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Pediatric Anesthesia and the Child with URI
Words of Wisdom
Greg & Joy Loy Gordon MD et alNov 2006
The Old School:
Elective surgery + URI =
Cancel (Postpone) case
Newer school?
URI increases risk but
Complications can be
anticipated
recognized
treated
So perhaps we ought to proceed
Anesth Analg 2005;100:59-65
Problems interpreting data
• What exactly is a URI?• Type/duration of surgery• Airway instrumentation• Anesthetic agent/technic
Evidence from observational studiesNot random double-blinded controlled
Alan R. Tait, PhDDirector of Clinical Research Professor of AnesthesiologyUniversity of MichiganAnn Arbor, MI [email protected]
Shobha Malviya, MDDirector, Pediatric Research Associate Professor of [email protected]
Frederic A. Berry, MD Professor of Anesthesiology and PediatricsUniversity of [email protected]
Charles J. Cote, MDVice ChairmanDirector of ResearchDepartment of Pediatric AnesthesiologyChildren's Memorial HospitalChicago, IL [email protected]
Anesthesia for the Child with an Upper Respiratory Tract Infection:Still a Dilemma?
Alan R. Tait, PhD, and Shobha Malviya, MD
Anesth Analg 2005;100:59-65
Reported events – what will happen to the kid with URI?
Bronchospasm
Faster drop in SpO2
Postop lower SpO2
Laryngospasm
Breath-holding
SpO2 < 90 %
Severe coughing
DeSoto et al. Anesthesiology 1988;68:276
Tait et al. Anesthesiology 1987;67:930
Specific predictors – which kids will it happen to?
ETT > LMA > FM
Parents say child had “cold”
Snoring history
Passive smoking
Thiopental > halothane > sevo > propofol
Sputum
Nasal congestion
Muscle relaxant not reversed
Parnis et al. Paediatr Anaesth 2001;11:29
Specific predictors – which kids will have more problems?
Tait et al. Anesthesiology 1987;67:930
Independent risk factors:
ETT in child < 5 yrs old
Premie (< 37 wks EGA)
Reactive airway disease
Parental smoking
Surgery involving airway
Copious secretions
Nasal congestion
Let’s do some math
9 URIs per year (day care)
Conservatively wait 6 wks for airway hyperreactivity
9 x 6 = 54 wks to postpone surgery
How many weeks in a year ?
Severe symptoms postpone 4 weeks
Mucopurulent secretions
Productive cough
Fever
Lethargy
Signs of pulmonary involvement
A one to two week delay may be all that is needed for children with uncomplicatednasopharyngitis.
Berry FA. Semin Anesth 1984;3:24
“children with a mild URI may be safely anesthetized, since the problems encountered are generally easily treated and withoutlong-term sequelae.”
“children with a recent URI fared as well a thosewith an acute URI. Delaying a procedure willnot significantly change the incidence of adverserespiratory events. Little is gained except to createinconvenience for the family, the surgeon, and the surgery schedule.” Anesthesiology 2001;95:383
J Clin Anesth 1992;4:200
“Nearly 2,000 procedures would have to be canceledto prevent 15 cases of laryngospasm.”
Anesthesiology 2001;95:383
“Despite the increased risk of respiratory eventsin children with URIs, there appears to be very little residual morbidity.”
No cases in ‘closed claim literature’ implicating URI
Only 3 of 742 current or recent URIs:
2 admitted for pneumonia after surgery
1 admitted for stridor
(uneventful recoveries)
What about child with “intermediate” symptoms?
Tait-Malviya URI Algorithm
No severe symptoms orRecent URIGeneral anesthesia needed
Risk factors
Hx of asthma
Use of an ETT
Copious secretions
Nasal congestion
Parental smoking
Surgery of airway
Hx of prematurity
Other factors?
Need for experience
Parents traveled far
Surgery canceled before
Comfort caring for child with URI
Estimating risk/benefit ratio
Tait-Malviya URI Algorithm
Anesthetic management of URI child
Avoid ETT
Consider LMA
Pulse oximetry
Hydration
Humidification?
Anticholinergics?
Anesthesia for the Child with an Upper Respiratory Tract Infection:Still a Dilemma? Alan R. Tait, PhD, and Shobha Malviya, MD Anesth Analg 2005;100:59-65
Dilemma remains for child with intermediate symptoms
Recommend:
Decide on case-by-case basis
Considering:
Identified risk factors
Need for expedient surgery
Your experience and
Your comfort level
Using:
“Tincture of common sense”
Good judgment
