A perioperative approach for pediatric asthma
Pediatrics patients with asthma who have to undergo surgery are at risk for complications.
Despite millions of dollars spent to help control asthma, the rates of emergency department (ED) visits due to asthma symptoms increased by about 18% for children aged 5 to 17 years and by 6% for children younger than age 5 years in California between 2005 and 2012, according to a Kaiser Health News analysis. In certain areas of the state, asthma is even more pervasive. In the San Joaquin Valley, for example, an estimated 157,000 (15.8%) children and adolescents have been diagnosed with asthma, far exceeding the national rate of 4% to 9%.
Although we have made great strides in the care and control of pediatric asthma, children are clearly at higher risk of asthma symptoms and complications. This is particularly important in the care of pediatric surgery patients with asthma. Asthmatic children are 5.5 times more likely to experience wheezing perioperatively than are nonasthmatics, and they are more likely to have perioperative respiratory complications.
Special attention must be paid to minimize the chance that pediatric surgery will not result in bronchospasms in asthma patients, as the severity of the disease correlates with the risk of respiratory complications. Several factors should be taken into account in the perisurgical care of pediatric asthmatic patients.
Preoperative anesthesiology assessment is critical. An uncontrolled baseline asthma condition represents the most important risk factor for perioperative events in asthmatic patients, especially in very young children. For children without optimal control of symptoms or with a recent respiratory tract infection, elective surgery should be postponed, if possible, after the optimization of therapy. Treating clinicians should also be diligent about scheduling a preoperative anesthesiology assessment, including clinician examination, complete medication history, functional tests such as spirometric evaluation, and even preoperative laboratory tests if necessary for very high-risk children with asthma.
Provide a low-stress, peaceful preoperative environment. There is a significant psychological element with asthma, exacerbated by the anxiety associated with even the most routine surgery. Allow a parent to stay with the child as long as possible until the induction of anesthesia, and consider administering an oral sedative to relax the child.
Use of regional anesthesia can minimize complications. Although each case is unique, there is a general consensus that for the pediatric asthmatic patient, the use of regional analgesia to control pain is the best course, while narcotics should be avoided due to the risk of respiratory depression and the potential for the release of histamine, a frequent cause of bronchospasm.
Incorporating a cautious and compassionate perioperative approach with the pediatric asthma patient can help to facilitate an uneventful surgery with the best possible health outcomes.—LINDA MASON, MD, is a professor of anesthesiology and pediatrics at Loma Linda University and director of pediatric anesthesiology at Loma Linda University Medical Center, Calif. (203-4)
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