Pediatric Anesthesia and the Child with URI Words of Wisdom Greg & Joy Loy Gordon MD et al Nov 2006.

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