Upper Respiratory Tract Infection Children
Presenting for Elective Surgery
A) Pathophysiology of Upper Respiratory
Tract Infection
Although viral URI’s are not situations that preclude a child from missing a
school day, it certainly poses a decision making situation for
anesthesiologists. A true URI may also be confused with allergic rhinitis.
Perioperative risks with subjecting children to anesthesia in the presence of a
URI are several –
1.
2.
3.
4.
5.
6.
Bronchospasm
Hypoxemia with increased A-a gradient
Atelectasis with cases needing postop. bronchoscopy
Stridor caused by subglottic edema
Larygospasm
Postoperative pneumonia
Bronchospasm and larygospasm has been shown to occur with increased
frequency in patients who are intubated specially in younger children.
Complications also have shown to increase in patients with RAD, oral
surgery, parental smoking and nasal congestion.
B) Anesthetic Evaluation of children with
URI for Elective Surgery
Overall, the decision to cancel surgery in these children has reached no
consensus as of now. Considerations as to how to make decisions on
these patients include-
1. Risk of cancelling surgery should be weighed against the physiologic,
psychological and financial implications of doing so.
2. The most conservative approach to the situation of a child with an
URI for surgery would be to postpone elective procedures for 1-2
weeks for uncomplicated rhinnorhea and non productive cough and
for 4-6 weeks for patients with productive cough and wheezing.
However, this may pose a problem of inconveniencing the patient,
financial loss and other problems to the patient. Also the
anesthesiologist must take into account that children have on an
average three to eight colds a year and “cold free period “ would be
hard to find.
3. Children with tonsillar or adenoid hypertrophy present for T &A have
“ baseline “ symptoms of URI. Therefore to postpone the surgery
would depend if the URI symptoms are truly different from the
baseline ones.
A definite decision to postpone surgery would be when1. Child has croupy cough
2. Rectal temperature greater than 38 degrees along with an URI
3. Lethargy, poor feeding
4. Lower respiratory tract symptoms such as wheezing, rales
5. Abnormal chest X-Ray. To note here is that an abnormal chest X-Ray
with negative clinical findings is not an indication to postpone surgery
as resolution of radiographic findings lag about 3 weeks after
resolution of clinical symptoms.
C) Anesthetic Management Principles of
Children with URI for Elective Surgery
1. Elective surgery- avoid intubation . Instead consider LMA or
regional anesthesia if feasible
Studies have shown a lower incidence of bronchospasm when a
LMA was used instead of an ETT.
If an ETT is needed, intubate when the patient is deep using
adjuvant methods such as Lidocaine 1mg/kg, or opoids.
Use of drying agents such as Atropine and Glycopyrrolate may be
helpful.
Tracheal suction after intubation and before extubation would help
mucus plugging and atelectasis.
Use of glucocorticoids in experiments has decreased airway
swelling but not recommended for URI ( recommended for
traumatic , difficult airways where multiple intubation attempts
have been made or for RAD)
2) Emergency Surgery - Proceed as necessary with intubation.
Consider drying agents , adequate hydration, frequent suctioning,
and postoperative humified oxygen
Albany Medical Center
Department of Anesthesiology
Policy and Procedure
PEDIATRICS
Section 7.2
Page 1 of 1
Effective: 5/91
Reviewed: 6/94, 8/95, 8/01
Revised: 4/98, 2/5/2003
GUIDELINES FOR CANCELLATION OF OUTPATIENT SURGERY IN CHILDREN WITH UPPER
RESPIRATORY TRACT INFECTIONS (URIs)
The scientific data to support rigid stands for or against cancellation of children with runny noses and colds
is not yet available. Meanwhile, it would be beneficial to all concerned (surgeons, nurses) if this department
would take a reasonably uniform stand on this matter.
A.
1.
2.
3.
4.
5.
6.
7.
Factors Favoring Cancellation:
Fever above 38°C Rectal Temperature
Tachypnea.
Productive cough.
Chest signs such as rales and rhonchi.
Flu-like syndrome: myalgias, malaise, etc.
History of Reactive Airway Disease or Bronchopulmonary Dysplasia.
Moderate to severe wheezing.
B.
1.
2.
3.
4.
5.
C.
Doubtful Grounds for Cancellation:
Clear rhinorrhea, allergic rhinitis.
Nasopharyngitis with sore throat, sneezing, congestion.
Non-productive cough.
Short procedures (e.g. myringotomy).
Mother describes the syndrome profile as occurring frequently, i.e. "not much difference from
usual".
Other Possible Considerations:
1. Under one year of age.
2. Intubation required.