2024 FSA Podium and Poster Abstracts
P041: OPTIMIZATION OF PERIOPERATIVE MANAGEMENT FOR RUPTURED MCA ANEURYSM IN 13-MONTH-OLD INFANT
Grace Chalhoub, DO1; Jacquelin Peck, MD2; Cecilia Nosti, MD1; 1Memorial Healthcare system; 2Envision Physician Services
Introduction: Intracranial aneurysms in children less than two years of age comprise less than 2% of total aneurysms. Aneurysms in this age group present with symptoms secondary to rupture or mass effect, and prompt neurosurgical intervention is critical to prevent permanent morbidity and mortality.
Case report: A 13-month-old male (10 kg) with a 1-day history of fever and emesis was admitted due to lethargy and altered mental status. Brain MRI showed subarachnoid and intraventricular hemorrhage, left MCA aneurysm and mild hydrocephalus (Figure 1). The patient was transferred to the pediatric ICU and scheduled for craniotomy with aneurysm clipping the following morning. Multiple attempts to obtain vascular access were unsuccessful in the ICU, and subcutaneous hydration was initiated. The patient was brought to the preoperative area with neither IV access nor type or screen. Preoperative laboratory values noted mild anemia (Hb 10) but were otherwise unremarkable. The patient also received breast milk two hours prior to surgery.
After joint discussion between the anesthesiologist and surgeon, the decision to proceed was made despite NPO violation due to the urgent indication for surgery. The patient was sedated with 10 mg of oral midazolam to provide anxiolysis and avoid hypertension. A 22 gauge IV was placed in the left forearm in the operating room to obtain type and screen, pre-operative labs and administer fluids. Rocuronium and Fentanyl was used for rapid sequence intubation. Following induction and endotracheal intubation, a 24G left radial arterial line and right basilic vein PICC line were placed. 120 mL of PRBC was transfused after intraoperative ABG showed a hemoglobin decrease to 8.3. Surgical EBL was estimated at about 100 mL. The surgery proceeded uneventfully and the patient returned to the ICU intubated and mechanically ventilated. The patient was extubated the next day, and a repeat brain MRI on post-operative day 5 was reassuring. The patient was discharged home on post-operative day 15 and completed a 21-day course of nimodipine and Keppra as an outpatient.
Discussion and Conclusion: The anesthetic management of aneurysm repair in young children can be challenging and should be completed in referral centers with specialized teams. Difficult vascular access posed a significant challenge because multiple attempts resulted in agitation of the infant, which increased blood pressure and risked additional hemorrhage. Interosseus and central vascular access were not pursued in our case, but were available if initial attempts in the operating room failed.
The patient’s full stomach was another concern, but the risk of further delay was deemed greater than the risk posed by potential aspiration. Suction was readily available and the airway was secured as quickly as possible after obtaining IV access. Emergency, uncrossmatched blood was in the room prior to induction given the small allowable blood loss of a 10kg child and was administered after the blood bank confirmed compatibility. Concerns regarding perioperative optimization in the setting of emergency surgery was best facilitated due to close communication and teamwork among operating room staff.