A 4-year-old boy with asthma requires general anesthesia for umbilical hernia repair. He is maintained on inhaled steroids, inhaled cromolyn, an orally administered leukotriene antagonist, and occasionally requires nebulized albuterol for acute episodes of wheezing. Two weeks prior to the surgery, he required one week of oral prednisone for an asthma exacerbation that was worse than usual.

Does the recent exacerbation and oral steroid requirement change your approach to the anesthetic management?

There are two ways the history of a recent asthma exacerbation may change my anesthetic management approach. First, I will make sure the child is now in excellent health, and without any wheezing or URI. The procedure is purely elective and should not be performed if the child is still having symptoms of his illness. Second, if his illness has completely abated this child may be a candidate for prophylactic oral steroid therapy for several days prior to the procedure. I will make this determination by speaking with the boy’s parents several days prior to the procedure. If he has required previous hospitalization for his asthma, or frequent systemic steroid use in the past, it indicates that his disease is prone to flare-ups. I will ask his pediatrician to see him prior to the scheduled surgery and prescribe oral steroids for several days. This usually consists of prednisone, up to 1mg/kg daily.
If this child has had frequent asthma recurrences, I will alter my intraoperative management approach by avoiding endotracheal intubation. Most surgeons who perform umbilical hernia repair prefer intraoperative paralysis and there is no reason I can’t use a LMA with controlled ventilation during the procedure. I will avoid administration of medications that are associated with histamine release, such as morphine and atracurium, and I will remind the surgeon to administer local anesthetic into the wound, up to 1mL/kg of 0.25% bupivacaine or 0.2% ropivacaine. Alternatively, a rectus sheath block can be performed.