Cerebral palsy with severe reflux for fundoplication12-year-old boy, 24 kg, with spastic quadriplegic cerebral palsy
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Know this first
- Cerebral palsy has no link to MH; suxamethonium is not contraindicated.
- Lower MAC, slower emergence, and prone to hypothermia.
- Reflux and poor pharyngeal tone favour rapid sequence intubation.
- Antiepileptic doses stay on schedule throughout.
- Parents or carers are often the best judges of his pain.
The patient
The examiner asks
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Consider
What are your considerations?
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- A 12-year-old, non-verbal, with quadriplegic cerebral palsy and severe reflux, for fundoplication. Patient
- As a child who can't speak, his consent and pain cues come through his parents.
- Chest: repeated aspiration and scoliosis leave little reserve, and his cough is weak. Disease
- Weekly seizures on three antiepileptics: doses must not be missed.
- Poor nutrition, contractures and pressure-injury risk; he cools fast in theatre. Surgery
Prepare
How do you get him ready?
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- Chest examined; no active infection before elective surgery. Disease
- Antiepileptics given on time this morning, with IV options while he's nil by mouth.
- Consent with his parents, in his best interests. Patient
- Venous access will be hard; ultrasound and an experienced cannulator.
- Latex history asked; repeated surgery in cerebral palsy raises the risk. Disease
Plan
How do you conduct the anaesthetic?
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- Rapid sequence induction: his reflux and weak pharynx make aspiration likely. Airway
- Suxamethonium is acceptable in cerebral palsy, or rocuronium 1.2 mg/kg.
- Lower volatile requirement; I expect slower waking. Disease
- Active warming from the start, with a core temperature probe. Patient
- Train-of-four monitoring; his recovery from relaxant is often slow. Airway
- Contractures and pressure points padded carefully. Surgery
Crisis
During the rapid sequence, before the tube is in, green fluid fills his pharynx and SpO2 is 88%. What now?
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- Aspiration: head down, suction his pharynx, intubate straight away. Crisis
- Suction down the tube on 100% oxygen before positive pressure.
- No saline lavage; bronchoscopy to clear particles if needed.
- Proceed or stop with the surgeon, depending on his oxygenation.
- Chest X-ray, and ventilation afterwards if gas exchange is poor. After surgery
Crisis
At the end he breathes 8 times a minute, shallowly; temperature 34.8 °C; TOF ratio 0.6. What do you do?
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- Residual block, hypothermia and his low anaesthetic need, together. Crisis
- He stays asleep and ventilated; no extubation below a TOF ratio of 0.9.
- Rewarm him with forced air and warmed fluids.
- Sugammadex 2 mg/kg once the second twitch is back after rocuronium.
- Extubate when warm with TOF over 0.9; HDU overnight. After surgery
- Pain judged with his parents; regional analgesia and diazepam for spasm.
Fatal mistakes
- Unprotected airway with his severe reflux.
- Missed antiepileptic doses.
- Extubation with residual block and no monitoring.
Checked against: Stoelting 8e · Miller 10e · Faust · 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade · BRIDION (sugammadex) injection, US prescribing information (2015)
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