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YOUR PATIENT

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A 15-year-old male with asthma develops intraoperative bronchospasm.

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PREOPERATIVE CONSIDERATIONS

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The goal of preoperative assessment in an asthmatic patient is to gauge the severity and control of the asthma. Key factors in determining the severity of the asthma are:

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  • Number of acute exacerbations, hospital presentations, and admissions in a year

  • Recent asthma symptoms, medical interventions, and hospital visits

  • Level of maintenance therapy

  • Albuterol frequency, recent use, and recent escalation of therapy

  • Number of episodes of oral corticosteroid use for acute exacerbations within the past year

  • Previous intensive care admission and invasive ventilation

  • Any specific triggers for bronchospasm

  • Presence of recent cold symptoms within the last two weeks

  • Functional exercise tolerance is a useful marker of severity

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A patient with severe asthmatic attacks is more likely to develop perioperative bronchospasm and would benefit from a preoperative consultation with a pulmonologist to optimize his or her asthma control.

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Common triggers for childhood asthma exacerbation include the following:

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  • Upper respiratory infection (URI)—usually viral

  • Smoke or other inhaled irritant gases

  • Pollen

  • Foreign bodies

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Potential trigger agents should be identified and avoided. The usual inhaled and oral medications should be taken the day of surgery.

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ANESTHETIC MANAGEMENT

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  • A patient with a history of prolonged oral prednisolone or high dose of inhaled corticosteroids within the previous 12 months may benefit from a single intraoperative dose of corticosteroids.

  • Consider a premedication to avoid or reduce the patient’s anxiety upon induction. Crying or coughing during uncooperative inhalational induction may trigger acute bronchospasm.

  • A deep plane of anesthesia reduces airway reactivity associated with intubation.

  • Avoid carinal irritation, which may precipitate bronchospasm.

  • Avoid irritant volatile agents (desflurane), which may precipitate bronchospasm.

  • Consider the total intravenous anesthesia (TIVA) technique and regional anesthesia.

  • Consider using ketamine for IV induction (1-2 mg/kg) and maintenance (12.5-45 μg/kg/min infusion) of anesthesia.

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Intraoperative management of bronchospasm

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  • Ensure adequate oxygen delivery and carbon dioxide clearance.

  • Eliminate mechanical causes: blocked or kinked endotracheal tube (ETT), carinal irritation, or a defective circuit.

  • Eliminate other causes of increased airway pressures: pneumothorax, abdominal splinting due to light anesthesia, or anaphylaxis.

  • Limit ventilator pressures to reduce risk of barotraumas and cardiovascular collapse: increase fraction of inspired oxygen (FiO2), reduce respiratory rate, reduce inspiratory:expiratory (I:E) ratio (prolong expiratory time to avoid gas trapping).

  • Deepen the level of anesthesia with volatile agents or with propofol.

  • Inhaled albuterol (metered-dose inhaler [MDI] + spacer): up to 10 puffs (1 mg) every 20-30 minutes.

  • Subcutaneous terbutaline 10 μg/kg (maximum dose of 250 μg).

  • Aminophylline: 5-7 mg/kg IV over 30 minutes followed by a 0.5-1.5 mg/kg/h infusion.

  • Corticosteroids:

    • Hydrocortisone 4 mg/kg IV

    • Methylprednisone 1 mg/kg IV

  • Epinephrine (1:1000) IV: 1-10 mcg/kg:

    • Subcutaneous: 10 μg/kg (maximum dose of 400 μg)

    • ETT: 1 μg/kg

  • Magnesium: 40 mg/kg IV over 20 minutes.

  • Volatile anesthetic agents.

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