Paediatric anaesthesia16 / 17
Myelomeningocele with shunt and latex allergy10-year-old girl, 32 kg, with repaired lumbar myelomeningocele
From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.
Know this first
- Repeated latex exposure, including daily catheters, makes latex allergy common in myelomeningocele.
- Latex reactions are typically delayed, up to 30 minutes after exposure.
- IM adrenaline 0.01 mg/kg, maximum 0.3 mg in a child; infusion if refractory.
- Tryptase rises within 1–2 hours; skin testing is done 6–8 weeks later.
- Over 90% have a Chiari II malformation.
The patient
10-year-old girl, 32 kg, with repaired lumbar myelomeningocele, VP shunt and neurogenic bladder, for elective bladder augmentation.
Lip swelling after a urinary catheter last year; no shunt symptoms now. Wheelchair user; self-catheterises.
Drugs: oxybutynin, nitrofurantoin prophylaxis.
Vitals: HR 88, BP 108/66, SpO2 98% on air, RR 18. Creatinine 0.6 mg/dL.
The examiner asks
Answer aloud, then press Show.
Consider
What are your considerations?
Show the answerHide the answer
- A 10-year-old with myelomeningocele, a shunt and probable latex allergy, for bladder augmentation. Patient
- At 10 she has had many operations; as a wheelchair user, her skin and positioning need care.
- Lip swelling to a catheter points to latex allergy, common in her condition. Disease
- Shunt: lethargy, vomiting or slow pulse would suggest blockage before surgery.
- Chiari II: I ask about stridor, swallowing and breathing pauses.
- Long bladder surgery: blood loss, fluid shifts, and her kidneys to protect. Surgery
Prepare
How do you get her ready?
Show the answerHide the answer
- Latex-free theatre and kit throughout her stay, set up before she arrives. Disease
- No shunt symptoms; neurosurgical review if any appear.
- Creatinine 0.6 and urine culture checked, given her neurogenic bladder.
- Adrenaline for anaphylaxis drawn up before induction. Crisis
Plan
What is your anaesthetic plan?
Show the answerHide the answer
- General anaesthesia; no neuraxial block over her repaired spine. Disease
- Pressure points padded; her numb legs can't warn of injury. Surgery
- Warming, fluid balance and blood loss tracked through a long case.
- Titrated opioids with paracetamol 15 mg/kg IV for pain. After surgery
Crisis
Forty minutes in, BP drops to 60/30, HR 150, wheeze with airway pressure 35, and a flushed rash. What do you do?
Show the answerHide the answer
- Anaphylaxis, likely latex at 40 minutes: help called, surgeon told. (Crisis)
- Remove the trigger: all latex out, gloves and catheters changed.
- Adrenaline 0.01 mg/kg IM, maximum 0.3 mg, repeated every 5–15 minutes.
- 100% oxygen, legs raised, crystalloid 10–25 mL/kg IV fast.
- Refractory: adrenaline infusion from 0.05–1 mcg/kg/min, titrated.
- Salbutamol for wheeze; methylprednisolone 1 mg/kg IV, maximum 125 mg, as second line.
- She takes no beta-blocker, so glucagon isn't needed.
Crisis
She stabilises. What next?
Show the answerHide the answer
- Tryptase within 1–2 hours of the reaction. (After surgery)
- With the surgeon, decide whether to finish or stop.
- PICU observation; anaphylaxis can recur.
- Skin testing in 6–8 weeks; latex alert on her record; family informed.
Fatal mistakes
- Exposing her to latex despite spina bifida.
- Delaying adrenaline in anaphylaxis.
- No shunt assessment before surgery.
Checked against: Barash 9e · Stoelting 8e · Miller 10e
Report a problem with this case
Mark Got it only if you said every point. Again brings the case back tomorrow; Got it brings it back in 3, then 7, 14 and 30 days.