Anesthesia Patient Safety Podcast
The official podcast of the Anesthesia Patient Safety Foundation (APSF) is hosted by Alli Bechtel, MD, featuring the latest information and news in perioperative and anesthesia patient safety. The APSF podcast is intended for anesthesiologists, anesthetists, clinicians and other professionals with an interest in anesthesiology, and patient safety advocates around the world.
The Anesthesia Patient Safety Podcast delivers the best of the APSF Newsletter and website directly to you, so you can listen on the go! This includes some of the most important COVID-19 information on airway management, ventilators, personal protective equipment (PPE), drug information, and elective surgery recommendations.
Don't forget to check out APSF.org for the show notes that accompany each episode, and email us at podcast@APSF.org with your suggestions for future episodes. Visit us at APSF.org/podcast and at @APSForg on Twitter, Facebook, and Instagram.
Anesthesia Patient Safety Podcast
#273 Breathless Moments: When Premature Babies Need Extra Vigilance
When our smallest patients need anesthesia care, their immature systems present unique challenges that demand specialized knowledge and vigilance. The risk of postoperative apnea in former preterm infants has long been recognized, but the evidence guiding management continues to evolve.
Join Dr. Alli Bechtel and pediatric anesthesiologist, Dr. Eva Lu-Boettcher as they explore the physiological vulnerabilities that make premature infants susceptible to respiratory complications after anesthesia. The conversation delves into the complex interplay between immature respiratory control centers and anesthetic agents, highlighting how premature infants respond differently to hypoxia and hypercapnia compared to their full-term counterparts.
Drawing from landmark studies and current literature, this episode offers clear, evidence-based recommendations for postoperative monitoring based on post-conceptual age and risk factors. You'll learn about the inverse relationship between post-conceptual age and apnea risk, the critical timing of apnea events, and practical guidelines for determining which patients require extended monitoring. The detailed discussion of monitoring protocols provides a roadmap for keeping vulnerable infants safe during the high-risk postoperative period.
What makes this episode particularly valuable is its practical approach to clinical decision-making. Whether you're determining if a 50-week post-conceptual age infant can be discharged after six hours of monitoring or establishing protocols for term infants who receive opioids, you'll find actionable guidance supported by the latest evidence. As Dr. Lu-Boettcher notes, ongoing meta-analyses and micro-analyses promise to further refine these recommendations in the near future, highlighting the dynamic nature of patient safety practices in pediatric anesthesia.
Curious about how your institution's protocols compare to current best practices? Wondering when it's truly safe to discharge a former preterm infant after anesthesia? Listen now to enhance your understanding of this critical aspect of pediatric anesthesia safety and help ensure that no child is harmed under your care.
For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/273-breathless-moments-when-premature-babies-need-extra-vigilance/
© 2025, The Anesthesia Patient Safety Foundation
You're listening to the Anesthesia Patient Safety Podcast, the official podcast of the Anesthesia Patient Safety Foundation. We're bringing you the very best from the APSF newsletter and website, as well as the latest information in perioperative patient safety. Thanks for joining us.
Speaker 2:Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel and I'm your host. Thank you for joining us for another show. We are continuing to cover the excellent articles from the June 2025 APSF newsletter. Today we are talking about keeping our littlest patients safe during anesthesia care. Before we dive further into the episode today, we'd like to recognize Fresenius Cobby, a major corporate supporter of APSF. Fresenius Cobby has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, fresenius Cobby. We wouldn't be able to do all that we do without you.
Speaker 2:Our featured article today is Postoperative Apnea and Former Preterm Infant Evolving Evidence for Management by Eva Lou Betker and colleagues. To follow along with us, head over to APSForg and click on the newsletter heading the first one down is the current issue and then scroll down until you get to our featured article today. You can also find the June 2025 APSF newsletter in the newsletter archives and, don't worry, I will include a link in the show notes as well. To help kick off the show today, we are going to hear from one of the authors. Here she is now.
Speaker 3:Hi, my name is Eva Lubetker, a pediatric anesthesiologist at the University of Wisconsin in the United States. I'm currently the Associate Vice Chair for Quality and Safety within the Department of Anesthesia.
Speaker 2:We are welcoming Lou Betker back to the podcast. You might remember her from episode number 247, nudge your Way to Greener Pediatric Anesthesia. If you haven't listened to that episode yet, we hope that you will check it out, especially if you are interested in learning more about safe and sustainable anesthesia care For our current featured article. I asked Lou Betker why she wrote this article. Let's take a listen to what she had to say.
Speaker 3:Post-abortive apnea is a critical concern for anesthesiologists, particularly in ex-premature and high-risk infants, due to the interplay of immature respiratory control, anesthetic pharmacodynamics and the life-threatening implications of undetected apnea events. Understanding and anticipating a post-operative apnea informs key anesthetic decisions and directly impacts patient safety. The evidence for post-operative admission in ex-premature infants, particularly for apnea monitoring and admissions, is evolving. I am hoping that this article helps summarize recent evidence and help our anesthesia communities make informed decisions.
Speaker 2:Thank you so much to Lou Becker for helping to introduce this topic, and now it's time to get into the article. Let's start with some important definitions. Premature or preterm infants are infants born at gestational age less than 37 weeks. Apnea of prematurity occurs in premature or preterm infants and involves a respiratory pause for more than 15 to 20 seconds or shorter respiratory pauses that are accompanied by oxygen desaturation or bradycardia, with a heart rate of less than 100 beats per minute. An important consideration is that the incidence of apnea is inversely correlated with gestational age. A study of preterm and premature infants found that almost all infants born at 28 weeks or less had recurrent apnea, while the incidence decreased to 85% for infants born at 30 weeks and it was down to 20% for infants born at 34 weeks gestation. We know that preterm and former preterm infants are at increased risk for postoperative apnea, but there are inconsistent definitions for apnea, desaturation and bradycardia, which means that we do not know the true incidence. As a result, monitoring protocols are different across institutions. What is the monitoring protocol at your institution for preterm or former preterm infants undergoing anesthesia? While you're checking on that protocol, let's talk a little more about postoperative apnea. In our youngest patients, apnea of prematurity occurs due to immature development of the respiratory control centers, with respiratory and chemoreceptors that are less likely to respond to changes in the postnatal environment. This means that premature infants have an initial increase in respiratory rate and volume in response to hypoxia, followed by a sustained decline in ventilation. When premature infants experience hypercapnia, the first response is an increase in ventilation by prolonging expiration time, without an increase in respiratory rate or overall tidal volume, leading to a lower minute ventilation than in term infants. This is a problem of a combination of central and obstructive pathophysiology. When premature infants experience airway obstruction, it is more likely that the response involves apnea and periodic breathing, but this response decreases with increasing post-gestational age, which you can calculate as the gestational age plus the postnatal age. General anesthesia leads to a decrease in upper airway tone and an increased risk for airway obstruction, which may lead to postoperative apnea. Risk factors for postoperative apnea include the following cardiac shunts, anemia, decreasing gestational age, hypothermia, glucose and electrolyte disturbances and patent ductus arteriosus Anesthesia. Professionals need to remain vigilant, since premature infants have a much higher risk for cardiopulmonary complications in the immediate postoperative period compared to term infants. Let's look at the literature, where you will see this population categorized based on post-conceptual age. If we look back at the early prospective studies from the 1990s, about 20-30% of otherwise healthy former preterm infants under 60 weeks post-conceptual age experienced postoperative apnea following general anesthesia.
Speaker 2:We're going to take a closer look at the 1995 study by Cote and colleagues Postoperative Apnea in Former Preterm Infants. Check out the show notes for the citation. The investigators looked at eight studies of former preterm infants undergoing inguinal hernia repair. Here are some of the results A combined apnea rate of about 25%, with variation between 5 to 49%. This variability was due to apnea detection monitoring. The majority of apnea events were detected by pneumogram, diagnosed and occurred in infants less than 44 weeks post-conceptual age with a history of anemia which was an independent risk factor.
Speaker 2:The incidence of post postoperative apnea in preterm infants was inversely related to the infant's gestational age and post-conceptual age at the time of anesthesia. Postoperative apnea decreased to less than 1% at 54 weeks post-conceptual age in infants with gestational age of 35 weeks and at 56 weeks post-conceptual age for infants with gestational age of 32 weeks. Check out figure one in the article for a picture of the predicted probability of post-operative apnea depending on the post-conceptual age for all patients for each investigator of the eight studies. The APSF authors did the homework for us and have summarized the findings of this study and other reports that showed that infants less than 45 weeks post-conceptual age were more likely to develop post-operative apnea. For older infants between 46 to 60 weeks post-conceptual age, you need to evaluate their comorbidities, which will influence their risk for apnea. These comorbidities include the following necrotizing enterocolitis. The following necrotizing enterocolitis, bronchopulmonary dysplasia, former apnea episodes, anemia and lower birth weight. Due to these findings, it has been recommended that infants between 46 to 60 weeks post-conceptual age should be monitored for 12 hours.
Speaker 2:Post-operative and respiratory monitoring is recommended for patients with a history of apnea episodes, chronic lung disease, neurologic disease or anemia. A high-risk time for apnea for infants who underwent general anesthesia is in the first 30 minutes post-op, and these episodes are more likely to require significant intervention rather than just tactile stimulation. Late apnea is just as likely to occur in infants who received general or regional anesthesia. It's time to look at the clock and talk about the timing of postoperative apnea. Studies have shown a variety of results, with first apneic episodes occurring as early as two hours after surgery or even up to 12 hours after surgery.
Speaker 2:There is a 1993 article in Anesthesiology by Malvia and colleagues that asked the important questions Are all preterm infants younger than 60 weeks post-conceptual age at risk for post-anesthetic apnea? This was a prospective study of 91 infants younger than 60 weeks post-conceptual age who underwent 101 general anesthetics. All of the infants had cardiorespiratory monitoring overnight and comorbidities were determined by a review of the medical records and history. The investigators found that the first episode of post-op apnea or bradycardia occurred within 12 hours after surgery. The authors concluded that ex-preterm infants younger than 44 weeks post-conceptual age are at the greatest risk for apnea after general anesthesia when compared to older infants, and I will include the citation in the show notes for more information. There are reports of recurrent apneic events that may occur for up to 72 hours post-operatively, so longer monitoring may be required for some infants.
Speaker 2:Let's check out Table 1 in the article for a review of postoperative admission and observation recommendations based on the current available literature. Keep in mind that patients who are term or preterm or former preterm and under 60 weeks post-conceptual age should be considered for postoperative monitoring and an observation period. Monitoring should include apnea and bradycardia monitoring, nursing observations, continuous pulse oximetry and a respiratory monitor. Here are some of the preterm recommendations Former preterm infants less than 55 weeks post-conceptual age should be admitted post-operatively. Former preterm infants less than 60 weeks post-conceptual age with risk factors for post-operative apnea should be admitted and observed for a minimum of 12 hours. Former preterm infants who are greater than 55 weeks and less than 60 weeks post-conceptual age without anemia, apnea or other risk factors can be observed postoperatively for six hours and then later discharged if no events occur. All infants should have apnea-free for 12 hours prior to discharge, and post-operative apnea in former preterm infants greater than 60 weeks post-conceptual age has not been reported. The most conservative approach would be to admit any preterm infant under 60 weeks post-conceptual age.
Speaker 2:Now let's look at recommendations for term infants, which include the following Term infants less than 44 weeks post-conceptual age should be admitted post-operatively and must remain apnea-free for 12 hours prior to discharge. Any term infant should be monitored for a minimum of two hours post-anesthetic and be discharged only with uneventful post-operative course. All patients less than six months who receive opioids should be monitored for a minimum of two hours and may require admission depending on the complexity and duration of the procedure. Term infants with a history of bradycardia and apneas or those with a sibling with sudden infant death syndrome should be considered for admission Term. Infants more than 30 days but less than six months old can be discharged based on attending anesthesiologist discretion, if without comorbidities or post-operative complications. This is a lot to remember, but Table 1 serves as an excellent resource that you can refer to the next time you're preparing to take care of our smallest and youngest patients. I will include this table in the show notes as well. Patients I will include this table in the show notes as well.
Speaker 2:The APSF authors support that, despite the variability from different studies, a 12-hour apnea-free period is likely safe for discharge planning. Keep in mind that patients who receive spinal or caudal anesthesia may have a decreased risk for early apnea, but they are still at risk for late apnea, which may be due to the residual depressant effects of the general anesthetic. There is a lot of variability in policies for postoperative monitoring depending on the institution, which may be due to the variability in the literature that we have seen. We need to remember that these often include smaller studies and with a variable incidence of these events. Going forward, we hope to see a detailed analysis from a much larger data set and drumroll please. This is happening right now and we are looking forward to results from a meta-analysis and micro -analysis in the near future. So stay tuned. Before we wrap up for today, we are going to hear from Lou Becker again Speaking of the future. I also asked her what she envisions for the future when it comes to postoperative apnea in former preterm infants. Here is her response.
Speaker 3:Although numerous pediatric surgical centers have established immunizations guidelines for former preterm infants after anesthesia, these protocols vary across institutions. This variability is partly explained by limited sample sizes and findings regarding postoperative apnea in prior studies. Current initiatives are focused on gathering data, with meta-analyses and micro-analyses that are underway. These efforts are expected to inform new guidelines for the post-operative management of this vulnerable population. So there's more to come.
Speaker 2:Thank you so much to Lou Becker for contributing to the show today. We love talking about guidelines and recommendations on this show, so we cannot wait to learn more about this in the future so that we can continue to keep these patients safe during and after anesthesia care. If you have any questions or comments from today's show, please email us at podcast at APSForg. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSForg for detailed information and check out the show notes for links to all the topics we discussed today.
Speaker 2:The APSF newsletter is the official journal of the Anesthesia Patient Safety Foundation. Readers include anesthesia professionals, perioperative providers, key industry representatives and risk managers. It is free of charge and available in a digital format with a focus on anesthesia-related perioperative patient safety issues. The 40th anniversary of the APSF newsletter is right around the corner and we will have a special newsletter publication. That's right. All new articles, the latest in perioperative patient safety and more ways for you to help keep yourself and your patients safe. Until next time, stay vigilant so that no one shall be harmed by anesthesia care. Thank you.