This case highlights a difficult airway management in 9-month-old boy with gross hydrocephalus during ventriculoperiotoneal shunt surgery.
A 9-month-old baby presented with a 4-month history of increasing head size. The baby was a second born, delivered normally and cried immediately after birth with no signs of perinatal complications. The case highlights difficult airway management in gross hydrocephalus.
Physical examination showed drowsy with no cry and Sun setting sign. The baby’s vitals were stable, the occipitofrontal circumference measured 65 cm, normal 35 – 35 cm conclusion hydrocephalus, weight 10 kg, in addition to presence of dilated scalp veins. Both pupils dilated 3 mm to light response. However, visual acuity of the baby could not be assessed. In addition to this, there was no sensorimotor deficit except for spontaneous activity in the upper limbs. The activity was more than the lower limbs. Furthermore, on pain stimuli, the lower limbs moved against gravity.
The 9-month-old was advised magnetic resonance imaging which was remarkable of Arnold chiari malformation Type II gross hydrocephalus. Additionally, dilation of bilateral lateral ventricle, third ventricle and brain matter as mantle around ventricle could also be seen. All other investigations did not show any significant findings.
The baby was referred for ventriculoperiotoneal shunt surgery
In this case, one of the primary problems the surgeons encountered was difficult intubation because of the presence of gross hydrocephalus. Moreover, the positioning of the baby for intubation also posed as a challenge with the probability of hypothermia.
During the procedure, the difficult airway card was kept on standby because the baby has gross hydrocephalus. The difficult intubation was mainly because of the size of the head and positioning. Spontaneous respiration was maintained with sevoflurane 8% after attaching all basic monitors with incremental dial settings. A towel was kept below the shoulders for positioning the baby for easy intubation.
After checking the patient for effective bag mask ventilation, succinylcholine 2 mg/kg body weight was given intravenously. Direct laryngoscopy was done, however, the floppy epiglottis could not be lifted. Therefore, the first attempt at intubation failed. The baby was ventilated using a bag mask. A second attempt was made at intubation under the supervision of a senior anesthesiologist, however, a similar difficulty was encountered and there was no glottic visibility. Bag mask ventilation was continued and successful intubation was achieved with 4 mm endotracheal tube (ETT). The anesthesia was maintained on oxygen, air, sevoflurane and injection atracurium 2.5 mg.
The surgery lasted for two hours, the patient was hemodynamically stable throughout. The patient was carefully extubated once protective airway reflexes were established and the patient was fully conscious. The 9-month-old was further monitored in the Intensive Care Unit.
References
Difficult Airway in a Case of Gross Hydrocephalus for Shunt Surgery https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5735462/
