Craniofacial surgery in paediatric patients is associated with several complications, including severe bleeding and venous air embolism. We present a case of an 18 months, 10 kilogramme weight child who had cardiac arrest after completion of surgery, but before extubation. Possibility of both haemorrhage and venous air embolism is discussed

Khan, Fauzia Anis

Salam, Asma Abdus

English

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eCommons@AKUDepartment of Anaesthesia Medical College, PakistanOctober 2013Cardiac arrest in a child following cranioplastyAsma Abdus SalamFauzia Anis KhanFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_anaesthPart of the Anesthesia and Analgesia Commons, and the Anesthesiology CommonsRecommended CitationSalam, A. A., Khan, F. A. (2013). Cardiac arrest in a child following cranioplasty. Journal of Pakistan Medical Association, 63(10),1307-1308.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_anaesth/190Abstract Craniofacial surgery in paediatric patients is associatedwith several complications, including severe bleeding andvenous air embolism. We present a case of an 18 months,10 kilogramme weight child who had cardiac arrest aftercompletion of surgery, but before extubation. Possibilityof both haemorrhage and venous air embolism isdiscussed.Keywords: Craniofacial surgery, Paediatric, Venous airembolism.Introduction Craniofacial surgery in paediatric anaesthesia isassociated with serious morbidity. Complications likesevere bleeding and venous air embolism have beendescribed before, but in majority of cases these occurduring the intraoperative period. We present a case ofsuspected venous air embolism that occurred aftercompletion of surgery, but prior to extubation in a childwho had undergone bifrontal cranioplasty.Case ReportA 10kg, 18-month-old female child presented for electivebifrontal cranioplasty. She had history of trauma followedby posttraumatic seizures and had undergone bifrontalcraniotomy three months earlier. She was on anti-convulsant medication.Standard monitoring in the operating room includedelectrocardiogram (ECG), non-invasive blood pressure(NIBP), pulse oximetre, end-tidal carbon dioxide,temperature, precordial stethoscope, end-tidalconcentration of gases and urine output. Two peripheralintravenous cannulae were inserted and anaestheticinduction was done with 10ug fentanyl, 20mg propofoland atracurium. Left radial artery was cannulated and acentral venous catheter was inserted in the right femoralvein. The patient was placed in supine position.Surgical procedure was of three-hour duration. Patientremained haemodynamically stable throughout.Intraoperative blood loss was calculated by observationof blood-soaked sponges, surgical drapes, suctionapparatus, changes in haemodynamics, trend of centralvenous pressure (CVP), urine output and was estimated tobe approximately 215mls. The patient received 460mlscrystalloids and 220mls of packed cells.After completion of surgery, but before reversal of themuscle relaxation, while the neurosurgical resident wasapplying the head bandage, we noticed a sudden fall inend-tidal CO2 from 31mmHg to 18, 11 and 0 within fewseconds. Bradycardia occurred at the same time withdecrease in heart rate from 127 beats min-1 to 60 beatsmin-1. Tracheal tube was rechecked. Upon auscultation,no heart sounds were audible and chest compressionswere initiated immediately and intravenous atropine0.2mg was administered. Simultaneously it was noticedthat the patient was extremely pale. Blood in both redivacdrains was noted to be approximately 150mls. Ventilationwith 100% oxygen was continued. Adrenaline was givenin boluses of 20ug three times, each one minute apart.Five minutes later, spontaneous cardiac rhythm returnedwith a heart rate (HR) 135-140 beats minute-1. Twohundred ml blood was also transfused with a 20mlsyringe. An arterial sample for blood gas analysis was sent.Ten mEq bicarbonate was also administered. Arterialblood gas which was sent showed metabolic acidosis - pH7.28, partial pressure of carbon dioxide (PaCO2) 33.6,partial pressure of oxygen (PaO2) 526.7, bicarbonate(HCO3) 14.8, saturation level of oxygen in haemoglobin(SaO2) 100%. Ten mEq bicarbonate was repeated alongwith colloid administration. Blood gas sample sent after20min showed improvement (pH 7.38, PaCO2 33.6, PaO2500, HCO3 19.7). Haemoglobin after 200mls of bloodtransfusion was repeated and was found to be 9.4g/dl.Further need to continue vasopressors/inotropes wasabandoned as blood pressures (BP) was maintained innormal range and the reason for sudden hypotension andcardiac arrest at that time was thought to be acute bloodloss in the drain.After the patient's condition stabilised, the surgeondecided to re-explore the wound and the surgical site. Nobleeding point was identified. The patient was extubatedat the end of second surgery, and had spontaneous eyeopening and was maintaining an end-tidal CO2 ofVol. 63, No. 10, October 20131307CASE REPORTCardiac arrest in a child following cranioplastyAsma Abdus Salam, Fauzia Anis KhanDepartment of Anaesthesiology, Aga Khan University, Karachi, Pakistan.Correspondence: Fauzia Anis Khan. Email: fauzia.khan@aku.edu40mmHg with stable vital signs (HR 148 beats minute-1,BP 116/77mmHg, SO2 100%). She was monitored for 10minutes in the operating room for any sudden fall of BP orany deterioration in condition and was then shifted to thepaediatric intensive care unit (ICU). Patient had oneepisode of generalised tonic clonic seizuresapproximately six hours after ICU admission. This wascontrolled on IV midazolam (0.5mg). Patient remainedstable and was discharged home after two days.Discussion Craniofacial surgery in paediatric patients can lead tosignificant morbidity. Perioperative bleeding can result inhypotension, coagulopathy, intraoperative cardiac arrestand even death.1 Other complications like postoperativeseizures, surgical site infections, facial swelling andunplanned postoperative mechanical ventilation havealso been documented.2 These procedures are alsoassociated with a high incidence of venous air embolism(VAE). Faberowski et al have reported this incidence to beas high as 82.6%,3 whereas previously it was reported as66%.2 Faberowski et al justified this high incidence basedon an observation that children have a large headcompared to the body and even in the supine position thehead maybe positioned above the heart. Use of aprecordial ultrasonic probe monitoring device helps inearlier detection of this complication.4 In our patient thehaemodynamic event occurred towards the end of thesurgery and before the reversal of muscle relaxation. Atthe time of the event, our initial diagnosis was the suddenblood loss associated with the release of pressure in thedrains by the surgeon, but later we included venous airembolism in our differential diagnosis. The point in favourof hypovolaemic shock was circumstantial evidence ofloss of approximately 150mls of blood in the drains, butCVP was maintained above 10cms H2O throughout theprocedure. No evidence of bleeding was seen on re-exploration. The suddenness of the event, an acute fall inend-tidal carbon dioxide and the extreme pallor observedon exposure of child are more in favour of mechanicalobstruction of stroke volume.Venous air embolism is more likely to occur during theintraoperative period, but recently the recurrence of VAEhas been reported at the end of procedure after skinclosure associated with change in position at end ofsurgery.5Movement of previously entrained air may occurat the end of surgery, while moving the patient fromprone or lateral position to the supine position and thiscan be considered one of the etiology of unexpectedsudden postoperative cardiovascular collapse.6Hypotension associated with VAE in children is also morepronounced because the volume of entrained air isgreater in comparison with blood volume.3In our patient, the head was raised at the end of thesurgery to apply the bandage, and the event occurredafter placing the head in supine position. One possibilitycould be that sudden release of blood into the redivacdrains could have led to a decrease of venous pressurebelow atmosphere and air trapped inside the closed drainor intra-thoracic vessels might have entered the venousblood stream and the right atrium with redistribution ofair bubbles. Unfortunately we do not have the facility ofDoppler probe or Trans Esophageal Echocardiography(TEE) available for use. Therefore, we do not haveobjective evidence of this event. Rapid initiation of resuscitation and chest compressionhas presumptively demonstrated efficacy for massive VAEthat results in cardiac standstill.7,8 Cardiac massage forcesair out of the pulmonary outflow tract into smaller vessels.This could also have happened in our patient.Conclusion VAE should be considered one of the causes ofunexpected cardiovascular collapse in craniofacialsurgery in children, and anaesthetists should be vigilantnot only intra-operatively, but also towards the end of thesurgery after wound closure.References1. Goobie SM, Meier PM, Pereira LM. Efficacy of tranexamic acid inpediatric craniosynostosis surgery: a double-blind, placebo-controlled rrial. Anesthesiology 2011; 114: 862-71.2. Stricker PA, Shaw TL, Desouza DG. Blood loss replacement andassociated morbidity in infants and children undergoingcraniofacial surgery. Pediatr Anesth 2010; 20: 150-9. 3. Faberowski LW, Black S, Mickle JP. Incidence of venous airembolism during craniectomy for craniosynostosis repair.Anesthesiology 2000; 92: 20-3.4. Chang JL, Albin MS, Bunegin L, Hung TK. Analysis and comparisonof venous air embolism detection methods. Neurosurgery 1980; 7:135-41.5. Schmitt HJ, Hemmerling TM. Venous air emboli occur duringrelease of positive end-expiratory pressure and repositioningafter sitting position surgery. Anesth Analg 2002; 94: 400-3.6. Seubert CN, Gravenstein N. Venous air embolism during changesin patient position or ventilation: an etiology for postoperativecardiovascular collapse. Anesth Analg 2002; 95: 1465-6.7. Ericsson JA, Gottheb JD, Sweet RB. Closed chest cardiac massagein the treatment of venous air embolism. N Engl J Med 1964; 270:1353-4.8. Mirski MA, Lela AV, Fitzsimmons L, Toung TJK. Diagnosis andtreatment of vascular air embolism. Anesthesiology 2007; 106:164-77.J Pak Med Assoc1308 A. A. Salam, F. A. Khan

Cardiac arrest in a child following cranioplasty

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Cardiac arrest in a child following cranioplasty

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