What are the risks of anesthetizing Covid + pediatric patients?
Myron Yaster MD, Melissa Brooks Peterson MD and John Fiadjoe MD
Original Article
Rita Saynhalath, Gijo Alex, Proshad N Efune, Peter Szmuk, Hong Zhu, Ethan L Sanford. Anesthetic Complications Associated With Severe Acute Respiratory Syndrome Coronavirus 2 in Pediatric Patients. Anesth Analg. 2021 Aug 1;133(2):483-490. PMID: 33886516
“Just when I thought I was out, they pull me back in” Michael Corleone (Al Pacino), The Godfather III.
With the introduction of vaccines last winter, I (Myron) naively thought we were out of the woods. I didn’t account for the huge knucklehead factor of the American population or the virulence of the delta variant. With more and more children getting infected and sick, with vaccines still not available for children under age 12, and schools reopening, this timely article from the University of Texas Southwestern (Dallas) provides some guidance for the anesthetic management of infected children coming to your operating rooms for routine and emergent surgery. I’ve asked Melissa Brooks Peterson and John Fiadjoe, leaders in the Pediatric airway collaborative and the perioperative management of children with Covid, to weigh in and offer their views as well.
Adult patients infected with SARS-CoV-2 who undergo surgery and anesthesia suffer high postoperative pulmonary complications and death (38% at 30 days).1 Saynhalath et al. wondered about children who tested positive for Covid-19. Specifically, “in children with non-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, are there higher rates of perianesthetic respiratory complications as compared to matched controls”? And are the complications as severe as in adult patients? The short answer is yes and no. “The incidence of respiratory complications in children with non-severe SARS-CoV-2 infection was higher than in matched controls, but no children suffered severe complications such as postoperative pneumonia, acute respiratory distress syndrome (ARDS), or death”. So, this is some good and bad news.
First some very important caveats. This retrospective study at one hospital in Texas did not include children with severe disease who had concurrent pneumonia, sepsis, respiratory failure, or multiorgan failure. It also did not account for regional variations in Covid prevalence. Further, this study was performed in the “good old days” of COVID-19, before the arrival of the delta variant and when the pediatric Covid burden and disease severity was low. Will these results pan out now? Or in regions with different disease loads? We simply don’t know. A multicenter international registry (PAWS-COVDI-19) has been looking prospectively at respiratory adverse events in COVID patients and will add to the accumulating evidence soon.
In essence, the authors found that “the incidence of complications for children with non-severe SARS-CoV-2 infection was similar to what has been reported for an upper respiratory tract infection”. Although Covid positive, few patients had evidence of an active upper respiratory infection. Most of the procedures were emergent and IV induction and endotracheal intubation was common (90+%). “No patients from either cohort suffered postoperative pneumonia, ARDS, or death. No child with SARS-CoV-2 infection required noninvasive or invasive ventilatory support at postoperative day 7”. Thus, based on this study, we can expect that, similar to children with garden variety URIs, children infected with COVID-19 will experience more hypoxemia, bronchospasm, and laryngospasm, than in non-infected children.
Finally, a plea from all of us. Don’t become complacent, keep your guard up, and protect yourselves (and your family and patients) by wearing PPE, masking, and getting yourself and your loved ones and friends vaccinated! And remember Michael Corleone: ”Just when I thought I was out, they pull me back in”!
Myron Yaster MD, Melissa Brooks Peterson MD and John Fiadjoe MD
References
1. COVIDSurg collaborative: Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet 2020; 396: 27-38