Upper Respiratory Tract Infection, Murmurs and the risk of General Anaesthesia in Children.

Transcription

1 Rural SIG June 2018 URTI Murmurs & Risk Upper Respiratory Tract Infection, Murmurs and the risk of General Anaesthesia in Children. Dr. Patrick T Farrell John Hunter Hospital Newcastle

2 Mortality Mortality 1:57,023 procedures 2.96 per million population per annum (ACT NT) There was no reported paediatric mortality Anaesthesia risk is now extremely low in patients who are fit and well (ASA 1-2)

3 Paediatric Mortality RCH 101,885 anaesthetics to 56,263 patients per 10, hr mortality. Highest incidence infants < 30 days old 10 anaesthetic related 1:10,188 All had pre-existing medical conditions of which 5 had Pulmonary Hypertension No deaths in children without comorbidities van der Griend A&A 2011

4 Morbidity French Paediatric Hospital ,165 Anaesthetics over 30 months 724 adverse events intraoperative (31:1000) 1105 adverse events in PACU (48:1000) Respiratory events represented 53% of all intraoperative events. They were more frequent in infants compared with older children, in ENT surgery compared with other surgery, in children in whom the trachea was intubated and in children with ASA status 3 5 compared with those with ASA score 1 or 2. Cardiac events accounted for 12.5% of intraoperative events and were mainly observed in children with ASA score 3 5. Cardiac arrest 3.5:10,000. Infants < 1yr 11:10,000 PONV 77% of all PACU events

5 Adverse events Age and ASA

6 Lancet Respir Med 2017; 5: participants and procedures analysed 5.2% incidence overall 30 day mortality 10:10,000 = 0.1 % none anaesthesia related laryngospasm bronchospasm pulmonary aspiration drug error anaphylaxis cardiovascular instability neurological damage perioperative cardiac arrest stridor at emergence

7 Incidence of severe critical events across 33 sites (%) Incidence of critical events: Respiratory 3.1% Cardiovascular 1.9% Large range of respiratory (0.4%-13.3%) and cardiac events (0.2%-6.7%) Overall about 1:20 cases Age 3.77 years (receiver operating characteristic analysis ROC) Physical condition ASA >2, handicap, prematurity, snoring, airway sensitivity Airway management, inhalation induction. Senior anaesthetists had 1% fewer critical respiratory events per year of experience. Type of health institution or providers.. no effect

8 PRAm Score Paediatric Risk Assessment Score Anesth Analg 2017;124:1514 9

9 Events per million opportunities Preventable hospital death Death from motor vehicle collision Death from general anaesthesia Death of a commercial airline passsenger All heads 20 consecutive coin tosses Acquiring HIV from a single blood transfusion Agency for healthcare research and quality

10 URTI Rhinorrhoea (66%) Nasal congestion (37%) Sneezing (29%) Productive cough (26%) Sore throat (8%) Fever (8%) Tait AR, Malviya S, Voepel-Lewis T, et al. Anesthesiology 2001; 95:

11 What are the risks of proceeding? Perioperative respiratory adverse events PRAE = laryngospasm, bronchospasm, desaturations, breath holding Regli A, Becke K, von Ungern-Sternberg Curr Opin Anesthesiol 2017, 30: Patients who developed laryngospasm were twice as likely to have had an URTI within 2 weeks. Schreiner et al Anesthesiology (3): Increased risk of oxygen desaturation.

12 BUT However in otherwise healthy children morbidity is minimal BUT There are rare case reports of death related to laryngeal spasm and viral myocarditis. Tait AR Malviya S. Anesth Analg 2005;100:59-65

13 Are there risks of not proceeding? Social and emotional burden to the parents and carers. Economic cost to parents and the health system; lost work, wasted time on list. Car trip to the hospital Airway hyperactivity increased for 2 weeks with 6-8 URTI / year, may not be well in a months time Tait AR, Voepel-Lewis T, Munro HM, et al. J Clin Anesth 1997;9:213 9.

14 Features where cancellation is advised Malaise Is it something else? chicken pox Fever > 38 C However, the implications of our findings are that measurements taken with infrared ear thermometry cannot be used as an approximation of rectal temperature, even when the device is used in rectal mode. How accurate is temperature measurement? Axillary, rectal, mercury, infrared.. Infrared ear thermometry compared with rectal thermometry in children: a systematic review Lancet : 603-9

15 Cancellation Advised Wheezing ± coarse crackles Any signs in the chest as this is Asthma or a lower respiratory track infection Age < 1yr ± ex premature infant Age < 3? Higher risk elective surgery Risk decreases 11% per year

16 Lancet 2010;376:773-83

17 A positive respiratory history nocturnal dry cough, wheezing during exercise, wheezing more than three times in the past 12 months, or a history of present or past eczema was associated with an increased risk for bronchospasm RR 8 46, 95% CI ;p< laryngospasm RR 4 13, ; p< perioperative cough desaturation airway obstruction RR 3 05, ; p< URTI Associated with an increased risk for perioperative respiratory adverse events only when symptoms were present RR 2 05, 95% CI ; p< or less than 2 weeks before the procedure RR 2 34, ; p< Laryngospasm RR 4.03

18 Parental smoking Laryngospasm RR 3.01 Cough, desaturation obstruction RR 1.95 Bronchospasm RR 2.6 Parents belief that their child had a cold The child snores Passive smoking Nasal congestion or a moist cough Parnis S Barker D van der Walt J. Paed.Anaesth. 2001; 11:29-40

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20 Anaesthetic predictors of increased risk of adverse respiratory event. Staff Registrar v Consultant RR 1.61 Premedication with midazolam RR 1.83 Myorelaxants used RR 1.47 Airway device (best to worse) Face mask > LMA > Cuffed ETT > Uncuffed ETT > three attempts RR 4.25 Maintenance Propofol > Isoflurane > Sevoflurane >> Desflurane

21 Regli A, Becke K, von Ungern-Sternberg Curr Opin Anesthesiol 2017, 30:

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23 Heart Murmur: Innocent or not?

24 Heart Murmur A 2 year old presents to day stay for excision of branchial cyst to take 90 minutes. An aunt may have a heart murmur. On examination the child is well but you hear a hear murmur at the left sternal border. How will you decide what it is and whether or not it is pathological? Should you proceed with surgery? Is antibiotic prophylaxis necessary? Cyanosis always pathological!

25 Normal murmurs in children Venous hum Continuous Pulmonary flow murmur Neonatal pulmonary artery flow Precordial vibratory or stills murmur Supraclavicular systemic flow murmurs All midsystolic

26 Location of innocent murmurs 1. Venous hum 2. Pulmonary flow 3. Neonatal peripheral pulmonary flow 4. Precordial vibratory 1. Still s murmur 5. Supraclavicular systemic flow Spain SO Pediatrics 1997; 99:

27 Feature of innocent versus pathological murmurs

28 Cardinal clinical signs to differentiate heart murmurs in children Pan systolic Intensity grade 3 = immediately audible Maximum intensity at upper left sternal border. Harsh quality Click or abnormal second heart sound McCrindle et al Arch Pediatr Adolesc Med 1996 Vol 150: Diastolic murmurs Intensity with patient standing McConnell et al Am Fam Physician 1999; 60(2):

29 Murmur discovered pre operatively Venous hum Soft early to mid systolic no thrill NO = Any other murmur Post pone surgery and refer for investigation NO YES Asymptomatic Age greater than 1year Proceed with surgery Antibiotics if indicated Refer for investigation post op McEwan A Paediatric Anaesthesia 1995;5 : YES YES ECG normal? Ventricular hypertrophy

30 ECG criteria ventricular Hypertrophy STD 5mm=0.5mV RVH 1-5 years 5-12 years R wave amp. V > 1.75 mv > 1.25mV R/S ratio in V1 >3mV >2mV Upright T wave in V1 a sign RVH in first 5 years LVH 1-5 years 5-12years R V6+ SV1 >4.0mV >4.55mV RV5 >3.5mV > 3.75mV Q waves in V5 or V6 > 4mV a sign of LVH Bi VH >1 year R+S in V4 >5mV

31 Antibiotic Prophylaxis for Endocarditis Who requires prophylaxis? Patients with structural cardiac defects. Unrepaired cyanotic CHD. CHD repairs with, prosthetic materials and or valves, previous endocarditis or RhHD For what procedures? Any procedure where bacteremia is possible, major dental, respiratory tract, infected area, surgical prophylaxis. Ts As What drugs should you use/when? Amoxycillin ± Gentamicin Clindamycin, Vancomycin if penicillin allergy

32 Nobby's & Newcastle Harbour & thenac