Update on perioperative management of the child with asthma

Perioperative Care of the Pediatric Patient and an Algorithm for the Treatment of Intraoperative Bronchospasm

Asthma remains a common comorbid condition in patients presenting for anesthetic care. As a chronic inflammatory disease of the airway, asthma is known to increase the risk of intraoperative bronchospasm. As the incidence and severity of asthma and other chronic respiratory conditions that alter airway reactivity is increasing, a greater number of patients at risk for perioperative bronchospasm are presenting for anesthetic care. As bronchospasm remains one of the more common intraoperative adverse events, recognizing and mitigating preoperative risk factors and having a pre-determined treatment algorithm for acute events are essential to ensuring effective resolution of this intraoperative emergency. The following article reviews the perioperative care of pediatric patients with asthma, discusses modifiable risk factors for intraoperative bronchospasm, and outlines the differential diagnosis of intraoperative wheezing. Additionally, a treatment algorithm for intraoperative bronchospasm is suggested.

Perioperative management of patients with asthma during elective surgery: A systematic review

Asthma is one of the commonest respiratory illnesses among elderly patients undergoing surgery. Detailed preoperative assessment, pharmacotherapy and safe anaesthetic measures throughout perioperative period are the keys to decrease complications. Resistance to expiratory airflow results in positive alveolar pressures at the end of expiration, which causes air-trapping and hyperinflation of the lungs and thorax, increased work of breathing, and alteration of respiratory muscle function. This systematic review was conducted according to the Preferred Reporting Items for systematic review and metanalysis (PRISMA) statement. Search engines like PubMed through HINARI, Cochrane database and Google Scholars were used to find evidences. Low-dose IV ketamine, midazolam, IV lidocaine or combined with salbutamol are recommended to be used as premedication before induction. Propofol, ketamine, halothane, isoflurane and sevoflurane are best induction agents and maintenance for asthmatic surgical patients respectively. Among the muscle relaxants, vecuronium is safe for use in asthmatics. In addition, Succinylcholine and pancronium which releases low levels of histamine has been used safely in asthmatics with little morbidity.

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Asthma is one of the commonest respiratory illnesses among patients undergoing surgery.

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This systematic review was conducted according to PRISMA protocol.

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Propofol, ketamine, halothane, isoflurane and sevoflurane are best pharmacologic agents for asthmatic surgical patients.

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Vecuronium is safe for use in asthmatic surgical patients.

Recognizing Risks and Optimizing Perioperative Care to Reduce Respiratory Complications in the Pediatric Patient

There have been significant advancements in the safe delivery of anesthesia as well as improvements in surgical technique; however, the perioperative period can still be high risk for the pediatric patient. Perioperative respiratory complications (PRCs) are some of the most common critical events that can occur in pediatric surgical patients and they can lead to increased length of hospitalization, worsened patient outcomes, and higher hospital and postoperative costs. It is important to determine the various factors that put pediatric patients at increased risk of PRCs. This will allow for more detailed and accurate informed consent, optimized perioperative management strategy, improved allocation of clinical resources, and, hopefully, better patient experience. There are only a few risk prediction models/scoring tools developed for and validated in the pediatric patient population, but they have been useful in helping identify the key factors associated with a high likelihood of developing PRCs. Some of these factors are patient factors, while others are procedure-related factors. Some of these factors may be modified such that the patient’s clinical status is optimized preoperatively to decrease the risk of PRCs occurring perioperatively. Fore knowledge of the factors that are not able to be modified can help guide allocation of perioperative clinical resources such that the negative impact of these non-modifiable factors is buffered. Additional training in pediatric anesthesia or focused expertise in pediatric airway management, vascular access and management of massive hemorrhage should be considered for the perioperative management of the less than 3 age group. Intraoperative ventilation strategy plays a key role in determining respiratory outcomes for both adult and pediatric surgical patients. Key components of lung protective mechanical ventilation strategy such as low tidal volume and moderate PEEP used in the management of acute respiratory distress syndrome (ARDS) in pediatric intensive care units have been adopted in pediatric operating rooms. Adequate post-operative analgesia that balances pain control with appropriate mental status and respiratory drive is important in reducing PRCs.

Common medical illnesses that affect anesthesia and their anesthetic management

Patients undergoing an office-based anesthetic require a thorough preoperative evaluation to identify medical illnesses and undertake appropriate investigations or studies. This article addresses common medical illnesses seen in oral surgery offices and provides insight into their anesthetic management, concentrating on open-airway office-based anesthesia.