urti murmurs & risk - anzca...rvh 1-5 years 5-12 years r wave amp. v > 1.75 mv > 1.25mv...
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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
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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
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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
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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
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Adverse events Age and ASA
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• 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
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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
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PRAm ScorePaediatric Risk Assessment Score
Anesth Analg 2017;124:1514–9
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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/
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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.
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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.
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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
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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.
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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.
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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
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Lancet 2010;376:773-83
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• 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
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• 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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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
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Regli A, Becke K, von Ungern-Sternberg
Curr Opin Anesthesiol 2017, 30:362–367
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Heart Murmur: Innocent or not?
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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!
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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
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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
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Feature of innocent versus pathological murmurs
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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
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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
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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
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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