LETTER TO THE EDITOR
|Year : 2020 | Volume
| Issue : 3 | Page : 343-344
Meningomyelocele with kyphoscoliosis: Ventilation challenges for anesthesiologist
Sharmishtha Pathak, Saurav Singh, Sanjay Agrawal
Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, , India
|Date of Submission||28-Jan-2020|
|Date of Decision||09-Feb-2020|
|Date of Acceptance||12-Mar-2020|
|Date of Web Publication||06-Nov-2020|
Dr. Sharmishtha Pathak
Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand.
Source of Support: None, Conflict of Interest: None
|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
Meningomyelocele (MMC) results from neural tube defect during first 4 weeks of gestation. It may be associated with other congenital anomalies such as anal atresia, trachea-esophageal fistula, renal dysplasia, cardiac, vertebral, and limb abnormalities (VACTERL).
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. 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. 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. This necessitates the need for timely identification and correction of these problems to prevent further catastrophic events.
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Conflicts of interest
There are no conflicts of interest.
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