Correspondence Address:
Dr. Indu Kapoor
Department of Neuroanaesthesiology and Critical Care, Neurosciences Centre, All India Institute of Medical Sciences (AIIMS), New Delhi 110029.
India

Full Text



Symptoms of raised intracranial pressure (ICP) in infants include additional signs that involve separated suture of the skull and bulging fontanel. Cushing’s triad may be seen, which involves raised systolic blood pressure, bradycardia, and an abnormal respiratory pattern.[1] In children, a low heart rate (HR) is highly suggestive of raised ICP.

We report a case of 3-month-old boy with congenital aqueduct stenosis and hydrocephalus posted for endoscopic third ventriculostomy (ETV) under general anesthesia. Written informed consent was obtained from his parents. After attaching routine monitors, general anesthesia was induced with sevoflurane at 8% concentration. A 24-G intravenous line was secured in the right hand. Fentanyl 2 µg/kg and rocuronium 1mg/kg injection was given and trachea was intubated with a 3-mm Microcuff polyvinyl chloride endotracheal tube (ET). For maintenance of anesthesia, sevoflurane with nitrous oxide and oxygen mixture (FiO2 = 40%) was commenced with a fresh gas flow of 2L/min. At the end of surgery, while suturing skin, the patient had severe bradycardia with HR lowering down to 50 beats per minute (bpm) from 110 bpm. His rest of vital parameters remained normal. Injection atropine 0.3mg was given, which raised HR from 50 to 130 bpm. At this point, surgeon was suspecting extradural hemorrhage (EDH). Neuromuscular blockade of the patient was not reversed. He was shifted to the computed tomography (CT) scan room with ET in situ. CT scan ruled out the presence of EDH; however, ventricles were found to be dilated. Lumbar puncture was performed on the patient and cerebrospinal fluid was drained in intensive care unit and his trachea was extubated next day.

ETV is treatment of choice for noncommunicating hydrocephalus.[2] The hemodynamic changes following ETV can occur either due to hypothalamic stimulation or damage or due to acute rise in ICP.[3] Rise in ICP is common during neuroendoscopic procedures. Pressure inside endoscope (PIN), a reliable surrogate of ICP, should be measured during intraoperative period.[4] Postoperative high ICP can account for the presence of symptoms such as bradycardia. It has been recommended that a cycle of one to three lumbar punctures should always be performed in pediatric patients who remain symptomatic and whose postoperative CT scan shows ventricular dilatation, before assuming that ETV has failed.[2] Close postoperative surveillance is essential in pediatric patients after ETV. In our case, intraoperative PIN was not measured. The presence of dilated ventricles after ETV and occurrence of bradycardia postoperatively were suggestive of raised ICP. Our case is reiterating the fact that knowledge about management of hydrocephalous following ETV is important for all attending anesthesiologists. Timely and correct intervention can prevent catastrophes.

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