1. Dr James F Peerless

2.  Assessment of the child preoperatively: ◦ Heart murmur ◦ Current or recent infection ◦ Recent immunisation

4.  Relatively common finding  Most are innocent ◦ Incidence of congenital heart disease ~1%  However, differentiation between innocent and pathological is difficult

5.  History ◦ Recurrent chest infections ◦ Failure to thrive ◦ Cyanosis ◦ Sweating ◦ Feeding difficulties  In older children ◦ Decreased exercise tolerance ◦ Syncope ◦ FHx of sudden death

6.  Examination ◦ Palpation of pulses  Equality and delay ◦ Palpation of precordium  Thrills ◦ Ausculation of HS  Location/timing/quality/intensity/variation with posture ◦ Abdominal  Hepatic enlargement

7.  Most CHD is identified antenatally or within first three months  High degree of suspicion in syndromic children ◦ e.g. Down’s  Any child <1yr with a murmur  paediatric cardiologist prior to anaesthesia  Investigations ◦ ECG ◦ TTE

8. MurmurInnocentPathological SymptomsAsymptomaticSymptomatic TimingEarly systolic or continuous (venous hum) Diastolic, pansystolic, or late systolic QualityBlowing/musical /vibratory Variable/harsh Precordial thrillNeverSometimes Variation with posture OftenRarely

10.  The problem ◦ Airway hyperreactivity ◦ Laryngospasm ◦ Bronchospasm ◦ Breath holding ◦ Desaturation ◦ Post-operative pneumonia  The solution ◦ Postpone symptomatic children for four weeks

11.  The dilemma ◦ Average of seven URTI episodes per year ◦ Mostly viral aetiology ◦ Estimated 25% of children have a runny nose due to other causes  Hypertrophic adenoids  Allergic rhinitis  Social ◦ High caseload and pressure to expedite surgery ◦ Increased emotional and economic burdens on parents

12. Infective  Croup  Influenza  Epiglottitis  Streptococcal sore throat  Herpes simplex  Bronchiolitis  Pneumonia Non-infective  Allergic rhinitis  Asthma  Foreign body  Gastro- oesophageal reflux

13.  History ◦ Current/recent purulent nasal discharge ◦ Productive cough ◦ Dyspnoea ◦ Systemic features of infection  Fever  Malaise  Irritable behaviour  Reduced appetite

14.  Examination ◦ Inspection  Nasal discharge  Inflamed oropharynx ◦ Auscultation  Crackles  Wheeze  Bronchial breathing ◦ Fever >38°C

15. Continue  Clear runny nose  Dry cough  Minor surgery Cancel  Child <1yr  Purulent nasal discharge  Productive cough  Signs on auscultation  Systemic features  Parental concern

16.  Asthma  Prematurity  Parental smoking  Airway anomaly  History of snoring

17.  Patient comorbidities  Age  Urgency of surgery  Will the symptoms improve?  Anaesthetic experience  Type of surgery ◦ Airway surgery  Need for intubation

18. Suggested algorithm for the assessment and anaesthetic management of the child with URTI.6 Hx, history; TT, tracheal tube; LMA, laryngeal mask airway. Bhatia N, and Barber N Contin Educ Anaesth Crit Care Pain 2011;bjaceaccp.mkr039 © The Author [2011]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com

20.  Elective anaesthesia following vaccination of children is contraversial ◦ Possibility of altered immune response during surgery and anaesthesia will reduce the effectiveness of the vaccine ◦ Muddled clinical signs and symptoms of a post- operative fever

21.  In survey of anaesthetists: some suggest delaying surgery 3 weeks for live vaccine, but 1 week for an inactive vaccine  UK Immunisation Handbook ◦ Recent or imminent elective surgery are not contraindications to immunisation  Netherlands and New Zealand ◦ Advise the delaying of surgery to reduce confusion of post-op. adverse events Short et al., 2006 (Pediatr. Anesth.)

23.  Risk factors for perioperative adverse respiratory complications are: a) Nasal congestion b) Copious secretions c) Passive smoking d) Airway surgery e) Parent’s confirmation that the child has a cold

24.  Which of the following should be considered when deciding to cancel or proceed with an elective surgery in a child with URTI? a) Child’s age and presenting symptoms b) Type of surgery to be performed c) Need for endotracheal intubation d) Frequency of the child’s URTI e) Anaesthetist’s comfort and experience

25. In children with upper respiratory tract infection (URTI), the following are most likely to be a risk factor for perioperative respiratory complications: a) Parental smoking. b) Use of a tracheal tube. c) Parental denial of the child having a ‘cold’. d) Age <1 year. e) A history of snoring.

26. A trainee discusses a child’s immunization status with a senior anaesthetist. The following statements are most likely: a) Immunomodulatory effects of anaesthesia are permanent. b) Lymphopenia may represent the redistribution of lymphocytes to the site of trauma. c) Postpone immunization by 2 months in a child scheduled for elective surgery. d) A delay of 48 h between inactivated vaccine and anaesthesia may be useful. e) Do not administer any vaccine in a child scheduled for anaesthesia.

27. Cardiological evaluation of a child with a murmur is recommended when the child: a) Is an infant. b) Has an ECG that shows an R wave in V6 >4mV. c) Has a congenital syndrome. d) Is asymptomatic and has no other history. e) Has a family history of sudden death.

28. The following statements apply to the anaesthetic management of a child with URTI: a) Goals are to minimize secretions and limit stimulation of the airway b) The airway should be suctioned after the child loses the eyelash reflex c) Sevoflurane is a better induction agent than propofol d) An ETT should be used in preference to a LMA or facemask to secure the airway e) The general consensus is to remove the ETT awake rather than deep

29.  Bernardo-Ocampo MC. Upper respiratory tract infection and paediatric anaesthesia. Anaesthetic tutorial of the week. January 2012, 246. http://www.aagbi.org/sites/default/files/246- Upper-Respiratory-Tract-Infection-and- Paediatric-Anaesthesia2_0.pdf (accessed 14.04.14)  Bhatia N, Barber N. Dilemmas in the preoperative assessment of children. Continuing education in anaesthesia, critical care and pain, 2011; 11(6): 214-8