BJA Education, 18(7): 211e217 (2018)
doi: 10.1016/j.bjae.2018.04.004
Matrix codes: 1A01,
1A02, 2D02, 3D00
Anaesthesia for inguinal hernia repair in the
newborn or ex-premature infant
N. Ahmad1,2,* and S. Greenaway1,3
1
Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK, 2University College London
Institute of Child Health, London, UK and 3Barts Health NHS Trust, London, UK
*Corresponding author: nargis.ahmad@gosh.nhs.uk
Learning objectives
By reading this article, you should be able to:

Explain the risks and benefits of general and
regional anaesthesia for inguinal hernia repair in
infants.

Identify which patients are at greatest risk of
complications.

Select appropriate postoperative monitoring for
ex-premature infants.

Discuss the challenges of laparoscopic hernia
repair in infants.
A hernia is defined as the protrusion of an organ or tissue
through the wall of the cavity in which it is contained. Most
inguinal hernias presenting in infancy are indirect. An indi-
rect inguinal hernia arises as a consequence of herniation of
bowel through the deep inguinal ring in the presence of a
widely patent processus vaginalis.
The processus vaginalis is a diverticulum of peritoneum
which, in boys, is pushed down the inguinal canal as
Nargis Ahmad MA (Cantab) FRCA is a consultant at Great Ormond
Street Hospital and an honorary Senior Lecturer at University College
London Institute of Child Health. She is a member of the Association
of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI)
Education & Training Committee and Chair of the London Neonatal
Anaesthesia Network.
Sarah Greenaway BSc FRCA PGCME is a clinical research fellow at
Great Ormond Street and the Royal London Hospitals. Her research
interests include transfusion and coagulopathy in neonates. She is
the new project coordinator on the APAGBI Paediatric Anaesthesia
Trainee Research Network.
Accepted: 7 March 2018
© 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
For Permissions, please email: permissions@elsevier.com
Advance Access Publication Date: 21 May 2018
Key points

Inguinal hernia repair may be an elective or an
emergency procedure.

Ex-premature infants and neonates are at
increased risk of perioperative complications.

A comprehensive understanding of develop-
mental physiology and pharmacology is essential.

Awake spinal anaesthesia without sedation re-
duces the risk of early apnoea.

Infants at risk of respiratory complications
including apnoea should receive extended
cardiorespiratory monitoring.
the testes descend into the scrotum. A patent processus
vaginalis provides an open communication between the
peritoneal cavity and the scrotum. In the course of
normal development, the processus vaginalis closes spon-
taneously by the age of 2 yr, with closure usually occurring
in the first 2 months of life. In girls a corresponding
protrusion of peritoneum extends from the uterus to
the labia majora and is known as the diverticulum of Nuck.
This normally closes at a gestational age of around
7 months.
The incidence of inguinal hernia is highest in the first
year of life and there is a peak in the neonatal period: the
incidence in newborn infants is 1e5%. Inguinal hernias are
more common in premature infants with an incidence of
around 11%. In extremely low birth weight (LBW) infants
(i.e. those weighing less than 1000 g), inguinal hernia is very
common with rates of around 40%.1 The incidence of
incarceration has been considered to be extremely high in
premature infants, but this finding has not been consis-
tently reproduced across all studies.1,2 A recent large
retrospective study showed that the overall incidence of
211
Anaesthesia for inguinal hernia repair in the newborn

inguinal hernia in children was 6.62% in males and 0.74% in Table 1 Factors relevant to the provision of anaesthesia for
females.2 neonates
The presentation and features of inguinal hernia in males
System Consideration Precautions
and females reflect aspects of development in utero. Sixty
percent of congenital inguinal hernia are right-sided, 30% are Airway Large head with Avoid flexion and
on the left. This pattern is a consequence of delayed descent prominent occiput. hyperextension during
of the right testis and a persistence of patency of the proc- Short neck. mask ventilation as
essus vaginalis on the right side for longer than the left Epiglottis is large, this may obstruct the
during infancy in boys. Ten percent of hernias in term neo- floppy, U shaped, airway.
and cephalad. Avoid gastric
nates are bilateral; this bilateral presentation is more com-
Airway calibre is insufflation during
mon in premature and LBW infants, occurring in up to 50% of smaller and of mask ventilation.
patients.1,3 relatively high Consider choice of
In addition to prematurity and low birth weight, inguinal resistance. technique for
hernia in infants may also be associated with other conditions:1 Trachea is short, intubation (e.g. a
compliant and prone straight blade may be
(i) urological anomaliesdhypospadias, cryptorchidism, to malacia particularly useful to elevate the
bladder extrophy; in the ex-premature epiglottis at direct
(ii) increased intra-abdominal pressuredpresence of infant. laryngoscopy).
Upper airway reflexes Awareness and
ventriculo-peritoneal shunts, ascites, peritoneal dialysis;
are pronounced. anticipation of risks of
(iii) abdominal wall defectsdexomphalos and gastroschisis; Ex-premature infants (e.g. laryngospasm).
(iv) family history of inguinal hernia; may have acquired Availability of a range
(v) other conditions (e.g. cystic fibrosis, mucopolysacchar- sub-glottis stenosis. of tracheal tubes sizes
idosis, EhlerseDanlos syndrome, and Marfan syndrome). with careful selection
of tube size
particularly during
laparoscopic surgery.
Presentation Careful positioning of
tracheal tube tip and
There is usually a history of a painless and intermittent
avoidance of
swelling in the groin; the swelling may have been noted to be
endobronchial
associated with straining. There may be no mass on exam- intubation.
ination or a reducible groin mass may be found. A hernia Respiratory The respiratory During mechanical
that cannot be reduced by manipulation is incarcerated. system system, notably ventilation use a
Bowel within the hernia can become erythematous and alveolar development, ‘protective’ or ‘open
is immature. lung’ ventilation
trapped within the hernia sac, and this can lead to bowel
Respiratory control strategy to ensure
obstruction. In females the sac may contain an ovary. There
is immature. adequate minute
may be vascular compromise of the entrapped contents of Respiratory ventilation.
the hernia as a result of progressive swelling and oedema; at mechanics are Adjust ventilation to
this stage, the hernia is described as strangulated. Bowel altered with limit the tidal volume
perforation may result and, rarely, bowel resection may be predominantly and peak inspiratory
diaphragmatic pressure in order to
necessary. An infant with a strangulated hernia will be
breathing. limit lung injury but
extremely unwell.
High ventilatory ensure maintenance of
frequency and work functional residual
of breathing hence capacity.
Surgical management during spontaneous Use positive end
The definitive treatment for any hernia is surgical repair: respiration the infant expiratory pressure.
reduction followed by surgical closure of the patent processus is prone to fatigue. Consider the
The diaphragm has respiratory time
vaginalis and repair of the floor of the inguinal canal. The
less ‘fatigue resistant’ constant when
timing of surgery is determined by the presentation and the type 1 fibres. selecting inspiratory
co-morbidity, but the optimal timing is controversial.1 An The chest wall is and expiratory times.
asymptomatic hernia may be scheduled electively but re- compliant with Select an appropriate
mains at risk of incarceration. The risks of anaesthesia in in- horizontal ribs. ventilatory frequency.
fancy must be balanced with the risk of incarceration, which Functional residual Consider a longer
capacity is low and expiratory time in
is highest in the first 6 months of life, and surgical preference
is maintained by high infants with
is usually to schedule surgery sooner rather than later.1,3 ventilatory frequency bronchopulmonary
An incarcerated hernia carries a risk of serious complica- and laryngeal braking dysplasia.
tions such as intestinal obstruction and strangulation of the (laryngeal adductors Ensure appropriate
hernial sac contents, and must be reduced. Manual reduction restrict expiration postoperative apnoea
is usually attempted. After successful manual reduction, and maintain PEEP). monitoring.
The alveolar Use equipment which
there is a risk of reincarceration. Open surgery after successful
ventilation to minimises dead space.
manual reduction may be technically more challenging functional residual Ensure anaesthetic
because of localised swelling, and some surgeons will admit, capacity ratio is high. machine and
observe, and delay (e.g. 24e48 h) definitive repair for a short Ex-premature infants breathing circuit check
interval after manual reduction. If manual reduction fails, may have includes
then surgical reduction is indicated and should be undertaken bronchopulmonary compensation for
dysplasia. compressible loss (i.e.
as an emergency.

212 BJA Education - Volume 18, Number 7, 2018

 Anaesthesia for inguinal hernia repair in the newborn

Table 1 (continued ) Table 1 (continued )

System Consideration Precautions System Consideration Precautions

There is significant the compliance of Immature hepatic e8 mg kg1 min1).

risk of postoperative tubing). enzyme systems Early return to feeding.
apnoea in ex- Consider result in altered Glucuronidation is
premature infants. supplementary pharmacokinetics immature in neonates
Anaesthesia monitoring (e.g. use of (e.g. CYP so caution should be
ventilators do not transcutaneous CO2 isoenzymes). exercised with, for
perform as well as monitoring), in a sick example, paracetamol,
neonatal unit premature infant morphine, and
ventilators (e.g. flow direct arterial propofol and doses
sensors are located monitoring may be adjusted to reflect
within the anaesthetic indicated. decreased hepatic
machine). This may clearance.
lead to inaccuracies Temperature Extremely prone to Warm the
with, for example, regulation hypothermia. environment,
tidal volume inspiratory respiratory
measurements. gases and intravenous
ETCO2 monitoring fluids. Use heating
can be problematic devices and monitor
particularly in core temperature.
premature infants. Keep baby dry.
Cardiovascular Younger term Avoid rises in Immature At risk of oxygen Use preductal oxygen
system neonates and pulmonary vascular oxidative toxicity as a result of saturation as a guide
premature neonates resistance (e.g. avoid systems cellular activity of and titrate inspired
may have patent intra hypoxia and reactive oxygen oxygen.
and extracardiac hypercapnia). species. Avoid hyperoxia, aim
communications Consider monitoring for saturation level of
(e.g. patent foramen pre- and post-ductal 91e95% in premature
ovale and patent saturation if ductus infants.
ductus arteriosus). arteriosus is patent.
Shunting may occur Maintain adequate
across these. preload, afterload and Some patients presenting with a unilateral hernia may be
Pulmonary vascular heart rate as
at risk of developing a second hernia on the contralateral side,
resistance is low fluctuations are poorly
compared with fetal tolerated especially in and some surgeons will also explore the contralateral side
values but higher the premature infant. during surgery.1,3
than in older infants. Laparoscopic repair is an option for the management of
Stiff non-compliant inguinal hernia in infancy. Advantages of laparoscopic repair
ventricles. include better visualisation of the anatomy with better ability
Stroke volume
to explore the contralateral side and ligate if indicated. Mini-
relatively fixed.
Rate-dependent mally invasive surgery is also associated with improved
cardiac output. cosmesis, reduced length of stay, and improved postoperative
High myocardial pain scores.3,4 Anaesthetic considerations for laparoscopic
oxygen consumption. surgery in infants are outlined below.
Renal system The full complement Limit fasting time to 2
of nephrons is h for clear fluids and
present at birth in consider if a dextrose
term infants, but infusion is necessary
renal vascular Minimise Age terminology
resistance is high, transepidermal fluid
A premature infant is born before 37 completed weeks of
this decreases from loss in premature
birth. As the infants and adjust fluid gestation. An ex-premature infant is born before 37 completed
resistance decreases, balance to include weeks of gestation and is now older than 37 weeks of age. The
an increasing increased evaporative American Association of Pediatrics (AAP) recommends the
proportion of CO is insensible losses. following definitions of age terminology:5
directed to the Replacement fluid
kidneys. should usually be a (i) Gestational age (in completed weeks) is the time elapsed
Low GFR and balanced salt solution between the first day of the last normal menstrual period
immature tubular adjusted to maintain (LNMP) and the date of birth. In the setting of assisted
function. intravascular volume,
reproductive technology, gestational age is calculated by
Immature kidney any deficit and ongoing
may not be able to losses. adding 2 weeks to the conceptional age.
excrete a water load (ii) Postmenstrual age is the sum of gestational age plus
and there is a risk chronological age (weeks).
of hyponatraemia. (iii) Chronological age (days, weeks, months, or years) is the
Hepatic and Limited glycogen Monitor blood glucose time elapsed from birth.
metabolic stores make neonates levels.
(iv) Corrected age (weeks or months) is the chronological age
vulnerable to Administer dextrose in
hypoglycaemia premature infants (5 minus the number of weeks born before 40 weeks of
gestation; this term should be used only for children up
(continued on next page)
to 3 yr of age who were born preterm.

BJA Education - Volume 18, Number 7, 2018 213

Anaesthesia for inguinal hernia repair in the newborn
Table 2 Major morbidities associated with extreme prematurity
Respiratory distress syndrome (RDS)
Bronchopulmonary dysplasia (BPD)
Patent ductus arteriosus (PDA)
Retinopathy of prematurity (ROP)
Necrotising enterocolitis (NEC)
Sepsis
Intraventricular haemorrhage (IVH)
Periventricular leucomalacia (PVL)
Anaesthetic management
Conduct
A range of patients may present for elective hernia repair; the
group is heterogeneous and includes premature infants, ex-
premature infants, and term infants. A thorough assessment
of both the developmental stage of the infant and any co-
morbidity is essential. The timing of surgery should be care-
fully considered in each patient. Multidisciplinary care can be
helpful in the more complex premature or ex-premature
infants.
Table 1 highlights some of the factors to consider when
anaesthetising any neonate.
Prematurity has an impact on many of the developing or-
gan systems. The major comorbidities associated with pre-
maturity are listed in Table 2. The risks of these comorbidities
increase with decreasing gestational age. Extreme prematu-
rity (defined as <28 weeks gestational age) has been exten-
sively studied.6e8 Many of the findings arising from studies of
extremely premature infants have a bearing on the care of all
premature and ex-premature patients (e.g. persisting
impairment of respiratory function, neurocognitive
morbidity, and the vulnerability to oxidative stress).8
Choice of technique: general or awake
regional anaesthesia
The choice of anaesthetic agent and technique must be
informed by patient and surgical factors. There are few
comparative studies that examine different general anaes-
thetic agents. One study did compare recovery after mainte-
nance of anaesthesia with sevoflurane and desflurane, and
found no difference in postoperative respiratory events.9
General inhalation anaesthesia with shorter-acting agents
such as sevoflurane, supplemented with caudal or ilioinguinal
blockade, is widely utilised for open inguinal hernia repair.
Neuromuscular blockers and opioids should be used with
caution because neonates and infants are particularly
vulnerable to the respiratory depressant action of opioids and
the effects of residual neuromuscular block. Neonates are
more likely to develop respiratory complications, although, as
described below, studies have not confirmed that the use of
either opioids or neuromuscular blockers are risk factors for
the occurrence of postoperative apnoea. Neonates exhibit
extensive interindividual variability in pharmacokinetics and
pharmacodynamics. This is pertinent to drugs such as
morphine, which should be carefully titrated to effect when
used.
Airway support must be tailored to the needs of the
neonate. Placement of a tracheal tube and artificial ventilation
is usual and appropriate for premature neonates, those with
respiratory co-morbidity (e.g. bronchopulmonary dysplasia),
or those undergoing laparoscopic repair, whereas a
214 BJA Education - Volume 18, Number 7, 2018
supraglottic airway device may be considered for the healthy
term neonate undergoing surgery later.
Regional anaesthesia has a significant role in the man-
agement of infant hernia repair. There has been renewed in-
terest in awake spinal anaesthesia in the light of concerns
about the potential neurotoxicity of anaesthetic agents.
Neurotoxicity is further discussed below. Neuraxial tech-
niques used to facilitate inguinal hernia repair include spinal,
caudal, and epidural blocks, usually as a single bolus injection
or sometimes as an infusion via a catheter. They may be used
as a sole technique (e.g. awake spinal), in combination (e.g.
awake spinal plus caudal), or to supplement general anaes-
thesia. Ilioinguinal blockade and field blockade may also be
used to supplement spinal or general anaesthesia. The dura-
tion of the block may limit the use of single shot spinal
anaesthesia; surgery should be completed within approxi-
mately 60 min. It is also noteworthy that when used in
isolation, the rate of failure and subsequent conversion from
spinal to general anaesthesia is significant. Adjuvants can be
used to prolong the duration of blockade, but the use of these
should be considered carefully. Some adjuvants such as
clonidine have sedative effects and could predispose to
apnoea, although there is little robust evidence to provide
guidance. The benefits of neuraxial anaesthesia include a
reduction in respiratory complications (see below), but this is
not sustained if sedatives are administered. Complication
rates after neuraxial block in neonates are higher than in older
children but severe complications, for example meningitis
and neurological injury, are rare.10,11
During a neonatal spinal anaesthetic, the infant is placed
in the sitting or lateral decubitus position and lumbar punc-
ture is performed at the interspace between L4 and L5; this can
be identified using the intercristal line. In term neonates the
conus normally lies at the L1eL2 level, but extends to L3eL4 in
premature babies, and the dural sac usually terminates be-
tween S2 and S4. CSF volume is greater in neonates.11
Full aseptic precautions should be taken and a sterile field
established. Chlorhexidine 0.5% solution should be used for
skin asepsis and allowed to dry before skin puncture. Spinal
needles, 22e25G 25 mm are used; pencil point needles and
needles with introducers are available.11
Local anaesthetic drugs that have been used include
bupivacaine, levobupivacaine, ropivacaine, tetracaine, and
lidocaine, although the evidence comparing their efficacy is
limited. There are also few systematic studies that have
examined toxicity to the developing spinal cord. Suggested
doses are isobaric bupivacaine, ropivacaine, or levobupiva-
caine 0.5% 1e1.2 mg kg1. Adjuvants used in conjunction with
neuraxial blockade include fentanyl, morphine, dexmedeto-
midine, clonidine, and ketamine.10,11
It is essential that all members of the team are sensitive to
the needs of the infant during awake spinal anaesthesia, and
care and attention should be given to the environment and
lighting. The baby may benefit from soothing, and oral sucrose
may be administered using a pacifier.11
Within the past decade, there has been increasing concern
about the potential for neurotoxicity, and subsequent neuro-
logical morbidity, as a result of exposure to general anaes-
thesia in neonates. This is after persuasive preclinical
evidence emerged detailing neuronal apoptosis as a result of
exposure to general anaesthetic agents, and also demonstra-
tion of long-term cognitive deficits in rodent models. How-
ever, several large multi-centre clinical trials have failed to
provide conclusive evidence in human studies. The GAS study

is an international, randomised, and multi-centre trial looking
at the long-term effects of anaesthesia on the developing
brain in infants.12,13 Subjects recruited were ex-premature
and term infants between 26 and 60 weeks postmenstrual
age undergoing inguinal hernia repair. Those with an existing
risk of adverse neurodevelopmental outcome were excluded.
Subjects were randomised to receive general or regional
anaesthesia. Regional anaesthesia consisted of spinal or
caudal anaesthesia alone or spinal plus caudal or ilioinguinal
block. General anaesthesia consisted of sevoflurane for in-
duction and maintenance, and was supplemented with
caudal or ilioinguinal blockade. Neuromuscular blockers were
permitted, but opioid analgesia was not. At 2 yr of age, the
study did not find any significant difference in psychomotor
scores between the two groups. A single brief exposure to
general anaesthesia is not felt to contribute to significant
neurotoxicity at present.14
Laparoscopic surgery
Increased intra-abdominal pressure can restrict diaphrag-
matic excursion and this is exacerbated by head down posi-
tioning. Tidal volume and functional residual capacity are
reduced. Ventilator settings may need to be adjusted to
maintain adequate minute ventilation.
Pnuemoperitoneum is achieved with CO2 insufflation, and
intraperitoneal pressures should not exceed 10 mm Hg.
Insufflation can lead to significant CO2 absorption into the
circulation, and this can contribute up to 20% of the exhaled
CO2.15 Ventilation will need to be adjusted accordingly.
In order to optimise ventilation and control arterial CO2, a
close-fitting or cuffed tracheal tube is necessary. Use of neuro-
muscular blockers may result in lower intra-abdominal pres-
sure. Sidestream capnography, even with very low dead space
systems, will often significantly underestimate arterial CO2. In
the smaller more premature infants, intermittent sampling from
an arterial catheter or a continuous transcutaneous CO2 monitor
may better guide adjustments to ventilation.
Pneumoperitoneum also leads to compression of the
abdominal vessels, and as a result of this an increase in sys-
temic vascular resistance. The compression also leads to a
decreased venous return and reflex tachycardia. This is poorly
tolerated in the presence of intravascular fluid depletion.
Pulmonary vascular resistance decreases at birth as the
circulation transitions but initially remains relatively high.
The ductus arteriosus normally closes within 48 h in a well
term baby, but there is a significant incidence of patent ductus
arteriosus in premature infants. The presence of patent
communications (e.g. ductus arteriosus or foramen ovale),
can lead to shunting across the heart. Early neonates are at
risk of pulmonary hypertensive crises with right to left
shunting; this can be precipitated by hypoxia or acidosis and
will be detected by a decrease in lower limb oxygen saturation
relative to right upper limb oxygen saturation. Management
should be directed at reduction of pulmonary vascular resis-
tance. In the event of a gas embolus during laparoscopic
surgery, the presence of intracardiac communications adds to
the risk of adverse neurological sequelae as gas may traverse
the communication between the atria.
Postoperative care
A retrospective analysis from 2011 analysed almost 300 in-
fants undergoing herniorrhaphy and found that four variables
Anaesthesia for inguinal hernia repair in the newborn
predicted an increase in the duration of PACU stay; these were
postmenstrual age <45 weeks, prematurity, general anaes-
thesia, and postoperative opioid administration (nalbuphine).
In contrast, they found that both use of regional anaesthesia
alone and the use of intraoperative regional anaesthesia
(ilioinguinal and iliohypogastric block) predicted a decrease in
the duration of PACU stay.16
Risk of postoperative apnoea
Postoperative respiratory complication rates are higher in
infants, and this is further exaggerated in the ex-premature
infant. Ex-premature infants are at increased risk of apnoea
after inguinal hernia repair. The incidence of apnoea is
inversely related to both postmenstrual age (the most
important risk factor) and gestational age.13,17
Most apnoeas occur in infants <44 weeks postmenstrual
age and often resolve without intervention, but some need
interventions such as tactile stimulation, administration of
oxygen, bag and mask ventilation, continuous positive airway
pressure, and cardiopulmonary resuscitation. Anaesthesia
may unmask impaired and immature respiratory function
and expose vulnerability in both central ventilatory control
mechanisms, and the developmental immaturity of the chest
wall and diaphragm and lungs.
It is important to recognise that apnoea may arise as a
result of other co-existing pathology, for example neurological
abnormalities, patent ductus arteriosus, intracerebral hae-
morrhage, metabolic disturbances such as hypoglycaemia, or
evolving systemic illness such as sepsis. The aetiology of any
apnoea must be carefully considered, and appropriate in-
vestigations should be undertaken.
There can be considerable variation in practice in the
management of ex-premature infants at risk of postoperative
apnoea, and there is no clear consensus about the timing of
discharge and the nature and duration of postoperative
monitoring.12,16e20 Consideration should always be given to
individual patient factors, the risks associated with delayed
hernia repair, local institutional policies, and availability of
resources for extended cardiorespiratory monitoring in the
postoperative period.
Evidence base: postoperative apnoea
The occurrence of postoperative apnoea in the ex-premature
infant initially came under scrutiny in the 1980s.17 One of
the core issues explored has been identification of those most
at risk with consideration of whether anaesthetic technique
could modify that risk. Other aspects considered include the
definition of a clinically significant apnoea, the role of over-
night admission, the optimal type of monitoring, and the role
of intensive care in the postoperative phase.13,17e21
Studies of postoperative apnoea have been limited by the
heterogeneity of the ex-premature group of patients with any
one institution usually caring for small numbers. Sample size
in individual studies has remained an issue, despite attempts
to offset this by pooling data and recruiting at multiple cen-
tres. Different studies have used different definitions of
apnoea (15e20 s) and bradycardia (rates of 80e100 min1). In
addition, terms such as postconceptual age (PCA) and post-
menstrual age have been problematic and used inconsis-
tently, although some of the work was undertaken before the
AAP’s publication of guidance on terminology. Many studies
have excluded patients with significant co-morbidity.13,17
BJA Education - Volume 18, Number 7, 2018 215
Anaesthesia for inguinal hernia repair in the newborn
One consistent finding has been that the incidence of
apnoea varies with the type of monitoring used. There is no
standardised set of neonatal postoperative monitors. The
most sensitive techniques for detection of apnoea, such as
those incorporating continuous polysomnographic-type elec-
tronic recording (e.g. impedance pneumography, end-tidal
carbon dioxide, and nasal thermistry) are unlikely to be prac-
ticable or available. Neonatal respiratory monitors that use an
abdominal sensor to detect abdominal movement, or under
mattress movement sensors are sometimes used but may not
be available in all institutions. Oxygen saturation, ECG, and
nursing observation are usually more readily available. Where
duration of cardiorespiratory monitoring has been specified in
the literature, it has been for a minimum of 6 or 12 apnoea-free
hours in accordance with estimated risk.13,17e19
One of the most significant studies was undertaken by Cote
and colleagues using pooled data from several studies.17 Lo-
gistic regression was used to generate models examining the
risk of apnoea at different gestational and postconceptual
ages (this study precedes the AAP policy statement about
terminology and uses the term PCA, and postmenstrual age is
estimated as PCA plus 2 weeks). Multivariate models were also
used to determine whether the risk of apnoea was influenced
by other potential risk factors (i.e. birth weight, history of
respiratory distress syndrome, bronchopulmonary dysplasia,
neonatal apnoea, necrotising enterocolitis, ongoing apnoea,
anaemia, and use of opioids or non-depolarising neuromus-
cular blockers). Not all patients had data available for each
potential risk factor.
Pooled data analysis found significant variability in the
incidence of postoperative apnoea between institutions
(ranging between 5% and 49%). The incidence of apnoea
doubled when using continuous monitoring devices as
opposed to bedside monitors and observation. The incidence
of apnoea was found to be strongly and inversely related to
PCA and gestational age. Anaemia was found to be the only
independent risk factor, and a relationship with the other
variables considered was not found. When intervention with
bag mask ventilation was required, it usuallydbut not
exclusivelydoccurred in PACU and not in the ward. The
concluding recommendations were guarded and suggested
that ‘given the limitations of this combined analysis each
physician and each institution must decide what is an
acceptable risk for apnoea’. After publication of this work, the
thresholds adopted for overnight admission were usually be-
tween 54 and 60 weeks PCA. The thresholds were derived from
the upper limits of the 95% confidence intervals (CIs) at which
the probability of apnoea decreased below 1%. In this model,
infants with either anaemia or those who experienced apnoea
in the PACU were excluded:
(i) At 54 weeks PCA, the probability of apnoea (upper limit
of 95% CI) decreased below 1% in infants born at 35
weeks gestational age.
(ii) At 56 weeks PCA, the probability of apnoea (upper limit
of 95% CI) decreased below 1% in infants born at 32
weeks gestational age.
(iii) At 60 weeks PCA, the probability of apnoea (upper limit
of 95% CI) decreased below 1% in infants born at 28
weeks gestational age.
Extrapolating from logistic regression models that
included anaemic infants or infants who experienced apnoea
in the PACU, the probability of apnoea (upper limit of 95% CI)
216 BJA Education - Volume 18, Number 7, 2018
did not decrease below 1% in infants who were born at 28, 32,
or 35 weeks gestational age. The analysis was not projected
beyond 60 weeks PCA.
A Cochrane review has examined the role of prophylactic
methylxanthine (caffeine) to prevent postoperative apnoea
after general anaesthesia in preterm infants. The review was
based on a small number of subjects from three trials. The
review found some evidence that caffeine given at the time of
surgery reduces apnoea, bradycardia, and cyanosis after
anaesthesia but was cautious about recommendations for a
change in practice.22
As described above, the more recent GAS study examined
the influence of general anaesthesia on neurodevelopment as
the primary outcome measure; a secondary aim was to
compare the incidence of apnoea in patients undergoing
inguinal hernia repair.13 The incidence in ex-premature in-
fants (awake regional and general anaesthesia) was 6.1% and
0.3% in term infants. Less early apnoea (<30 min) occurred
with regional anaesthesia, and similar rates of late apnoea
occurred after both regional and general anaesthesia. Occa-
sional life-threatening apnoea occurred in PACU after both
regional and general anaesthesia. Overall, 9 of 642 patients
required positive pressure ventilation or cardiopulmonary
resuscitation to treat apnoea. Two infants from that group of
nine experienced multiple apnoeas, which started at 6e7 h
after surgery; both of these infants had received regional
anaesthesia. This underscores the importance of close and
extended cardiorespiratory monitoring. Notably, although
early apnoea was found to be a strong predictor of late apnoea,
it is not a sensitive measure and late apnoea may occur in the
absence of an early episode.
The study found that 19% of patients in the regional
anaesthesia group needed conversion to general anaesthesia.
No association with anaemia was found. Associations iden-
tified were prematurity (the strongest association), lower
gestational age at birth, lower weight, lower postmenstrual
age, a history of recent apnoea, a history of methylxanthine
use, a history of ever being ventilated with a tracheal tube, and
a history of ever needing oxygen support. Risk factors identi-
fied for both early and late apnoea were similar.
Ideally, the evidence base would provide a robust predic-
tive model of the need for overnight admission in the ex-
premature infant undergoing minor surgery, and also sup-
port more selective use of ICU resources. As this is not the
case, many centres continue a policy of overnight admission
with extended cardiorespiratory monitoring for ex-premature
infants undergoing minor surgery such as inguinal hernia
repair until a postmenstrual age of 56e60 weeks. The risk of
apnoea in term neonates is not clear as there are limited data,
but term infants are usually considered at risk below the age
of 44 weeks postmenstrual age.
Declaration of interest
None declared.
MCQs
The associated MCQs (to support CME/CPD activity) will be
accessible at www.bjaed.org/cme/home by subscribers to BJA
Education.

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