Vol 10 | Issue 2 | May-August 2024 | Page: 19-21 | Vaibhavi Baxi, Maitri Shah
DOI: https://doi.org/10.13107/jaccr.2024.v10.i02.241
Submitted: 08/03/2024; Reviewed: 01/04/2023; Accepted: 14/06/2024; Published: 10/08/2024
Author: Vaibhavi Baxi [1], Maitri Shah [1]
[1] Department of Anaesthesia, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India.
Address of Correspondence
Dr. Vaibhavi Baxi,
Department of Anaesthesia, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India.
E-mail: drvaibhavi13@gmail.com
Abstract
Administering anaesthesia in the pediatric population is challenging because of various physiological and anatomical changes in them compared to adults. It becomes more difficult when associated with congenital anomalies. One of the major anaesthetic challenges in meningomyelocele (MMC) includes securing the airway with proper positioning of the child. The airway becomes a challenge, especially in small babies with associated congenital anomalies, raised intracranial pressure (ICP), and in emergency presentations with upper airway obstruction. Here is a case report of a 5-month-old 6 kg baby with big lumbar MMC and hydrocephalus, raised intracranial pressure with grunting noise indicating upper airway obstruction with respiratory distress for emergency ventriculo-peritoneal shunt placement. Video laryngoscopy (C-MAC)® with pediatric Millers blade was used as the first choice as a difficult airway was anticipated and helped us secure a difficult airway within seconds without any rise in ICP. The baby was placed supine for surgery while avoiding any pressure on the swelling to prevent its rupture, cerebrospinal fluid leak, or increase in ICP. Apart from airway control, intraoperative anaesthetic management in this case of V-P shunt also included proper positioning of large MMC, prevention of any rise in ICP, and prevention of hypothermia.
Keywords: Video-laryngoscope, Pediatric millers blade, Difficult pediatric airway, Meningomyelocele, Ventriculo-peritoneal shunt.
Introduction
Meningomyelocele (MMC) a common open neural tube defect (NTD) is characterized by failure of the neural tube to close in the lumbosacral region during embryonic development (4th-week post-fertilization), leading to the herniation of the meninges and spinal cord through a vertebral defect [1]. Infants born with MMC may present with hydrocephalus due to abnormal accumulation of cerebrospinal fluid (CSF) in the ventricles and ventricular shunts (V-P shunt) remains the cornerstone of treatment for hydrocephalus in these patients [2]. A thorough pre-operative anaesthetic assessment and planning is needed, especially as congenital cardiac anomalies such as atrial septum defect, ventricular septal defect, and tetralogy of fallot are often associated with skeletal malformations and difficult airways [3]. Here, we report a case of emergency V-P shunt for a 5-month-old baby with a lumbosacral MMC and hydrocephalus. Raised intracranial pressure (ICP) had further compromised his respiration and made airway control further significant. Apart from airway control, intraoperative anaesthetic management in this case of V-P shunt also included proper positioning of large MMC, prevention of any rise in ICP, and prevention of hypothermia.
Through this case, we would like to emphasize on the significance of using a video-laryngoscope with the pediatric blade as the first choice for intubation to secure the airway quickly and without any increase in ICP.
Case Report:
A 5-month-old 6 kg male child, firstborn of consanguineous marriage, delivered by cesarean section was diagnosed with MMC. MMC was not operated due to financial constraints and the unavailability of medical facilities and the baby developed hydrocephalus. He presented with complaints of drowsiness with up rolling of the eyeball and grunting noise while breathing. On examination, the baby had a large MMC at the lumbosacral region (Fig. 1). He was drowsy making grunting noises while breathing, lethargic with uprolling of eyeballs, and with bulging frontanelles; all symptoms of raised intracranial pressure. Sunset sign was present with an occipitofrontal circumference of 46.5 cm (normal 32–35 cm), and both pupils were pinpoint and sluggishly reacting.
There was no movement in both lower limbs. The baby had obstructive breathing (stridor) with oxygen saturation around 90–92% on air. The child had micrognathia with a high-arched palate and rhonchi all over the chest on auscultation. On ultrasound examination of the brain, there was marked dilatation of both lateral ventricles measuring approximately 3.6–4.6 cm with a prominent third ventricle (9 mm width). On chest X-ray (Fig. 2) there was the absence of ribs on the left side. As this was an emergency surgery 2D echo was not done to rule out other congenital cardiac abnormalities.
We anticipated difficult intubation due to the presence of micrognathia, high arched palate, stridor with poor respiratory reserve, raised ICP, and positioning of the baby for intubation due to the large size of MMC.
The MMC warranted careful attention to positioning for both intubation and the procedure of V-P shunt. The difficult airway cart with a video-laryngoscope was kept ready in anticipation of difficult intubation. For intubation, the baby was placed supine with the head resting on a head ring elevated on folded sheets. Silicon pads were kept below the shoulder and folded sheets under the hips creating a potential space for the MMC at the back to hang freely without any external pressure underneath (Fig. 3).
Securing the intravenous (IV) line was also difficult due to dehydration. After attaching all vital monitors induction was done with IV midazolam, glycopyrrolate, propofol in doses as per weight, and 1% sevoflurane in 100% oxygen until cessation of spontaneous respiration. After checking for effective bag-mask ventilation IV atracurium was given. On direct laryngoscopy done with a video-laryngoscope with a Miller pediatric blade, the glottic view was Cormack and Lehane grade 2 after external laryngeal pressure. Successful intubation was achieved with a 3.5 mm micro cuff endotracheal tube with the help of a stylet with difficulty while negotiating but within 45 s.
Forced air warmer was used along with cotton pads to cover up the limbs of the baby to prevent hypothermia. Adequate depth of anaesthesia was maintained to avoid a rise in intracranial pressure. Throughout the intraoperative period, vitals remained stable. The surgery lasted for 1 h. The baby was not extubated immediately postoperatively because of the absence of any breathing attempts and was shifted to the post-operative intensive care unit. The baby was extubated on 2nd-day post-procedure as the ICP settled down, baby neurologically improved with good breathing attempts. The baby was posted for MMC repair after 5 days. The procedure was done uneventfully and the baby recovered well after the procedure.
Discussion:
NTDs are severe congenital malformations affecting around one in every 1000 pregnancies. Open NTD can be associated with hydrocephalus which often requires CSF shunting [4]. Our patient was born to parents with a consanguineous marriage and low socioeconomic stratum; hence was prone to develop NTDs because of genetic causes and less awareness regarding the use of prenatal supplements. He was born with lumbosacral MMC and due to financial constraints, no intervention was done at birth. At 5 months of age as the condition of the baby deteriorated medical advice was sought and he was posted for emergency V-P shunt surgery.
Pre-operative evaluation for such cases should include a thorough history and assessment of neurological status for evidence of raised ICP, altered sensorium, and cranial nerve palsies. Infants with intracranial hypertension present with irritability, lethargy, decreased consciousness, failure to feed, bulging fontanel, and cranial enlargement [5]. In children, it may present with early morning headache, vomiting without nausea, diplopia, and papilledema, and in late stage, with Cushing’s triad. Frequent vomiting episodes may lead to dehydration and electrolyte imbalances, and increase the risk of aspiration [5]. In our case, the baby presented with complaints of drowsiness, grunting, uprolling of the eyeball, and bulging of anterior fontanelles. On examination signs of raised intracranial pressure were present with bilateral pinpoint pupils which were sluggishly reacting to light. Furthermore, these babies can have cardiac, skeletal, renal, and other congenital anomalies too which should be evaluated preoperatively. This baby had a congenital absence of the 4th and 5th rib in the chest X-ray.
The pediatric airway is considered more difficult than adults because of the large head and tongue, omega‑shaped epiglottis, anterior larynx, and the subglottis being the narrowest part [6]. We anticipated a difficult airway in the baby due to the presence of micrognathia, high-arched palate and stridor with poor respiratory reserve, raised ICP, and difficulty in positioning of the baby for intubation due to the large size of MMC. We kept the difficult intubation cart ready and achieved an optimal position for intubation by placing the child supine and elevating the body with folded towels under the head and shoulders as well as under the pelvis thus leaving space in between for the MMC. Optimal positioning and the use of a video-laryngoscope (C-mac) helped us well during intubation which was otherwise predicted to be a difficult airway. Video-laryngoscope allowed us to visualize the small larynx better with gentle laryngoscopy in a neutral position without much flexion or extension of the head thus preventing the rise in ICP. Low pulmonary reserve and rapid rate of desaturation in the pediatric population make time for endotracheal intubation critical. Neonatal Resuscitation guidelines limit the intubation attempts to 30 s [7]. We chose a video-laryngoscope with a pediatric Miller blade as our first choice in this difficult airway patient with poor pulmonary reserve we managed to intubate him even though with difficulty within 45 s.
We used IV induction with neuromuscular blockade to facilitate intubation as is ideal for patients with raised ICP instead of inhalational induction without neuromuscular blockade despite anticipated difficult airway and poor respiratory reserve [8]. Our experience in pediatric use of video-laryngoscopes gave us the confidence to do so.
A video-laryngoscope improves glottic visualization and successful intubation in the first attempt [9]. Successful intubation in the first attempt avoids other complications which occur due to repeated laryngoscopy such as airway trauma, hypoxia, rise in intracranial pressure, etc. video-laryngoscopy helped us achieve successful endotracheal intubation in less time and first attempt with stable hemodynamics. There are many pediatric video-laryngoscopes available with unique features, and clinical applications and the designs continue to evolve.
The neurosurgical procedures are carried out in different positions therefore proper fixing of the E.T. tube, padding of pressure points, protection of eyes, and good access to the IV line, airway, and breathing circuit should be ensured before the commencement of the surgery. In this case, surgery was done in the supine position and all necessary care was taken.
During shunt procedures, a large area of the body is exposed and children are more prone to develop hypothermia, particularly neonates with their poor regulatory capacity, reduced weight-to-surface-area ratio, increased heat loss from the head, and limited stores of subcutaneous fat for thermal insulation [10]. We used an air-warming blanket and warm fluids and adequately covered the limbs to avoid hypothermia.
Postoperatively baby was not extubated because of the absence of any respiratory efforts and was shifted to pediatric intensive care for elective ventilation. He was extubated on 2nd post-operative day and was vitally stable. He was posted for MMC repair which was done uneventfully and recovered well after the procedure.
Conclusion:
Babies with MMC when associated with congenital anomalies, hydrocephalus with raised ICP and difficult airway pose a challenge to the anaesthetist especially in emergency surgeries. This case emphasizes on the significance of being prepped for a difficult airway, optimized positioning, and using a video-laryngoscope with the pediatric blade as well as paralyzing the patient even in an emergency case with respiratory distress to get good relaxed laryngoscopy conditions. We all agree that the best attempt at intubation is the very first one.
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| How to Cite this Article: Baxi V, Shah M | Video-Laryngoscope For Difficult Paediatric Airway Management In A Case Of Meningomyelocele For Emergency Ventriculo Peritoneal Shunt Surgery | Journal of Anaesthesia and Critical Care Case Reports | May-August 2024; 10(2): 19-21. https://doi.org/10.13107/jaccr.2024.v10.i02.241 |
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