Pediatric Anesthesia and the Child with URI

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Pediatric Anesthesia and the Child with URI

• Words of Wisdom

Greg Joy Loy Gordon MD et al Nov 2006
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The Old School
Elective surgery URI
Cancel (Postpone) case
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Newer school?

• URI increases risk but
• Complications can be
• anticipated
• recognized
• treated
• So perhaps we ought to proceed

Anesth Analg 200510059-65
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Problems interpreting data

• What exactly is a URI?
• Type/duration of surgery
• Airway instrumentation
• Anesthetic agent/technic

Evidence from observational studies Not random
double-blinded controlled
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Alan R. Tait, PhDDirector of Clinical Research
Professor of Anesthesiology University of
Michigan Ann Arbor, MI atait_at_umich.edu
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Shobha Malviya, MDDirector, Pediatric Research
Associate Professor of Anesthesiologysmalviya_at_um
ich.edu
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Frederic  A.  Berry,  MD Professor of
Anesthesiology and Pediatrics University of
Virginia fab_at_virginia.edu
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Charles J. Cote, MD Vice ChairmanDirector of
ResearchDepartment of Pediatric
AnesthesiologyChildren's Memorial
HospitalChicago, IL ccote_at_anesthesiaweb.com
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Anesthesia for the Child with an Upper
Respiratory Tract Infection Still a Dilemma?
Alan R. Tait, PhD, and Shobha Malviya, MD
Anesth Analg 200510059-65
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Reported events what will happen to the kid
with URI?
DeSoto et al. Anesthesiology 198868276
Bronchospasm Faster drop in SpO2 Postop lower
SpO2 Laryngospasm
Tait et al. Anesthesiology 198767930
Breath-holding SpO2 lt 90 Severe coughing
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Specific predictors which kids will it happen
to?
Parnis et al. Paediatr Anaesth 20011129
ETT gt LMA gt FM Parents say child had
cold Snoring history Passive smoking Thiopental
gt halothane gt sevo gt propofol Sputum Nasal
congestion Muscle relaxant not reversed
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Specific predictors which kids will have more
problems?
Tait et al. Anesthesiology 198767930
Independent risk factors
ETT in child lt 5 yrs old Premie (lt 37 wks
EGA) Reactive airway disease Parental
smoking Surgery involving airway Copious
secretions Nasal congestion
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Lets 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 ?
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(No Transcript)
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Severe symptoms ? postpone 4 weeks
Mucopurulent secretions Productive cough Fever
Lethargy Signs of pulmonary involvement
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A one to two week delay may be all that is needed
for children with uncomplicated nasopharyngitis.
Berry FA. Semin Anesth 1984324
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children with a mild URI may be safely
anesthetized, since the problems encountered are
generally easily treated and without long-term
sequelae.
J Clin Anesth 19924200
children with a recent URI fared as well a
those with an acute URI. Delaying a procedure
will not significantly change the incidence of
adverse respiratory events. Little is gained
except to create inconvenience for the family,
the surgeon, and the surgery schedule.
Anesthesiology 200195383
Nearly 2,000 procedures would have to be
canceled to prevent 15 cases of laryngospasm.
Anesthesiology 200195383
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Despite the increased risk of respiratory
events in 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)
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What about child with intermediate symptoms?
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(No Transcript)
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Tait-Malviya URI Algorithm
No severe symptoms or Recent URI General
anesthesia needed
Estimating risk/benefit ratio
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
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Tait-Malviya URI Algorithm
Anesthetic management of URI child
Avoid ETT Consider LMA Pulse oximetry Hydration Hu
midification? Anticholinergics?
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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
Anesthesia for the Child with an Upper
Respiratory Tract Infection Still a Dilemma?
Alan R. Tait, PhD, and Shobha Malviya, MD
Anesth Analg 200510059-65