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.
Gestational Age
|
Postmenstrual age on the day of
surgery at which apnoea risk is <1%
|
Corrected age on the day of surgery
at which apnoea risk is <1%
|
Preterm infant born 32-35 weeks
|
56 weeks PMA
|
16 weeks corrected age
|
Preterm infant born <37 weeks
|
54 weeks PMA
|
14 weeks corrected age
|
Full term infant born >37 weeks
|
46 weeks PMA
|
6 weeks of age
|
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 777 (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
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.