LETTER TO THE EDITOR
|Year : 2021 | Volume
| Issue : 2 | Page : 170-172
Airway management of a giant encephalocele using mega pillow
Sunaakshi Puri1, Rajeev Chauhan1, Rashi Sarna1, Summit D Bloria2
1 Department of Anesthesia and Intensive Care, PGIMER, Chandigarh, India
2 Department of Critical Care, Sri Mata Vaishno Devi Narayana Superspeciality Hospital, Kakryal, Jammu & Kashmir, India
|Date of Submission||11-Jun-2020|
|Date of Decision||21-Jul-2020|
|Date of Acceptance||17-Aug-2020|
|Date of Web Publication||02-Jul-2021|
Dr. Rajeev Chauhan
Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh.
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Puri S, Chauhan R, Sarna R, Bloria SD. Airway management of a giant encephalocele using mega pillow. J Pediatr Neurosci 2021;16:170-2
| Introduction|| |
Pediatric patients with neural tube defects are a challenge to manage intraoperatively because of difficult airway, intraoperative positioning, and the possibility of having multiple congenital anomalies. We describe anesthetic management of a neonate with a huge occipital encephalocele posted for encephalocele resection in whom we had to apply a novel method for airway management.
A 3-day-old male neonate, weighing 3.5 kg, was scheduled for emergency resection of a giant occipital encephalocele of size approximately measuring 22 cm × 20 cm [Figure 1]. Preanesthetic evaluation was done; other congenital anomalies were ruled out. The child was kept fasting for 4 h (mother’s milk) prior to surgery; an i.v. cannula was established and i.v. fluid administration was initiated during this time.
The patient was placed supine, his skull supported by a mega pillow made by rolled cloth sheets covered by sterile gauge pads kept on the lap of the sitting anesthesiologist [Figure 2]A. After inhalation induction using sevoflurane, mask induction maintaining spontaneous ventilation was coupled with direct laryngoscopy using a C-Mac video laryngoscope. With a grade1 view, a 3.0-mm endotracheal tube was placed orally. The patient was then positioned lateral for the procedure. Intraoperatively, anesthesia was maintained with a mixture of oxygen, nitrous oxide, and sevoflurane. Muscle relaxation was induced using Inj. Atracurium and Isolyte-P was used as the intraoperative intravenous fluid. On completion of the surgery, the patient’s trachea was extubated in the operating room. Breastfeeding was started 2 h after the surgery. Postoperatively the patient had an uneventful course and was discharged 7 days after the surgery.
|Figure 2: Mega pillow made by rolled cloth sheets and covered by sterile gauge pads was kept on the lap of the sitting anesthesiologist during mask ventilation and laryngoscopy|
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Encephaloceles occur in 1 of 5000 births worldwide. Occiput is the most common site (75%) of occurrence, with 90% of the cases involving the midline. Abnormal positioning, difficult airway, comorbid conditions, and associated systemic abnormalities, along with the inherent implications of anesthesia and surgery in children, make encephalocele repair challenging for anesthesiologists. Positioning of the patient for intubation contributes to the difficulty with airway management. Management of the airway of neonates presenting for surgical repair of a large occipital encephalocele may require more than one person to support the body and the head and to avoid pressure on the encephalocele sac. Positioning any patient with an occipital encephalocele using a mega pillow covered by sterile pads (on the anesthesiologist’s lap) with the back of the neck of the patient supported by an assistant creates optimal conditions for induction and tracheal intubation by providing the anesthesiologist airway alignment and stability without increasing pressure on the encephalocele [Figure 2]A and [B]. Also, no additional personnel is needed during positioning and intubation. However, the operator must ensure the safety of the child and maintenance of his own body balance during the intubation lest the child might slip/move risking rupture of the encephalocele. Also, the operator must have a back-up plan in mind if intubation proves to be difficult. Manual suspension of the patient’s head (held by a second assistant) beyond the operating table risks unwanted pressure on the encephalocele during laryngoscopy (due to hanging of encephalocele) while also needing additional personnel. Lateral positioning provides a less ideal approach for the laryngoscopy and may prove to be difficult. Provided a video laryngoscope is available, this technique can be used to intubate pediatric patients with huge encephaloceles.
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
There was no financial support and sponsorship for this work.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mealey J Jr, Dzenitis AJ, Hockey AA. The prognosis of encephaloceles. J Neurosurg 1970;32:209-18.
Walia B, Bhargava P, Sandhu K. Giant occipital encephalocele. Med J Armed Forces India 2005;61:293-4.
Dey N, Gombar KK, Khanna AK, Khandelwal P. Airway management in neonates with occipital encephalocele: adjustments and modifications. Paediatr Anaesth 2007;17:1119-20.
[Figure 1], [Figure 2]