URTI Murmurs & RiskUpper Respiratory Tract Infection, Murmurs and

the risk of General Anaesthesia in Children.

Rural SIG June 2018

Dr. Patrick T Farrell John Hunter Hospital Newcastle NSW@PTFazza

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)”

http://www.anzca.edu.au/documents/mortalityreport_2012-2014-high-res.pdf

Paediatric Mortality RCH

• 101,885 anaesthetics to 56,263 patients

• 2003-2008

• 13.4 per 10,000 24 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

MorbidityFrench Paediatric Hospital 2000-2

• 24,165 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

Adverse events Age and ASA

• 30874 participants and 31127 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

Lancet Respir Med 2017; 5: 412–25

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

PRAm ScorePaediatric Risk Assessment Score

Anesth Analg 2017;124:1514–9

0. 75. 150. 225.

208

187

7.5

2.4

1

0.7

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 http://webmm.ahrq.gov/

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; 95:299–306.

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, 30:362–367

• Patients who developed laryngospasm were twice as likely to have had an URTI within 2 weeks.

– Schreiner et al Anesthesiology 1996 85(3):475-80

• Increased risk of oxygen desaturation.

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

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.

Features where cancellation is advised

• Malaise

– Is it something else?

– “chicken pox”

• Fever > 38°C

• How accurate is temperature measurement?• Axillary, rectal, mercury, infrared …..

• Infrared ear thermometry compared with rectal thermometry in

children: a systematic review Lancet 2002 360: 603-9

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.

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

Lancet 2010;376:773-83

• 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 6·18–11·59;p<0·0001

– laryngospasm RR 4·13, 3·37–5·08; p<0·0001

– perioperative cough desaturation airway obstruction RR 3·05,

2·76–3·37; p<0·0001

• URTI– Associated with an increased risk for perioperative respiratory

adverse events only when symptoms were present RR 2·05, 95%

CI 1·82–2·31; p<0·0001 or less than 2 weeks before the

procedure RR 2·34, 2·07–2·66; p<0·0001

– Laryngospasm RR 4.03

• 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

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

Regli A, Becke K, von Ungern-Sternberg

Curr Opin Anesthesiol 2017, 30:362–367

Heart Murmur: Innocent or not?

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!

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

Location of innocent murmurs

1. Venous hum

2. Pulmonary flow

3. Neonatal peripheral

pulmonary flow

4. Precordial vibratory1. Still’s murmur

5. Supraclavicular

systemic flow

Spain SO Pediatrics 1997; 99: 616-619

Feature of innocent versus pathological murmurs

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: 169-174

• Diastolic murmurs

• ↑ Intensity with patient standing– McConnell et al Am Fam Physician 1999; 60(2): 558-565

Murmur discovered pre operatively

Venous hum

Soft early to mid systolic no thrill

NO

= Any other

murmur

YES

Post pone surgery and refer for

investigation

Asymptomatic

Age greater than 1year

YES

NO

ECG normal ?

Ventricular hypertrophy

YES

Proceed with surgery

Antibiotics if indicated

Refer for investigation post op

McEwan A Paediatric Anaesthesia 1995;5 :151-156

ECG criteria ventricular Hypertrophy

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

http://www.ich.ucl.ac.uk/clinical_information/clinical_guidelines/cmg_guideline_00028/

STD 5mm=0.5mV

Antibiotic Prophylaxis for Endocarditishttps://tgldcdp.tg.org.au.acs.hcn.com.au/viewTopic?topicfile=infection-prevention-

endocarditis#toc_d1e187

• 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

Nobby's & Newcastle Harbour & theNAC

http://thenac.com.au