1. พญ. ภารดี ศิริบูรณ์ กลุ่มงานวิสัญญีวิทยา โรงพยาบาลสรรพสิทธิประสงค์
Cases Discussion
พญ. ภารดี ศิริบูรณ์
กลุ่มงานวิสัญญีวิทยา โรงพยาบาลสรรพสิทธิประสงค์

2. High risk ?
Case discussion

3. High risk ?
Case discussion

4. It’s risk
Case discussion

5. Prevalence
: In the past suggested surgery postpone up to 6 weeks in child with URTI for decrease risk of perioperative respiratory adverse events
: Perioperative respiratory adverse events (PRAE) are the major complications in children with URTI (incidence 24-30%)
: Children with less than 4 years may have 6-8 episodes of URITs per year with each lasting up to 2 weeks and residual pulmonary effect of 2-6 weeks
(PRAE : laryngospasm, bronchospasm, desaturation, breath holding, etc)

6. Case discussion 18 months old boy Diagnosis : Cleft palate
Operation : palatoplasty
History : Schedule for palatoplasty but 2 days ago he has runny nose and dry cough, no fever, no lethargy
Past history :
no underlying disease
no anormaly of other organ,
no history of surgery/anesthesia,
he was admitted due to bronchiolitis for 2days at the age of 8 months
Case discussion

7. Case discussion Physical examination
Active boy fully conscious, Body weight 11 kg.
BT 36.7 °C, PR 110 bpm., RR 24 tpm.
HEENT : not pale, no jaundice, watery rhinorrhea, pharynx and tonsil : not injected, cleft palate
Heart and Lung : normal
Other within normal
CBC : not show bacterial infection
Case discussion

8. Case discussion What should we do? How do you assess the patient?
Proceed or postpone
How do you assess the patient?
What is your management?
Case discussion

9. หลัง intubation บีบ bag ลำบาก
Thiopental 60 mg.
Fentanyl 10 mg.
Succinylcholine 20 mg.
Cisatracurium 2 mg.
Ventolin 2.5mg.+Nss 3ml.
X 2 dose => wheezing ลดลง
หลัง intubation บีบ bag ลำบาก
Airway resistance เพิ่มขึ้น + lung : wheezing
O2 sat 99%=>95%

10. Assess severity of URTIs
Mild URTIs : recent Hx of URTI, with no current sign and symptom within the past 2-4 weeks.
Moderate URTIs : any symptoms of URTI and no systemic symptoms for one or two days before the day of surgery
Severe URTIs : any symptoms of URTI with systemic manifestation

11. Risk factor for occurrence of PRAE in children with URTIs

12. Mild Moderate Severe Proceed Anesthetic management plan Child < 1yr
Hx and recent asthma, apnea, snore
Passive smoke
Airway, ENT, Eye Surgery
Experienced anesthetis
Pre medication
Outline appropriate anesthetic management
Proceed

13. When discuss with parent and surgeon => off operation
He has admitted for observe respiration and salbutamol nebulizer for 2days
Follow up 2 weeks for re evaluate
Case discussion

14. What is optimal timing for elective surgery in children with recent URTI.? What is perioperative management in the patient?
Case discussion

15. The duration of hyper reactive airway following URTI remain unclear
But is known to persist well beyond resolution of symptoms
No randomized controlled trials
Largest observational study found the children with current or recent URTI (<2wks) had more PRAE than children without URTI or with URTI between 2-4wks

16. The theory suggest more caution and reschedule delaying surgery by 4-6 weeks
Following each of 6-8 URTI per year, severly restricts the ideal surgical time frame
In general, should be decision balancing risk and benefit for each individual child

17. Perioperative management

18. Case discussion 3 weeks later, no sign and symptom of URTIs
Reschedule for palatoplasty
Pre medication with salbutamol and induction with sevoflurane, intubation with cisatracurium
Uneventful anesthesia and operation
Case discussion

19. THANK YOU