PRACTICE RECOMMENDATIONS
• Consult the anesthesiologist if a pediatric patient is about to undergo an elective surgical procedure and is febrile or coughing—especially if the child has significant comorbidities. These conditions may warrant postponing the procedure. A
• Avoid surgery in a child with cardiac disease who has inflammatory respiratory disease—especially if he or she has had palliative procedures for cyanotic lesions or has a hypoplastic right or left heart. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE You are seeing a 2-year-old boy with a runny nose in your busy clinic. He was sent to you by a local surgeon who plans to repair a hernia 3 days from now. Other than the upper respiratory tract infection, the child is healthy. The surgeon wants you to clear the boy for surgery to avoid the possibility of the anesthesiologist canceling on the day of the procedure.
What are your next steps?
In our experience, children are regularly brought to the ambulatory surgery suite after having seen their family physician or pediatrician. To better equip you for such visits, we’ve put together the following summary of the risks for a child with an upper respiratory infection (URI) who is about to undergo surgery. We’ve also detailed some of the reasoning and evidence behind the decisions that anesthesiologists make in cases like this.
Making decisions in the absence of consensus
While the American Society of Anesthesiologists has a consensus statement on preoperative fasting to reduce the risk of pulmonary aspiration,1 there is no consensus on how to manage a child scheduled for elective surgery who develops a URI.
Historically, any child with a current or recent URI would not be considered a candidate for elective surgery due to the potential for respiratory complications caused by airway irritability.2 These complications can include bronchospasm, laryngospasm, hypoxemia, croup, pulmonary shunting, atelectasis, postoperative apnea, negative pressure pulmonary edema, and airway or endotracheal tube obstruction from increased secretions.3
This concern has been based on the clinical observation that children with URI-related airway irritability are at a greater risk of having such events during the perioperative period.4 In fact, pulmonary function studies reveal an increase in airway irritability for as long as 6 weeks after a significant URI.
Many children with a URI will have airway edema and increased secretions in the upper nasopharynx and the posterior oropharynx down to the level of the vocal cords. In addition, patients with some viral infections—including respiratory syncytial virus—may experience increased edema in the larynx, trachea, and small and large bronchi. The presence of airway inflammation increases mucus production, which is normally coughed out in an awake patient.
The period between the awake state and surgical anesthesia—referred to as Stage 2— is the time of highest risk for the development of laryngospasm. Stage 2 occurs both during the induction of and the emergence from general anesthesia. Children who develop laryngospasm may be difficult to ventilate by mask, and tracheal intubation can be difficult through the closed glottis. In these clinically emergent situations, patients become hypoxemic rapidly. Ventilation may be possible only if the vocal cords are relaxed with agents such as succinylcholine.5
If the anesthesia team cannot quickly treat such laryngospasm, it can lead to postobstructive pulmonary edema. Negative pressure developed in the thorax during spontaneous ventilation against a closed glottis causes a pressure gradient across the alveolar-capillary membrane, leading to movement of fluid into the alveoli, characterized by a typically pink, frothy transudate. Hypoxia may ensue, and the chest x-ray will reveal pulmonary edema. Mild forms may respond to an increase in ambient oxygen alone, but severe cases may require intubation, ventilation, and diuretics to restore the child to a normal state.6
Certain anesthetic agents may be problematic
Unfortunately, airway irritability is only one of many problems to contend with. Inhalational anesthetic agents have an adverse effect on the mucociliary elevator, as well.7,8 Cilia on the surface of epithelial cells lining the trachea and bronchi act to move mucus from the distal to the proximal airway so that it can be coughed out. Failure of this mechanism in a child with an inflammatory condition in the airway increases the risk of atelectasis from thickened secretions and occasionally from pneumonia.
Most of the potent general anesthetic agents have significant bronchodilatory properties. But desflurane, a commonly used agent, causes bronchoconstriction when used in a patient with an irritated, infected airway.9This agent will produce predictable wheezing from bronchospasm, especially in patients who have confounding pulmonary disease such as asthma.
Talk to the anesthesiologist. With these concerns in mind, clinicians must consider the type of anesthetic and the nature of the surgical procedure and discuss these issues with the anesthesiologist in the preoperative period. Some anesthetic agents and techniques are less irritating to airways.2,3 Avoidance of both desflurane and endotracheal intubation, for instance, will minimize airway irritation.