognition that this is the period in which patients are most at risk of postoperative apnoeas.. 

• Document any apnoeas, including time, length, vital signs or colour changes and interventions on the EMR. 
  

Ongoing observations: 

• Once RPAO are completed the patient should remain on continuous cardiorespiratory monitoring (regardless if awake or asleep) and have hourly observations recorded in the patient’s flowsheets; including oxygen saturation, respiratory rate and heart rate. It is acceptable to take 4 hourly temperature and blood pressure unless otherwise indicated. 

• Monitor for any signs of respiratory distress, obstruction or increased work of breathing including nasal flaring, increased accessory muscle use, head bobbing and stridor. If any signs of respiratory distress the patient should be reviewed by the treating team.  

• Document any apnoeas, including time, length, vital signs or colour changes and interventions on the EMR.

Management of an Apnoea

In the event of a monitor alarming the nurse should: 

• Assess the infant and confirm that it is an apnoeic episode and the type of apnoea (central or obstructive). 

• Stimulate the infant by startle or rubbing its face, abdomen, feet or chest. 

• Position the airway in a neutral position. 

• If apnoea resolves and the patient’s breathing has returned, report to medical team or request a rapid review as clinically indicated. 

• If the infant does not begin to breath, commence resuscitation and follow the Basic Life Support algorithm. 

• If any staff member or parent is concerned about the patient deteriorating, escalate to the medical team or notify the Medical Emergency Team (MET) urgently by dialling 22 22 (state MET, building, level, ward, room and specialty). 

• RCH Policy and Procedure: Medical Emergency Response Procedure 

• RCH Nursing Guideline: Apnoea (neonatal) 
   

Most apnoeic episodes will resolve spontaneously or with minor stimulation. All episodes should be documented in flowsheets and reported to medical staff. 

• Documentation should include length of apnoea, any vital sign or colour changes to the patient and management of the apnoea and any ongoing interventions or recommendations. 

If the patient is having multiple episodes of apnoeas requiring intervention (not self-resolved) the medical team should be notified. The patient may require respiratory support or mechanical ventilation such as HFNP or CPAP and potentially require transfer to a HDU bed or PICU/NICU as clinically indicated.  

Cessation of Apnoea Monitoring 

Apnoea monitoring should continue until the patient has had 12 apnoea-free hours and all observations are at the patient’s baseline/age-appropriate limits.  

• Most postoperative apnoea occurs within the first 2 hours. 

• After 12 apnoea free hours, apnoea risk approaches pre-operative levels in healthy infants. 

Monitoring can then continue as clinically indicated, see RCH Nursing Guideline: observation and continuous monitoring for more information.  

Family Centred Care

Education & Support 

• Parents/caregivers should be educated on what an apnoea is and signs to observe for if an apnoea was to occur. 

• Educate/caregivers parents how to raise concerns OneTeam Escalation Pathway 

• Parents/caregivers should be informed that the patient needs to be on the apnoea monitor at all times, regardless if they are awake or asleep. 

• Parents/caregivers should be informed never to silence the monitor’s alarms. 

• Parents/caregivers should be educated on what to do in the event of an apnoea – e.g. how to seek help and attempt to startle the patient. 

• In the event of an apnoea occurring, it is important to provide support and reassurance to the family. 

Silencing or Pausing Alarms 

• It is imperative that nursing staff and family members do not silence or pause alarms on the observation monitor, unless the patient is awake and in direct supervision such as being held. This is to prevent adverse incidents from occurring. 

• It is recommended that the alarm monitor is not placed on PAUSE, as this alarm will be silenced for 2 minutes. Given an apnoea is defined as 20 seconds this is too long for the patient to be unmonitored and may lead to significant clinical events occurring.    

• It is acceptable that if the infant is feeding or unsettled and the patient is being held by an alert and responsible carer or staff member that the monitoring is put on standby until the patient settles – provided the parents are educated and are aware to alert nursing staff once patient has settled or returned to bed so that apnoea monitoring can re commence. 

Special Considerations

Criteria led discharge: 

• Depending on the surgery the patient has had performed, the surgeon may order a Criteria Led Discharge. 

• If a patient has had 12 hours of apnoea-free monitoring it may be acceptable for the patient to be discharged home the following morning on a Criteria Led Discharge if the Surgeons and Anaesthetist are in agreement. 

Criterion for patients who are admitted overnight for apnoea monitoring following a minor surgery should include: 

• Completion of 12 hours of apnoea monitoring with no apnoeas detected. 

• Pain managed.

• The patient has remained afebrile, and all observations have returned to the patient’s base line. 

• Surgical site clean, dry and intact with no signs of inflammation, infection or bleeding. 

• Patients are feeding appropriately. 

• Parents have received all discharge information and education. 

• Parents have a clear follow up plan. 
  

• If there have been any clinically significant apnoeas in the post -operatively period or any of the above criteria is not met, the patient must be reviewed by the surgical team and treating anaesthetist prior to discharge.  

 Companion Documents

RCH Policy and Procedures 

• Medical Emergency Response Procedure  
  

RCH Nursing Guidelines 

• Apnoea (Neonatal) 
• Observations and Continuous Monitoring 
  
• Oxygen Saturation SpO2 level targeting in neonates 
  
• Routine Post Anaesthetic Observation 
  
• Safe Sleeping  
  
• Ward management of a neonate 
  
• Temperature Management 
  

RCH Departmental Guidelines 

• Apnoea Risks in Infants Following Anaesthesia and Sedation.  
  

Other Links 

• ANZCA – Professional Documents. http://www.anzca.edu.au/resources/professional-documents 
• SIDS Safe Sleeping – Red Nose. https://rednose.org.au/section/safe-sleeping 
  

Please remember to read the disclaimer.

The development of this nursing guideline was coordinated by Ebony Larter, CNS, Possum and Amy Carle, CNS, DOS and approved by the Nursing Clinical Effectiveness Committee. Guideline reviewed March 2025.