ANESTHESIA AND URI- SHOULD WE POSTPONE SURGERY?

Upper respiratory infection (URI) is a common illness, and children often present for anesthesia with a current or recent URI. Children with current or recent URIs are at increased risk for perioperative respiratory adverse events (PRAEs) including laryngospasm, bronchospasm, oxygen desaturation, cough, and breath-holding, though most of these events are mild and easily treated.

●Our approach to the timing of anesthesia for children with current or recent URI is as follows

URI found on preoperative screening – For children who are found during preoperative screening for elective surgery to have a current or recent URI, we postpone the procedure until two to four weeks after symptoms subside.

ACTIVE URI the day of an elective procedure – For patients with an active URI on the day of an elective procedure, our decision to postpone surgery is individualized, taking into account the severity of URI symptoms, the patient’s risk factors, the planned procedure, and the medical and practical disadvantages of postponement:

–For patients with only mild rhinorrhea and mild symptoms at the time of a minor procedure, we do not postpone anesthesia.

–For patients who present with fever ≥38°C or a wet cough, or who are obviously ill, we postpone elective procedures until two to four weeks after symptoms subside.

–For patients with moderate symptoms, we make an individualized decision.

RECENT URI discovered the day of an elective procedure – For patients who are currently asymptomatic but are found to have had a recent URI, we use the following approach:

–URI within two weeks – In general, we proceed with elective procedures for older children who have been asymptomatic for more than one week. We often postpone the procedure for two to four weeks for younger, higher-risk patients who are to undergo higher-risk procedures.

–URI two to four weeks ago – We do not usually postpone a procedure when a patient has been asymptomatic for two to four weeks after a URI, recognizing that airway hyperreactivity may persist for up to six weeks.

•Urgent procedures – For patients who present with a URI for urgent or semiurgent procedures, the risks and benefits of postponement should be weighed in a discussion between the anesthesiologist, the surgeon, and the other care providers.

For children with symptoms of a URI, we usually premedicate as follows:

•We administer a short-acting beta₂ agonist (eg, albuterol via nebulizer 2.5 mg if <20 kg, 5 mg if >20 kg, or via metered dose inhaler [MDI] with spacer, two to eight puffs).

•For children ≥6 years of age with rhinorhea, we administer topical nasal decongestant spray (eg, oxymetazoline nasal spray 0.05%, not more than two to three sprays per nostril) before induction.

•Once intravenous (IV) access is established, we administer an antisialagogue (eg, glycopyrrolate 4 mcg/kg IV).

●Principles for induction and maintenance of anesthesia for the child with a URI are similar to those for the child with asthma or recurrent wheezing.

When possible, we minimize airway instrumentation for patients with a current or recent URI. We prefer facemask to the use of a supraglottic airway (SGA) and SGA placement to endotracheal intubation.

Intraoperative laryngospasm can quickly lead to hypoxia and bradycardia and can result in morbidity and mortality. The risk of laryngospasm increases with airway instrumentation, especially under light levels of anesthesia, and with the presence of airway secretions. Treatment of laryngospasm includes continuous positive airway pressure with 100 percent oxygen and, if necessary, administration of a neuromuscular blocking agent (NMBA).

●Laryngospasm, bronchospasm, and other PRAEs can occur at the time of emergence from anesthesia and extubation. We prefer to remove airway devices under deep levels of anesthesia.