Evidence Based Strategies: Timing of Elective Surgical Procedures in Children with Upper Respiratory Infections

Children experience on average three to six upper respiratory tract infections (URIs) per year, mostly in the fall and winter.¹ As a result, many pediatric patients scheduled for anesthesia or sedation currently have or recently had a URI. Frequently, general practitioners are the first people approached by families about whether an upcoming procedure needs to be postponed, and URIs remain the most common causes of procedure cancellation. This is related to the risk of perioperative respiratory adverse events (PRAEs) due to the hyperreactivity of the pulmonary system. PRAEs include breath holding, desaturation, bronchospasm, laryngospasm and need for supplemental oxygen that may require an unplanned admission or an escalation in the level of care. These risks must be balanced against urgency and the type of procedure, severity and duration of symptoms, and the patient’s other comorbidities.

When these patients present to a clinic, a thorough history and physical exam is typically sufficient to determine whether it is appropriate to proceed or delay. Viral testing is not typically indicated as the decision to proceed is based on symptoms, patient comorbidities, surgical procedure and type of anesthetic planned. In addition, viral PCR results can remain positive for several weeks after testing. Symptoms of a URI that are especially concerning perioperatively include a fever, wet cough, thick or green nasal drainage, and overall malaise. A study of 83,491 patients showed the risk of PRAE in patients with a recent URI or current URI is 9.1%-14.6% with clear secretions and 22.2% with thick secretions, compared with 6.3% for their healthy counterparts.² The risks of PRAE decrease as symptom resolution time increases. Some studies have shown increased airway reactivity up to four weeks after resolution of URI,^3,4 while some show no increase in adverse effects after two weeks.^5,6 Additional patient risk factors include passive smoke exposure, a personal history of reactive airway disease or prematurity, or parent perception that the child is unusually sick. Certain surgical procedures, particularly those involving the airway, as well as the anesthetic plan such as the need for endotracheal intubation, further increase the overall level of risk. The “COLDS” (Current symptoms, Onset, Lung disease, airway Device, Surgery) score is a helpful mnemonic to remember the risk factors for increased anesthesia-related respiratory complications.⁷

So how should you counsel the family? Frequently, most children with URIs can be safely anesthetized, especially those with mild symptoms. If surgery does need to be postponed, it should be scheduled no less than two weeks from symptom resolution. However, it is important to note that there may be an increased benefit waiting until four weeks after symptom resolution. This is particularly true for patients at high risk for respiratory complications due to their medical complexity or type of surgery. These guidelines are the same for children with COVID-19 infections. Some procedures, such as orthopedic hardware implants, may need to be canceled if a bacterial cause is suspected. If the patient presents to the office wheezing in conjunction with their URI, optimization with bronchodilators is helpful, especially when the case is urgent. Occasionally, some clinicians will empirically start the patient on steroids or antibiotics to decrease the risk of cancellation, but this is not recommended unless there is a clinical indication. When in doubt, it is best to collaborate with an anesthesiologist, and most centers have on-call resources or a pre-admission testing clinic to help with questions.

References:

1. Teoh Z, Conrey S, McNeal M, et al. Burden of respiratory viruses in children less than 2 years old in a community-based longitudinal US birth cohort. Clin Infect Dis. 2023;77(6):901-909. doi:10.1093/cid/ciad289
2. Mallory MD, Travers C, McCracken CE, Hertzog J, Cravero JP. Upper respiratory infections and airway adverse events in pediatric procedural sedation. Pediatrics. 2017;140(1):e20170009. doi:10.1542/peds.2017-0009
3. Tait AR, Malviya S, Voepel-Lewis T, Munro HM, Seiwert M, Pandit UA. Risk factors for perioperative adverse respiratory events in children with upper respiratory tract infections. Anesthesiology. 2001;95(2):299-306. doi:10.1097/00000542-200108000-000084.
4. Parnis SJ, Barker DS, Van Der Walt JH. Clinical predictors of anaesthetic complications in children with respiratory tract infections. Paediatr Anaesth. 2001;11(1):29-40. doi:10.1046/j.1460-9592.2001.00607.x
5. Bordet F, Allaouchiche B, Lansiaux S, et al. Risk factors for airway complications during general anaesthesia in paediatric patients. Paediatr Anaesth. 2002;12(9):762-769. doi:10.1046/j.1460-9592.2002.00987.x
6. von Ungern-Sternberg BS, Boda K, Chambers NA, et al. Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study. Lancet. 2010;376(9743):773-783. doi:10.1016/S0140-6736(10)61193-2
7. Lee LK, Bernardo MKL, Grogan TR, Elashoff DA, Ren WHP. Perioperative respiratory adverse event risk assessment in children with upper respiratory tract infection: Validation of the COLDS score. Paediatr Anaesth. 2018;28(11):1007-1014. doi:10.1111/pan.13491