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Anesthesia in Cerebral Palsy

Anesthesia in Cerebral Palsy. R i 鄭玠峰、林鉉智 Directed by R3 林子富 VS 范守仁. 《Part 1》 Case Presentation. <Brief history>. 蔡╳╳ 3-year & 7-month-old boy <Chief Complain> Dyspnea with fever for 2 days. <Present Illness>. ‧3-year & 7-month-old boy

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Anesthesia in Cerebral Palsy

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  1. Anesthesia in Cerebral Palsy R i 鄭玠峰、林鉉智 Directed by R3 林子富 VS 范守仁

  2. 《Part 1》 Case Presentation

  3. <Brief history> 蔡╳╳ 3-year & 7-month-old boy <Chief Complain> Dyspnea with fever for 2 days

  4. <Present Illness> ‧3-year & 7-month-old boy ‧Cerebral palsy secondary to Reye’s syndrome ‧Multiple episodes of aspiration pneumonia and acute bronchiolitis ‧Dyspnea with fever was noted, for further evaluation.

  5. <Brief History> Birth history： G3P3, C/S due to twin pregnancy, Twin B GA=36+ weeks, BBW=2416 gm Vaccination： BCG1, HBV3, DPT & Polio, Measles, MMR,JVE, Varicella (as scheduled) Feeding： on full diet

  6. Growth & Development Body weight=12 Kg (<3 percentile) DMS：Developmentally delay Gross motor：Cannot stand or jump Fine motor： Putting on clothes (-) Wearing shoes (-) Feeding with spoon (-) Verbal：Just nonsense murmuring voice

  7. <Past History> (1) 881026~881028: 婦幼H for suspected TTNB (2) 890511~890530: NTUH for Reye-like syndrome, r/o fatty acid oxidation defect (3) 890719~890901: NTUH for acute bronchitis, respiratory failure (4) 890906~890922: NTUH for aspiration pneumonia (5) 890923~890928: NTUH for upper GI bleeding (6) 891105~891118: NTUH for aspiration pneumonia (7) 891121~891219: NTUH for aspiration pneumonia (8) 891226~900113: NTUH for cellulitis (9) 900208~900215: NTUH for acute bronchiolitis (10) 900503~900601: NTUH for AGE, UTI, and pneumonia (11) 900627~900622: bronchopneumonia (12) 900707~900712: NTUH for acute bronchiolitis (13) 900806~900812: NTUH for aspiration pneumonia

  8. <Past History> (14) 901008~901016: NTUH for RSV bronchiolitis (15) 901020~901105: NTUH for acute bronchiolitis (16) 901108~901111: NTUH for laryngomalacia & Bilateral retracted testes and hydrocele, s/p flexible bronchoscope, rigid bronchoscope & bilateral orchiopexy (17) 910626~910703: NTUH for aspiration pneumonia (18) 910713~910718: NTUH for bronchiolitis (19) 911122~911128: NTUH for acute bronchiolitis (20) 920424~920502: NTUH for acute bronchiolitis (21) 920424~920502: NTUH公館 for bronchopneumonia (22) 920512~920515: NTUH公館 for bronchopneumonia (23) 920517~920527: 萬芳H for dyspnea, r/o asthma

  9. Medication • Befon (Baclofen) for spasm relief • Meptin (β-agonist as bronchodilator) • Rhinathiol (mucolytic agent) • Rivotriol (Clonazepam) • Eurodin (Estazolam) • Dupin (Diazepam)

  10. PE findings Polyphonic wheezing (+) Suprasternal retraction (+) Subcostal retraction (+) Nasal flaring (+) Trunk：increased spasticity

  11. Procedure Bronchoscopy for evaluating his airway functions.

  12. 《Part 2》Discussion Topic： Anesthesia in Cerebral Palsy J. Nolan, G.A. Chalkiads, J. Low, C.A. Olesch and T.C.K. Brown. Anaesthesia and pain management in cerebral palsy. Anaesthesia, 2000; 55: 32-41

  13. Cerebral Palsy ‧Non-progressive disorder of motion and posture. ‧CP is a result of an injury to the developing brain during the antenatal, perinatal, or postnatal period. ‧Clinical manifestation relate to the area affected. ‧CP is the leading cause of childhood motor disability in developed country. ‧Such disabilities include cognitive impairment, sensory loss, seizures, communication and behavioral disturbances.

  14. Etiology of Cerebral Palsy Premature： ‧Periventricular hemorrhage  Periventricular leucomalacia ‧In spastic diplegia type Term baby： ‧Antenatal infection ‧Thyroid disease ‧Neuronal migration disorder Postnatal causes： ‧Meningitis, viral encephalitis, hydrocephalus, trauma, etc.

  15. Classification for Cerebral Palsy

  16. Pre-operative assessment

  17. Gastrointestinal Problems Gastro-esophageal reflux： Esophageal dysmobility、LES abnormal、 Spinal deformity Salivary drooling： Impaired swallowing or tongue thrust and poor head control  Drooling  Tx：Anticholinergics MalnutritionFailure to thrive： Poor chewing and swallowingpre-operative nutrition support is needed. Electrolyte imbalance & Associated anemia

  18. Respiratory Problems Pulmonary aspiration from reflux Recurrent respiratory infections Chronic lung disease Pre-operative physiotherapy、antibiotics、 bronchodilators may be required. Scoliosis： Cardiopulmonary compromise Others： Dental caries、loose teeth、temporomandibular joint dysfunction、tongue thrusting  oral bite & overjet may be needed.

  19. Epilepsy ‧Common in spastic hemiplegia ‧Tonic-clonic seizures ‧Complex-partial seizures Normal anticonvulsant therapy should be continued up to and including the day of surgery.

  20. Visual deficits Visual abnormalities： ‧40% of children with CP ‧Prematurity (1) Retinopathy of prematurityvisual impairment (2) Oculomotor problemsStrabismusAmblyopia (3) Visual field defect (4) Cortical blindness

  21. Behavioral & Communication Problems Intellectual disability ‧2/3 children with CP ‧Learning problemsCommunication concern Attention deficit disorders ‧In higher functioning children ‧Self-injurious behaviors Depression and emotion problems ‧Common adolescent problems

  22. Premedication • Sedativesto reduce anxiety and spasm during induction • Antacids • Local anesthetic cream at puncture site • AnticonvulsantCarbamazepine and sodium valproate • AntispasmodicsBenzodiazepine、Baclofen to reduce muscle toneClonidine、Botulinum neurotoxin • AnticholinergicsAtropine (hyperthermia)、Neostygmine、Edrophonium • Antidepressant TCA、MAOI

  23. Anaesthesia in CP

  24. Peri-operative management • Have primary carers during induction • Vascular access may be difficult • Airway maintenance • Anti-emetics • Careful positioning • Drug responses may vary • Latex allergy has been reported • Intra-operative hypothermia • Standard monitoring

  25. Airway maintenance • Excessive secretions, A concern or a history of gastro-oesophageal reflux • Tracheal tube size selection should be based on their age as this usually provides the most appropriate fit.

  26. Drug responses • Resistance to non-depolarising muscle relaxants • Reduced MAC relative to normal controls • Most anaesthetic agents are anticonvulsants

  27. Patients with upper motor neuron disease are resistant to NDMR. • Moorthy SS, Krishna G, Dierdorf SF. Resistance to vecuronium in patients with cerebral palsy. Anesthesia and Analgesia 1991; 73: 275-7

  28. An increase number of junctional and extrajunctional acetylcholine receptors • Immobilization with muscle atrophy • Concomitant administration of phenytoin and phenobarbital • Drug interactions: • increased metabolism of the muscle relaxant via hepatic enzyme • decreased sensitivity of muscle receptors to the MR • increased numbers of receptors • increased muscle end-plate cholineasterase activity

  29. Children with CP and severe mental retardation may require lower concentration of inhalational anaesthetics than healthy children. • Frei FJ, Haemmerle MH, Brunner R, Kern C.Minimum alveolar concentration for halothane in children with cerebral palsy and severe mental retardation. Anaesthesia 1997; 52: 1056-60

  30. Elevated pain threshold, decreased central pain perception • Lower motor neuron more sensitive to inhalational anaesthetics • Children with CP had significantly lower MAC values whether they took anticonvulsant drugs or not.

  31. Post-operative management

  32. Emergence from anaesthesia may be delayed • Hypothermia • Residual volatile anaesthetic agents

  33. Postoperative chest Physiotherapy • Drooling • Poor cough • Recurrent respiratory infections • Impaired clearance of secretions

  34. Irritability on emergence from anaesthesia is common • Pain • Urinary retention • Unfamiliar environment

  35. Maintain anticonvulsant / baclofen • Long half-lives • IV or rectal route • Pre-operative referral

  36. Children with CP are prone to constipation • Reduced mobility • Reduced fluid intake • Undiagnosed gut mobility problems

  37. Reference: • J. Nolan, G.A. Chalkiads, J. Low, C.A. Olesch and T.C.K. Brown. Anaesthesia and pain management in cerebral palsy. Anaesthesia, 2000; 55: 32-41 • Moorthy SS, Krishna G, Dierdorf SF. Resistance to vecuronium in patients with cerebral palsy. Anesthesia and Analgesia 1991; 73: 275-7 • Frei FJ, Haemmerle MH, Brunner R, Kern C. Minimum alveolar concentration for halothane in children with cerebral palsy and severe mental retardation. Anaesthesia 1997; 52: 1056-60 • Delfico AJ, Dormans JP, Craythorne CB, Templeton JJ. Intraoperative anaphylaxis due to allergy to latex in children who have cerebral palsy: a report of six cases. Developmental Medicine and Child Neurology 1996; 39: 194-7

  38. Anaesthesia in CP --END--

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