|Year : 2017 | Volume
| Issue : 6 | Page : 602-604
Anesthesia for cerebral palsy - Need for meticulous perioperative planning
Sukhminder Jit Singh Bajwa1, Rudrashish Haldar2
1 Department of Anaesthesiology and Intensive Care, GSMCH, Banur, Patiala, Punjab, India
2 Department of Anaesthesiology and Intensive Care, SGPGI, Lucknow, Uttar Pradesh, India
|Date of Web Publication||17-Jan-2018|
Dr. Sukhminder Jit Singh Bajwa
House No-27-A, Ratan Nagar, Tripuri, Patiala - 147 001, Punjab
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Singh Bajwa SJ, Haldar R. Anesthesia for cerebral palsy - Need for meticulous perioperative planning. Med J DY Patil Univ 2017;10:602-4
Cerebral palsy (CP) is a term which encompasses a diverse range of nonprogressive motor, sensory, and neurological disorders with different degrees of impairment. The diversity of clinical spectrum extends from mild monoplegia with normal intelligence to severe quadriplegia with mental retardation. The genesis of this disorder is multifactorial, but the inciting event is the injury to the developing brain. Known factors include perinatal hypoxia, infection, trauma, congenital abnormalities, and genetic influences. Diagnosis of this disorder is essentially clinical, but advanced imaging modalities such as magnetic resonance imaging reveals periventricular changes in majority of the patients. Patients with CP often have to be bought to the operation theater for certain surgical procedures, namely, orthopedic procedures, dental extractions or restorations, gastrostomy and antireflux procedures, imaging, and other procedures pertaining to the specialties of neurosurgery, ophthalmology, and ENT. Thus, these patients have to be administered anesthesia and anesthesia providers should be well-versed with the etiology, pathophysiology, and management of these patients for smooth and safe conduct of anesthetic course.
Preoperative assessment of these patients should be meticulous and exhaustive and preferably involve multidisciplinary evaluation. Communication and cognitive problems may pose difficulties in eliciting history and physical evaluation. However, since feelings and emotions is present in these patients, gentle, and sympathetic approach goes a long way in establishing the rapport of the attending anesthesiologist with the patients and the parents. Preoperative assessment includes eliciting the history of seizures (focal/generalized), visual/auditory impairment. Respiratory abnormalities such as chronic lung disease, aspiration, swallowing impairment, esophageal dysmotility, or scoliosis may coexist which necessitates physiotherapy, bronchodilators, and antibiotics for optimization. Gastrointestinal disorders such as decreased lower esophageal sphincter tone predispose to aspiration. Tongue thrusting and inadequate head movement contribute to difficult airway management. Poor feeding contributes to malnutrition, anemia, dehydration, and electrolyte imbalance. Nasogastric or gastrostomy tubes might have been in position for feeding these patients which needs to be taken care of during surgical procedure. These patients have muscle contractures and are prone to dislocations and decubitus ulcers. Deformities increase the complexities of intravenous access, invasive monitoring, and regional anesthesia. Thus, meticulous preoperative plans for the same should be clearly formulated beforehand. Latex allergies may be present, so the history of same needs to be taken and documented. Concurrent medications for seizures, spasticity, reflux, constipation, and depression should be enquired about and their anesthetic interactions should be considered. Anticonvulsant medications effect enzymatic functions, cause blood dyscrasias, and may cause over sedation. Antispasticity medications such as baclofen, botulinum, benzodiazepines, tizanidine, or vigabatrine are often prescribed which needs to be ascertained. Their overdosage or intravascular administration may cause respiratory muscle paralysis. In addition, ataxia, lethargy, bradycardia, hypotension, delayed arousal from anesthesia, or seizures may occur.
Preoperative investigations include full blood counts, renal parameters, electrolytes, Chest X-ray, and electrocardiography. Grouping and cross matching of blood and products should be done before major surgeries. Standard guidelines for fasting should be advised to avoid inadvertent dehydration.
Intraoperative management should be unhurried and meticulous. Sedative premedications should be administered by titrating them against their unpredictable responses and general state of the patients. Antacids and antireflux medications are necessary. Anticholinergics reduce secretions but can also increase the risk of thickening of pulmonary secretions. EMLA cream administration beforehand decreases the distress and pain associated with venipuncture. Standard noninvasive monitoring should be instituted. Intravenous access might require expert assistance and ultrasound guidance. For induction propofol is desirable, especially in patients with reactive airways. Theoretically, resistance to nondepolarizing muscle relaxants can be expected due to upregulation of acetylcholine receptors with reduced duration of action. Succinylcholine can be expected to increase the potassium levels; however, it is not seen clinically. Pooled secretions in the oropharynx might impair mask ventilation and the glottis view during laryngoscopy. Thus, frequent suctioning may be necessary. Coexisting scoliosis can also complicate airway management. Endotracheal intubation using appropriate sized tubes (based on weight) should be accomplished bearing in mind that majority of the patients are small for age. Rapid sequence induction in patients with florid gastroesophageal reflux can be considered on the individual case basis. Postintubation, positioning of the patient, may pose difficulty due to contractures and spasticity. Tendency for decubitus ulcers requires careful padding of the pressure points to prevent them. Increased sensitivity to narcotics has been observed. Tramadol lowers the threshold for seizure generation and hence is avoided. Other epileptogenic drugs such as ketamine, methohexitone, etomidate, and pethidine should be avoided. Minimum alveolar concentration of inhalational agents is lowered for these patients. A further reduction occurs due to chronic intake of anticonvulsants. Hence, they should be titrated accordingly or better still, bispectral index monitoring may be employed to avoid excessive depth of anesthesia. Neuromuscular monitoring is useful as patients may have altered responses to muscle relaxants.
Hypothermia is a common and serious concern in these individuals. This occurs due to altered thermoregulatory responses because of hypothalamic dysfunction, lack of insulation with muscles/fat, and malnourishment. Serious adverse effects of perioperative hypothermia include wound infection, prolonged hospitalization, physical discomfort, increased blood requirement for transfusion, cardiac arrhythmias, and delayed awakening from anesthesia. Temperature monitoring is therefore to be done very stringently. Measures to conserve temperature should include warming of intravenous and irrigating fluids plus warming blankets or forced air warmers. Furthermore, warm humidified gases can be used to preserve body heat.
Regional anesthesia techniques are strongly recommended for intraoperative as well as postoperative pain relief. Regional techniques however require higher degree of technical skills as scoliosis; muscle contractures and the uncooperative patients make performance of the same, demanding. Opioids in regional techniques should be used with caution as they can accumulate, cause nausea and vomiting, and respiratory depression.
Postoperative care should also be individualized according to the preoperative condition of these patients. Emergence may be delayed. Irritability on arousal is common. This may be compounded further due to reduced communication and cognitive skills of the patients. Parental presence can be helpful in these situations. Drooling can be a cause of postoperative aspiration requiring frequent suctioning and airway protection. Preoperative anticonvulsants should be restarted as early as possible to maintain the therapeutic plasma levels. In patients who are kept nil orally or are vomiting, intravenous formulations may be necessary. Children with CP are prone to constipation. Oral, intravenous, and epidural opioids may compound this problem.
Therefore, attention to normal bowel habits for that child and the prescription of laxatives, supplemented by enemas, may be necessary. Chest physiotherapy is required in patients with poor cough, secretions, and chest infections. Tracheostomy or elective ventilation may be rarely required in some patients.
Postoperative pain management is compounded by the fact that these patients have limited communication skills and poor levels of intellect. Subjective indicators such as facial grimacing, groaning, moaning, or altered sleep patterns may be difficult to interpret. It is advisable to plan the postoperative analgesic regimen on a continuous basis. Multimodal analgesia regimens using nonsteroidal anti-inflammatory drugs, paracetamol, and local anesthetics should be customized according to the patient profile. Opioids should be used very cautiously and with vigilance to detect episodes of oversedation and respiratory depression. An important aspect in orthopedic postoperative patients is the development of compartment syndrome. Decreased communication skills and use of postoperative analgesia techniques can delay the diagnosis of this event. The use of splitting plaster casts and limb elevation can reduce this risk. Additional postoperative issues which might be encountered are poor wound healing due to nutritional deficiencies. The incidence of decubitus ulcers is also high in these patients who remain nonambulatory in the postoperative period due to musculoskeletal contractures.
To conclude, CP is a group of nonprogressive disorder with varying degrees of motor, sensory, and behavioral impairment. Anesthesia for these patients should be customized to suit their specialized pathophysiology. Thorough understanding of their pathophysiology and drug interactions can guide the attending anesthesiologist to formulate the best possible anesthetic regimen and meticulous perioperative planning for a better outcome.
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