A #periopmedicine #tweetorial/#medthread

It’s that time of year again!
Sunday football?
ERAS applications?
Girl Scout cookies?
Well, yes…but for the purposes our discussion, it’s “COLD & FLU SEASON”

What do you do if a patient scheduled for surgery has a URI?

1/N
what is the theoretical concern?
That presenting for surgery, and the anesthetic management including intubation required to facilitate it, will lead to #perioperative complications if the patient has (or has recently had) an upper respiratory tract infection.

2/N
these concerns include the risk of periop pulmonary complications:
🔘respiratory failure
🔘airway hyperreactivity (during induction or emergence) ➡️laryngo/bronchospasm
🔘deeper infection like pneumonia

does this “biologic plausibility” translate into real-world events?

3/N
spoiler alert!
The adult data is limited, and most of the literature on periop URIs comes from the pediatric literature because, well, kids get sick…a lot

4/N
The general interpretation of the pediatric data that I’ve previously seen is no peri-op complications if:
❇️No mucopurulent secretions
❇️No asthma
❇️Afebrile
❇️No dyspnea
❇️No wheezing

Here’s one resource:
5/N
journals.lww.com/anesthesia-ana…
Here’s another recent resource, examining the COLDS score. You can see from the graphic what it takes to earn "points" that increase your risk of periop pulmonary complications. Scoring items will stay in this discussion!
onlinelibrary.wiley.com/doi/full/10.11…
6/N
how do you extrapolate to adults (who have larger airways)?
A 1996 study in Anesthesiology on periop respiratory complications in patients WITH asthma examined a lot of variables, INCLUDING acute/recent URI--recent URI did not increase complications 🤔
anesthesiology.pubs.asahq.org/article.aspx?a…
7/N
Might a recent/active URI NOT be a contraindication to surgery in a healthy (or a less health and/or older) adult?
How do you assess that?
8/N
let’s start with background. Recall my #periopmedicine “mantras”:

mantra 1: “this patient, this surgery, this indication, and this time”

and add “this anesthetic technique (ex. General with intubation? LMA? Regional with sedation?)

9/N
the patient-centered risk/benefit discussion even applies to proceeding to surgery with a URI…

❓can the surgery be delayed?
❓If you delay, how long should you wait?
❓How long does the airway hyperreactivity last even after symptoms resolve?

10/N
mantra 2: “quantify and qualify the known comorbid conditions”

🌀nature of the patient?
🌀underlying pulmonary disease?
🌀🌀Asthma?
🌀🌀COPD?
🌀🌀Bronchiectasis?
🌀🌀Tobacco use?

If so, how severe is the condition, what at the baseline symptoms and degree of control?

11/N
Also apply this to the URI
🌀timing of onset
🌀specific symptoms
🌀dyspnea?
🌀Productive cough?
🌀Pulmonary Exam?
🌀Oropharyngeal exam? (edema/tonsillitis)
🌀Ill appearing?

12/N
Don’t forget your med reconcilliation as an indicator of URI severity as well as the potential for drug-drug interactions/periop needs:

⏺️Needing bronchodilators?
⏺️Oral decongestants v sympathomimetic effects?
⏺️Antihistamines v post-op sedation?

13/N
Let’s explore this up with some audience participation!
What would you do in these hypothetical situations?

14/N
A healthy 35yo with resolved childhood asthma had a mild URI (rhinorrhea, sinus pressure, non-productive cough, no fevers, “scratchy” throat) beginning 8 days before laparoscopic cholecystectomy.
3 days preop she feels “90% better”. Pulm exam normal.
15/N
A 22yo college athlete w exercise-induced asthma (w prior mild exacerbations with URIs) had a mild URI 9 days before ACL repair. Has used prn albuterol twice for mild “chest tightness”. No sputum or fevers. Exam w/o wheezing or bronchial breath sounds. It's now 3 days preop
16/N
Prior case—one more detail.
What if surgery was scheduled during winter break? If it doesn’t happen this week, it won’t happen again until summer break in 6 months??
17/N
65yo w mild COPD & former tobacco had URI (from grandkids) 2weeks before carpal tunnel release. Tmax 101 w minimally productive cough. He feels “95% better” 7 days pre-op. No longer using prn ipratropium/albuterol. Exam with slightly prolonged expiratory phase, no rhonchi.
18/N
70yo w moderate COPD & active 1ppd develops malaise, sore throat, mild fever, increase in chronic cough w change in sputum 4days before lumbar fusion. Needed steroids & antibiotics the last time this happened. Exam: O2 92%, prolonged expiratory phase, rhonchi, mild tachypnea
19/N
Apparent consensus?
🔘Healthy adult w acute URI day of surgery➡️delay 1-2 weeks?
🔘Adult with asthma w acute URI➡️delay 1-2 weeks
🔘Healthy adult w recent URI but asymptomatic➡️proceed?
🔘Moderate to severe COPD w acute URI➡️delay elective surgery, recovery may be variable

20/N
By the way, I started this #tweetorial by colloquially referring to “cold and flu season”. If someone truly had INFLUENZA, given the potential for severe complications including cardiac and other non-pulmonary, I would cancel surgery

21/N
so, to summarize:
✅Data limited
✅Ask about URI symptoms before surgery, along w
✅severity of symptoms
✅presence/severity of underlying lung disease
✅Don’t automatically cancel surgery JUST because someone has or is recovering from a URI
✅Get your flu vaccine!
22/FIN
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