Note: This guideline is currently under review.

Introduction
Aim
Definition of Terms
Pre-Operative Assessment

Risk Factors

Minimising Risk Intraoperatively

Overnight admission and monitoring   

Management of an Apnoea 

Family Centred Care 

Cessation of Apnoea Monitoring 

Special Considerations

Companion Documents

Links

Evidence Table

References

Introduction

Apnoeas in infants following anaesthesia and sedation can be potentially life threatening. 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, apnoeas can occur within 12 hours following surgery. Regional anaesthesia has shown to decrease the risk of apnoea in the early postoperative period ( <30 minutes), however in late postoperative apnoea (30 minutes – 12 hours) there 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 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:
  
  • >15 seconds
    
  • Associated with bradycardia (HR <100/min or a drop of 30/min from resting baseline)
    
  • Associated with oxygen desaturation ( <90%)
    
• 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. 
  
• Conceptual age – the age of the child from date of conception to date of delivery. Used more specifically for patients who were conceived through assisted reproductive technology such as IVF where their date of conception is known.
  
• 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.  
  
• SIDS – Sudden Infant Death Syndrome - SIDS is ‘the sudden and unexpected death of an infant under one year of age with an onset of a fatal episode occurring during sleep, that remains unexplained after a thorough investigation, including performance of a complete autopsy and review of the circumstances of death and the clinical history’.
  

Pre-Operative Assessment

Nursing staff should be aware on admission of the patients that require post-operative apnoea monitoring based on their gestational and postmenstrual age (please refer to table). This can help ensure that an overnight bed has been arranged for the patient and that they have not been incorrectly booked as a day case. 
Nursing staff should take a detailed history including comorbidities (e.g chronic lung disease), degree of prematurity, duration and degree of respiratory support, history of apnoeas, need for caffeine or oxygen therapy. 
Nursing staff should assess the patient pre-operatively for any signs of respiratory distress. 

Risk Factors 

Risk factors for apnoeas post-operatively may be related to:

• Postmenstrual age (PMA)
  
  • For any given gestational age, the risk of postoperative apnoea is greater at 40 weeks PMA than it is at 45 weeks PMA. 
    
  • There have been no reports of postoperative apnoea in infants >60 weeks PMA 
    
• Gestational age (GA)
  
  • For any given PMA, infants of a lower GA will have an increased risk of apnoea. 
    
  • For example, an ex 32 week old infant at 45 weeks PMA will have a greater risk of apnoea than an ex 36 week old infant who is 45 weeks PMA. 
    
• Pre-operative apnoea of prematurity 
  
• Anaemia 
  
• Chronic lung disease or airway obstruction 
  
• Anaesthetic technique
  
• Stress response from surgery including pain
  
• Other risk factors may include however are not limited to patients with a history of congenital cardiac disease, metabolic disorders, neurological disorders, seizures, reflux or hypotonia. 
  

The Anaesthetist in consultation with Surgeons must determine the need for overnight admission 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.

Healthy preterm infants who have reached a PMA of 60 weeks can be sent home on standard discharge criteria if the Anaesthetist and Surgeon agree.

For term infants between 46-60 weeks PMA there is currently no consensus as to whether or not these infants need overnight apnoea monitoring. At RCH it is at the discretion of the Anaesthetist, in discussion with the Surgeon whether an infant of 46-60 weeks PMA warrants admission or an extended stay for post-operative apnoea monitoring. 

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 then review the patient later in the day and determine to send the patient home if there have been no clinically significant apnoeas or other issues. 

Any infant who has had a clinically significant apnoea in the postoperative period should be admitted for overnight apnoea monitoring.

Minimising 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.

Opioid analgesia

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

Supplemental oxygen

• Hypoxia reduces the effectiveness of the CO2 response in some infants with apnoea of prematurity.
• Some high-risk infants who have been on oxygen at home or on the ward should continue this postoperatively.
• Be aware that oxygen therapy can mask the detection of apnoea by delaying the onset of desaturation.

Other measures

• Careful positioning to avoid upper airway obstruction should include placing the patient supine with their head in a neutral position.
• Good environmental temperature control should be implemented to ensure that the patient stays warm, which can be done by dressing the patient, wrapping in a warm blanket and keeping them away from drafts. 
• High risk infants may be required to be admitted to the HDU in Butterfly of 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 need to be cared for in Butterfly or Rosella (ICU) postoperatively include infants who weigh less than 2.5kg or who may be dependent on respiratory support such as CPAP.
  
• It is the discretion of the Surgeons, Anaesthetist and the bed management team to determine the need for a HDU or ICU bed for these high risk infants. 
  

Overnight admission and monitoring   

Apnoea monitoring should commence immediately in the Post Anaesthetic Care Unit (PACU) and continue once the patient arrives to the ward.

Apnoea Monitoring should include:

• 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 appropriate parameters and that the apnoea alarm is set to 15 seconds.
• Routine Post Anaesthetic Observations (RPAO) should be completed once transferred to a ward according to nursing clinical guideline “Routine post anaesthetic observation”.
• If regional anaesthesia was used, patients should receive RPAO every 30 minutes for 2 hours, in recognition that this is the period in which patients are most at risk of postoperative apnoeas.

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 the patient’s 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. 

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, contact the treating team for a rapid review.
• 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).
  
  

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

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

If a patient is having frequent significant apnoeas 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. 

Family Centred Care

Parental Education/Support

• Parents should be educated on what an apnoea is and signs to observe for if an apnoea was to occur.
• Parents should be informed that the patient needs to be on the apnoea monitor regardless if they are awake.
• Parents should be informed never to silence the monitor’s alarms.
• Parents should be educated on what to do in the event of an apnoea – e.g. 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.
• When a monitor’s alarms are paused, the alarm will be silenced for 2 minutes. Given an apnoea is defined as 15 seconds this is too long for the patient to be unmonitored.  
• 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.

SIDS safe sleeping:

• Parents/guardians should be educated on the importance of safe sleeping. Cots are to be flat and clear from any equipment, toys or pillows.
• Infants should be placed at the bottom of the cot ensuring all sheets and blankets are thoroughly tucked into the mattress and cannot be pulled on top of the patient.
• It is not appropriate and not acceptable for infants to be sleeping in prams or co sleeping with parents or other children. If parents do not follow this advise it is important to document this in the patients progress notes.

Cessation of Apnoea Monitoring

Apnoea monitoring should continue until the patient has had 12 apnoea-free hours.

• Most postoperative apnoea occurs within the first 2 hours.
• After 12 apnoea free hours, apnoea risk approaches pre-operative levels in healthy infants.
• For all term and preterm infants, once they have had 12 hours of monitoring with no apnoea and all observations are at the patient’s baseline, apnoea monitoring can be ceased. 

Special Considerations

Line-of-site 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 if an apnoea was to occur.

Criteria led discharge:

• Depending on the surgery the patient has had, 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 agree.
• Criteria led discharge for patients who are admitted overnight for apnoea monitoring following a minor surgery should include:
  • Completion of 12 hours of apnoea monitoring with no clinically significant apnoeas.
  • 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 post-operatively (or any of the above criteria are not met) then the patient must be reviewed by the treating team prior to discharge. 

Companion Documents

• Apnoea (Neonatal). Clinical Guideline (Nursing) https://vpn.rch.org.au/+CSCO+0h75676763663A2F2F6A6A6A2E6570752E6265742E6E68++/rchcpg/hospital_clinical_guideline_index/Apnoea_Neonatal/
  
• Apnoea Risks in Infants Following Anaesthesia and Sedation. Clinical Guideline (Anaesthesia). https://vpn.rch.org.au/+CSCO+0h75676763663A2F2F6A6A6A2E6570752E6265742E6E68++/anaes/intranet_resources/Apnoea_Risk_in_Infants_Following_Anaesthesia_and_Sedation/
  
• Medical Emergency Response Procedure https://vpn.rch.org.au/+CSCO+0h75676763663A2F2F6A6A6A2E6570752E6265742E6E68++/policy/policies/Medical_Emergency_Response_Procedure/
  
• Observations and Continuous Monitoring. Clinical Guideline (Nursing). https://vpn.rch.org.au/+CSCO+0h75676763663A2F2F6A6A6A2E6570752E6265742E6E68++/rchcpg/hospital_clinical_guideline_index/Observation_and_continuous_monitoring/
  
• Oxygen Saturation SpO2 level targeting in neonates. Clinical Guideline (Nursing). https://vpn.rch.org.au/+CSCO+0h75676763663A2F2F6A6A6A2E6570752E6265742E6E68++/rchcpg/hospital_clinical_guideline_index/Oxygen_Saturation_SpO2_Level_Targeting_Premature_Neonates/
  
• Routine Post Anaesthetic Observation. Clinical Guideline (Nursing). https://vpn.rch.org.au/+CSCO+0h75676763663A2F2F6A6A6A2E6570752E6265742E6E68++/rchcpg/hospital_clinical_guideline_index/Routine_post_anaesthetic_observation/
  
• Safe Sleeping. Clinical Guideline (Nursing). https://vpn.rch.org.au/+CSCO+0h75676763663A2F2F6A6A6A2E6570752E6265742E6E68++/rchcpg/hospital_clinical_guideline_index/Safe_sleeping/
  
• Ward management of a neonate. Clinical Guideline (Nursing). https://vpn.rch.org.au/+CSCO+0h75676763663A2F2F6A6A6A2E6570752E6265742E6E68++/rchcpg/hospital_clinical_guideline_index/Ward_management_of_a_neonate/

Links

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

Evidence Table

Please see attachment. 

References

• ANZCA PS07. (2017). Guidelines for Pre-Anaesthetic Consultation and Patient Preparation. From: http://www.anzca.edu.au/documents/ps07-2008-recommendations-for-the-pre-anaesthesia.pdf
  
• ANZCA PS29. (2019). Guideline for the Provision of Anaesthesia Care to Children. From: http://www.anzca.edu.au/documents/ps29-2008-statement-on-anaesthesia-care-of-childre.pdf
  
• ANZCA PS29BP. (2019). Guideline for the Provision of Anaesthesia Care to Children Background Paper. From: http://www.anzca.edu.au/documents/ps29bp-guideline-for-the-provision-of-anaesthesia.pdf
  
• Cote, C, J., Zaslavsky, A., Downes, J, J., Kurth, C, D., Welborn, L, G., Warner, L, O., & Malviya, S, V. (1995). Postoperative apnea in former pre-term infants after inguinal herniorrhaphy, A combined analysis. Anaesthesiology. 82: 809-822
  
• Davidson, A, J., Morton, N, S., Arnup, S, J., De Graaff, J, C., Disma, N., Withington, D, E., Frawley, G., et al. (2015). Apnoea After Awake Regional and General Anaesthesia in Infants: The General Anaesthesia Compared to Spinal Anaesthesia Study – Compairing Apnea and Neurodevelopmental Outcomes, a Randomized Control Trial. Anaestheiology. 123(1). 38-54.
  
• Disma, N., Clunies-Ross, N., & Chalkiadis, G. (2018). Is Spinal Anaesthesia in Young Infants Really Safer and Better than General Anaesthesia? Current Opinion in Anaesthesiology 31(3). 302-307.
  
• Engle, W, A. (2004). American Academy of Paediatrics Committee on Fetus and Newborn. Age and Terminology During the Perinatal Period. Paediatrics. 114. 1362-1364.
  
• Jones, L, J., Craven, P, D., Lakkundi, A., Foster, J, P., & Baldawi, N. (2015). Regional (spinal, epidural, caudal) Versus General Anaesthesia in Preterm Infants Undergoing Inguinal Herniorrhaphy in Early Infancy. The Cochrane Database of Systematic Reviews. 9. DOI: 10.1002/14651858.CD003669.pub2
  
• Red Nose. (2016) https://rednose.org.au/article/what-is-sudden-infant-death-syndrome-sids
  
• Sale, S, M. (2010). Neonatal Apnoea. Best Practice & Research Clinical Anaesthesiology. 24. 323-336. DOI: 10.1016/j.bpa.2010.04.002

Please remember to read the  disclaimer.

The development of this nursing guideline was coordinated by Ebony Larter, CNS, Possum and approved by the Nursing Clinical Effectiveness Committee. First published March 2020.