|Ahead of print
A Novel method of airway management in a neonate with a large occipital encephalocoele
Mano S Praveen, Anita N Shetty, Priti S Devalkar, Gayatri R Sakrikar, U Shashank Paliwal, C Indrani Hemantkumar
Department of Anaesthesia and Criticalcare, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
|Date of Submission||03-Dec-2020|
|Date of Decision||03-Jan-2021|
|Date of Acceptance||26-Jan-2021|
|Date of Web Publication||07-Jan-2022|
Mano S Praveen,
Department of Anaesthesia and Critical Care, Seth G S Medical College, KEM Hospital, 400012, Maharashtra.
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Encephalocoeles are one of the rarest open neural tube defects that usually present at birth with a large occipital or frontoethmoidal swelling and require surgical correction in the neonatal period. Airway management in a neonate with a large occipital encephalocoele is difficult due to inadequate neck extension and positioning difficulties.
Keywords: Difficult airway, encephalocoele, neonatal anaesthesia, positioning
| Introduction|| |
Encephalocoele, also known as cranium bifidum, is one of the most common type of open neural tube defects involving the failure of a neuropore formation. It is characterized by a sac-like protrusion or projection due to the leakage of cerebrospinal fluid (CSF) and is accompanied by herniation of the brain and the meninges. The most common encephalocoeles are occipital (75%) > frontal > nasal. Based on the contents, it can be meningoencephalocoele (CSF and meninges) or myelomeningocoele (CSF, meninges and brain tissue).
Positioning and airway management of the neonates with a large occipital swelling is quite challenging. Here, we present a novel positioning method adopted in the neonate with a large occipital encephalocoele to tide over the problem of intubation during anaesthesia.
| Case Report|| |
It was planned to do surgical repair in a 27-day-old female neonate, weighing 3.9 kg, diagnosed antenatally with an occipital encephalocoele. There was a large cystic swelling of size 9 × 10 cm in the posterior part of the head. The swelling was almost the size of the neonate’s head [Figure 1].
|Figure 1: A large cystic swelling of size 9 × 10 cm in the occipital area, approximately the size of the neonate’s head|
Click here to view
USG and MRI confirmed an 8 × 10 × 6 cm cystic swelling with a 12 mm defect in the occipital area with hyper-echoic contents, dilated choroid plexus with partial herniation of cerebellum. On examination, the baby was alert, active with no other congenital anomaly and no neurological deficit. Cardiovascular and respiratory systems were normal. Airway examination revealed retrognathia. Investigations were as follows: Hb—16.4 g%; TLC—13,000/mm3; and platelet—1 lakh/m3.
After confirming the duration of fasting and taking informed consent, the baby was covered with a warm blanket and transferred inside the operating room. A difficult airway cart was kept ready. As the encephalocoele was as big as the neonate’s head, the head was placed on top of a stack of four head rings with a soft bolster below the body. Care was taken to place the encephalocoele sac gently within the cavity of the assembly, which was cushioned with the layers of a cotton roll. This enabled us to align the head and body in the same plane and achieve intubation in supine position. Peripheral IV line was secured in the dorsum of the left hand with a 24G IV cannula. Ringer lactate with 2% Dextrose drip was started at the rate of 10 mL/kg/h. All precautions to prevent hypothermia were taken, such as the use of warming mattress and fluid warmers. Monitoring included pulse oximetry, NIBP, capnography, 5-lead ECG, and temperature monitoring.
The neonate was induced with an increasing concentration of sevoflurane in oxygen. Once mask ventilation was achieved, cis-atracurium 1.2 mg IV was administered for orotracheal intubation with 3.5 mm plain ETT by using a video-laryngoscope. Fentanyl 8 μg IV was given after intubation [Figure 2].
|Figure 2: The bag and mask ventilation and intubation being done in the supine position with the help of the headring assembly and ensuring proper care to the sac without the airway compromise|
Click here to view
Post-induction, the neonate was made prone with the head in neutral position, supported on a prone head rest gel with a slot for an endotracheal tube.
Anaesthesia was maintained with 50% O2 + 50% N2O and 1–2% sevoflurane and cis-atracurium 0.03 mg/kg boluses. Intraoperatively, 140 mL of Ringer lactate with 2% Dextrose IV was given. Around 110 mL of fluid was aspirated from the encephalocoele before surgery, which was replaced with an additional 50 mL of IV Ringer lactate. The neonate had a blood loss of approximately 80 mL that was replaced with blood. Paracetamol 60 mg IV was given during closure. The surgery lasted for 3 h.
Postsurgery, the neonate was reversed with Neostigmine 2 mg IV and Glycopyrrolate 32 μg IV and extubated when fully awake and moving all four limbs. The neonate was then shifted to the NICU on an oxygen mask. The postoperative course of the neonate was uneventful.
| Discussion|| |
The goal during intubation is to avoid undue pressure on the encephalocoele sac to prevent rupture of the membranes. Airway management in these type of cases is usually done by various techniques, such as (i) placing the neonate laterally and doing mask ventilation and intubation in the lateral position, by elevating the sac with a doughnut-shaped support to avoid undue pressure over the sac; (ii) holding the neonate in the air with an assistant supporting the body and head separately; (iii) placing the neonate in the supine position on a platform of rolled-up blankets and the head is supported by an assistant temporarily or by placing on a hollow head cushion; and (iv) intubation done with the head supported from below while the head of the neonate is hanging beyond the edge of the table to facilitate extension of the head.
In this case, the head of the neonate was placed on a stack of four head rings with adequate cushioning to prevent pressure on the sac and the body was placed on a soft bolster, aligning the head and body in the same plane in supine position. To get a good glottic view with the video-laryngoscope, the alignment of the oral–pharyngeal–laryngeal axes is not mandatory. This novel method of intubating a large occipital encephalocoele in supine position with the available resources made difficult intubation simple.
| Conclusion|| |
Intubation can be done in supine position in neonates with a large encephalocoele by using this innovative method and the video-laryngoscope. Proper planning can help in managing such difficult airways.
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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Da Silva SL, Jeelani Y, Dang H, Krieger MD, McComb JG. Risk factors for hydrocephalus and neurological deficit in children born with an encephalocele. J Neurosurg Pediatr 2015;15:392-8.
Jain K, Sethi SK, Jain N, Patodi V. Anaesthetic management of a huge occipital meningoencephalocele in a 14 days old neonate. Ain-Shams J Anesthesiol 2018;10:13.
Mowafi HA, Sheikh BY, Al-Ghamdi AA. Positioning for anaesthesia induction of neonate with encephalocele. Internet J Anaesthesiol 2001;5:3.
Walia B, Bhargava P, Sandhu K. Giant occipital encephalocele. Med J Armed Forces India 2005;61:293-4.
[Figure 1], [Figure 2]