Pediatric Anesthesia and the
Child with URI
Words of Wisdom
Greg & Joy Loy Gordon MD et al
Nov 2006
The Old School:
Elective surgery + URI =
Cancel (Postpone) case
Newer school?
URI increases risk but
Complications can be
anticipated
recognized
treated
So perhaps we ought to proceed
Anesth Analg 2005;100:59-65
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
Alan R. Tait, PhD
Director of Clinical Research
Professor of Anesthesiology
University of Michigan
Ann Arbor, MI
atait@umich.edu
Shobha Malviya, MD
Director, Pediatric Research
Associate Professor of Anesthesiology
smalviya@umich.edu
Frederic A. Berry, MD
Professor of Anesthesiology and Pediatrics
University of Virginia
fab@virginia.edu
Charles J. Cote, MD
Vice Chairman
Director of Research
Department of Pediatric Anesthesiology
Children's Memorial Hospital
Chicago, IL
ccote@anesthesiaweb.com
Anesthesia for the Child with an Upper Respiratory Tract Infection:
Still a Dilemma?
Alan R. Tait, PhD, and Shobha Malviya, MD
Anesth Analg 2005;100:59-65
Reported events – what will happen to the kid with URI?
DeSoto et al. Anesthesiology 1988;68:276
Bronchospasm
Faster drop in SpO2
Postop lower SpO2
Laryngospasm
Tait et al. Anesthesiology 1987;67:930
Breath-holding
SpO2 < 90 %
Severe coughing
Specific predictors – which kids will it happen to?
Parnis et al. Paediatr Anaesth 2001;11:29
ETT > LMA > FM
Parents say child had “cold”
Snoring history
Passive smoking
Thiopental > halothane > sevo > propofol
Sputum
Nasal congestion
Muscle relaxant not reversed
Specific predictors – which kids will have more problems?
Tait et al. Anesthesiology 1987;67:930
Independent risk factors:
ETT in child < 5 yrs old
Premie (< 37 wks EGA)
Reactive airway disease
Parental smoking
Surgery involving airway
Copious secretions
Nasal congestion
Let’s 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 ?
Severe symptoms  postpone 4 weeks
Mucopurulent secretions
Productive cough
Fever
Lethargy
Signs of pulmonary involvement
A one to two week delay may be all that
is needed for children with uncomplicated
nasopharyngitis.
Berry FA. Semin Anesth 1984;3:24
“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 1992;4:200
“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 2001;95:383
“Nearly 2,000 procedures would have to be canceled
to prevent 15 cases of laryngospasm.”
Anesthesiology 2001;95:383
“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)
What about child with “intermediate” symptoms?
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
Tait-Malviya URI Algorithm
Anesthetic management of URI child
Avoid ETT
Consider LMA
Pulse oximetry
Hydration
Humidification?
Anticholinergics?
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 2005;100:59-65