Abstract
Children presenting with a recent or active upper respiratory tract infection present a clinical dilemma for the anesthesia team. Some of these patients are getting procedures to help with recurrent infections. The severity of the infection and the urgency of the procedure will play a role in the decision to proceed with the procedure. The anesthesiologists should discuss potential risks with the parents and the surgeon preoperatively.
Keywords
anesthesia, complications, laryngospasm, pediatric, respiratory tract infections
Case Synopsis
A 4-year-old girl with a history of recent upper respiratory tract infections (URIs) and symptoms of clear rhinorrhea and occasional nonproductive cough and a history of low-grade fever 3 days ago presents for a tonsillectomy and adenoidectomy under general anesthesia. She has a history of frequent URIs and has had four episodes in the last 3 months. Laryngospasm occurs during inhalation induction of anesthesia with sevoflurane.
Acknowledgment
The authors wish to thank Dr. Susan Nicolson and Dr. James Steven for their contributions to the previous edition of this chapter.
Problem Analysis
Definition
Conflicting information is available regarding the outcome of children with active URIs who undergo anesthesia for elective surgical procedures. Some studies suggest that children with URIs are at increased risk for perioperative respiratory complications. Others indicate that these children have no increased risk ( Table 28.1 ). Increased mortality has not been demonstrated in any controlled study. Study design limitations that clinicians need to understand when drawing conclusions regarding the risk-to-benefit ratio of anesthetizing these children include retrospective study data acquisition for these case-control studies, absence of well-defined criteria for URI between studies, heterogeneous group of children with regard to age, type of surgery, anesthetic technique included in the cohort, nonuniform definition and reporting of adverse patient occurrences between studies, and selection bias based on the cancellation practice of each anesthesiologist. Retrospective data indicate that children with a recent URI (during the previous 2 to 6 weeks) have an increased risk of pulmonary complications compared with either those without or with an active URI. The clinical importance of these potential complications will further influence the decision to cancel or proceed. Does an increased incidence of laryngospasm, for example, lead to increased morbidity, or can this complication be identified and treated without harm by anesthesiologists? A recent prospective study suggested that although children with acute and recent URIs have a greater risk for respiratory complications, most of those children might undergo elective procedures without significant increase in adverse anesthetic outcomes. The study was, however, nonrandomized, and the decision to proceed was left to the discretion of the attending anesthesiologist taking care of the patient. The common reasons for cancellation were severe URI, presence of lower respiratory tract infection, and bacterial infection. A prospective cohort study found that among pediatric patients receiving a general anesthesia with an laryngeal mask airway for an elective surgical procedure, presence of a recent URI was associated with increased odds of developing a perioperative respiratory complication (odds ratio: 1.8; confidence interval: 1.3–2.6).
| Frequency (%) (URI Status) | ||||||
|---|---|---|---|---|---|---|
| Outcome Measure | Active | Recent | None | N | Intubated | Study Design |
| Airway obstruction ∗ | 1.6 | 5.3 | 1.6 | 3585 | Most | R |
| Laryngospasm | 1.3 | 2.4 | 1.2 | 489 | None | P |
| Bronchospasm | 13.3 | 0.6 | 402 | Half | P | |
| Croup | 3.8 | 0.7 | 22,159 | Some | P | |
| Hypoxemia | 32 | 25 | 10 | 130 | None | P |
| Hypoxemia | 40 | 16 | 402 | Half | P | |
| Hypoxemia | 20 | 0 | 50 | Most | P | |
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