2024 FSA Podium and Poster Abstracts
P036: TO CANCEL OR NOT TO CANCEL, THAT IS THE QUESTION- A CASE OF A TODDLER WITH A RECENT URI PRESENTING FOR ELECTIVE SURGERY
Omowonuola Ogundele1; Titilopemi Aina-Jones, MD, MPH, FASA2; 1University of Florida College of Medicine; 2Texas Children's Hospital/Baylor College of Medicine
Introduction: Recent or current upper respiratory tract infection (URI) in a pediatric patient is associated with up to seven-fold increased risk of perioperative respiratory adverse events (PRAEs)(1,2) including bronchospasm, laryngospasm, oxygen desaturation <95%, airway obstruction or stridor(3,4). PRAEs often occur without sequalae but are associated with increased hospital length of stay(5) and can contribute to more serious events; Bhananker et al report PRAEs to account for 27% of causes of cardiac arrest in anesthetized pediatric patients(6).
Methods: Report of case
Case Description: A 17-month-old male with congenital bilateral ptosis, no other medical history and no prior surgery or anesthesia presented for blepharoptosis repair. During the preoperative evaluation, the parents reported that he experienced URI symptoms within the last 2 weeks. He had a fever for 2 days and a cough which lasted 5 days. The cough initially subsided but recurred a week prior to presentation. He was currently asymptomatic. The anesthesiologist recommended case cancellation; however, the surgeon was adamant that the surgery must proceed as scheduled because the family drove over 6 hours to the hospital.
Discussion: Congenital blepharoptosis is defined as an abnormally low-lying upper eyelid on upward gaze and most commonly occurs due to poor function of the levator palpebrae superioris muscle(7). Although non-progressive, it is associated with impaired visual function and development of other conditions including astigmatism and amblyopia. For moderate ptosis, surgery is ideally delayed until after 6 months of age(8).
Tait et al(9) proposed a risk stratification algorithm for evaluating a child with recent URI (Figure 1). The patient should be evaluated for fever, dyspnea, productive cough, nasal congestion, lethargy and wheezing. Otherwise healthy, afebrile children with clear secretions may undergo surgery if their URI is noncomplicated and non-infectious(3,9,10). Regli et al(11) proposed a similar algorithm considering the severity of the symptoms when deciding which patients are appropriate for proceeding versus cancelation (Figure 2).
When proceeding with surgery, adjustments to intraoperative management may aid in optimizing patient outcomes. For example, a study comparing the use of laryngeal mask airway (LMA) and endotracheal tube (ETT) in children undergoing surgery with URI reported no bronchospasm in the LMA group and 12.2% incidence among the ETT group(12). Coughing, which may be a precursor of laryngospasm, was less severe during placement of the LMA than during placement of the ETT. For our patient, a 17-month-old in good health with no current URI symptoms, surgery proceeded as planned. He received albuterol nebulization prior to surgery and experienced no intraoperative or postoperative complications. He was routinely discharged and suffered no long-term sequalae.
Appropriate wait time for postponed surgeries is not agreed upon(11). A survey of anesthesiologists revealed that approximately 50% postponed surgery for 3 to 4 weeks following the resolution of URI symptoms and about 35% waited for 1 to 2 weeks(13). Other authors propose waiting a minimum of 2 weeks after signs of infection while some encourage waiting up to 6 weeks(9,10). The ultimate goal is to reduce the risk of perioperative respiratory adverse events (PRAEs).
Figure 1:
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Figure 2:
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