Sir, The incidence of hydrocephalus with meningomyelocele (MMC) in an infant is high (70%–80%).1,2 They might be associated with other congenital anomalies,3 but their association with kyphoscoliosis becomes really challenging for the anaesthesiologists, especially the airway management part. We hereby discuss the successful airway management of a 55-day-old infant with severe kyphoscoliosis, hydrocephalus and MMC posted for ventriculoperitoneal shunt. A 55-day-old female infant, weighing 3.6 kg, was diagnosed with hydrocephalus (enlarging head size since birth and head circumference: 44 cm) and was planned for a ventriculoperitoneal shunt. On preoperative examination, she also had swelling in the lumbosacral region since birth and severe kyphoscoliosis (chest circumference: 32 cm) Figure 1. All other congenital anomalies were ruled out. The cardiovascular system, on examination, was normal. Her two-dimensional echocardiography findings were situs solitus with levocardia, with no regional wall motion abnormality, raised systolic pulmonary artery pressures: 31 mm Hg and normal biventricular function. On auscultation of the chest, air entry was significantly reduced on the right side.Figure 1: Infant with severe kyphoscoliosis, meningomyelocele and hydrocephalusAfter taking written, informed consent, the infant was taken to the operating theatre. Standard monitoring, including pulse oximetry, electrocardiography and non-invasive blood pressure, was performed. The baby was covered in warm sheets to prevent hypothermia. The child was preoxygenated with 100% oxygen and induced with sevoflurane and propofol 6 mg intravenous (IV) and atracurium 2 mg IV, followed by IV fentanyl 8 μg. Securing the airway is the major concern in this case. In view of this, a difficult airway cart was kept ready. A ring of outer diameter 24 cm was used to avoid compression and rupture of MMC. Furthermore, a head ring was kept below the head, and a shoulder roll was used to bring the torso in line with the head to facilitate optimum positioning and to aid in intubation. Intubation was performed using a video-laryngoscope with a paediatric blade in this case. Anaesthesia was maintained with sevoflurane and atracurium. The intraoperative course was uneventful. The infant was extubated at the end of surgery and was transferred to the postanaesthesia care unit for observation. Dealing with kyphoscoliosis in an infant has its own complications. First, the positioning of these patients for intubation is a major concern. Second, as pulmonary function tests cannot be performed in them, the extent of the restrictive lung pattern is difficult to assess. This may lead to respiratory complications in such patients. Another important aspect in such patients is cardiovascular system involvement which is primarily because of severe respiratory compromise; thus, echocardiography should be advised before surgery. Also attention should be given to pulmonary artery pressures that may be elevated secondary to chronic hypoxemia associated with kyphoscoliosis. Moreover, marked respiratory restriction and associated gas exchange abnormalities (e.g., hypoxia and hypercarbia) in kyphoscoliotic patients can further elevate the intracranial pressures, especially in obstructive hydrocephalus. Proper planning and preoperative assessment help in the successful management of such cases. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient’s guardians/parents to conceal identity, but anonymity cannot be guaranteed. Author contribution Swati Ojha- Writing- Original draft, Data curation Richa Kewalramani- Writing-Review and editing Manbir Kaur- Conceptualization, Review and editing, Supervision Sugandhi Nemani- Data curation, resources Kamlesh Kumari- Conceptualization, Supervision. Disclosure of use of artificial intelligence (AI)-assistive or generative tools No, we have not used AI tools. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Ojha et al. (Thu,) studied this question.