July FY24

[kristenhorsman]

To kick off the new FY24, Aileen Mendez chose an article about about pediatric patients with URI symptoms undergoing anesthesia and surgery.

Use this link and answer the following two questions:

1. What criteria do you use for proceeding with or cancelling a patient ( adult or pediatric ) for surgery who has a URI? Include patient's URI s/s or type of surgical procedure. 
2. What types of Intraop or post op problems have you encountered when proceeding with anesthesia on a patient with URI?

[sjsimmons]

1. According to Hines (2018), purulent nasal drainage, fever > 38.0, lethargy, persistent cough, poor appetite, wheezing or rales that do not clear with coughing, and children < 1 years old or previous preemie are good reasons to cancel a case. These symptoms are consistent with the URI questionnaire described in the discussion article. If we must proceed with anesthesia, it is best to avoid mechanical irritation of the airway (facemask > LMA > ETT), use a smaller ETT, administer dexamethasone, ensure a deep plane of anesthesia (sevo > des & iso due to pungent odor), and pretreat with an inhaled bronchodilator.

2. Although I have not personally experienced intraoperative or postoperative complications after proceeding with anesthesia for a patient with URI, I understand it puts the patient at an increased risk of pulmonary complications, such as increased airway reactivity (bronchospasm, laryngospasm), mucous plugging, atelectasis, desaturation events, and postoperative hypoxemia.

[kels]

Years ago I has a young adult patient that had travelled from another counrty just to have a surgery at Hopkins. The surgey was not a " major " surgery but it did require GA . On exam she had modertate wheezing after she had a URI weeks ago. The attending at the time basically had a discussion with the pt and the surgeron in preo op at the same time about the risks of proceeding .Since the pt had traveled from so far the attending was willing to proceed if both the surgery team and pt understood the aditional risks . Both the patient and surgeon made the decision to delay the case .

I have not done anethesia on pts with know URIs . There have been pts that "recovered" from URIs and on emergence there is a lot of coughing with thick mucus on the end of the ETT after extuabtion .

[aileenm4]

1. as you can imagine, we have a lot of pediatric patients coming in with cold symptoms, had colds recently etc. if we went with text book answer of waiting 4-6 weeks after every cold: we would never get any cases done since children have exposure in day care, from siblings etc. so we use symptom free for 2 weeks as a good rule, however, we often push through as long as s/s are mild such as clear runny nose, no fever, eating and playing as normal and clear lungs. it also depends on which cases are being done as airway cases are most irritating or if the child has mod to severe baseline pulm diseases
2. we often do these peds patients with mild cold s/s or who had recent URIs and it can be very dicey, coughing, secretions, wheezing, desaturations and irritation with intubation and extubation is common. we suction, use albuerol, sometimes magnesium, and even epi in small doses to bronchodilate are needed.

[Anne McNulty]

1.I have done peds in the past. I can recall assembly line myringotomies. Many of these children had chronic URI symptoms. Febrile pts. were cancelled. An IV was not started!! The myringotomy was performed with the patient deep with Sevo. An oral airway was always used. The PACU nurses were excellent. The face mask was humidified. This was not at JHU. I was alone without an ASA! There were no complications. This article used a protocol that maintained anesthesia with SEVO or Desflurane on peds pts with URI's. I would never use Desflurane on an adult or child with a URI. I do recall prior to the development of sugammadex, reversal with neostigmine was always a consideration in a peds or adult pt with a URI. Now we have a better reversal choice. The severity of the URI symptoms needs to be evaluated carefully. Patients do not always answer honestly. (2) I have given pre-op and intra-op inhaled bronchodilators. I have used inhaled steroids pre and post-op. (the patient had this in their possession.) I have given intra-op Decadron, and glycopyrrolate. When the chest congestion causes peak airway pressure to rise , 10 micrograms of EPI is very helpful with bronchodilation. It is always a challenge, child or adult.

[Amy Swank]

Haven't done pediatric cases in a while, so haven't had the conundrum as described above from Aileen with all the cold symptoms and deciphering out the valid risks but proceeding anyway with caution.
With regards to the adult ambulatory patients that I do anesthetize, if they have witnessed coughing, coughing with production of secretions, fever, breath sounds that aren't clear bilaterally, that's usually my threshold for elective surgery to be rescheduled. Tough call if it's of an urgent nature with cancer or cases that present urgently.
I always enjoy reading the Anne McNulty posts and remembering those cases as well.

[Benjamin Waldbaum]

1.) In order to proceed I want to know that they have no history of pulmonary hypertension or RV failure, clear breath sounds, resumption of baseline activity level, absolutely clearly breath sounds and no sputum production. I also want to know how severe the URI, how long it lasted, and what were the symptoms. What I am trying to get at is that a lot of clinical assessment is warranted to ensure the correct decision is made.

2.)Well, recently I actually had a patient death with someone who was 2 weeks post URI. I also had a patient with COVID who died 5 days post op 4 weeks after COVID infection. More commonly I have seen hypoxia. So this is not benign stuff and much caution is warranted