Week 6 - Child Upper Respiratory Infection Management

Question 1

What are the symptoms of an upper respiratory infection in a child?

Answer 1

Nasal Congestion
Rhinorrhea
Cough
Sore throat
Fever
Sneezing
Pain

Question 2

How are URIs diagnosed for a child?

Answer 2

Clinical: fever, dyspnea, cough, sputum, congestion, lethargy, wheezing

Lab Test (not practical): viral cultures, WBC, Ag test, PCR

Chest X-Ray: lags symptoms (only get if concerned about lower resp tract infection

Question 3

What are the anesthetic complications that can occur in a child with a URI?

Answer 3

Laryngospasm
Rapid desaturation with apnea
Bronchial hyperreactivity
Unplanned hospital/PICU admission

Question 4

How long does airway hyperractivity last in a child with URI? what are the mechanisms behind it?

Answer 4

Lasts up to 6 weeks – decrease airway conductance with stimulants

Mechanisms:

• vagal
• inflammatory mediators
• viral inhibition of neutral endopeptidase –> increased tachykinins –> increased constriction

Question 5

What should be considered when deciding on whether or not to cancel a case for a child with a URI?

Answer 5

• Afebrile vs Fever
• Nasal discharge characteristics
• Wheezing?
• URI recent or current?
• Dry vs productive cough
• Active or lethargic
• Age (>1 year or <1 year old)
• Around second hand smoke?

Question 6

When is the risk for respiratory complications the highest after a URI?

Answer 6

Highest 3 days after URI

*remain increased up to 4-6 weeks

Question 7

What is the recommended length to postpone a case due to an URI?

Answer 7

4-6 weeks

• most anesthesiologists wait 3-4 weeks
• 1-2 weeks after uncomplicated nasopharyngitis

Question 8

What can be done to prevent complications of a URI if the case cannot be cancelled?

Answer 8

• Decrease secretions
• Anticholinergics (atropine, glycopyrrolate)
• Avoid stimulation
• Hydration status
• Steroids with beta-agonist effective
• Bronchodilation – albuterol nebulizer
• Avoidance of airway manipulation
• Preference mask > LMA > ETT if surgery permits
• Adequate depth before airway manipulation
• Induction agent: sevo > iso > des

Question 9

How do you treat laryngospasm in a child with URI?

Answer 9

• Avoid risk factors
• Early recognition is very important *hypoxia doesn’t break it!
• Positive pressure ventilation (avoid gastric inflation)
• 100% FiO2
• Larson trigger point pressure (conversion of complete to partial laryngospasm)
• Drugs

Question 10

What drugs are used to treat laryngospasm?

Answer 10

• IV hypnotic agents preferred over volatile (1-2 mg/kg of propofol)
• Antimuscarinergic (atropine) – early admin to preserve cardiac output and ensure delivery of muscle relaxants
• Succinylcholine – sublingual > deltoid > gluteal IM injection site (must give atropine with admin)

Question 11

How do you treat bronchospasm in a child with URI?

Answer 11

• Early recognition
• 100% O2
• Removal of triggering stimulus (if possible)
• Positive pressure ventilation (high enough to overcome resistance of conducting airways, audible breath sounds – increase expiratory time to minimize alveolar trapping)

Question 12

What drugs are used to treat bronchospasm?

Answer 12

• IV agents superior to volatile agents in acute situation (faster, less stimulating)
• Ketamine (causes bronchodilation) > Propofol > Thiopental
• Lidocaine 1mg/kg IV
• Bronchodilators (once able to move some air): albuterol, low dose epinephrine

Question 13

How do you treat a mucus plug in a child with URI?

Answer 13

• Recognition is critical (increased PIP, decreased TV)
• Fiberoptic exploration
• Soft suction catheter
• Saline irrigation (controversial)
• Acetylcysteine (Mucomyst)