Review of unusual patient care experiences is a cornerstone of medical education. Each month, the AQI-AIRS Steering Committee abstracts a patient history submitted to the Anesthesia Incident Reporting System (AIRS) and authors a discussion of the safety and human factors challenges involved. Real-life case histories often include multiple clinical decisions, only some of which can be discussed in the space available. Absence of commentary should not be construed as agreement with the clinical decisions described. Feedback regarding this article can be sent by email to firstname.lastname@example.org. Report incidents or download the AIRS mobile app at www.aqiairs.org.
Case 2019-11: Another URI Dilemma
A three-year-old male with a background of 32-week prematurity presented for scheduled circumcision. A resolving URI had started three weeks ago and had been treated with antibiotics. He received preoperative midazolam for anxiety and nebulized albuterol. He was calm on arrival in the O.R. and an inhalational induction with oxygen, nitrous oxide and sevoflurane was performed. A dental rotator was granted a last-minute request to manage the airway during induction. Despite PEEP and increased jaw thrust, airway obstruction developed, and the patient vomited milky fluid. Intramuscular succinylcholine and atropine were administered, and the trachea was intubated. ETT suction yielded no secretions and an orogastric tube was placed to empty the stomach. Nasal suction produced copious green secretions. A planned caudal was deferred in favor of a surgically administered penile block. The patient was extubated awake at the end of the case with no further sequelae. During debrief, the parent endorsed that she regularly observes signs of sleep disordered breathing in her son.
Anesthesia for the child with upper respiratory tract infection (URI) remains a hotly debated topic in pediatric practice. This practitioner faced two common dilemmas – whether to proceed when faced with a child presenting with a history of recent URI and additional risk factors, and how best to balance the learning experience of trainees while maintaining patient safety.
Children experience up to eight URIs per year1 and between one quarter to almost half of pediatric patients presenting for elective surgery will have a history of a recent URI.2 It may, therefore, be unsurprising that URI is the most common cause of surgery cancellation in children.3 In a similar mechanism to asthma, airway inflammation from URI can lead to increased secretions, airway susceptibility, and bronchial hyperreactivity, therefore increasing the risk of Perioperative Respiratory Adverse Events (PRAE).4 Approximately 15 percent of all children undergoing anesthesia will experience at least one PRAE2 and around three percent will experience a critical respiratory event, defined as a PRAE that led or could have led to major disability or death.5
Traditional conservative policy has been to delay surgery by four to six weeks following a URI. In children suffering eight URIs per year, this makes it very difficult to find a time when the child can be given the all clear. Recurrent cancellations can lead to a large burden on patients and their families in terms of inconvenience, travel time and distance, wait time, time off work and school, emotional impact and arrangements for care of siblings. For the institution it leads to a loss of output, waste of resources and delay for other patients awaiting surgery.
Conversely, PRAEs are associated with an increased need for unplanned hospital admission or prolonged length of stay, higher health care costs and adverse impact on patient and family.6 Although there is a demonstrable increase in risk of PRAE with current or recent URI, the actual chance of long term harm is very small.7 The window of increased risk for PRAE begins when symptoms present and continues until two weeks after resolution.2 A summary of risk factors can be found in Table 1. Of note for the patient in this case report, they include history of prematurity and reactive airway disease.8
To assist the anesthetic practitioner in assessing these risk factors, Lee et. al. have created a simple risk score, COLDS, but this is as yet unvalidated.9 Another option to assist decision making is a simple evidence-based algorithm, as shown in Figure 1. As can be seen from Figure 1, anesthesia can frequently proceed in the average child with a cold in the absence of other risk factors and with adequate experience in dealing with the issues that might arise.
If deciding to proceed, considerations in the anesthesia strategy begin with choice of premedication. Although minimizing secretions and congestion from crying is essential, two studies have found an association between benzodiazepine premedicants and increased PRAE in children with URI2,10 so an alternate agent, such as clonidine, may be preferable. A preoperative beta agonist inhaled 10-30 minutes before induction has been demonstrated to reduce overall PRAE in children with current and recent URI.11
The arrival of a calm child to the O.R. may open the option of using an intravenous induction technique. Although volatile anesthetic agents have excellent bronchodilatory properties, they have limited effects in suppressing airway reflexes.12 In addition, an adult study showed that when nitrous oxide was added to sevoflurane, an inflammatory response was induced and the anti-inflammatory response was suppressed in the local milieu of the airway.13 Children with at least two risk factors who receive intravenous propofol as their induction agent are significantly less likely to experience PRAE when compared with those who received inhalational sevoflurane when a laryngeal mask airway (LMA) is used. This is due to the superior suppression of laryngeal reflexes when propofol is used. The difference may be even greater with the increase in mechanical stimulation of the airway with an endotracheal tube (ETT). This increased risk of PRAE from inhalational induction does not appear to reduce after the addition of a propofol bolus.14 Interestingly, a recent systematic review also found that ETT use during anesthesia demonstrated no difference in incidence of laryngospasm or arterial oxygen desaturation in children with a URI when compared with LMA, although the authors acknowledged that the quality of evidence available was poor.15 In this particular case, the ETT was the only appropriate choice to quickly gain full control of the deteriorating situation.
A further risk factor for PRAE is the experience and competence of the anesthesiologist. Years of experience in pediatric anesthesia of the most senior team member has a demonstrated beneficial effect on incidence of perioperative severe critical events.5 Conversely, multiple attempts at airway manipulation by less experienced staff have been shown to increase the incidence of PRAE.2 This may suggest that although there is an increase in PRAE from trainee airway management, if an experienced anesthesiologist is present in the team, this increase may not lead to significant patient harm. It is the trainer’s duty to preemptively ensure that they are confident in the trainee’s ability to manage the situation and, in the presence of additional risk factors, to lower their threshold for direct intervention should patient safety become threatened.
The value of debrief involving a parent after significant intraoperative events is clear in this case, as it uncovered an additional risk factor that may influence clinical decision-making. Sleep disordered breathing (SDB) carries a prevalence of 12 percent in the pediatric population and significantly increases a patient’s risk of intraoperative airway obstruction, laryngospasm and oxygen desaturation.16 This can lead to prolonged recovery time and a two-fold increased risk of PRAE.17 Unfocussed patient/parent history and physical examination are unreliable in detecting those at risk.18 An alternative is STBUR, a simple pre-operative questionnaire that can be used to help to predict children with SDB who are at increased risk of prolonged recovery, oxygen therapy requirement and escalation of care.17,19,20 Once a patient is identified as having SDB, the gold standard for obstructive sleep apnea diagnosis in children remains in-laboratory polysomnography.16 In this case, preoperative investigation was not possible. SDB adds an additional risk of need for escalation of care and postoperative short-term oxygen therapy and therefore, the clinician should strongly consider inpatient admission for overnight pulse oximetry.
Finally, it should be noted that an awareness of the effect of a stressful patient emergency on the attending anesthesiologist and their ability to focus on subsequent tasks may necessitate revision of the perioperative plan. In this case, to the credit of the reporter, the provision of regional anesthesia was handed to the surgeon, who performed a penile block.
We appreciate the submission of our colleague and thank them for allowing us this opportunity to examine the ongoing dilemma in managing the pediatric patient with a current or recent URI. The fine balance of judgement between risk and benefit required in deciding whether to proceed with the case depends on multiple patient factors and carries both family and organizational pressures.