Brief procedures that do not involve major body cavities (eg, abdominal, thoracic, and intracranial) may be done without instrumenting the trachea. Face masks and laryngeal mask airways have been shown to decrease the incidence of adverse reactions because these forms of airway management are less invasive and physiologically insulting than direct laryngoscopy and endotracheal intubation.
Clinical observations suggest that endotracheal intubation increases pulmonary risks for the child with a URI.10,11 Long procedures, a patient position that limits access to the airway, the anticipated need to use muscle relaxants, airway surgery, and surgery in major cavities all require intubation for airway management. In these circumstances, it’s best to plan the perioperative care of a child suffering from a URI with an anesthesiologist who is comfortable caring for pediatric patients.12
Proceeding with surgery despite the risks
During emergency procedures on infants and children, the anesthesiologist has to do the best possible job under less than ideal conditions. Bowel obstruction, an incarcerated inguinal hernia, or a foreign body in the airway can all be life-threatening. In these cases, the anesthesiologist will counsel the surgeon and parent on the risks of the anesthetic. They likely will proceed with the knowledge that the usual methods of anesthetizing a child may have to be altered to provide the safest possible conditions.
But even certain nonemergent procedures may require taking some risks. Anesthesiologists are likely to anesthetize a child for placement of pressure-equalizing (PE) tubes, for instance, even with a mild infection in the upper oropharynx. This is because the possibility is high that the patient will be infected throughout the winter season, and waiting for a URI-free period might mean that the child would not get the PE tubes at all. Furthermore, PE tube placement is performed very quickly, with no instrumentation of the airway necessary. The anesthesiologist performs a mask anesthetic, always has control and access to the airway, and the procedure can be aborted at any time, with no incision to close.
How long should you wait it a URI is serious?
As mentioned earlier, there is no consensus on how long to wait, but clinical studies have suggested delaying surgery for as long as 6 weeks after the acute episode.4 The thinking was that this long period allowed time for the inflammatory response to dissipate completely. Unfortunately, in the middle of the winter, it’s likely that the child will be exposed to another viral strain and develop yet another URI. Clinical judgment plays a pivotal role here; it is always best to establish a relationship with an anesthesiologist in your community and call him or her with questions about individual patients.
Before you sign off on surgery
There are several other circumstances to consider when approving a child with a URI for surgery.
Children with cardiac disease, especially those who have had palliative procedures for cyanotic lesions or who have a hypoplastic right or left heart, are characteristically unstable in the face of inflammatory respiratory disease. Unless the surgical procedure is an emergency, such patients should not be considered for general anesthesia if they have a URI.13 As an example, bronchiolitis plus cyanotic heart disease can be rapidly fatal, requiring prolonged ventilation or extracorporeal membrane oxygenation in order to save the patient.
Intensive care nursery “graduates” may present to your office for preoperative assessment. Many of these infants and children will have marginally compensated lung disease, some with substantial pulmonary hypertension. Their respiratory function will continue to improve, some until the age of 7 to 10 years. In the meantime, they, too, are at high risk for complications from general anesthesia if they have a URI, and the decision to take them to the operating room should be discussed with other care providers and the parents.
Children with fever, mucopurulent discharge, wheezing, lethargy, and cough are at high risk for complications during the perioperative period, regardless of any comorbidities. Many anesthesiologists would cancel surgery in these circumstances, even if the patient has been seen recently by his or her primary care physician and is taking antibiotics for coverage of a potential bacterial infection.
Other indicators of increased risk of pulmonary complications include a history of reactive airway disease, exposure to tobacco smoke, snoring, nasal congestion, the need for endotracheal intubation, and surgery on the airway.14
CASE You evaluate the 2-year-old and note that he has a history of mucopurulent nasal discharge and a productive cough. The child’s temperature in the clinic is 99.8°F and his chest x-ray is consistent with bronchitis. After talking with a local anesthesiologist and the surgeon, you all agree that the boy’s surgery should be postponed for a month.