The relation between upper respiratory tract infection and mild hypoxemia during general anesthesia in children]

Anesthesiologists often face the problem of a child with symptoms of an acute upper respiratory infection (URI) presenting for surgery. Anesthesia in the presence of uncomplicated URI may not be contraindicated. However, we experienced three cases of such children in which lung atelectasis developed after the induction of general anesthesia. Because continuous monitoring of arterial oxygen saturation by pulse oximetry (SpO2) was useful for detecting mild hypoxemia in these patients, we retrospectively examined the possible association between URI symptoms and SpO2 in 63 children. Patients with symptoms of URI showed a significantly high incidence of decreased SpO2 to below 95% for 5 minutes. Our results suggest that, with URI symptoms even uncomplicated, symptomatic patients have increased risks for the development of mild hypoxemia during anesthesia.     

上呼吸道感染小儿的麻醉处理

背景 上呼吸道感染（upper respiratory tract infections,URIs）常见于小儿,大多由病毒感染所引起.URIs小儿手术进行麻醉时,呼吸不良事件发生率增加,麻醉风险增高,择期手术是否应该取消或应该推迟多久,一直是麻醉医师比较难以抉择的问题. 目的 综述近几年URIs小儿麻醉的研究文献,为麻醉医师的临床工作提供理论参考. 内容 阐述了小儿URIs的病理生理学机制、围术期呼吸不良事件的危险因素、术前评估、麻醉管理以及常见不良事件的预防和处理. 趋向 随着小儿手术日益增多,URI小儿的择期手术时机,需要根据具体情况做出抉择.     

Upper respiratory tract infections and general anaesthesia in children

Conflicting reports regarding the hazards of anaesthesia in children presenting for surgery with an upper respiratory tract infection have appeared in the literature. In the present study 130 children undergoing general anaesthesia with face mask for myringotomy and grommet insertion were graded as having either an acute or recent upper respiratory tract infection or were asymptomatic according to predetermined clinical symptoms and signs. The severity of respiratory and related complications were scored during induction, emergence and recovery. The peripheral oxygen saturation was recorded during induction, emergence, transfer to the recovery ward and in the recovery ward itself. There were no significant differences (p greater than 0.05) in the complication scores between the three groups of children. However, the incidence of hypoxaemia (oxygen saturation less than or equal to 93%) was significantly greater during transfer in the acute infection group (p = 0.001) and the recent infection group (p = 0.02), as well as during recovery in the acute group (p = 0.03) compared with asymptomatic children.     

Frequency and severity of desaturation events during general anesthesia in children with and without upper respiratory infections.

STUDY OBJECTIVE: To determine whether anesthesia in the presence of a mild upper respiratory infection (URI) was associated with episodes of desaturation or reactive airway problems. DESIGN: A prospective study. SETTING: Inpatient and outpatient units of a university medical center. PATIENTS: Four hundred two pediatric patients. INTERVENTIONS: Patients were monitored with continuous recordings of oxygen saturation (SpO2), capnography, and electrocardiogram. A separate anesthesiologist was present throughout each case to observe for complications and interview the anesthesia team. The decision to anesthetize patients with a URI was left to the discretion of the anesthesia team. MEASUREMENTS AND MAIN RESULTS: Thirty patients with a URI and 372 patients without one were studied. One hundred ninety-six patients were managed with endotracheal intubation and 206 with face mask; 15 in each group had a URI. There was no increase in major desaturation events (SpO2 of 85% or less for 30 or more seconds) but minor desaturation events (SpO2 of 95% or less for 60 or more seconds) were increased (p = 0.02). There was no increased frequency of laryngospasm (1 in 30 vs. 22 in 372), but there was a higher frequency of bronchospasm in intubated patients (2 in 15 vs. 1 in 181; p = 0.016). CONCLUSIONS: Children with a mild URI have an increased frequency of minor desaturation episodes, and intubated patients with a URI have an increased frequency of bronchospasm. It appears that children with a mild URI may be safely anesthetized, since the problems encountered are generally easily treated and without long-term sequelae.     

Risk factors for perioperative adverse respiratory events in children with upper respiratory tract infections

BACKGROUND: Anesthesia for the child who presents for surgery with an upper respiratory infection (URI) presents a challenge for the anesthesiologist. The Current prospective study was designed to determine the incidence of and risk factors for adverse respiratory events in children with URTs undergoing elective surgical procedures. METHODS: The study population included 1,078 children aged 1 month to 18 yr who presented for an elective surgical procedure. Parents were given a short questionnaire detailing their child's demographics, medical history, and presence of any symptoms of a URT. Data regarding the incidence and severity of perioperative respiratory events were collected prospectively. Adverse respiratory events (any episode of laryngospasm, bronchospasm, breath holding > 15 s, oxygen saturation < 90%, or severe cough) were recorded. In addition, parents were contacted 1 and 7 days after surgery to determine the child's postoperative course. RESULTS: There were no differences between children with active URIs, recent URIs (within 4 weeks), and asymptomatic children with respect to the incidences of laryngospasm and bronchospasm. However, children with active and recent URIs had significantly more episodes of breath holding, major desaturation (oxygen saturation < 90%) events, and a greater incidence of overall adverse respiratory events than children with no URIs. Independent risk factors for adverse respiratory events in children with active URIs included use of an endotracheal tube (< 5 yr of age), history of prematurity, history of reactive airway disease, paternal smoking, surgery involving the airway, the presence of copious secretions, and nasal congestion. Although children with URIs had a greater incidence of adverse respiratory events, none were associated with any long-term adverse sequelae. CONCLUSIONS: The current study identified several risk factors for perioperative adverse respiratory events in children with lulls. Although children with acute and recent URIs are at greater risk for respiratory complications, these results suggest that most of these children can undergo elective procedures without significant increase in adverse anesthetic outcomes.     

Upper respiratory tract infections and pediatric anesthesia

Anesthesia for the child with an upper respiratory infection (URI) presents a challenge for the pediatric anesthesiologist. Differences in study design have made interpretation and comparison very difficult. The general lack of evidence-based research has led to disparities in the manner in which children which URI have been traditionally managed. Many studies have described associations between URIs and adverse events and we must decide whether to proceed or postpone the procedure and how long to postpone it. More recent research, however, suggests that children with uncomplicated infections can undergo elective procedures without significant increase in adverse anesthetic outcomes. This presentation summarizes the evolving literature about cancellation of surgery for the child with an upper respiratory infection, perioperative outcomes and anesthetic management.     

Anaesthesia in children with viral respiratory tract infections

The effects and consequences of anaesthesia in a child with a respiratory tract infection (RTI) are controversial. There is a high incidence of viral RTI in children presenting for surgery and anaesthesia. The social and economic impact of postponing the procedure is significant; for the child, family and institution. The clinical effects of the common cold are well known, affecting the respiratory tract from the nose down to the small airways and lung parenchyma. The systemic effects of the toxic viraemic phase are also well recognized but not so the potential risk of a viral myocarditis. There is an increased incidence of intra- and postoperative respiratory related complications up to six weeks after a RTI. These include airway obstruction, laryngeal spasm, vagally mediated reflex bronchoconstriction, increased bronchial secretions, desaturation, atelectasis and postoperative respiratory complications. Children with symptoms of a moderate to severe RTI presenting for elective surgery should be postponed for six weeks. Emergency surgery should proceed with a mask anaesthetic for minor surgery or by adopting a modified rapid sequence induction (atropine but no cricoid pressure) to gain rapid control of the airway to avoid laryngeal spasm and vagally mediated reflex bronchoconstriction; IPPV, awake extubation, postoperative monitoring of respiratory function and appropriate analgesia.     

Topical lidocaine reduces the risk of perioperative airway complications in children with upper respiratory tract infections

Purpose

To determine the effect of topically applied lidocaine on perioperative airway complications when using a laryngeal mask airway device (LMAD) in children either with or without a history of recent or ongoing upper respiratory tract infection (URI).

Methods

In a randomized controlled double-blind trial, 34 children with a history of recent or ongoing URI and 32 non-URI children— all of whom were younger than age ten and scheduled to undergo minor surgical procedures—were randomly assigned to either a lidocaine or a placebo group. In the lidocaine group, an LMAD was lubricated with lidocaine gel before insertion, and a clear lubricating gel was used in the placebo group. The following data were recorded after standardized anesthesia induction and airway management: postoperative complications, such as coughing, desaturation, laryngospasm, and increased oral secretions, as well as length of stay in the postanesthetic recovery unit.

Results

Children with URI had a lower overall perioperative complication rate if they received a lidocaine gel (35%) rather than placebo (94%) (P < 0.01). Also, the incidence of postoperative coughing was less (12% vs 53%; P = 0.03). In non-URI patients, lidocaine did not significantly reduce the rate of airway complications compared with placebo (17% vs 24%, respectively).

Conclusion

Lubrication of the LMAD with lidocaine gel reduces the incidence of airway complications in children with an upper respiratory tract infection.     

Psychological effects of repeated general anesthesia in children

BACKGROUND: Although methods for reducing preoperative anxiety have been a major interest of pediatric anesthesiologists, there are no reports of the effects of repeated anesthesia on psychological development of children. METHODS: To determine the overall effect of multiple anesthetics on the psychology of children, we undertook to compare the children undergoing repeated anesthesia (Group S) for the treatment of corrosive esophagitis with a control group (Group C) with chronic renal disease and frequent hospital admissions. Psychological tests and diagnosis of children Group S (n = 23) were compared prospectively with Group C (n = 20). All children had been appropriately treated over the previous 5 years and 50% of patients in Group C had general anesthesia once and those in Group S underwent at least 5 GAs. Parents completed a child behavior checklist (CBCL) and Marital Conflict Questionnaire; the children were evaluated by a child psychiatrist using DSM-IV criteria and completed the Child Depression Inventory (CDI). RESULTS: The children in Group S underwent a total of 251 (11 +/- 7) GAs over 4-60 months. The incidence of psychopathology was nine and 10 children in groups S and C, respectively. The CBCL and CDI scores were parallel with a psychiatric diagnosis. Marital conflict scores were higher in Group S. CONCLUSIONS: Both chronic disease states affect psychology of children. Repeated anesthesia in addition to chronic disease does not seem to disturb the child's psychological health further when tentative and precautious approach modalities are undertaken.     

Glycopyrrolate does not reduce the incidence of perioperative adverse events in children with upper respiratory tract infections

Two recent studies have identified copious secretions as an independent risk factor for perioperative adverse events in children who present for elective surgery in the presence of an upper respiratory tract infection (URI). We designed this study, therefore, to determine whether the administration of the anticholinergic drug, glycopyrrolate, to children with URIs would reduce the incidence of adverse perioperative respiratory events. One hundred thirty children (1 mo to 18 yr of age) who presented for elective surgery with a URI were randomized to receive either 0.01 mg/kg glycopyrrolate or placebo and were followed for the appearance and severity of any perioperative respiratory adverse events. The two groups were similar with respect to demographics, presenting URI symptoms, anesthetic management, and surgical procedure. In the intention-to-treat analysis, there were no statistical differences in the incidence or severity of perioperative respiratory adverse events between the glycopyrrolate and placebo groups (45.2% vs 37.5% respectively, P = NS). Furthermore, there were no differences in outcome between the two groups when children with congestion and secretions were analyzed separately (45.0% vs 37.0%, respectively). However, compared with the placebo group, children in the glycopyrrolate group had significantly shorter discharge times (83.9 min vs 111.4 min, P = 0.024), and significantly less postoperative nausea and vomiting (10.7% vs 33.3%, P = 0.005). These results suggest that glycopyrrolate, administered after induction of anesthesia to children with URIs, does not reduce the incidence of perioperative respiratory adverse events, and thus may not be clinically indicated for routine use in this population.     

Pulmonary atelectasis during anesthesia in a boy with upper respiratory tract infection

A 6-year-old boy was scheduled for adenoidectomy and bilateral myringotomy. The main features of his case history were chronic otitis media, bronchial asthma and signs and symptoms of upper respiratory tract infection (persistent runny nose and cough, occasionally with fever). Immediately after tracheal intubation we observed that the right side of the chest failed to rise with inspiration; breathing sounds were absent on the right and hypoxemia developed. A chest film taken in the operating room revealed upper right lobe atelectasis. Surgery was postponed and tracheobronchial lavage was performed with fiberoptic bronchoscopy and aspiration of mucous plugs.Upper airway infections are a common problem in children and increase the risk of respiratory complications during anesthesia. Patients with upper respiratory tract symptoms present a dilemma, and consensus about how to deal with such situations is lacking.We review the literature, discuss the anesthetic implications of upper airway infections, and suggest a two-phase approach for cases such as we report: first myringotomy using general anesthesia and a face mask, and second, once the upper airway infection has resolved, adenoidectomy with general anesthesia and tracheal intubation.     

Effects of upper respiratory tract infections in patients with cystic fibrosis.

BACKGROUND: The polymerase chain reaction has improved the detection of picornaviruses and rhinoviruses and our understanding of their role in reversible airways disease. The effects of colds on lower respiratory morbidity and bacterial colonisation in cystic fibrosis remain uncertain. METHODS: Children with cystic fibrosis were evaluated regularly in the clinic and the parents notified the investigators when their child developed a cold. Nasopharyngeal specimens were collected at the start of the infection for polymerase chain reaction, bacteriology was also undertaken and again three weeks later, and pulmonary function was measured in children aged > or = 6 years at four day intervals for three weeks. The effects of colds on rate of progression of cystic fibrosis were assessed by pulmonary function, Shwachman scores, and radiology. RESULTS: Thirty eight children suffered 147 colds over 17 months. Picornaviruses were detected in 51 (43%) of 119 nasopharyngeal specimens, and 21 of the 51 were further identified as rhinoviruses. Pulmonary dysfunction was similar following picornavirus and non-picornavirus infections; the mean change from baseline in forced expiratory volume in one second (FEV1) was -16.5% and -10.3% at 1-4 days and 21-24 days, respectively, after onset of a cold. Children who experienced more colds than average had evidence of disease progression with reduction in Shwachman score, increasing Chrispin-Norman score, and greater deterioration in FEV1 per annum. Ten of 12 new bacterial infections were associated with a cold. CONCLUSIONS: Picornavirus and non-picornavirus colds are associated with pulmonary function abnormalities and disease progression in patients with cystic fibrosis, and predispose to secondary bacterial infection and colonisation.