Cohen MM, Cameron CB. Should you cancel the operation when a child has an upper respiratory tract infection? Anesth Analg 199 1; 72:282-8.

The title of this paper by Drs. Cohen and Cameron asks an important question that affects anesthetic practice and patient safety. In recent years, several publications have been aimed at seeking an answer to this question. The Cohen and Cameron paper increases our understanding of the risks involved when administration general anesthesia to children with infected upper airway tracts.

The authors prospectively studied 1,283 children with URIs who had been identified in a large pediatric anesthesia data base of 29,220 children. Their findings indicate a two to seven-fold increase in respiratory-related adverse events during the perioperative period. In addition, when endotracheal intubation was performed in their URI population, them was a striking eleven-fold increase in respiratory complications.

Of interest was the observation of no age-related variation in respiratory risk in this study. Both intraoperatively and in the recovery room, airway obstruction was identified as the most common adverse respiratory event. Of note is the high incidence of post-intubation croup in children less than one year of age who underwent endotracheal intubation in the presence of a URI.

These authors are to be commended for taking on such a challenging and important investigation. It is unfortunate that they did not quantify the degree or severity of preoperative respiratory disease by symptomatology (e.g. cough, clear vs. purulent rhinitis, sore throat, etc.). In addition, the use of pulse oximetry data would have likely driven home their conclusions even more strongly. Despite this criticism, the authors have contributed significantly to our understanding of the safe clinical practice of pediatric anesthesia.

When discussing general anesthesia risk during URI’s, several other studies deserve mention. Dueck et al.(1) demonstrated that acute viral respiratory infection m their sheep model significantly worsened the pulmonary effects of anesthesia. DeSoto et al. (2) demonstrated a significantly increased risk for postoperative oxygen desaturation after general anesthesia in children with URI’s. While both of these studies she-d important understanding on the risk factors associated with general anesthesia during URI’s, they still leave unanswered the issue of exactly what type of URI symptom complex leads to a worse outcome.

This author believes the answer lies in distinguishing rhinitis from the more significant pharyngitis/laryngitis/tracheobronchitis/pneumonitis Complex. (3) In the face of a URI, following symptomatology should help distinguish these entities when a child presents with acute upper respiratory illness:

1. Cough (especially during your exam or if the parent states the child coughs while sleeping)

2. Sore throat

3. Hoarseness

4. Fever (temperature>38 degrees C rectally with an associated URI symptom)

5. Malaise, lethargy or increased irritability

6. Vomiting, diarrhea or generalized rashes

Points four through six above appear to be indicative of systemic infection and likely indicate a virulent viral pathogen with associated illness. Symptomatology points one through three above are observations from clinical practice. The isolated “runny nose” without any of the associated symptoms mentioned above seems to be a different risk entity for general anesthesia. The difficulty comes in developing the clinical acumen to distinguish between these two clinical entities.

Once surgery and anesthesia have been cancelled, the next question pertains to rescheduling. Past investigations that examine pulmonary function parameters have noted residual dysfunction up to eight weeks after a URI. However, Wald et al. (4) recently concluded that the duration of a “URI effect” in children is two to three weeks based on the time to resolution of all symptoms and return to normal premorbid activity. It is reasonable to suggest that ” guideline is suitable for rescheduling elective surgery after postponement.

With more clinical studies W that of Cohen and Cameron, we may someday be able to more accurately answer the question, When should you cancel the anesthetic when a child has an upper respiratory tract infection? Placing the patient’s safety first, the anesthesiologist should be the decision-maker on the operating room team on this issue

Abstracted by: Allen J. Hinkle, M.D., Associate Professor of Anesthesiology and Pediatrics, Director, Pediatric Anesthesia Services, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.

References

1. Dueck R, Prutow R, Richman D: Effect of parainfluenza infection on gas exchange and FRC response to anesthesia in sheep. Anesthesiology 199 1; 74: 1044-105 1.

2. DeSoto H, Paid R, Soliman IE, Hannallah RS: Changes in oxygen saturation following general anesthesia in children with upper respiratory infection: signs and symptoms undergoing otolaryngological procedures. Anesthesiology 1988; 68:276-279.

3. Hinkle, AJ: What wisdom is there in administering elective general anesthesia to children with active upper respiratory tract infection? Anesth Analg 1989; 68:414-415.

4. Wald ER, Guerra N, Byers C: Upper respiratory tract infections in young children: duration of and frequency of complications. Pediatrics 1991; 87:129-133.