Introduction

Anaesthetic and surgical staff are often presented with children who have recently been immunised, for either emergency or elective surgery. Although there is no direct evidence of any major interaction between immunisation and commonly used anaesthetic agents and techniques in children, it is possible that the anaesthesia or surgery may affect the immune response of the vaccine. It is also possible that the systemic effects from immunisation, such as fever, may confuse the clinical management of the patient during the post-operative period. It is therefore important that an immunisation history is undertaken prior to surgery. 

Aim

The aims of this guideline are:

• To inform medical and nursing staff about practice regarding the timing and side effects of immunisation with respect to general anaesthesia and surgery.
• To outline eligibility criteria where a patient could receive vaccination whilst under general anaesthesia.
• To outline the steps of getting a patient vaccinated under general anaesthesia if indicated.
• To indicate if scheduled immunisation should be delayed if a child has had either elective or emergency surgery.
  

Definition of terms

• AIR – Australian Immunisation Register, a national register where vaccinations are recorded
• Anaesthesia – insensitivity to pain, especially as artificially induced by the administration of gases or the injection of drugs before surgical operations. 
• EMR – Electronic Medical Record
• Immunisation – the process of inducing immunity to an infectious agent by administering a vaccine.
• Inactivated vaccine -- the viruses or bacteria in vaccines are completely inactivated (or killed) with a chemical so that they cannot reproduce themselves or cause disease but are still recognised by the body's immune system to achieve immunity.
• Live attenuated vaccine -- the live viruses used in vaccines are weakened (or attenuated) and they replicate themselves to cause the immune system to produce protective antibodies.
• Needle phobia – severe fear of medical needle procedure and/or recent prior failure to vaccinate due to severe fear or distress of the procedure.
• NIP – National Immunisation Program
• Vaccination – the administration of a vaccine; if vaccination is successful, it results in immunity.

Eligibility for immunisation under anaesthetic

There may be circumstances where vaccination under general anaesthesia may be the best option for the patient.  Specifically:

• Patients with developmental or behavioural disorders (such as autism spectrum disorder);
• Children and adolescents with extreme anxiety or needle phobia;
• Patients requiring four (4) or more injections.

Assessment

Preoperative assessment

• Pre-assessment of patients who are going for surgery to be done by the Nursing Care Coordinator at least one day before the surgery to determine if the patient requires vaccination under general anaesthesia.
  
• If yes, inform the perioperative team and the anaesthetist and arrange with the RCH Immunisation Centre.

Admission assessment

On admission the nurse should check the patient’s immunisation status with a parent or care giver.

The nurse should document if a patient is up to date with vaccination as well as if a patient has received a live attenuated parenteral vaccine in the last 10 days or an inactivated vaccine within 48 hours of the planned surgery.  

If the patient has received a vaccine, the perioperative team should be advised.

Immunisation under anaesthetic

• If upon pre-operative assessment, the patient meets the eligibility for immunisation under anaesthetic, then discuss with the perioperative staff a plan for vaccination. 
• For patients who are unable to receive an immunisation under anaesthetic, vaccines can be administered upon discharge at the RCH Immunisation Drop-in Centre, at a follow-up outpatient appointment at RCH, or via the patient’s General Practitioner.
  

Management

Pre-operative / Intra-operative

As both anaesthesia and surgery may impair the immune system, there is the theoretical risk of altered response to vaccines if surgery is performed in close proximity to vaccine administration.   Also, vaccine side effects can be similar to postoperative events, possibly confusing the signs of surgical complications.  There is no absolute contraindication to opportunistic vaccination during general anaesthesia, but plans for opportunistic vaccination should be made on a case-by-case basis and take into consideration the patient’s medical history and the procedure itself (see eligibility criteria above).  Immunisation could be given when the child has recovered, before discharge.  

In situations where intra-operative vaccination is required, this is to be negotiated with the Royal Children’s Hospital (RCH) Immunisation Centre nursing staff and the perioperative staff prior to the patient entering the Operating Suite. This can be via the Nurse Coordinator.  Steps:

• Inform the nursing staff of RCH Immunisation Centre at least one day before the patient’s surgery or procedure under general anaesthesia (or on Friday if the surgery is on the following Monday);
• Consent for vaccination under general anaesthesia needs to be documented on the RCH Policy and Procedure: Consent Form;
• Nursing/Pharmacy staff of RCH Immunisation Centre need to go through the pre-vaccination screening checklist and discuss the vaccine side effects with the parent/carer prior to vaccination, as well as obtain and document in the EMR parent/guardian consent;
• Anaesthetist or other perioperative staff member contacts the RCH immunisation Centre ten (10) minutes prior to taking the patient into the Anaesthetic Induction Room;
• Nursing staff of RCH Immunisation Centre administers vaccinations according to the Clinical Practice Guideline on Immunisation of Inpatients once the patient is anaesthetised.
• If the RCH Immunisation service staff are unable to administer the vaccine(s) due to time constraints, then the anaesthetist can administer if the vaccine is prescribed in the EMR.  Theatre staff will need to obtain the required vaccine(s) from RCH pharmacy.

Please note:

• Recent immunisation does not impact upon the outcome of surgery.
• Possible side effects such as mild fever, irritability or sleepiness may occur up to 48 hours following immunisation with inactivated vaccines, or high fever around 7 to 10 days following immunisation with live attenuated vaccines. This is more likely to be a real problem following major surgical procedures, as fever and malaise may cause confusion in the post-operative period.
• Record date of recent vaccination in the Nursing assessment and inform surgical and anaesthetic staff so that this can be taken into account when managing the patient post-operatively.

Documentation of vaccination:

All vaccines administered to patients should be documented in the patient’s EMR and the individual child health record.  Once documented in the EMR, an inbasket message is automatically sent to the Immunisation staff for recording on the Australian Immunisation Register (AIR).

Post-operative 

• There is no contraindication to immunisation immediately after surgery, once the child is well and has recovered from the procedure.
• Delaying immunisation increases the risk of infection in the affected child, and has been shown to result in non-completion of the immunisation schedule in some children. The importance of completing the immunisation schedule both for the child and the community outweighs any concerns about the impact of immunisation upon surgery and the impact of surgery upon immunisation.

Splenectomy

• Where possible people having a planned splenectomy should ideally receive all additional vaccines at least 2 weeks prior to surgery. This is to ensure optimal protection prior to spleen removal.
  
• Those who undergo an unplanned or emergency splenectomy should defer vaccines for at least 7 days following surgery to allow time for recovery.

As per: https://mvec.mcri.edu.au/references/asplenia/

Blood products during surgery

A person who receives any blood products during surgery will need to delay some vaccinations. As per: https://immunisationhandbook.health.gov.au/contents/vaccination-for-special-risk-groups/vaccination-before-or-after-anaesthesia-or-surgery

Notes

RCH Immunisation Drop-in Centre opens from 9:00am - 4:30pm Monday to Friday (except public holidays). Phone: 93454899 

Links

• Immunisation of inpatients
• Australian Immunisation Handbook
  • Pre-vaccination screening checklist (Table 2.1.1)
• Association of Paediatric Anaesthetists - The timing of vaccination with respect to anaesthesia and surgery
• NIP Schedule 2023
  

Please remember to read the disclaimer . 

The development of this clinical guideline was coordinated by Sonja Elia, Nurse Practitioner, Immunisation . Approved by the Clinical Effectiveness Committee. Updated December 2023.