Anaesthesia Management of a 28-day-old Male Neonate Undergoing Surgery for Occipital Region Meningo-Myelo-Encephalocele: A Case Report

Introduction

Anaesthesia management in neonates requires specialized knowledge due to their unique physiological characteristics and the complexities associated with congenital anomalies.^1,2 This case report focuses on a 28-day-old male neonate who presented with an occipital region meningo-myelo-encephalocele, a condition that necessitated careful planning and execution of anaesth- esia management. The neonate's parents did not undergo prenatal check-ups, contributing to the late diagnosis of this congenital anomaly. The report outlines the challenges faced during the perioperative period, including difficult intubation, prone positioning, intra- venous access, intraoperative hypothermia management, and postoperative care.^3,4

Case Report

Patient Details and Surgical Plan

The patient was a 28-day-old male neonate, weighing 2.9 kg, diagnosed with an occipital meningo-myelo- encephalocele. Pre-anaesthetic assessment was suggestive of full-term normal delivery and ICU admission due to occipital swelling. Magnetic Res- onance Imaging (MRI) was suggestive for Occipital meningo-myelo-encephalocele with herniation of cerebellar tonsil (S/O Arnold-Chiari malformation Type 3). All other reports, including 2D echocar- diogram (2d Echo), were normal. It was planned to operate on the neonate at the earliest. The surgical plan involved excision of the encephalocele and repair of the underlying defect. Preoperative imaging confirmed the extent of the anomaly, and a multidisciplinary team was assembled to address the complexities of the case (Figure 1).

Perioperative Preparations

Preoperative assessments included a thorough evaluation of the airway, with a high likelihood of difficult intubation due to the neonate's anatomical considerations. Various airway management tools, including video laryngoscopes and various sizes of endotracheal tubes (ETTs), were prepared. The anaesthetic team also ensured that appropriate intravenous access was established, although this proved challenging due to the neonate's small veins.

Intraoperative Management

The anaesthesia management for the 28-day-old male neonate was meticulously planned to address the unique challenges presented by the patient's age and condition.

Induction of Anaesthesia: After securing IV access, induction was initiated using inhalational sevoflurane. The patient was placed in a comfortable position, and sevoflurane was delivered via a face mask.⁵ The concentration was gradually increased (from 1% to 5%) to achieve adequate depth of anaesthesia. The induction was supplemented with intravenous dexmedetomidine (1 µg/kg) to provide sedation and reduce the risk of emergence agitation, which is a common concern in paediatric patients.⁶

Intubation: Due to the anticipated difficulty in intuba- tion, the anaesthesiology team was prepared. After achieving an adequate depth of anaesthesia, the patient was intubated using a size 3.0 cuffed armored ETT (as surgery was to be conducted in prone position). A video laryngoscope was utilized to visualize the airway effectively, and intubation was successfully achieved on the first attempt. The cuff of the ETT was inflated to ensure proper ventilation and to minimize the risk of aspiration during the procedure.^2,7

Maintenance of Anaesthesia: This was achieved using a combination of sevoflurane (2%) and continuous infusion of dexmedetomidine (0.5 µg/kg/hour) to maintain sedation and analgesia throughout the surgical procedure. Additionally, intravenous Fentanyl (1 µg/kg) was administered for analgesia during the surgery, with careful monitoring of the patient's hemodynamic status to avoid respiratory depression.3 For muscle relaxation, Inj. Atracurium (0.5 mg/kg IV loading dose, followed by 0.1 mg/kg IV every 20 minutes) was given. Inj. Dexamethasone was added (0.1 mg/kg IV) to prevent airway hyperreactivity and to deal with postoperative nausea and vomiting.¹ Prophylactic antibiotic (Inj. Ceftriaxone 50 mg/kg IV) was administered. Prophylactic anticonvulsant (Inj. Levetiracetam 10 mg/kg IV) was also given. The patient was continuously monitored for vital signs, including heart rate, blood pressure, and oxygen saturation. Prone position was maintained with appropriate care, eye protection and proper padding (Figure 2). To prevent intraoperative hypothermia, which is particularly critical in neonates, the team employed air warmers and warmed intravenous fluids. The operating room temperature was also maintained warmer to ensure the neonate's body temperature remained stable throughout the procedure. Continuous temperature monitoring was conducted and any significant drop in temperature was promptly  addressed.⁷ No arrhythmias were detected during the surgery, and no blood transfusion was required.⁸

 Extubation: Following the completion of the surgical procedure, which lasted for two hours, the patient was assessed for extubation readiness. The patient was placed in supine position, and suctioning was performed. Extubation was carried out in the operating room after administering a reversal agent (Inj. Glycopyrrolote 50 mcg/kg with Inj. Neostigmine 50 mcg/kg IV). Post extubation, the patient was monitored closely for signs of respiratory distress or airway obstruction.2 Postoperative Care in PICU After extubation, the patient was transferred to the Paediatric Intensive Care Unit (PICU) for postoperative monitoring. The focus of care included pain manage- ment, which was achieved through a combination of intravenous Acetaminophen (10 mg/kg every six hours) and continuous monitoring for any signs of complications, such as infection or respiratory distress. Prophylactic antibiotics (Inj. Ceftriaxone 25 mg/kg IV BD) were administered to prevent postoperative infections, given the nature of the surgery and the risk factors associated with the patient's condition.9 The patient remained stable throughout the postoperative period and was discharged from the PICU on postoperative day 12, demonstrating a satisfactory recovery without significant complications.

Discussion

The management of anaesthesia in paediatric patients, particularly neonates, presents unique challenges that necessitate a tailored approach. This case highlights several critical aspects of anaesthesia management in a high-risk surgical scenario.

Difficult airway management: The anticipated difficulty in intubation due to the neonate's anatomical considerations required thorough preoperative planning. The use of video laryngoscopy proved beneficial in achieving successful intubation on the first attempt, emphasizing the importance of having advanced airway management tools readily available in paediatric cases.¹⁰

Positioning: The need for placing the patient in a prone position during the surgery posed additional challenges, particularly concerning airway management and hemodynamic stability. Continuous monitoring and adjustments were necessary to ensure that the airway remained patent and that the patient’s vital signs were stable throughout the procedure.¹¹

Intraoperative management: Hypothermia is a signi- f icant concern in paediatric anaesthesia, particularly in neonates. The implementation of forced-air warming blankets and warmed intravenous fluids effectively maintained normothermia, which is crucial for reducing the risk of postoperative complications, including infection and delayed recovery. Intraopera- tive management of fluid balance, continuous monitoring of vitals were also equally important.¹²

Postoperative care: The importance of vigilant postoperative monitoring in the PICU cannot be overstated. The use of multimodal analgesia, including intravenous Acetaminophen and continuous monitoring for complications, contributed to a smooth recovery process. The administration of prophylactic antibiotics further reduced the risk of postoperative infections, which is particularly important in patients with congenital anomalies.¹³

Tailored anaesthesia strategies: This case underscores the necessity of individualized anaesthesia strategies in paediatric patients. The combination of inhalational and intravenous agents, along with careful monitoring and management of potential complications, resulted in a successful outcome.¹⁴

Conclusion

The successful anaesthesia management of a 28-day-old male neonate undergoing surgery for occipital region meningo-myelo-encephalocele underscores the need for specialized approaches in paediatric anaesthesia. By anticipating challenges such as difficult intubation, prone positioning, and intraoperative hypothermia, and by employing a comprehensive monitoring strategy, the anaesthesia team was able to ensure a safe and effective perioperative experience. This case serves as a valuable reference for future practices in similar high-risk paediatric surgical scenarios, highlighting the importance of thorough preoperative assessments, tailored anaesthesia strategies, and vigilant postoperative care to enhance patient outcomes.

Conflict of interest

None