The Child with an Upper Respiratory Tract Infection
The anesthetic implications of an upper respiratory tract infection
(URI) in a child can be quite important and are a major concern for the anesthesiologist.
Unfortunately, the data regarding URIs and the anesthetic implications are difficult
to place in perspective because the complications are not particularly common and
the definitions of what a URI consists of have varied from study to study. The decision
regarding whether to proceed with surgery and anesthesia is dependent on a number
of factors. The URI may represent a prodrome of a much more serious illness, or
it may simply be the usual viral infection so common in children, particularly in
the wintertime.[247]
It is likely that a child
with a URI has an irritable airway and is at increased risk for laryngospasm, bronchospasm,
postintubation croup, atelectasis, pneumonia, and episodes of desaturation.[248]
[249]
[250]
[251]
[252]
Several studies have found an increased incidence
of airway-related problems in children
who are passively exposed to tobacco smoke.[253]
[254]
[255]
These
complications can be reduced by avoiding endotracheal intubation or the use of an
laryngeal mask airway (LMA).[256]
Because bronchial
hyperreactivity may last for up to 6 weeks after a URI, cancellation will make a
difference only if surgery is delayed for this period.[249]
It is also known that the incidence of airway-associated complications in children
who are recovering from a URI is virtually the same.[252]
[253]
The approach that I take with these patients
is rather commonsense. If the child is acutely ill and obviously getting worse,
the operation is canceled. If the child has rhonchi and a productive cough, the
operation is canceled. If the child is stable, afebrile, and has had the URI for
several days, I usually proceed. My main concern is for children who are going to
have a very long procedure and children who will be admitted to the hospital postoperatively,
which may in turn result in exposure of hospitalized children who may be immunocompromised.
When faced with this dilemma in a child who will be going home postoperatively,
I inform the family and the surgeon of the increased risks, and they generally end
up making the decision. It is my feeling that we have the tools to deal with the
reasonably common complications. We have oxygen to treat hypoxemia, we have albuterol
and inhaled anesthetics to treat bronchospasm, we have muscle relaxants to treat
laryngospasm, and we can usually find a way to avoid intubation for simple procedures.
[257]
Cancellation of a case at the last minute
is unfair to the family and upsets the operating room schedule.[258]
On the other hand, one should not place the patient at risk merely for economic
or social concerns. The best way of avoiding last-minute cancellations is a phone
call by nursing staff the day before to inquire about the child's health. If the
child has a URI, the anesthesiologist can call the family and take a history to determine
how best to proceed. In this way wasted trips to the hospital are avoided and the
father or mother or both do not take a day off from work unnecessarily. Physicians
are really left to their own best clinical judgment for the individual patient on
a particular day undergoing a specific procedure. If the decision is made to proceed,
it is helpful to write a note in the chart documenting the discussion.
