Uri

[KungPOWChicken]

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So we regularly have patients who come in with recent sore throats or coughs. For some reason where I practice people have the idea that these cases should be canceled and delayed two to four weeks after symptom free. Recently, we had a 41 y/o patient who said she had a sore throat. Her primary physician thought her tonsils were large and so she was swabbed. Negative rapid group strep. Culture positive for moderate group b strep. So she received IM penicillin. Well, 4 days later she arrives for surgery improved but not 100%. Patient wants the surgery. Feels good, looks well on exam. Case canceled by CRNA. There's no way I would have canceled the case. All of the literature on uri's appears to deal with pediatrics. In training and in practice for adult patients otherwise healthy meaning no asthma who have upper respiratory infections, I see no reason to cancel so long as the patients exam is good and the patient wishes to proceed.

 

[Arch Guillotti]

Why are nurses cancelling cases in the first place???

 

[KungPOWChicken]

Unfortunately, in the military crna's practice independently. I see no point in arguing with their decisions, although patients suffer a huge inconvenience. This patient waited around all morning and I'm sure had arranged a lot of time off and other arrangements as she was having a hysterectomy. She was not happy to say the least

 

[pgg]

Why are nurses cancelling cases in the first place???

Par for the course in opt-out land and the military.

 

[cchoukal]

I agree most of the literature on this is in kids. I recently read a retrospective study on post-op pulmonary complications that included a regression analysis identifying independent risk factors for such complications (which often included post-op mech ventilation, bronchospasm, desaturations and others), and "URI within 30 days" was one of the things that shook out as being a significant predictor. I searched my Papers database and couldn't find the paper, but I'm sure you could pubmed this.

 

[Arch Guillotti]

Par for the course in opt-out land and the military.

oh yeah the military

 

[OB1🤙]

Par for the course in opt-out land and the military.

Seems to me then that this ought to be one of the sharper tools in the PACs' arsenals, if we can collect evidence that independent CRNAs cancel more cases than when physicians are involved in preop assessment.

On an individual hospital level, lost revenue from case cancellations is lost revenue. And surgeons should notice the difference too.

Now someone other than me should get out there and start collecting some stats.

 

[KungPOWChicken]

I agree most of the literature on this is in kids. I recently read a retrospective study on post-op pulmonary complications that included a regression analysis identifying independent risk factors for such complications (which often included post-op mech ventilation, bronchospasm, desaturations and others), and "URI within 30 days" was one of the things that shook out as being a significant predictor. I searched my Papers database and couldn't find the paper, but I'm sure you could pubmed this.

Was this study conducted on adults or children. I don't believe you can extrapolate data from children to adults as kids have much smaller airways that are much more sensitive to irritation. That being said I wouldn't cancel most pediatric cases if they had a minor URI. I don't recall canceling any cases in adults for a uri as a resident. "Patients who have had a uri for days or weeks and are stable or improving can be safely managed without postponing surgery...The economic and practical aspects of canceling surgery should be taken into consideration before a decision is made to postpone" Stoelting

 

[Arch Guillotti]

I probably wouldn't cancel based on the info give. Feels good, looks good, pent, sux, tube. This seems very ticky-tacky.

 

[cchoukal]

Was this study conducted on adults or children. I don't believe you can extrapolate data from children to adults as kids have much smaller airways that are much more sensitive to irritation. That being said I wouldn't cancel most pediatric cases if they had a minor URI. I don't recall canceling any cases in adults for a uri as a resident. "Patients who have had a uri for days or weeks and are stable or improving can be safely managed without postponing surgery...The economic and practical aspects of canceling surgery should be taken into consideration before a decision is made to postpone" Stoelting

This was in adults. I'll see if I can find the paper.

 

[KungPOWChicken]

I agree most of the literature on this is in kids. I recently read a retrospective study on post-op pulmonary complications that included a regression analysis identifying independent risk factors for such complications (which often included post-op mech ventilation, bronchospasm, desaturations and others), and "URI within 30 days" was one of the things that shook out as being a significant predictor. I searched my Papers database and couldn't find the paper, but I'm sure you could pubmed this.

Was this study conducted on adults or children. I don't believe you can extrapolate data from children to adults as kids have much smaller airways that are much more sensitive to irritation. That being said I wouldn't cancel most pediatric cases if they had a minor URI. I don't recall canceling any cases for a uri as a resident. "Patients who have had a uri for days or weeks and are stable or improving can be safely managed without postponing surgery...The economic and practical aspects of canceling surgery should be taken into consideration before a decision is made to postpone" Stoelting

 

[BLADEMDA]

Despite the increased risk of respiratory events in children with URIs, there appears to be very little residual morbidity. Indeed, there are no cases in the pediatric and adult anesthesia closed claims literature implicating URIs with serious adverse events (18,19).

 

[BLADEMDA]

http://bja.oxfordjournals.org/content/78/4/352.full.pdf

Airway activity in adults is increased following a URI for 2 weeks.

Barash recommends waiting 6 weeks after a URI for elective, ambulatory Surgery:

http://books.google.com/books?id=UFVjFYeIUOoC&pg=PA482&lpg=PA482&dq=uri+in+adults+and+anesthesia&source=bl&ots=59_MGZWcTY&sig=p2kRikfYBkiCkDKmimEHo94XyxI&hl=en&sa=X&ei=QHygT5bnOYqi8QSEk9mDAQ&sqi=2&ved=0CEwQ6AEwBg#v=onepage&q=uri%20in%20adults%20and%20anesthesia&f=false Page 482

 

[BLADEMDA]

http://books.google.com/books?id=x9RXkpBOHh8C&pg=PA103&dq=uri+in+adults+and+anesthesia&hl=en&sa=X&ei=FX6gT6ntHpOK8QTUm_XCAQ&ved=0CFYQ6AEwBjgK#v=onepage&q=uri%20in%20adults%20and%20anesthesia&f=false page 103


This author states adults have no increased risk with anesthesia despite the presence of a URI.

 

[Orin]

This was in adults. I'll see if I can find the paper.

Is it this one:

http://journals.lww.com/anesthesiol...Prediction_of_Postoperative_Pulmonary.20.aspx

Prediction of Postoperative Pulmonary Complications in a Population-based Surgical Cohort

Of 2,464 patients studied, 252 events were observed in 123 (5%). Thirty-day mortality was higher in patients with a PPC (19.5%; 95% [CI], 12.5–26.5%) than in those without a PPC (0.5%; 95% CI, 0.2–0.8%). Regression modeling identified seven independent risk factors: low preoperative arterial oxygen saturation, acute respiratory infection during the previous month, age, preoperative anemia, upper abdominal or intrathoracic surgery, surgical duration of at least 2 h, and emergency surgery. The area under the receiver operating characteristic curve was 90% (95% CI, 85–94%) for the development subsample and 88% (95% CI, 84–93%) for the validation subsample.

 

[KungPOWChicken]

Is it this one:

http://journals.lww.com/anesthesiol...Prediction_of_Postoperative_Pulmonary.20.aspx

Prediction of Postoperative Pulmonary Complications in a Population-based Surgical Cohort

Their definition of respiratory infection isn't a URI it's more of a Pneumonia which obviously has a higher risk

 

[fakin' the funk]

Recently, we had a 41 y/o patient who said she had a sore throat. Her primary physician thought her tonsils were large and so she was swabbed. Negative rapid group strep. Culture positive for moderate group b strep. So she received IM penicillin. Well, 4 days later she arrives for surgery improved but not 100%. Patient wants the surgery. Feels good, looks well on exam. Case canceled by CRNA. There's no way I would have canceled the case. All of the literature on uri's appears to deal with pediatrics. In training and in practice for adult patients otherwise healthy meaning no asthma who have upper respiratory infections

Maybe I'm wrong but I think the term "URI" is being used to mean a couple different things here (and most incorrectly by the CRNA in question)...

In kids we think about "URI" as viral laryngitis/tracheitis/bronchitis predisposing to laryngospasm and bronchospasm.

This adult has bacterial pharyngitis. While I suppose this is technically a "URI" in the strictest sense of those words, it ain't the same clinnical entity, and I can't see any way that this has anything to do with severe laryngospasm/bronchospasm that we worry about in kids.

 

[dhb]

Would you use an LMA if you were to do this case?

 

[BLADEMDA]

Would you use an LMA if you were to do this case?

When a patient has a uri or recovering from a uri I try and avoid an ETT whenever possible.
Regional or LMA are solid choices.

I rarely cancel (never cancelled an adult for a uri in my career) but I do advise that an outpatient case may turn into a 23 hour stay if the uri is severe. Of course, that event is rare.

If the uri is more of a bronchitis then avoiding an ETT makes even more sense

 

[TrustMe]

I agree with the economical and logistical interference with canceling cases without a "solid" reason. It is a very big problem for some patients, especially if they have driven from a distance, taken time off from work, and arranged transportation to and from the hospital. I ran into this last year as a CA-3. I was in an adult ENT room (otology to be exact) and one of my patients had had a cold with clear rhinorrhea but was feeling better. I had completed the pre-op (healthy 41 y/o) and placed an IV. My attending came by and talked to the patient and decided to cancel the case based on her "URI". Surgeon obviously upset with very soft call and pt. and husband upset that they had both taken the day off of work to be here. Said attending consults with the coordinator (who happened to be our chairman). He backed her up on the cancellation, but told me later it was only because he rarely if ever will not back one of our staff in front of the surgeons, and that he would not have canceled. Then I feel bad because I had told the pt. everything was fine to go and attending then cancels.

 

[fakin' the funk]

Would you use an LMA if you were to do this case?

OP doesn't say what the case is. Let's hope it's not a robotic prostate in a patient with an SBO. I probably wouldn't use an LMA for that case.

 

[dhb]

When a patient has a uri or recovering from a uri I try and avoid an ETT whenever possible.
Regional or LMA are solid choices.

I was referring to the setting of a sore throat.
Personally if the patient has an erythematous oropharynx i wouldn't use an LMA

 

[KungPOWChicken]

This case was a lap hysterectomy so lma not an option. This lady looked good to go from across the room though. She looked like she could have ran a marathon that day. Oh bye the way, same crna was wanting to get a cardiology consult for a post-op c-section because she was having pvc's. Are you kidding??? The state of healthcare will surely take a turn for the worse with midlevel encroachment.