Book Text

Pediatric Neurosurgery (also see Chapter 60 )

Table 53-14 identifies common pediatric procedures and their anesthetic considerations. The most frequent procedures are probably placement and revision of CSF shunts (discussed in the preceding section "CSF Shunting Procedures"). The majority of pediatric tumors occur in the posterior fossa. Most are near the midline, and many are associated with hydrocephalus. For pediatric posterior fossa procedures, the risk of VAE, monitoring, and treatment are similar for adults and children (see the section "Venous Air Embolism"). Doppler is invariably indicated, and right heart catheters are generally placed when procedures are performed in the sitting position. Craniosynostosis procedures have the potential for substantial blood loss that is roughly proportional to the number of sutures involved. The significant risk for VAE justifies the use of precordial Doppler.^[102]

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**TABLE 53-14** -- Common pediatric neurosurgical disorders and their anesthetic considerations
Age Group	Lesion	Pathogenesis	Anesthetic Considerations
Neonates	Intraventricular hemorrhage	Subependymal vascular rupture	Associated problems of prematurity
	Depressed skull fracture	Forceps injury	Associated cerebral edema
Infants	Hydrocephalus	Varied	Increased ICP, especially dangerous in shunt-dependent revisions
	Meningocele	Outpouching of meninges through skull defect	Large size creates airway management problems
			Prone-lateral position
			Substantial blood loss
			Repair may increase ICP
	Encephalocele	Outpouching of meninges through skull defect with brain tissue enclosed
	Myelomeningocele	Protrusion of spinal meninges and roots	Prone or lateral through spina bifida
			Substantial blood loss
			Respiratory restriction after covering large defects
	Arnold-Chiari malformation	Impaction of posterior fossa contents into foramen magnum	Brainstem compression with head flexion
		± Hydrocephalus	Increased ICP; latex allergy
		± Myelomeningocele	Postoperative respiratory depression
	Craniosynostosis	Premature fusion of cranial sutures	Substantial blood loss
			Air embolism
			Supine or prone
	Craniofacial dysostosis	Developmental abnormality	Lengthy procedures
			Substantial blood loss
			Brain retraction
			Air embolism
			Endotracheal tube damage
	Vascular malformations	Varied	Congestive heart failure
			Large blood loss
			Elective hypotension
	Subdural hematoma/effusion	Trauma	Associated injuries
Older children	Posterior fossa tumors	Ependymoma	Malnutrition-dehydration
		Astrocytoma	Hydrocephalus
			Increased ICP
			Prone or sitting position
			Air embolism
			Brainstem compression
			Postoperative cranial nerve dysfunction or brainstem swelling or compression
ICP, intracranial pressure.