|Year : 2017 | Volume
| Issue : 6 | Page : 599-601
A case of cerebral palsy: The need of perioperative multidisciplinary approach
Sunita Milind Khedkar, Pradnya Milind Bhalerao, Kalpana Vinod Kelkar, Rohit Pravinkumar Sancheti
Department of Anaesthesiology, B.J. Medical College, Pune, Maharashtra, India
|Date of Submission||29-Apr-2017|
|Date of Acceptance||21-Jun-2017|
|Date of Web Publication||17-Jan-2018|
Dr. Sunita Milind Khedkar
B-16, Vishnu Sadashiv Parisar, New Mangalwar Peth, Pune - 411 001, Maharashtra
Source of Support: None, Conflict of Interest: None
Cerebral palsy (CP) occurs as a result of an insult to the developing brain which may be due to birth asphyxia, trauma, infection, or prematurity in the antenatal, perinatal, or postnatal period. It is characterized by varying degrees of motor, sensory, and intellectual impairment. CP clinically manifests as spastic, dyskinetic, ataxic, and mixed type according to the involvement of brain. Additional developmental disabilities such as mental retardation, epilepsy, visual, hearing, speech, cognitive, behavioral abnormalities, and chronic systemic diseases may be present in these patients. Here, we have discussed the successful management of a case of spastic CP for removal of bladder calculus with proper perioperative care.
Keywords: Anesthesia, cerebral palsy, muscle spasticity, perioperative care
|How to cite this article:|
Khedkar SM, Bhalerao PM, Kelkar KV, Sancheti RP. A case of cerebral palsy: The need of perioperative multidisciplinary approach. Med J DY Patil Univ 2017;10:599-601
|How to cite this URL:|
Khedkar SM, Bhalerao PM, Kelkar KV, Sancheti RP. A case of cerebral palsy: The need of perioperative multidisciplinary approach. Med J DY Patil Univ [serial online] 2017 [cited 2020 Oct 21];10:599-601. Available from: https://www.mjdrdypu.org/text.asp?2017/10/6/599/223368
| Introduction|| |
The incidence of CP is about 3/1000 live births in the developing countries like India. It has not changed in the recent years, despite improved public health and antenatal care. This may be due to an increase in the survival rate of premature infants. Cerebral palsy (CP) is the result of pathological injury to the developing fetal or infant brain. There are four types of CP which include spastic (70%), dyskinetic (10%), ataxic (10%), and mixed (10%). These patients are also commonly associated with mental retardation, epilepsy, and other behavioral abnormalities. These patients may come for multiple surgeries who need proper pre-, intra-, and post-operative care.
| Case Report|| |
An 11-year-old, 15 kg female child, a known case of spastic CP with severe mental retardation, was admitted with complaints of burning micturition and pain in abdomen for 6 months. She had been investigated and diagnosed to have bladder calculus of 1.8 cm × 1.8 cm on ultrasonography abdomen and was posted for removal of calculus.
She was born of first-degree consanguineous marriage and delivered by lower segment cesarean section at full term. She had a delayed cry and birth asphyxia, for which there was a history of neonatal intensive care unit admission for 15 days. Her milestones were also delayed. She had verbal communication with her parents only. There was a history of focal convulsions for 2 years for which she was receiving tablet carbamazepine 100 mg BD.
All the blood investigations were normal, except successive serum potassium (K+) levels were high with no electrocardiogram (ECG) changes. The two serum K+ levels were 6.6 and 7.5 mEq which came to normal, i.e., 4.5 and 4.1 mEq with nebulization of 0.5 cc salbutamol in 2.5 cc NS. On general examination, her weight was 15 kg. She was conscious and had a slurred speech with severe mental retardation (intelligent quotient 13). Sensory examination and bowel and bladder sensations were normal. When motor examination was done, the tone was increased in all the four limbs (clasp knife rigidity), with hyperreflexia, planters were upgoing, and power could not be accessed.
Morning dose of tablet carbamazepine 100 mg was given, and a written, informed, valid consent of parents was obtained. After local application of eutectic mixture of local anesthetic (EMLA) cream, an intravenous (IV) line was secured with 22-gauge cannula. 30 min before surgery, injection glycopyrrolate 75 μg intramuscularly was given with fine needle. ECG, pulse oximeter, noninvasive blood pressure, end-tidal CO2, temperature, and bispectral index monitors (BIS) were attached to the patient. After adequate preloading with normal saline, IV premedication was given with injection ondansetron 1.2 mg, injection hydrocortisone 30 mg, and injection dexmedetomidine 7.5 μg bolus slowly over 10 min followed by infusion at 0.2 μg/kg/h. The patient was preoxygenated with 100% oxygen for 3 min and was induced with injection propofol 70 mg IV slowly till the loss of eyelash reflex. After checking of bag mask ventilation with cricoid pressure, the patient was intubated with 5 mm cuffed endotracheal tube and connected to a closed circuit. The patient was maintained on O2:N2O (50%:50%), sevoflurane was started with 5 volume% and then reduced to 1.5 volume%, and dexmedetomidine infusion was started at 0.2 μg/kg/h so as to maintain BIS level between 40 and 60. The surgery was completed within 1 h uneventfully. Intraoperatively, the patient remained stable. Postoperative analgesia was given with injection paracetamol 150 mg IV and local infiltration along the line of incision with injection Sensorcaine ® 3cc and injection lignocaine 3 cc. The patient was extubated uneventfully after full awakening and regaining of airway reflexes. The patient was observed in the postanesthesia care unit for 2 h and then shifted to the ward. She was discharged after 7 days.
| Discussion|| |
Although genetic abnormalities, perinatal anoxia, infection, and trauma have been proposed as etiologic factors in CP, no clear simple cause has been identified till now. However, a notable feature of CP is that infants generally have very low birth weight. Periventricular lesions can be identified on magnetic resonance imaging in upto 90% of children born prematurely who go on to develop the clinical signs of CP in the postnatal period. Other hypotheses in term infants include antenatal infection, thyroid disease, and neuronal migration disorders. Postnatal causes include meningitis, viral encephalitis, hydrocephalus, and trauma.
In the present case, history suggests that the cause of CP may be genetic or perinatal hypoxia of the developing brain.
Clinical manifestations usually relate to the areas of brain affected. This patient had spastic CP with clasp knife rigidity and severe mental retardation which might be because of injury to the cerebrum. Visual and hearing defects are present in 40% of CP patients including strabismus, myopia, and retinopathy of prematurity and cortical blindness.
The patients with CP often present for elective surgical procedures to correct various deformities. This patient was posted for removal of bladder calculus.
Epilepsy occurs in 47% of patients with CP and is most common in spastic quadriplegia. All medications, particularly those for convulsions and spasticity, should be continued in the perioperative period to avoid problems with acute withdrawal and worsening of seizure control.
A complete history and physical examination is essential before anesthetizing these children. Cognitive and communication problems may make preoperative assessment more difficult. Parents and caretakers are best to be involved during this period. In this case, a multidisciplinary approach is necessary. The involvement of a pediatrician, psychiatrist, surgeon, and physiotherapist in the perioperative period is preferred.
Contractures may make positioning and intravenous access difficult. The airway should be assessed properly for the severity of the airway obstruction, because as the age increases, there is worsening of hypotonia of pharyngeal musculature. These children have an impaired ability to handle pharyngeal secretions. This is because of hyperactive salivary glands and impaired cranial nerve function. The use of anticholinergic drugs is necessary. Injection hydrocortisone was used to prevent airway hyperactivity and laryngeal edema.
These patients may have chronic respiratory problems because of gastroesophageal reflux, recurrent pneumonias, pulmonary aspiration, and chronic lung disease. Hence, optimization with the help of proper antibiotics, physiotherapy, and nebulization preoperatively can reduce the chances of intra- and post-operative respiratory complications. Sedation may cause loss of airway tone and aspiration in hypotonic children. Hence, it is better to avoid sedation in the preoperative period. EMLA cream was used for taking IV access. For premedication, oral midazolam or ketamine may be considered. Injection dexmedetomidine was used as sedative and analgesic as it is short acting and has less respiratory depressant effect.
The extremities of these children are often cold and vasoconstricted, so the use of a warming device may help in peripheral venous access. Careful positioning is paramount in the child with spastic CP to avoid nerve and muscle damage. Fixed contracture may add to difficulty in positioning.
Propofol was used for induction of anesthesia.
It is a good choice since many children with CP have reactive airway disease and propofol unlike thiopentone decreases the airway tone and reflexes. Succinylcholine is not contraindicated in patients with CP. There may be resistance to nondepolarizing muscle relaxants, although this is of doubtful clinical significance. The use of succinylcholine was avoided as serum potassium levels were preoperatively high. The association of CP and high potassium could not be found in any literature. This could be because of increased muscle tone.
Children with CP are often underweight. Our patient weighed 15 kg which was very less for her age. Tracheal tube size selection should be based on their age not on weight as this usually provides the most appropriate fit. The endotracheal intubation was done with cricoid pressure in this patient, as these patients are prone to gastroesophageal reflux and aspiration, so we avoided the use of supraglottic airway devices (such as laryngeal mask, I-gel) and used more safer technique. The use of sevoflurane and dexmedetomidine according to BIS value showed the requirement of these agents also less in this case as compared to normal patients.,
Hypothermia may be a major problem in these children because of hypothalamic dysfunction and malnourishment. Hence, we used warm IV fluids and room warmers to tide over this issue.
For prevention of severe postoperative muscle spasms because of pain, combined general and regional anesthetic techniques are highly recommended. This patient received local infiltration and IV paracetamol for postoperative analgesia.
Emergence from anesthesia may be delayed due to hypothermia and residual volatile anesthetic agents. This patient regained activity within 5 min after stoppage of agents.
| Conclusion|| |
The key to successful management of CP are the knowledge of disease and associated problems therein, preoperative optimization, intraoperative use of appropriate anesthetic agents, postoperative care, and pain management. Thus, the multidisciplinary approaches in the perioperative period can change the outcome.
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.
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