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LETTER TO THE EDITOR
Year : 2020  |  Volume : 15  |  Issue : 3  |  Page : 343-344
 

Meningomyelocele with kyphoscoliosis: Ventilation challenges for anesthesiologist


Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, , India

Date of Submission28-Jan-2020
Date of Decision09-Feb-2020
Date of Acceptance12-Mar-2020
Date of Web Publication06-Nov-2020

Correspondence Address:
Dr. Sharmishtha Pathak
Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand.
, India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpn.JPN_16_20

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How to cite this article:
Pathak S, Singh S, Agrawal S. Meningomyelocele with kyphoscoliosis: Ventilation challenges for anesthesiologist. J Pediatr Neurosci 2020;15:343-4

How to cite this URL:
Pathak S, Singh S, Agrawal S. Meningomyelocele with kyphoscoliosis: Ventilation challenges for anesthesiologist. J Pediatr Neurosci [serial online] 2020 [cited 2020 Nov 24];15:343-4. Available from: https://www.pediatricneurosciences.com/text.asp?2020/15/3/343/300046




Dear Editor,

Meningomyelocele (MMC) results from neural tube defect during first 4 weeks of gestation.[1] It may be associated with other congenital anomalies such as anal atresia, trachea-esophageal fistula, renal dysplasia, cardiac, vertebral, and limb abnormalities (VACTERL).[2]

We report a case of 1-week-old term neonate, weighing 2.4kg with ruptured MMC and thoracic kyphoscoliosis posted for MMC repair and ventriculoperitoneal shunt placement surgery [Figure 1].
Figure 1: Chest X-ray showing the thoracic kyphoscoliosis with crowding of ribs (above) and MRI image of the lumbosacral meningomyelocele (below)

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On the day of surgery, after shifting the child to operating room, carefully placing MMC in a doughnut rest and attaching routine monitors, anesthesia was induced using fentanyl 2 mcg/kg, thiopentone 4 mg/kg, and atracurium 0.5 mg/kg. Trachea was secured with uncuffed endotracheal tube (ETT) (size 3mm). In total, 60% nitrous oxide in oxygen, sevoflurane (MAC 0.9–1), and intermittent boluses of atracurium and fentanyl were used for anesthesia maintenance. Right femoral artery was cannulated for invasive blood pressure and arterial blood gas (ABG) monitoring. Child was ventilated initially with volume control ventilation with tidal volume (Vt) 15mL and respiratory rate (RR) 40 /min. After turning patient prone, increase in peak airway pressure from 11 to 21mm Hg was observed. Adjustments for correcting endobronchial ETT migration or pressure over abdomen had no impact. ABG revealed increased arterial carbon dioxide (PaCO2). PaCO2–EtCO2 gradient was 15 at the stage as opposed to normal of 5–8mm Hg. Institution of positive end-expiratory pressure (PEEP) (3mm Hg) improved ventilation but the gradient kept on increasing. Ventilation was switched to pressure control with inspiratory pressure of 15 delivering 15–18mL Vt. With an RR of 35 /min and I:E ratio 1:1.5, adequate ventilation was achieved. This gradually improved the PaCO2–EtCO2 gradient. Intraoperative blood loss of 250mL was replaced with packed red blood cell. Surgery lasted 6–7h and complete excision of MMC with flap rotation for primary cover was carried out successfully. In view of prolonged duration, replacement of almost complete blood volume, and ventilatory difficulties, the child was ventilated overnight and extubated next morning.

MMC is considered as one of the causes of infantile paralysis associated with other anomalies. MMC repair surgeries thus pose a challenge due to these associated clinical conditions.[3] Thoracic kyphoscoliosis produces significant restriction in lung function and makes controlled ventilation difficult. Special positioning requirements of the surgery further complicate the ventilation–perfusion mismatch, thus increasing the EtCO2–PaCO2 gradient.[4] In the postoperative period, pulmonary dysfunction is common due to restrictive lung disease and respiratory muscle weakness. If not foreseen timely, the patient may suffer a respiratory arrest and end up with hypoxic brain damage.[1] This necessitates the need for timely identification and correction of these problems to prevent further catastrophic events.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Singh D, Rath GP, Dash HH, Bithal PK Anesthetic concerns and perioperative complications in repair of myelomeningocele: a retrospective review of 135 cases. J Neurosurg Anesthesiol 2010;22:11-5.  Back to cited text no. 1
    
2.
Chen Y, Liu Z, Chen J, Zuo Y, Liu S, Chen W, et al. The genetic landscape and clinical implications of vertebral anomalies in VACTERL association. J Med Genet 2016;53:431-7.  Back to cited text no. 2
    
3.
Sardar A, Khanna P, Singh A, Sharma A Long-standing meningomyelocele can be a predictor of difficult airway and postoperative hypoventilation: challenge to the anaesthesiologist. BMJ Case Rep 2016;2016:bcr2016214456.  Back to cited text no. 3
    
4.
Rath GP, Dash HH Anaesthesia for neurosurgical procedures in paediatric patients. Indian J Anaesth 2012;56:502-10.  Back to cited text no. 4
    


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