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Preoperative atropine treatment and fever in children.

This report highlights the high frequency of fever in children treated with atropine eye drops or ointment for three to five days prior to ophthalmic examination under anaesthesia. In our group of 66 atropine treated children, 72% had a temperature of 38[degrees]C or more on admission.

Children scheduled for ophthalmic examinations or procedures need adequate pupillary dilatation and also accommodation paralysis. For this purpose, the Ophthalmology Department at this institution initiates atropine drops (1%) or ointment (1%) three to five days preoperatively. The ocular administration of atropine has systemic effects due to absorption via the conjuctival sac and nasal mucosa (1). Most of the side-effects of atropine are directly related to its anti muscarinic action. Occasionally, therapeutic doses dilate cutaneous blood vessels, particularly in the 'blush' area (atropine flush), and may cause 'atropine fever' due to suppression of sweat gland activity especially in infants and small children. Atropine use in children may also be associated with tachycardia, arrhythmia, tremor, drowsiness, headache and constipation. Transient bradycardia has also been described at the onset of atropine's action, particularly when given intravenously in low dose. Atropine is said to be relatively contraindicated in children with fever, Down syndrome and convulsive disorders.

We recorded the temperatures of 66 children scheduled for ophthalmic examination or procedures for which they were prepared with ocular atropine (Table 1). All received atropine until the morning of the procedure. A temperature of 38[degrees]C or greater was recorded in 46 (72%) of the 66 children. Treatment of the fever was initiated for the 20 children (30%) with a temperature of 39[degrees]C or more. I n the children with a temperature less than 39[degrees]C, none had signs of infection and no treatment of the fever was initiated and anaesthesia was administered uneventfully. Of the 20 children with a temperature >39[degrees]C, six children had features suggestive of respiratory tract infection and hence were postponed. The other 14 children were managed conservatively in the preoperative room until the temperature was less than 39[degrees]C and then were anaesthetised uneventfully.

Preoperative fever is commonly a clinical indicator of possible infection in children. In this group of atropine treated patients, the frequency of fever made temperature a poor indicator of infection. Only six (9%) of our patients had high fever and clinical signs of respiratory infection which prompted us to postpone the procedure. Recent respiratory infection in children is associated with an increased incidence of perioperative respiratory adverse events (2). In our atropine treated patients, fever was so common that we did not use fever alone as a criterion for cancelling the procedure. Cancellation of procedures may impose emotional and economic burdens on parents (3). Unless clinical indicators of recent respiratory infection such as running nose, cough or sneezing (4) or indications of general infection such as fatigue, malaise or loss of appetite were present, we proceeded with the case. Investigation of cases where infection is suspected should be guided by the clinical history and examination.

Alternative mydriatic regimens are used at many centres. If an atropine-based regimen such as ours is used, the systemic effect of ocular atropine can be avoided or minimised, by instilling it only once daily, using a microdropper for infants and digital pressure over the lacrimal duct for five minutes after instillation of the atropine to reduce systemic absorption. Atropine can be stopped 24 to 48 hours prior to a planned eye examination under anaesthesia to avoid systemic effects on the day of the procedure, as the ocular effects of atropine persist for five to seven days. Children with atropine fever can be managed with tepid sponging, anti-pyretic and adequate fluid therapy.

References

(1.) Kaila T, Korte JM, Saari KM. Systemic bioavailability of ocularly applied 1% atropine eyedrops. Acta Opthalmol Scand 1999; 77:193-196.

(2.) Tait AR, Malviya S. Anesthesia for the child with an upper respiratory tract infection: Still a dilemma. Anesth Analg 2005; 100:59-65.

(3.) Clinch J, Dale S. Managing childhood fever and pain--the comfort loop. Child Adolesc Psychiatry Ment Health 2007; 1:7.

(4.) Pappas DE, Hendley JO, HaYden FG, Winther B. Syptom profile of common colds in school aged children. Pediatr Infect Dis J 2008; 27:8-11.

R. GARG

R. SINHA

New Delhi, India
TABLE 1
Number of children in each 'temperature range' on admission,
in children receiving ocular atropine

Temperature ([degrees]C) Number of children (n=66)

<38 18
38-38.9 28
39-40 14
>40 6
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Article Details
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Title Annotation:Correspondence
Author:Garg, R.; Sinha, R.
Publication:Anaesthesia and Intensive Care
Article Type:Clinical report
Geographic Code:9INDI
Date:Jul 1, 2008
Words:743
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