Delay or proceed? What to do when patient gets URI before undergoing anesthesia
Justin B.Long, M.D., FAAP
Focus on Subspecialties
Pediatricians commonly are the first call parents make when their child develops an
upper respiratory infection (URI) before a procedure requiring anesthesia due to concerns
that the procedure may need to be cancelled.
URIs are the most common cause of procedure cancellation among children due to the
increased risk for perioperative respiratory adverse events (PRAE). These events include
laryngospasm, bronchospasm, breath holding, desaturation and unexpected need for oxygen
supplementation postoperatively, which can lead to prolonged admission or unexpected
escalation in care, such as admission to the intensive care unit.
Historically, anesthesiologists have considered the period of increased risk for PRAE
in children with a recent URI to be up to six weeks after symptom resolution. However,
a large observational investigation suggests the period of increased risk generally
is limited to two weeks (von Ungern-Sternberg BS, et al. Lancet. 2010;376:773-783).
Risk factors for PRAE
Viral URIs are among the risk factors for PRAE. They are the most common infectious
ailment of childhood, with children under age 6 experiencing an average of one URI
per month during fall and winter.
No two URIs are the same, and some features of severe URI are especially concerning
preoperatively: fever, wet cough, thick or green nasal discharge, and malaise. Testing
for the infective virus is not done routinely in pediatric patients with URI. That
said, influenza or respiratory syncytial virus (RSV) may increase the risk of PRAE
compared to other viral infections, even when severe URI symptoms are not present
(Spaeder MC, et al. BMC Anesthesiol. 2011;11:16).
Suspicion of a bacterial cause of symptoms such as strep throat may prompt delay of
some procedures such as cardiac surgery or catheterization and orthopedic implants
due to the risk of bacteremia.
Additional preoperative risk factors for PRAE in the setting of ongoing or recent
URI include passive smoke exposure, history of reactive airway disease, history of
prematurity or parental concern that the child is unusually sick.
Risk of PRAE varies depending on the type of surgery or procedure being performed
as well as the anesthesia plan.
The risk of PRAE in children without ongoing or recent URI who are undergoing sedation
for nonsurgical procedures is 6.3%. Children with URI within two weeks, current URI
with clear secretions or current URI with thick secretions have a PRAE risk of 9.1%,
14.6% and 22.2%, respectively (Mallory MD, et al. Pediatrics. 2017;140:e20170009).
Among children having elective surgery, risk of PRAE in those without ongoing or recent
URI is 12% vs. 29% among those with URI less than two weeks prior to the procedure
and 25% among those with an ongoing URI (von Ungern-Sternberg BS, et al. Lancet. 2010;376:773-783).
Guidance for pediatricians
So how should a pediatrician counsel a family whose child has a URI before a planned
Recurrent URIs, the effect of rescheduling the procedure on the family, the relative
risk of proceeding vs. delaying the procedure, severity and cause of illness, and
the nature of the procedure all affect the decision to delay.
History and physical examination are all that are required for most patients with
generic URI symptoms. However, suspicion of strep throat, RSV or influenza may prompt
diagnostic testing. Additionally, reactive airway disease that manifests with a URI
may require intervention such as steroids or bronchodilators. While some clinicians
empirically prescribe steroids or antibiotics before a procedure to reduce the risk
of cancellation, this is not recommended.
Most children with perioperative URI can be anesthetized safely. However, it is optimal
for the pediatrician to collaborate with an anesthesiologist to determine whether
a patient can proceed with elective surgery. Most centers have on-call anesthesiology
resources or preoperative evaluation clinics that can answer questions prior to the
day of the procedure.
Dr. Long is a member of the AAP Section on Anesthesiology and Pain Medicine.