Home Archive Vol 35, No.3, 2009 For Practitioner Recently Immunization and Anesthesia of the Children

Recently Immunization and Anesthesia of the Children

Adriana Popa, Anca Malos, Daniela Cernea

Department of Anesthesiology and Intensive Care, Emergency University Hospital, University of Medicine and Pharmacy, Craiova

Abstract: Many children presenting for medical or surgical procedures which require general anesthesia can be recently vaccinated. There is no direct evidence of any major interaction between immunization and commonly used anesthetic agents and techniques in children, but is a theoretical risk associated with anesthesia and surgery in recently immunized children. The current evidence does not provide any contraindication to the immunization of healthy children scheduled for elective surgery. Respecting a minimal delay of  2 days (inactivated vaccines) or 14-21 days ( live attenuated viral vaccines) between immunization and anesthesia may be useful to avoid the risk of misinterpretation of vaccine-driven adverse events as postoperative complications.

Keywords: anesthesia, vaccination, risk, children


Introduction

Motto: ” Immunization has prevented more suffering and saved more lives than any other medical intervention in this century” (“National  Health and Medical Research Council” - 1991)

For immunization programs is utilized the principle of immunological memory.  Modified antigen in the form of attenuated living organism ( measles, mumps, rubella and poliovirus vaccines) killed organism (pertussis vaccine) or inactivated toxins ( tetanus and diphtheria toxoids) are used as immunizing  agents and lead to stimulation of  specific T and B antigen cell responses similar to those seen with natural infection [1]. These responses are associated with memory cell development offering varying degrees of protection upon future exposure to infection.

A ”vaccine”  (the more correct term of  “immunization” is used to describe the result and the term “vaccination”  applies to the inoculation of vaccinia virus) is a suspension of attenuated or killed microorganism ( bacterium, virus or rickettsia) which induces immunity and prevents infectious disease.[2]

Vaccines result in active immunization. Passive immunization is provided by immunoglobulin which is a sterile solution containing antibody isolated from large pools of the human blood and is given prophylactic to certain immunodeficiency patients or to patients with risk from specific infections.

Immunization programmes

The WHO Expanded Program for Immunization has been a very significant global strategy in making immunization against the major preventable childhood illnesses available to all children.

The usual immunizations provide protection against diphtheria, pertussis, tetanus, H. influenza type b, poliovirus (either oral or intramuscular vaccine), measles, mumps, rubella.  In many countries, as Romania, immunization against Hepatitis B and Tuberculosis is offered to all children.

In Romania the immunization program available since December 2008 is presented in table 1.

Table 1  Schedule for the Romania’s routine childhood immunization

Age

Vaccin e

How

First 24 hours

Hep B

One injection

4-7days

BCG (tuberculosis)

 

2 months

DTPa-VPI, Hep B

One injection

4 months

DTPa-VPI

One injection

6 months

DTPa-VPI, Hep B

One injection

12 months

DTPa-VPI, MMR

One injection

4 years

DTPa

One injection

7 years

RRO

One injection

9 years

VPO

One injection

14 years

dT, Rubella (to girls)

One injection

DTPa=diphtheria,tetanus,pertussis; VPI=polio; MMR=measles, mumps, rubella; VPO=oral polio

Given the current schedule for childhood immunization in Romania, it is likely that many children presenting for medical procedures which require general anesthesia have been vaccinated recently.

Side effects of immunization

It is important that the anesthesiologist has an informed opinion as to the indications for proceeding or postponing the procedure and to know the side effects of immunization (see table 2).

Table 2  Adverse  Reactions of vaccines

 

Adverse reaction

Vaccine

Common

Pain, swelling, redness at site of injection

all

 

Local adverse reactions e.g. small painless nodule

all

 

Systemic adverse reactions e.g. fever, malaise, myalgia, irritability,             all

 

 

headache, loss of appetite, rash; timing varies e.g. within a few

 

 

hours of tetanus containing vaccines, 7-10 days after measles

 

 

containing vaccines

 

Rare

Seizures

DTPa,MMR

 

Hypotonic-hyporesponsive episodes (HHE)

DTPa, VPO,VPI

 

Idiopathic thrombocytopenic purpura (ITP)

MMR

 

Acute arthropathy

MMR

 

Allergic reactions

all

 

Anaphylaxis

all

 

Headache, myalgia, diarrhea, poliomyelitis

VPO

Anesthesia and the immune system

It is known that the process of anesthesia, surgery, stress and trauma suppress the immune system and have influences on endocrine and metabolic responses.[3]

Some anesthetic agents e.g. nitrous oxide, depress bone marrow function. Halothane, nitrous oxide and to a lesser extent isoflurane have been found to depress neutrophil biocidal activity.

Anesthetic techniques that ablate the stress response may avoid the depression and even potentiate the biocidal activity of neutrophils. Spinal anesthesia avoids the depression of neutrophil biocidal activity.[4] Opioids in large doses suppress the stress response in neonates undergoing cardiac surgery and it have reduced perioperative infection and improved survival.[5] Anesthesia and surgery exert additive or synergistic influences on vaccine efficacy and safety. [6,7] Alternatively, inflammatory responses and fever elicited by vaccines may interfere with the postoperative course.

While “in vitro” studies have demonstrated different effect of anesthesia on the immune system, the “in vivo” effects are not easily identified due to many factors such as: preoperative health status, pre-existing co-morbidities, type, extent and duration of surgery, amount of blood loss. Moreover, the anesthesia and surgery are in a chronological time sequence and it is hard to discriminate which from anesthesia or surgery mostly modulates the immune system.

Anesthetic implications and recommendations

Because there is no direct evidence suggesting increased risks associated with anesthetizing recently vaccinated children, it is a lack of consensus approach among anesthesiologists regarding the theoretical risk of anesthesia and vaccination. Accordingly, Short et al have confirmed the variety of approaches. They conducted an international survey of members of Association of Pediatric Anesthetists of Great Britain and Ireland and The Society for Pediatric Anesthesia of New Zeeland and Australia. The responses were: 60% of respondents would anesthetize a child for elective surgery within one week of receiving a live attenuated vaccine (MMR, OPV), but 40% would not. 28% of respondents would postpone the scheduled immunization for 2-3 weeks after the surgery.[8]

So, the anesthesiologist has three questions to answer:

1)      Should elective surgery under general anesthesia be postponed in recently-vaccinated children?

2)      Should elective vaccination be postponed in children scheduled for elective surgery?

3)      What are the risks of general anesthesia in recently-vaccinated children, especially when anesthesia must be performed in case of emergency?

By searching the major medical database (OVID Medline, PubMed, ISIWeb of Science) and references cited in the articles themselves and the articles published in English between 1970 and 2006, Siebert et al concluded that the immunomodulatory influence of anesthesia during elective surgery is both minor and transient (around 48 hours) and that evidence does not provide any contraindication to the immunization of healthy children scheduled for elective surgery. Because the risk of contacting a vaccine-preventable disease the author recommends not postponing immunization on a child scheduled for elective surgery, especially during the first year of life when the most vaccines are scheduled.[9]

 Also, The Guidelines from the Department of Health of  UK state that the recent imminent elective surgery and the imminent general anesthesia are not contraindications to routine immunizations. The decision whether to proceed with anesthesia should remain at the discretion of the individual anesthetist in the case of emergency surgery and the unwell child following vaccination.[10]

For polio eradication there are two types of vaccines: the inactivated poliovirus vaccine (IPV) and the oral poliovirus vaccine (OPV). IPV is used in the developed countries . The industrialized countries used either the IPV or OPV, alone or in sequence, in routine immunization. For Romania, until December 2008 it has been used OPV exclusively in the Expanded Program on Immunization for the polio eradication. The advantages of OPV were low cost, easy of administration, high vaccine efficacy for low number of doses, mucosal immunity to stop virus transmission and vaccine-related virus spread contributing to “contact immunization”. The risk of vaccine-associated paralytic poliomyelitis (VAPP) is a serious consequence of the administration of OPV; the incidence of VAPP in European countries is 0,4-3 per million vaccinated children and in Romania its incidence is 1 per 3 million doses administered [11] and higher if intramuscular injections are performed within 30 days after OPV administration.[12] For this reason it is very important that the anesthesiologist knows what type of vaccine was administered for postponing the scheduled surgery for 30 days after the OPV dose. Knowing that the virus is eliminated by fecal material, it is recommended to not touch the fecal material.

Because the vaccine administrated by injection is usually realized in the antero-lateral thigh during infancy and in toddlers and older children in the deltoid region it is straightforward to avoid of contact with these areas during most anesthetic procedures.

The vaccine-induced adverse events (fever, pain, irritability) may arise and they should not be misinterpreted as post-operative complications.

To avoid the risk of misinterpretation of vaccine-driven adverse events as post-operative complications it is prudent to respect a minimal delay of 2 days for inactivated vaccines such as diphtheria-tetanus-pertussis or 14-21 days for live attenuated viral vaccines such as measles-mumps-rubella or varicello between immunization and anesthesia. Special considerations are needed for measles-mumps-rubella vaccination or varicella vaccination.

People who received any blood product, including plasma or platelets in an  interval of 3 to 7 months should elapse, dependent on the blood product transfused, before vaccination whit an MMR or varicella vaccine (see table 3).[13]

An interval is needed because there may be low levels of antibodies present in the blood product that may impair the immune response to the live vaccine. Thus, if in time of elective surgery is expected an important bleeding who needs a blood transfusion one can consider to postpone the elective surgery after the immunization whit MMR vaccine.

Table 3  Recommended intervals between either immunoglobulins or blood products and MMR or varicalla vaccination

Blood product

Dose

Estimated IgG

Interval

RBCs

iv 10ml/kg

10mgIg/kg

3 months

Whole blood

iv 10ml/kg

80-100mgIg/kg

6 months

Plasma

iv 10ml/kg

160mgIg/kg

7 months

Platelet products

iv 10ml/kg

160mgIg/kg

7 months

Immunoglobulins iv(therapy of immune deficiencies)

 

300-400mg/kg

9 months

Ig=immunoglobulins

An international study confirmed that only one third of anesthesiologists benefits from a hospital policies who varies from routine postponing the elective surgery to a recent vaccinated-child to decision at the discretion of the individual anesthesiologist. [8].

This guidance is based on a lack of evidence for adverse events rather than positive evidence of safety.

We therefore recommend that elective surgery and anesthesia should be postponed for one week after inactive vaccination and 3 weeks after live attenuated vaccination in children.

Emergency or urgent procedures that cannot be delayed will need to be managed in the light of the symptoms exhibited by the patient.

References

1.     Nossal GJV. Life, death and the immune system. Sci Am 1993;269:21-30;

2.     National Health and Medical Research Council. In: Immunisation Procedures, Canberra: Australian Government Publishing Service, 1994:5th edn,1;

3.     Weissman C The metabolic response to stress: an overview and update. Anesthesiology 1990;73:308-327;

4.     Erskine R, Janicki PK, Neil G, James FM. Spinal anaesthesia but not general anaesthesia enhances neutrophil biocidal activity in hip arthroplasty patients. Can J Anaesth 1994;41:632-638;

5.     Anand KJS, Hickey PR. Halothane-morphine compared with high-dose sufentanil for anesthesia and postoperative analgesia in neonatal cardiac surgery. N Eng J Med 1992;326:1-9;

6.     Salo M. Effects of anaesthesia and surgery on the immune response. Acta Anaesthesiol Scand 1992 Apr; 36(3): 201-220;

7.     Mannick JA, Rodrick ML, Lederer JA. The immunologic response to injury. J Am Coll Surg 2001 Sep;193(3):237-244;

8.     Short JA, van der Walt JH, Zoanetti DC. Immunization and anesthesia-an international survey. Paediatr Anaesth 2006 May; 16(5):514-522;

9.     Siebert JN, Posfay-Barbe KM, Habre W, Siengrist C-A. Influence of anesthesia on immune responses and its effect on vaccination in children:review of evidence. Pediatr anesth 2007;17:410-420;

10. Immunisation against infectious diseases. Department of Health 2006. http//www.dh.gov.uk/en/Policyand guidance/Healthandsocialcaretopics/Green book/DH_4097254;

11. Strebel PM, Ion-Nedelcu N, Baughman AL, Sutter RW, Cochi SL. Intramuscular injections within 30 days of immunization with oral poliovirus vaccinea risk factor for vaccine-associated paralytic poliomyelitis. New England Journal of Medicine 1995;332:500-6;

12. Strebel PM, Aubert-Combiescu A, Ion-Nedelcu N, Biberi-Moroeanu S, Combiescu M, Sutter RW, et al. Paralytic poliomyelitis in Romania, 1984-1991. Evidence for a high risk of vaccine-associated disease and reintroduction of wild-virus infection. American Journal of Epidemiology 1994;140:1111-24;

13. Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village IL: American Academy of Pediatrics. 2006.

 


 

 

Correspondence Adress: Popa Adriana,MD, Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy Craiova, Str Petru Rares nr. 4, 200456, Craiova, Dolj, Romania, e-mail oprea_elena_076@yahoo.com

 


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