Anaesthesia and children with chronic disease Dr. Kathy Wilkinson Norfolk and Norwich Health Care Trust
Which chronic diseases are common in childhood? Asthma Congenital heart disease Epilepsy Cystic fibrosis Haematological disease ( Sickle cell etc.) Chronic renal disease Juvenile Rheumatoid Cerebral palsy Asthma a common and chronic inflammatory condition of the airways whose cause is not completely understood Thorax 1993;48:S1-24 a spectrum of disorders which usually exhibit the common clinical features of wheeze and/or reversible airway obstruction Archives of Dis Child 1997;77:62-5 Asthma How common is it? Pathophysiology Clinical features Current medical management Anaesthetic management Analgesic management Asthma - how common is it? 10% of children Evidence of increased prevalence over last 20 years Evidence of increased number of hospital admissions for childhood asthma over same time period What was the frequency of asthma in an anaesthetic patient population 20 years ago ? Overall frequency of asthma in all age groups 3.5% Frequency in patients under 13, 3.1% BJA 1978, 50:793-798 Asthma- pathophysiology immediate (bronchospasm) phase late (inflammatory) phase Possible ways of defining asthma Severity of symptoms Number of attacks Wheeze occurring at or persisting to a certain age Wheeze in atopic children Wheeze associated with bronchial hyper-responsiveness Any child with a doctors diagnosis Asthma- clinical features there is evidence that acute viral wheezy episodes in the very young represent a type of airway disease clinically distinct from atopic asthma British Guidelines on Asthma Management 1997 Asthma- medical management B2 agonists Cromoglycate Glucocorticoids Theophyllines Leukotriene receptor antagonists Montelukast for Chronic asthma in 6 to 14 year old children Randomised double blind multicentre trial of Montelukast for chronic asthma in 6-14 year olds > 300 children with moderate asthma randomised to receive active treatment or placebo over an 8 week period JAMA 1998; 279: 1181-1186 Montelukast for Chronic asthma in 6 to 14 year old children Montelukast group showed a statistical improvement in FEV1, peak flow and use of B2 agonists Associated reduction in days with acute exacerbation, reduction in eosinophil count and quality of life scores JAMA 1998; 279: 1181-1186 Leukotriene receptor antagonist treatment of asthma -are we there yet? there are still miles to go before these drugs find their appropriate place in the management of childhood asthma J Peds 1999; 134:256-259 Asthma- anaesthetic management assessing severity effect of anaesthesia which anaesthetic what are the risks Asthma - assessing severity frequency and pattern of symptoms recent hospital admissions recent oral steroids recent upper or lower respiratory infections Effect of anaesthesia on lung function in children with asthma Healthy children (aged 5 -16) exhibit a decrease in FEV1 and PEFR after general anaesthesia for elective surgery The decrease does not appear to be any greater in well controlled asthmatic children BJA, 1996; 77: 200-202 Bronchospasm and anaesthesia more common in children ( 4/1000 cf. 1.6/1000 ) ? particularly common in infants under 3 months more common in children with a respiratory infection (10 fold increase) 5/6 cases of cardiac arrest associated with bronchospasm were in children under 5 Acta Anesth Scand 1987;31: 244-252 Perioperative respiratory complications in patients with asthma Very low overall incidence of complications in asthmatic patients undergoing surgery/anaesthesia (n=706) Of the 211 patients in the series aged , none developed bronchospasm Asthmatic patients with no symptoms are at a particularly low risk for severe morbidity from anaesthesia Anesth 1996; 85:460-467 Asthma and respiratory tract infections The association of asthma with respiratory infection is particularly significant when deciding whether to cancel elective surgery J Clin Anesth 1995; 7: 491-499 Asthma- Low risk not no risk ! US closed claims 1975-94 includes 3533 cases Bronchospasm was the damaging event or mechanism of injury in 88 cases 32% of this group died Anesth 1996; 85: 4555-6 Asthma - which anaesthetic ? Isoflurane, Halothane and Sevoflurane all reduce respiratory system resistance after tracheal intubation Sevoflurane may be superior Anesth 1997; 86: 1294-9 Asthma - which anaesthetic ? Propofol has a low capacity (cf. barbiturates ) to induce wheeze at induction Anesth 1995; 82: 1111-1116 Propofol or Halothane anaesthesia for children with asthma Respiratory mechanics during propofol anaesthesia were comparable in normal and asthmatic children Halothane produced a minimal decrease in resistance and tidal volume in both groups BJA, 1996;77: 739-74 Atracurium vs. Vecuronium in Asthmatic patients 60 (adult) patients on chronic bronchodilators Incidence of pulmonary events (increase in PAP, reduction VT, Wheeze) did not differ between atracurium and vecuronium Cardiovascular effects were more common with atracurium Anesth 1995; 83: 986-991
Asthma- What I do Pre-assess with care Premedicate Prophylactic bronchodilator Induction-sevoflurane or propofol Maintain with volatile (atracurium if MR used) Asthma- what to avoid Asthmatics with recent upper or lower respiratory infections Light anaesthesia Endotracheal tubes Asthma- analgesia LA blocks Synthetic opiates NSAIDs Paracetamol Asthma in children and ASA intolerance 16 child asthmatics with symptoms induced by ASA ingestion occurred in children as young as 1 year extrinsic and exercise induced asthmatics are most commonly affected associated urticaria frequent J Invest Allergol Clin Immunol 1993;3: 315-20 Cystic fibrosis Genetics Prevalence and prognosis Clinical features Current medical management Indications for surgery Anaesthetic management New therapies CF- prevalence and prognosis > 50% of patients now survive to age 20, and median survival is 30-32 years in most centres The number of CF patients is increasing by approximately 150-200 per year By the millennium it has been estimated that there will be approximately 6000 patients in the UK with CF, 2000 of whom are ᡊ CF- Genetics CF gene identified on Chr. 7 in 1989 Codes for Cystic fibrosis transmembrane conductance regulator (CFTR) which is involved in cAMP regulated chloride transport across cell membranes Absence or dysfunction of CFTR results in diminished electrolyte and water secretion by duct epithelium leading to concentration of macromolecules in the duct lumen and ultimately duct obstruction CF- pathophysiology pancreatic ductule obstruction leads to exocrine pancreatic insufficiency at the air fluid interface in the lung secretions precipitate in small airways initiating the cascade to chronic obstructive pulmonary disease CF- clinical features and complications Nasal polyps, chronic sinusitis Gastro-oesphageal reflux Meconium ileus Distal intestinal obstruction syndrome Rectal prolapse Fibrosing colonopathy Liver disease Diabetes Gastro-oesphageal reflux Common when assessed by oeshagoscopy, pH study Rarely symptomatic Improves with age Aetiology relates to decreased oesphageal sphincter tone, gravity (physio), changes in angle of His and possibly reduced stomach emptying CF- current management Aggressive treatment of pulmonary disease Physiotherapy Antibiotics Bronchodilators/steroids when appropriate DNAse Nutritional support CF- Indications for surgery Neonates Meconium ileus intestinal atresia Children/adolescents Vascular access Gastrostomy Oesphageal varices Transplantation CF- Heart lung transplantation referral criteria Prediction of death within 2 years (FEV1 < 30% predicted) Severely impaired quality of life Comparison of outcome in CF children undergoing HL transplant (GOS 1988-95) CF-anaesthetic management Careful pre-op assessment to include Pre-op CXR RFTs ( FEV1/ FVC ) Routine bloods to include sugar Sputum culture SaO2 in air Physiotherapy and all usual medications on day of surgery Consider premedication including H2 antagonist CF- anaesthetic management regional/local anaesthesia when possible maintain good hydration post op oxygen and monitoring CF- anaesthetic assessment post Tx Function of transplanted heart/lung Possibility of rejection Effect of immunosuppression on other organs Indication for surgery and its effect on transplant
Thanks for getting this far.
Back to home page