P023: ANESTHETIC MANAGEMENT OF A PATIENT WITH SYMPTOMATIC CONGENITAL CMV
Vanessa Zabala, MD, MPH1; Norman Carvalho, MD2; Patrick Ziarnowski , DO3
1UCF; 2Nemours Children's Hospital; 3HCA Ocala
Introduction/background: Congenital CMV is a major risk factor for the development of cerebral palsy in children. Cerebral palsy is known to lead to several neurodevelopmental disorders that can affect many organ systems and be a challenge to manage under anesthesia. Over half of patients with cerebral palsy develop intellectual disability, hearing/visual impairments, respiratory complications, thin body habitus, and an increased sensitivity to anesthetic drugs[1]. Due to their respiratory compromise, these patients are more likely to experience respiratory depression with medications like opioids.
Pain management can be difficult in a patient with many airway complications. This case offers a review of the evaluation and management of a child with several comorbidities undergoing hip surgery, to give anesthesiologists an alternative to using opioids in similar cases.
Body: This is a case of a 3-year-old male presenting for bilateral proximal femoral hemiepiphysiodesis and adductor lengthenings for repair of bilateral hip contracture and neuromuscular dislocation of hip joints. Surgical history included g-tube placement and supraglottoplasty. The patient had developed long-term sequelae of congenital CMV that led to profound global intellectual disabilities and affected major organ systems that left him nonambulatory and nonverbal. Neurologically, the patient developed cerebral palsy that left him quadriplegic and with a seizure disorder. He also had a history of microcephaly and cystic encephalomalacia. The patient had sialorrhea, chronic lung disease, oropharyngeal dysplasia, and OSA requiring oxygen at night.
Due to the vast number of comorbidities this patient had; the anesthetic plan was a general regional combination. He was to have a post-induction single shot caudal block and the possibility of a rescue post-op caudal block. Planned airway was with an ETT using glidescope for intubation to minimize attempts, damage to teeth, and hypoxia.
To minimize apnea, patient had a slow, mask induction with sevoflurane followed by IV propofol 20mg, rocuronium 10mg and glycopyrrolate 100mcg for an uneventful glidescope guided intubation. For pain management, patient received a caudal block with 10mL of ropivacaine 0.2% with clonidine, and was placed on a propofol infusion with a bolus dose of IV ketamine 10mg before incision. Patient remained hemodynamically stable and did not require pressors or intravenous fluids boluses. Normovolemia was maintained through normal saline administration throughout the procedure. Before extubation, patient was given another dose of 50mcg glycopyrrolate and neuromuscular blockade was antagonized with sugammadex 45mg. Anesthesia time was 2 hours. Patient was transported to PICU with nasal trumpet in place and supplemental oxygen via a face mask. Postoperative course was unremarkable.
Conclusion: Despite the many comorbidities this patient presented with, this case highlights a successful surgery, without the use of opioids, by using a combined regional and general anesthetic technique.
References:
1. Boppana SB, Ross SA, Fowler KB. Congenital cytomegalovirus infection: clinical outcome. Clin Infect Dis. 2013.