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Prophylactic caffeine to prevent postoperative apnea following general anesthesia in preterm infants
1NSW Centre for Perinatal Health Services Research, Queen Elizabeth II Institute for Mothers and Infants, Building DO2, University of Sydney, Sydney, NSW, Australia, 2006. dhs@perinatal.usyd.edu.au
Insights
Prophylactic caffeine administration significantly reduces postoperative apnea and bradycardia in growing ex-preterm infants. This intervention shows a high risk reduction with no reported adverse effects.
Area of Science:
- Neonatal Medicine
- Pediatric Anesthesiology
- Pharmacology
Background:
- Ex-preterm infants undergoing surgery around term-equivalent age are at risk for postoperative apnea, cyanosis, and bradycardia.
- Caffeine, a respiratory stimulant, may prevent these adverse events when administered perioperatively.
Purpose of the Study:
- To evaluate the efficacy and safety of prophylactic caffeine in preventing postoperative apnea, cyanosis, and bradycardia in ex-preterm infants.
- To assess for any clinically significant side effects associated with caffeine administration.
Main Methods:
- A systematic review and meta-analysis of randomized controlled trials comparing caffeine with placebo or no treatment.
- Searches included multiple databases (MEDLINE, EMBASE, CINAHL, Cochrane Library) and relevant MeSH terms.
- Data extraction and quality assessment followed standard Cochrane Collaboration and Neonatal Review Group methodologies.
Main Results:
- Three eligible trials demonstrated a significant reduction in apnea/bradycardia episodes in infants receiving caffeine (relative risk reduction 91%).
- Caffeine administration also reduced episodes of oxygen desaturation (<90%).
- No infants required mechanical ventilation, and no adverse effects were reported.
Conclusions:
- Caffeine is effective in preventing postoperative apnea/bradycardia and oxygen desaturation in growing preterm infants.
- Clinical application should be cautious due to small study numbers and uncertainty regarding the clinical significance of the episodes.
- Further research is needed to identify specific subgroups of infants who would benefit most from prophylactic caffeine therapy.
Background:
Growing ex-preterm infants who undergo general anesthesia for surgery at about term-equivalent age may have episodes of apnea, cyanosis and bradycardia during the early postoperative period. A breathing stimulant such as caffeine, given at the time of operation, might prevent these episodes.
Objectives:
In ex-preterm infants who undergo general anesthesia for surgery, does the prophylactic use of caffeine prevent episodes of apnea, cyanosis and bradycardia during the postoperative period without clinically important side effects?
Search Strategy:
The standard strategy of the Neonatal Review Group was used. This included searches of the Oxford Database of Perinatal trials, MEDLINE (1966 - July 2001), EMBASE 1980 - July 2001), CINAHL (1982 - July 2001) and Cochrane Library Issue 2, 2001. Search terms included text 'apnea', 'caffeine' and MeSH 'infant, premature'. Searches were also made of previous reviews including cross references. Abstracts of the Society for Pediatric Research were hand searched for the years 1996 - 2001 inclusive.
Selection Criteria:
All trials utilising random or quasi-random patient allocation, in which treatment was compared with placebo or no treatment, were included.
Data Collection And Analysis:
The standard methods of the Cochrane Collaboration and its Neonatal Review Group were used to select trials, evaluate quality and to extract data. The methodological quality of each trial was reviewed by the second author blinded to trial authors and institution(s). Each author extracted data separately, compared and resolved differences. Meta-analysis used relative risk and risk difference.
Main Results:
Three eligible trials were found. In each trial apnea/bradycardia occurred in fewer treated than control infants. The typical estimate for relative risk reduction was 91%, 95% CI 66%, 98%. Absolute risk reduction was 58%, indicating that fewer than two infants have to be treated with caffeine to expect to prevent one with postoperative apnea. In two trials continuous recordings of oxygen saturation detected hypoxaemic episodes (<90 %) in fewer treatment than control infants. No infant in any trial required intubation and mechanical ventilation. No adverse effects were reported.
Reviewer'S Conclusions:
Implications for practice. Caffeine can be used to prevent postoperative apnea/bradycardia and episodes of oxygen desaturation in growing preterm infants if this is deemed clinically necessary. In view of the small numbers of infants studied in these trials and uncertainty concerning the clinical significance of the episodes, caution is warranted in applying these results to routine clinical practice. Implications for research. There is a need to determine which infants might benefit most by this treatment. Studies confined to those most at risk of apnea (prior history, younger postmenstrual age) and those that might require mechanical ventilation (chronic lung disease) would be of value.