International Journal of Surgery Open 12 (2018) 17e24

Contents lists available at ScienceDirect

International Journal of Surgery Open

journal homepage: www.elsevier.com/locate/ijso

Review Article

Evidence-based perioperative management of a child with upper respiratory

tract infections (URTIs) undergoing elective surgery; A systematic review
Girmay Fitiwi Lema a, *, Yophtahe Woldegerima Berhe a, Amare Hailekiros Gebrezgi a,
Ayechew Adera Getu b
a
Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
b
Department of Physiology, College of Medicine and Health Sciences, School of Medicine, University of Gondar, Gondar, Ethiopia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Upper respiratory tract infections are frequently encountered medical problems in paedi-
Received 27 February 2018 atric age groups. Children with less than five years may have six up to seven episodes of URTIs per year
Received in revised form with each lasting up to two weeks. The issue of whether to proceed with elective surgery on a child with
17 May 2018
an URTI has been source of debate for many years. The rationale of this review was to avoid traditional
Accepted 24 May 2018
approach of blanket cancellation of surgery by stratified risk factors as well as optimization of the pa-
Available online 30 May 2018
tients. Furthermore, this review summarized current evidences regarding perioperative anaesthetic
management of children with URTIs.
Keywords:
Upper respiratory tract infection
Methods: The study was conducted according to the Preferred Reporting Items for Systematic Reviews
Respiratory adverse events and Meta-Analyses (PRISMA) protocol. Search engines like PubMed through HINARI, Cochrane database
Paediatric anesthesia and Google Scholars were used to find high-level evidences that help to draw appropriate conclusions.
Desaturation Discussion: Performing anaesthesia in children with URTIs increases the risk of perioperative respiratory
Hyper-reactive airway adverse events (PRAEs) like laryngospasm, bronchospasm, and desaturation and breath holding.
Conclusion: Children with mild and moderate URTIs can safely anaesthetized with optimal preparation
and optimization of the patient in the preoperative period. Prevention of stimulation of a potentially
irritable airway, use of bronchodilators and induction with propofol are helpful. Furthermore, adequate
suppression of airway reflexes with optimal depth of anaesthesia is highly recommended.
© 2018 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Background
Upper respiratory tract infections are the most frequent medical
problems in paediatric age groups undergoing surgery and the
leading medical causes to defer surgery [1,2].
Approximately, 200 viruses cause the infection that produces the
clinical syndrome of cough, nasal congestion, discharge, sore throat,
and sneezing. Rhinoviruses, parainfluenza viruses and influenza vi-
ruses are the most common viruses causing respiratory illness. The
type of virus most commonly causing URTIs varies with different age
groups. Respiratory syncytial virus, parainfluenza viruses, adenovirus
are the most common viruses infecting the infant and preschool child.
URTIs are self-limiting. However, it may produce hyper-reactive
airway that can persist for 6 weeks [3].
* Corresponding author.
E-mail addresses: tsagir.fitiwi@gmail.com (G.F. Lema), yophtii@gmail.com
(Y.W. Berhe), amaretom22@gmail.com (A.H. Gebrezgi), ayechewadera09@gmail.
com (A.A. Getu).
Children with less than five years may have six up to seven
episodes of URTIs per year with each lasting up to two weeks and
residual pulmonary effects of 2 to 6 weeks [4e6]. The issue of
whether to proceed with elective surgery on a child with an URTI
has been source of debate for many years. The purpose of this re-
view is to summarize current evidence regarding perioperative
anaesthetic management of children with URTIs undergoing elec-
tive surgery and to minimize traditional approach of blanket
cancellation of surgery.
1.1. Pathophysiology of upper respiratory tract infections (URTIs)
Viral invasion of the respiratory epithelium and mucosa leads to
airway inflammation, edema, dyscriny, and bronchoconstriction,
which sensitizes the airway to secretions and volatile agents [7].
Moreover, viral infections damage the ciliary apparatus and
mucosal epithelium [8].
The viral infection interacts with the autonomic nervous system
by inhibiting the cholinergic muscarinic M2 receptors, which is

https://doi.org/10.1016/j.ijso.2018.05.002
2405-8572/© 2018 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
18 G.F. Lema et al. / International Journal of Surgery Open 12 (2018) 17e24
followed by an increased release of acetylcholine [9]. In addition,
viral induced liberation of tachykinin and neuropeptidases with a
constriction of smooth muscles in the respiratory tract for weeks
may also result in bronchial hyper-reactivity, which can persist
for up to 6 weeks or even longer beyond the disappearance of all
clinical symptoms [10]. Bronchial hyper-reactivity can trigger se-
vere complications in the perioperative period, particularly lar-
yngospasm and bronchospasm, both of which can lead to fatal
hypoxemia, which is the main cause of perioperative morbidity and
mortality in children [11e13].
2. Justification
Anaesthesia for elective surgery in paediatric patients with a
recent URTI was commonly postponed for several weeks in the
past. The blanket defer of surgery can have an impact on social,
economic, and emotional consequences for the child, the family
and the health service system in general. Furthermore, inadequate
optimization of child with URTIs undergoing surgery will causes
high incidence PRAEs and unnecessary hospitalization, which could
affect the health-care cost and parents satisfaction.
Empirically, postponing surgery in a child suffering from upper
respiratory tract infection was usually based on an increased risk of
PRAEs, which can occur up to 6 weeks after the disease. Today there
is a notable trend for anesthesia to be safely performed in children
with URTIs when a careful assessment of potential risks and ben-
efits for the child is implemented and safety precautions are taken.
This review emphasis on comprehensive assessment, stratifi-
cation of sign and symptoms of URTIs, optimization in the preop-
erative period and design appropriate anaesthetic management,
which may avoid traditional blanket cancellation of surgery and
decrease the risk of perioperative respiratory adverse events
(PRAEs) following the surgery.
3. Methods
This study was carried out in accordance with the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) guideline [14]. A computerized systematic search of the
PubMed, Google Scholar, and ScienceDirect databases were used to
find articles. Prospective observational, interventional studies,
meta-analysis, systematic review and audit studies were included
in the review using the following MeSH terms: (Common cold OR
upper respiratory tract infections OR URTIs) AND Surgery AND
Anesthesia AND (child OR children OR pediatrics) AND periopera-
tive respiratory adverse events. In this review, publication dates
were not used as inclusion or exclusion criteria and research papers
published before 30 September 2017 were included. Only those
articles written in English language were considered for this re-
view. Furthermore, after comprehensive and in-depth appraisal of
literature, evaluation of quality was conducted by categorize them
into level 1 (* Meta-analysis, systematic review, randomized con-
trol trial) level 2 (** Well designed cohort study) and level 3 (***
case reports, commentaries, and expert opinions). Finally, conclu-
sion has drawn based the level of evidences and class of recom-
mendation (Fig. 1).
3.1. Selection of studies
Papers fulfilling the following criteria were included in the
study: studies presented as original articles, comparative studies on
airway intervention for child with common cold undergoing sur-
gery, premedication for child with common cold undergoing sur-
gery, incidence of perioperative respiratory adverse events in child
with URTIs undergoing surgery, studies written in English.
Studies done on child with URTIs undergoing emergency sur-
gery, surgery undergoing under local infiltration, studies where full
articles were no longer available online were not selected to be
included in the current review. All of the research articles that were
identified from searches of the electronic databases were imported
into the ENDNOTE software version X6 (Tomson Reuters, USA) and
duplicates were removed. Before data extraction had begun, full-
length articles of the selected studies were read to confirm for
fulfilling the inclusion criteria.
4. Discussion
Upper respiratory tract infections affect the apparatus of the
upper airways frequently and there is no single universally
accepted definition of URTIs. However; most clinical studies define
URTI as two of the following symptoms: rhinorhoea, sore or
scratchy throat, sneezing, nasal congestion, and malaise, cough, or
fever more than 38  C [1,15,16]***, **, ** respectively. The most
frequent symptoms are rhinorhoea (66%), followed by nasal
congestion (37%), sneezing (29%), productive cough (26%), sore
throat (8%), and fever (8%) [4,17]**.
Perioperative respiratory adverse events are the major compli-
cations during intraoperative and postoperative period in children
with URTI [18]. Typical adverse events in children with respiratory
tract infection are laryngospasm, bronchospasm, breath holding,
atelectasis, arterial oxygen desaturation, bacterial pneumonia, and
unplanned hospital admission [4,16,19]. Hence, these children may
benefit from preanaesthetic assessment and specifically targeted
perioperative anaesthetic management. When evaluating a child
with an URTI for whom elective surgery is planned, preoperative
information must be meticulously obtained for the best anaes-
thetic management, in order to reduce the risk of perioperative
respiratory adverse events.
4.1. Preoperative assessment
Identifying sign and symptoms of URTIs in preoperative period
for paediatric patients undergoing surgery through medical history
and physical examination is very crucial.
Studies classified the severity of URTIs based on clinical
manifestations.
 Mild URTIs is considered, if the child has recent Hx of URTI, with
no current sign and symptom within the past 2e4 weeks.
 Moderate URTIs is considered, if the child has any symptoms of
URTI (runny nose, dry cough), without wheeze and no systemic
symptoms such as fever or pyrexia (>38  C) or irritability
(lethargy), for one or two days before the day of surgery.
 Severe URTIs is considered, if the child has any symptoms URTI
with systemic manifestation (Fever, >38  C, productive cough,
mucopurulent secretion, nasal congestion, sore or scratchy
throat, wheezing, laryngitis and pulmonary involvement)
[4,8,10,20].
The potential for a lower respiratory tract infection after URTIs is
relatively common in children. So, preoperative evaluation should
consist of listening to the child's lungs for rhonchi or wheezing. It is
also important to determine if there is a history of asthma or
wheezing. Children who are exposed to common colds are at
greater risk for reactive airway disease and can hence have a
greater propensity for wheezing or bronchospasm during anes-
thesia [8]*.
Passive smoking, Age below 6 years, particularly infants below 1
year with severe sign and symptoms of URTIs, children with any
respiratory or pulmonale comorbidity, ENT surgery or eye surgery,
 G.F. Lema et al. / International Journal of Surgery Open 12 (2018) 17e24 19

and surgery with impairment of respiratory function, such as upper
abdominal surgery or cardiac surgery are identified independent
risk factors for perioperative respiratory adverse events [6,21,22]**.
Studies have suggested that a child with severe manifestation of
URTIs, and moderate URTIs with independent risk factors must
defer surgery for at least two weeks [8,23]** (Fig. 2).
4.2. Perioperative management
4.2.1. Premedication
4.2.1.1. Salbutamol. Preoperative administrations of beta-2 agonists
before 10e30 min of surgery have been shown reducing and treating
bronchoconstriction and perioperative respiratory events. Von
Ungern-Sternberg et al. showed that high-dose inhalational salbuta-
mol (2.5e5 mg) reduced the risk of PRAEs by at least 35%. Hence, sal-
butamol pre-treatment should be considered in all children presenting
with a URTIs undergoing surgery under general anesthesia [24]*.

The crucial points to optimize and prepared children with URTIs
are identifying the severity of infection, and risk factors for PRAE.
Moreover, the experience of anaesthetist has a great role in the
prevention of perioperative respiratory adverse effects in many
cases by early predicting the possible complication, providing
optimal depth of anesthesia, administration of the appropriate
drugs.
4.2.1.2. Lidocaine. Abouleish et al.suggested that topical adminis-
tration of lidocaine has protective effects against coughing and
laryngospasm [25]*. Incontrast to this, Hamilton et al. showed an
increase in respiratory adverse events [26]**. During general
endotracheal anesthesia, significantly higher rate of desaturation
was observed in children who were treated with topical lidocaine
compared with the placebo group. However, there was no

Fig. 1. Flowchart for selection of studies by PRISMA flow diagram.

20 G.F. Lema et al. / International Journal of Surgery Open 12 (2018) 17e24
Fig. 2. Preoperative decision algorithm for assessment of a child with URTIs undergoing surgery.
difference in the incidence of laryngospasm. These findings are
consistent with a study done by Von Ungern-Sternberg et al. [16]**.
Sanikop and Bhat showed that 1.5 mg/kg of intravenous lido-
caine given 2 min before extubation resulted in a decrease in
postextubation laryngospasm and coughing with statistical signif-
icance and clinical relevance [27]*.
4.2.1.3. Anticholinergics/Antisialagogue. A randomized trial study
done by Tait AR et al. showed that either glycopyrolate or atropine
has no difference regarding respiratory adverse events in children
with URTIs undergoing surgery [28]*.
4.2.2. Induction of anaesthesia
A comparative prospective study done on intravenous anaes-
thetic agents (thiopentone, propofol) and inhalational (halothane,
sevoflurane) showed that thiopentone was associated with the
highest probability of an adverse event followed by halothane and
Sevoflorane, and propofol was associated with the lowest proba-
bility of an adverse event [29]*.
Propofol is known to depress laryngeal reflexes and may
decrease airway responsiveness by relaxation of bronchial smooth
muscle. This may be the reason that it was associated with fewer
adverse events than the other agents [16]**.
4.2.3. Airway intervention
Facemask, laryngeal mask ventilation (LMA) or endo-
trachealtube can be used based on the proposed surgery, antici-
pated duration and patient condition during general anaesthetic to
provide the patient the ability to breathe spontaneously or to
provide positive pressure ventilation.
 G.F. Lema et al. / International Journal of Surgery Open 12 (2018) 17e24 21

Table 1
Evidence-based perioperative management of children with URTIs undergoing Elective Surgery.

Premedication Salbutamol (inhalational)  Salbutamol puff 10e30 min before induction.

 2.5 mg if weight <20 Kg.
 5 mg if weight >20 kg
Lidocaine (IV), 1.5 mg/kg  To suppress airway reflexes either before intubation or extubation
Anaesthetic agents Propofol  Propofol has good airway reflex blunting properties with mild bronchodilator effect
Volatile anaesthetic agents  Volatile anaesthetic agents have good bronchodilator properties but limited effects in suppressing airway reflexes.
 When using volatile anaesthetic agents sevoflurane followed by halothane anaesthetic agents.
 In high-risk children, IV induction with propofol over inhalational induction.
 Optimal depth of anesthesia during intraoperative period
Extubation  Adequate suctioning under optimal depth of anesthesia.
 Awake extubation.
 Immediate oxygen supplementation and CPAP
Post operative  Meticulous monitoring of SPO2, Oxygen supplementation via nasal prongs.
 Adequate hydration and analgesia

Child with URTIs undergoing surgery under general anaesthesia endotracheal intubation whenever possible, use of a face mask
with endotracheal intubation had the highest probability of ventilation or laryngeal mask ventilation. Moreover, prevention,
suffering adverse respiratory events than those whose airway was early recognition and immediate treatment of complications by an
managed by LMA or facemask [30]*. experienced anaesthetist are crucial.
A large trial showed that children with URTIs had a two to
seven times increased risk of suffering an adverse respiratory Ethical approval
event during anaesthesia, and eleven times increased risk if the
child was Intubated [6]***. The incidence of laryngospasm is Ethical approval is not required.
increased in intubated patients and in patients having airway
surgery [26,31]* and they concluded that LMA under optimal
Funding
depth of anaesthesia may be able to provide a clear safe airway
[19,27,32,33]*.
Department of anaesthesia, College of Medicine and Health
Sciences.
4.2.3.1. Techniques of extubation. In a randomized controlled trial
study done by Tait and Malviya found that there was no difference
in the incidence of complications in either awake or deep extuba- Authors' contributions
tion techniques. There was an increased incidence of coughing in
children who were extubated awake versus those extubated under All authors have participated in the stages of evidence search-
deep anesthesia (60% in wake vs. 35% in deep anesthesia extuba- ing, development, presentation and implementation of this evi-
tion) However, the incidence of airway obstruction in deeply dence-based guideline. Especially all authors critically appraise
anaesthetized patients was more frequent than awake extubation literature and present it to peers for discussion. They have partic-
(26% vs. 8%) [33]***. ipated in identifying areas of need within a perioperative period to
produce appropriate recommendations.
4.2.4. Postoperative management
It is important to recognize that children with URTIs may be Conflict of interests statement
prone to desaturation, bronchospasm, stridor or persistent cough-
ing. Furthermore, nasal oxygen supplementation, adequate hydra- There is no conflict of interest.
tion, and post-op adequate pain control is recommended for such
patients. See (Table 1). Guarantor

5. Conclusion Girmay Fitiwi Lema.

With the high incidence of URTIs in children and the increased

Research Registration Unique Identifying Number (UIN)
perioperative risk, anaesthetists are often confronted with de-
cisions that need to be made about the best management for these
Research registration Unique identifying number (UIN) Not
children. Most of the literature suggested that a child with severe
required.
symptoms of URTIs must be postponing the elective surgery for at
least greater than 2 weeks and should be re-evaluated.
Children with a mild and moderate URTIs may be safely un- Availability of data and material
dergoing surgery, since the respiratory adverse events are antici-
pated, recognized and generally easily treated and without long- Not applicable.
term complications. The algorithm suggested for the assessment
of a child with acute URTIs (Fig. 2) may be a useful tool to aid the Acknowledgments
decision.
The best anaesthetic management should include pre- We would like to acknowledge the Department of Anaesthesia,
treatment with salbutamol, the use of propofol and avoidance of University of Gondar.
22 G.F. Lema et al. / International Journal of Surgery Open 12 (2018) 17e24

Appendix A. Supplementary data

Supplementary data related to this article can be found at

https://doi.org/10.1016/j.ijso.2018.05.002.
Annex I
WHO level of evidences.

Level Description

I Meta-analysis, systematic review, randomized control trial

II Well-designed cohort study
III Observational cross-sectional study, clinical audits, commentaries and
expert opinions

Annex II
Quality assessment.

S.No Author Study Quality/

level

1 Heikkinen T and The common cold. The Lancet. 2003; 361 (9351):51-9. III
€rvinen A.
Ja
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3 Green RJ Symptomatic treatment of upper respiratory tract symptoms in children. South African Family Practice. 2006; 48 (4):38e42. I
4 Tait AR et al. Risk factors for perioperative adverse respiratory events in children with upper respiratory tract infections. Anesthesiology. 2001; III
95 (2):299e306.
5 Monto AS and Ullman Acute respiratory illness in an American community: the Tecumseh study. Jama. 1974; 227 (2):164-9. III
BM.
6 Parnis S et al. Clinical predictors of anaesthetic complications in children with respiratory tract infections. Pediatric Anesthesia. 2001; 11 (1):29 III
e40.
7 Jacoby DB and General Anesthesia in Patients with Viral Respiratory InfectionsAn Unsound Sleep? Anesthesiology: The Journal of the American II
Hirshman CA Society of Anesthesiologists. 1991; 74 (6):969-72.
8 Becke K Anesthesia in children with a cold. Current Opinion in Anesthesiology. 2012; 25 (3):333-9. II
9 Malisse M and Habre Pediatric anesthesia and upper respiratory tract infections. Revue medicale suisse. 2010; 6 (237):380, 2e3. II
W
10 Bo€senberg A The child with a runny nose! Upper respiratory tract infection in children: impact on anaesthesia. Southern African Journal of II
Anaesthesia and Analgesia. 2007; 13 (2):33-5.
11 Lee BJ and August DA COLDS: A heuristic preanesthetic risk score for children with upper respiratory tract infection. Pediatric Anesthesia. 2014; 24 II
(3):349-50.
12 Cote CJ The upper respiratory tract infection (URI) dilemma: fear of a complication or litigation? The Journal of the American Society of II
Anesthesiologists. 2001; 95 (2):283-5.
13 Parameswara G Anaesthetic concerns in patients with hyper-reactive airways. Karnataka Anaesthesia Journal. 2015; 1 (1):8. II
14 Moher D et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. International journal of surgery. I
2010; 8 (5):336-41.
15 Malviya S et al. Risk factors for adverse postoperative outcomes in children presenting for cardiac surgery with upper respiratory tract infections. III
Anesthesiology: The Journal of the American Society of Anesthesiologists. 2003; 98 (3):628-32.
16 von Ungern-Sternberg Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study. Lancet (London, England). III
BS et al. 2010; 376 (9743):773-83.
17 Regli A An update on the perioperative management of children with upper respiratory tract infections. Current opinion in II
anaesthesiology. 2017; 30 (3):362-7.
18 Flick RP et al. Risk factors for laryngospasm in children during general anesthesia. Pediatric Anesthesia. 2008; 18 (4):289-96. III
19 von Ungern-Sternberg Laryngeal mask airway is associated with an increased incidence of adverse respiratory events in children with recent upper II
BS et al. respiratory tract infections. Anesthesiology. 2007; 107 (5):714-9.
20 Shemesh S et al. To proceed or not to proceed: ENT surgery in paediatric patients with acute upper respiratory tract infection. The Journal of II
Laryngology & Otology. 2016; 130 (9):800-4.
21 Schreiner MS et al. Do children who experience laryngospasm have an increased risk of upper respiratory tract infection? Anesthesiology: The III
Journal of the American Society of Anesthesiologists. 1996; 85 (3):475-80.
22 Tait AR et al. The effects of general anesthesia on upper respiratory tract infections in children. Anesthesiology. 1987; 67 (6):930-5. II
23 Rachel Homer J et al. Risk factors for adverse events in children with colds emerging from anesthesia: a logistic regression. Pediatric Anesthesia. 2007; II
17 (2):154-61.
24 Ungern-sternberg V Salbutamol premedication in children with a recent respiratory tract infection. Pediatric Anesthesia. 2009; 19 (11):1064-9. I
et al.
25 Abouleish A et al. Topical lidocaine as adjunct to intubation without muscle relaxant in pediatric patients. Anesthesia & Analgesia. 1999; 89 I
(5):1328.
26 Hamilton ND et al. Does topical lidocaine before tracheal intubation attenuate airway responses in children? An observational audit. Pediatric I
anesthesia. 2012; 22 (4):345-50.
27 Sanikop C and Bhat S Efficacy of intravenous lidocaine in prevention of post extubation laryngospasm in children undergoing cleft palate surgeries. I
Indian journal of anaesthesia. 2010; 54 (2):132.
28 Tait AR Anaesthetic management of the child with an upper respiratory tract infection. Current Opinion in Anesthesiology. 2005; 18 II
(6):603-7.
29 Oberer C et al. Respiratory reflex responses of the larynx differ between sevoflurane and propofol in pediatric patients. The Journal of the I
American Society of Anesthesiologists. 2005; 103 (6):1142-8.
30 Megan Grelson S Risk of Complications Using Laryngeal Mask Airway versus Endotracheal Tube During General Anesthesia in Pediatric Patients II
with Upper Respiratory Infections: A Narrative Review. Creation of the Upper Respiratory Infection Screening Tool© and
Management Al. Anesthesia eJournal. 2013; 1 (1).
31 Mamie C et al. incidence and risk factors of perioperative respiratory adverse events in children undergoing elective surgery. Pediatric II
Anesthesia. 2004; 14 (3):218-24.
32 Tait AR et al. Use of the laryngeal mask airway in children with upper respiratory tract infections: a comparison with endotracheal intubation. II
Anesthesia & Analgesia. 1998; 86 (4):706-11.
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 G.F. Lema et al. / International Journal of Surgery Open 12 (2018) 17e24 23

Annex III
Prisma checklist.

Section/topic # Checklist item Reported on

page#

Title
Title 1 Evidence - based perioperative management of child with upper respiratory tract infections (URTIs) undergoing elective surgery: A 1
systematic review.
Abstract
Structured 2 Background: Upper respiratory tract infection is frequently encountered medical problems in paediatric age groups. A child with less 1
summary than five years may have six up to seven episodes of URTIs per year with each lasting up to two weeks and residual pulmonary effects
may lasting 2e6 weeks. The issue of whether to proceed with elective surgery on a child with an URTI has been source of debate for
many years. The rationale of this review is to avoid traditional approach of blanket cancellation of surgery by stratified risk factors as
well as optimization of the patient. Furthermore, this review summarizes current evidence regarding perioperative anaesthetic
management of children with an URTI.
Methods: Based on the formulated eligible criteria's, search engines like PubMed through HINARI, Cochrane data base and Google
Scholars were used to find high level evidences that help to draw appropriate conclusions.
Discussion: Performing anaesthesia in children with URTIs increases the risk of perioperative respiratory adverse events (PRAEs) like
laryngospasm, bronchospasm, and desaturation and breathe holding.
Conclusion: Children with mild and moderate URTIs can safely anaesthetized with optimal preparation and optimization of the patient
in the preoperative period. Prevention of stimulation of a potentially irritable airways, use of bronchodilators and induction with
propofol are helpful. Furthermore, adequate suppression of airway reflexes with optimal depth of anaesthesia is highly recommended.
Key words: Upper respiratory tract infection; Respiratory adverse events; paediatric anesthesia; Desaturation, Hyper-reactive airway.
Introduction
Rationale 3 Anesthesia for elective surgery in paediatric patients with a recent upper respiratory tract infection (URI) was commonly postponed for 3
several weeks in the past. The blanket defer of surgeries can have an impact on social, economic, and emotional consequences for the
child, the Family and the health service system in general.
Inadequate of optimization of child having URTIs undergoing surgery may increase the perioperative respiratory adverse events, which
may increase morbidity and mortality in the post operative period, increase and hospitalization.
Empirically, postponing surgery in a child suffering from upper respiratory tract infection was usually based on an increased risk of
perioperative respiratory adverse events (PRAEs), which can occur up to 6 weeks after the disease. Today there is a notable trend for
anesthesia to be safely performed in children with upper respiratory tract infections (URTIs) when a careful assessment of potential
risks and benefits for the child is implemented and safety precautions are taken.
This review focuses on Comprehensive assessment, stratification of sign and symptoms of URTIs, optimization in the preoperative
period and design appropriate anaesthetic management may avoid traditional blanket cancellation of surgery and decrease the risk of
perioperative respiratory adverse events (PRAEs) following the surgery.
Objectives 4  To avoid blanket cancellation of elective surgery in child with URTIs 3
 To develop decisional algorithm to continue elective surgery in child with URTIs
 To formulate possible perioperative management for child with mild and moderate URTIs undergoing elective surgery under general
anesthesia.
Methods
5 There is much debate regarding the optimal timing of elective surgery in children with recent URTIs. The duration of airway 3 and 4
susceptibility and bronchial hyper reactivity in children following a URTI remains unclear. However, it is known to persist well beyond
resolution of symptoms. Given the high frequency of URTIs in children, it can be difficult to find a time in which the child is truly well.
After formulating eligibility criteria for the evidences to be included a literature search was conducted. Evidences were collected, then
appraisal and evaluation of quality conducted using different institutional appraisal checklists to categorize them in to level 1 (* Meta-
analysis, systematic review, randomized control trial), level 2 (** Well designed cohort study) and level 3 (*** cross sectional, audit
study).
Furthermore, after comprehensive and indepth appraisal of literature, conclusion has drawn from the evidences on whether to proceed
surgery or not, preoperative optimization and perioperative management of mild and moderate URTIs.
Discussion
6 Perioperative respiratory adverse events are the major complications during intra operative and post operative period in children with 5
URTIs. Typical adverse events in children with respiratory tract infection are laryngospasm, bronchospasm, breath holding, atelectasis,
arterial oxygen desaturation, bacterial pneumonia, and unplanned hospital admission. Hence, these children may benefit from pre-
anaesthetic assessment and specifically targeted peri-operative anaesthetic management. When evaluating a child with a URTI for
whom elective surgery is planned, pre-operative information must be meticulously obtained for the best anaesthetic management, in
order to reduce the risk of perioperative respiratory adverse events
Conclusion
7 With the high incidence of URIs in children and the increased perioperative risk, anaesthetists are often confronted with decisions that
need to be made about the best management for these children. Most of the literature suggests that Child with severe symptoms of
URIs must be postponing the elective surgery for at least greater than 2 weeks and should re- evaluated.
Children with a Mild and moderate URI may be safely undergoing surgery, since the respiratory adverse events are anticipated,
recognized and generally easily treated and without long-term complications. The algorithm suggested for the assessment of a child
with acute URTIs may be a useful tool to aid the decision.
The best anaesthetic management should include pre-treatment with salbutamol, the use of propofol and avoidance of endotracheal
intubation whenever possible, use of a face mask ventilation or laryngeal mask ventilation. Moreover, prevention, early recognition
and immediate treatment of complications by an experienced anaesthetist are crucial.
Funding
Funding 8 Department of an aesthesia, University of Gondar

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS
Med 6(7): e1000097. doi:10.1371/journal.pmed1000097.
24 G.F. Lema et al. / International Journal of Surgery Open 12 (2018) 17e24

Annex IV [16] von Ungern-Sternberg BS, Boda K, Chambers NA, Rebmann C, Johnson C,
List of abbreviations. Sly PD, et al. Risk assessment for respiratory complications in paediatric
anaesthesia: a prospective cohort study. Lancet (Lond Engl) 2010;376(9743):
ETT Endotracheal tube 773e83.
GA General Anaesthesia [17] Regli A, Becke K, von Ungern-Sternberg BS. An update on the perioperative
LMA Laryngeal Mask airway management of children with upper respiratory tract infections. Curr Opin
URTI Upper respiratory tract infection Anaesthesiol 2017;30(3):362e7.
PRAE Perioperative respiratory adverse events [18] Flick RP, Wilder RT, Pieper SF, Vankoeverden K, Ellison KM, Marienau ME,
Intra -op Intra operative et al. Risk factors for laryngospasm in children during general anesthesia.
Post - op Post operative Pediatr Anesth 2008;18(4):289e96.
ENT Ear, Nose and Throat [19] von Ungern-Sternberg BS, Boda K, Schwab C, Sims C, Johnson C, Habre W.
Laryngeal mask airway is associated with an increased incidence of adverse
LRT Lower respiratory tract
respiratory events in children with recent upper respiratory tract infections.
Anesthesiology 2007;107(5):714e9.
[20] Shemesh S, Tamir S, Goldfarb A, Ezri T, Roth Y. To proceed or not to proceed:
ENT surgery in paediatric patients with acute upper respiratory tract infec-
tion. J Laryngol Otol 2016;130(9):800e4.
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