SARS‐CoV‐2 and paediatric anaesthesia: similar risk to classic viral upper respiratory tract infection, but still more to learn

We read with interest the editorial by Karlsson et al. [1] contextualising the study by Peterson et al. [2], who present a valuable analysis of peri‐operative risk during the initial months of the SARS‐CoV‐2 pandemic. Karlsson et al. [1] suggest applying existing management strategies used for children with symptomatic viral infection to those with confirmed SARS‐CoV‐2; using SARS‐CoV‐2 data to inform responses in future pandemics, and moving beyond data collection for children with SARS‐CoV‐2 undergoing general anaesthesia. We would like to add some alternative perspectives to some of these conclusions.

We agree that the published evidence and anecdotal experience suggest the current risk of peri‐operative respiratory adverse events in children with non‐severe SARS‐CoV‐2 is similar to the risk with symptomatic viral upper respiratory tract infection [2, 3]. Therefore, we agree that current management of children with non‐severe SARS‐CoV‐2 who present for anaesthesia should be consistent with established practice with other symptomatic viral upper respiratory tract infections. This may include discontinuation of universal pre‐operative testing for SARS‐CoV‐2 and replacement with symptoms or history‐based assessment, as has already occurred in many hospitals. Universal testing likely results in deferral or omission of beneficial surgical care without clear evidence that this prevents complications.

However, the current data regarding SARS‐CoV‐2 may not adequately describe the risk of severe complications during the initial phase of the COVID‐19 pandemic or for future viral pandemics. The COVIDSurg Collaborative assembled the largest study of peri‐operative outcomes in patients with SARS‐CoV‐2, which included data from children and young adults [4]. Analysis of these data identified increased risk of mortality in those with peri‐operative SARS‐CoV‐2. The data do not account for the severity of illness at the time of surgery, but do raise the possibility that children and young adults undergoing surgery early in the pandemic were at increased risk of death. The available studies of children with SARS‐CoV‐2 (including the study by Peterson et al. [2]) may be underpowered to detect occurrence or difference in mortality or other severe complications. Accordingly, if any increased risk exists, the incidence is likely quite low. However, the assumption that these peri‐operative severe complications did not occur due to COVID‐19 or will not occur with future viral pandemics in children undergoing anaesthesia may be flawed.

We disagree that future studies describing the effect of SARS‐CoV‐2 or other viral infections on peri‐operative outcomes are not valuable. Accumulated data may provide further evidence of whether children with SARS‐CoV‐2 are at increased risk of rare, severe complications. Additionally, current data concur with Karlsson et al. [1], that the omicron variant has resulted in less severe illness [5]. However, the correlation of these findings with studies describing peri‐operative risk in children with non‐severe infection of the omicron variant is warranted. Additionally, limited data exist to describe peri‐operative risk in the setting of asymptomatic viral infection with SARS‐CoV‐2 or other viral infections. Peterson et al. [2] found increased complications in children with symptomatic SARS‐CoV‐2, but the incidence of complications for asymptomatic children was 9%, greater than the 6% incidence among controls in that study and similar to that of other viral infections with active symptoms. Saynhalath et al. [3] also found increased risk of peri‐operative respiratory adverse events despite statistical adjustment for symptoms. It may be that asymptomatic children are at lower risk than symptomatic children, but data to concretely describe risk will be helpful for clinicians advising families with asymptomatic children who test positive for a virus before anaesthesia.