Difficult Airway in a Case of Gross Hydrocephalus for Shunt Surgery.

Children with gross hydrocephalus for emergency ventriculoperitoneal (VP) shunt present challenges to anesthesiologist due to increase in circumference of head, associated congenital anomalies. Here is a case report of child with gross hydrocephalus with Type 2 Arnold chiari malformation posted for emergency VP shunt placement possessed a difficult airway.

INTRODUCTION

Hydrocephalus is a Greek word hydro means water and cephalus means head, a condition in which there is an excessive accumulation of cerebrospinal fluid (CSF) resulting from increased production or decreased absorption of CSF. Hydrocephalus may be of two types, it may be communicating or noncommunicating (obstructive) hydrocephalus. Hydrocephalus cases require thorough preoperative anaesthetic assessment to rule out the congenital defects, delayed milestones, difficult airway assessment.

CASE REPORT

A 9-month-old second born child by normal delivery and cried immediately after birth with no perinatal complications presented with history of increasing size of head sine 4 months. On examination vitals were stable and drowsy with no cry Sun setting sign present, occipitofrontal circumference 65 cm, and (normal 32–35 cm conclusion hydrocephalus), weight 10 kg, dilated scalp veins. Both pupils were 3 mm reacting to light; visual acuity could not be assessed. No sensorimotor deficit except for spontaneous activity present in upper limbs more than lower limbs. Lower limbs moving against gravity on pain stimuli [Figure 1]. Magnetic resonance imaging suggestive of tethered cord syndrome with Arnold chiari malformation Type II gross hydrocephalus with dilation of bilateral lateral ventricle, third ventricle and brain matter seen as mantle around ventricle [Figure 2] other investigations were normal. This baby posted for ventriculoperitoneal shunt surgery. In our case, the problems we anticipated were difficult intubation[12] due to presence of gross hydrocephalus, positioning of the baby for intubation and probability of hypothermia.[3]

Figure 1

Gross hydrocephalus (sun set sign, dilated scalp veins)

Figure 2

Magnetic resonance imaging of head (dilated ventricles, atrophy brain)

This baby has gross hydrocephalus so the difficult airway cart was kept ready. Though here the chances of difficult intubation were likely due to head size and positioning was difficult for intubation. After attaching all basic monitors induction done with sevoflurane 8% in incremental dial settings maintaining spontaneous respiration. Towel is kept below the shoulders to easy for intubation positioning. After checking for effective bag mask ventilation intravenous IV injection succinylcholine 2 mg/kg body weight given. Direct laryngoscopy done with Macintosh blade number 1, Cormack and Lehane grade (CLG) 3 with floppy epiglottis noted which was unable to lift up. First intubation attempt was failed. Bag mask ventilation was done along with deepening the plane of anesthesia with sevoflurane. We immediately concluded it to be difficult airway. Second attempt of intubation was taken by the senior anesthesiologist along with the change of Macintosh blade number 2 and optimal external laryngeal maneuver, again there was no glottic visibility with similar difficulty. We continued with bag mask ventilation successfully in between ensuring oxygenation. Afterwards intubation attempt done with keeping towels below the shoulders properly and successful intubation achieved with 4 mm i.d. endotracheal tube (ETT) with little difficulty while negotiation [Figure 3]. Anesthesia was maintained on O2, air, sevoflurane, injection atracurium. 2.5 mg. Hemodynamic maintained stable, SpO2100, EtCO235 mmHg. Surgery lasted for 2 h. After the initiation of spontaneous respiration patient reversed with neostigmine and glycopyrrolate and was extubated carefully once the patient had protective airway reflexes and fully conscious [Figure 4]. Shifted to postoperative Intensive Care Unit for monitoring.

Figure 3

After intubation

Figure 4

Postextubation

DISCUSSION

Hydrocephalus is a clinical condition which occurs as a result of CSF accumulation resulting from complex mechanisms and cerebrospinal shunt procedures are life-saving. Management of patients presenting for shunt surgery can be challenging especially in children with congenital anomalies and will require thorough planning.

Congenital Hydrocephalus is capable of producing brain atrophy hence poor prognosis and may also be associated with severe mental retardation. Usually mental assessment together with other systems should be monitored cautiously because the birth asphyxia is associated with multi-organ damage. However in our case baby was having a possibility of severe mental retardation and delayed milestones due to brain cortical growth failure, if the surgical procedures were delayed, causes poor prognosis.

Therefore an urgent need to resolve this issue as failure rates is high particularly for complex shunt systems. Major complications of shunt surgery are like blockage, infection, shunt malfunction and hence the need for shunt revisions. Shunt failures occur due to catheter obstruction proximally or distally, migration of the catheter, disconnection, valve malfunction, hematomas and infection.

The anesthetic management includes careful planning and can be challenging given the fact that many procedures are done as emergency surgeries and expert help may not be available. A thorough preoperative examination is very crucial in conduction of anaesthesia. Induction of anaesthesia depends on the IV access if IV access is available then thiopentone or propofol can be used. If not then a volatile induction like sevoflurane can be used. An ETT should fix properly because migration of tube can occur easily in young children with changes in position. Cardiac function may be altered by persistent vomiting resulting in hypovolemia, hypotension and electrolyte abnormalities.

The goals of fluid management include maintaining adequate cerebral perfusion and normovolemia with isotonic fluids without hyperglycemia. Small children will require extended monitoring in the postoperative period to identify problems early to enable early treatment.[4]

CONCLUSION

The anaesthetic management in a gross hydrocephalic child can be particularly challenging due to complex issues like difficulties related to airway management, cardiovascular dysfunction, age-related needs of positioning and congenital anomalies. Proper positining of childerns is mandatory for successful intubation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.