Brief Communications 8. 9.
Heat and moisture exchange filter obstruction. Aust Ther Device Bull 1990;67. Prasad KK, Chen L. Complications related to the use of a heat and moisture exchanger. Anesthesiology 1990;72:958. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.139017
A giant intracranial hydatid cyst in a child: Intraoperative anaesthetic concerns
pressure, heart rate, oxygen saturation, end‑tidal CO2 (ETCO2), temperature, airway pressure and urine output throughout the intraoperative period. To decrease intracranial pressure (ICP) mannitol (1 g/kg) and hydrocortisone (5 mg/kg) were administered and keeping ETCO2 at 30-35 mm Hg. Apart from emergency drugs (epinephrine, atropine and sodium bicarbonate), injection pheniramine maleate, dexamethasone and salbutamol (inhaler) were kept to treat anaphylactic reaction if it presented intraoperatively. A fronto‑temporo‑parietal craniotomy was done. Brain was well relaxed. The cyst was large and soft to touch. It was semi‑transparent due to the presence of scolices and brood capsules [Figure 2]. Surgeon
INTRODUCTION Intracranial hydatid disease has predominance (50-75%) in the paediatric age group and is caused by the larval stage of Echinococcus granulosus or Echinococcus multilocularis.[1] Anaesthetic management of a child with huge intracranial hydatid cyst of the brain is a case of concern for the anaesthesiologist.
CASE REPORT A 4‑year‑old boy (weight 20 kg) presented with focal seizures in right arm since last 2 months and gradually increasing skull swelling on the left side since last 6 months. Computed tomography of the brain demonstrated a large, spherical, homogeneous cystic mass measuring 110 × 96 × 85 mm in the left frontoparietal region. The magnetic resonance imaging showed a well‑defined lesion, hypo‑intense on T1‑weighted images and hyper‑intense on T2‑weighted images. There was a mural nodule (daughter cyst) in the posterior wall and midline shift of the brain (24 mm) towards the right side [Figure 1]. Child was induced with sevoflurane‑oxygen and trachea was intubated after inj.atracurium (10 mg). Fentanyl (40 µg) was given for intraoperative analgesia. Anaesthesia was maintained with propofol infusion (4-6 mg/kg/h) along with O2:N2O (50:50) and atracurium. An arterial line was secured, and child was monitored for continuous invasive blood Indian Journal of Anaesthesia | Vol. 58 | Issue 4 | Jul-Aug 2014
Figure 1: Magnetic resonance image showing mural nodule attached to the posterior wall of the cyst
Figure 2: Giant intracranial hydatid cyst during the intraoperative period 477
Brief Communications
used hypertonic saline (3%) irrigation to separate the cyst from the surrounding brain parenchyma. Once cyst appeared free from the surrounding, head end of the operation table was lowered around 45° to extract the cyst with the help of gravitational force. During the extraction of the cyst from cranium to the collecting bowel, the cyst got ruptured. The cyst contents were aspirated immediately and hypertonic saline and hydrogen peroxide were administered into the remnants of cyst. Ruptured cyst was then resected completely. Child was monitored closely for anaphylaxis after rupture of the cyst. Child remained haemodynamically stable with no increase in airway pressure. He received hypertonic saline (200 ml) as irrigation fluid during surgery which was suctioned out continuously. Serum sodium was checked frequently to rule out hypernatremia. The blood loss during the surgery was approximately 200 ml which was replaced with packed red blood cells. Child was haemodynamically stable at the end of the surgery and was extubated. He was discharged on 10th postoperative day and was followed up regularly. After 1 year child was found to be normal and active with no h/o seizures.
DISCUSSION Intracranial hydatid cysts are more frequently located in the supratentorial compartment, especially in the watershed area of the middle cerebral artery.[2] They can be classified as primary (single) or secondary (multiple).[3] The patients present with headache, nausea and vomiting (due to increased ICP), neurological deficits, hemiparesis, visual deficit, diplopia and seizures as per the location of the cyst.[4] Features of a significant rise in ICP did not develop in our case because of progressive increase in size of the calvarium in the child. Hydrodissection of the cyst is recommended in which the cyst is separated from the brain gently by irrigating fluid between cyst wall and brain interface.[3] In our case, hypertonic saline (3%) was used for hydrodissection which decreases the tension inside the cyst by keeping the cyst in a hyperosmolar environment. It also acts as scolicidal agent.[5] The Dowling‑Orlando technique remains the preferred method of extruding the intracranial hydatid cyst, in which the cyst is delivered by lowering the head of the operating table by 45° using gravity.[6] Other surgical 478
options include puncture and aspiration of the cyst fluid and expulsion of the cyst by insufflations of air in the contralateral ventricle.[3] Providing adequate surgical field for excision of large intracranial cyst in a child is a challenge for anaesthesiologist. Aims of anaesthesia include keeping brain well relaxed throughout the intraoperative period and prevent any movement of the patient during surgery; surgical field should be free of bleeding to assist the surgeon to excise the cyst smoothly. Numerous scolicidal agents have been used to prevent recurrence of the cysts resulting from rupture of cyst and release of parasites’ protoscolices.[5] Hypertonic saline, although very effective scolicidal agent, may give rise to hypernatremia leading to seizure and dehydration of cerebral cells with shrinkage of the brain giving rise to subdural haematoma.[7] Therefore, frequent and regular monitoring of sodium is necessary. We used lesser concentration of hypertonic saline (3%) to prevent these complications and monitored serum sodium level regularly. Hydrogen peroxide is another scolicidal agent. It releases gaseous oxygen which has scolicidal property. Ouerghi et al. reported severe oxygen embolism after use of hydrogen peroxide in cases of thoracic hydatid cysts.[8] It has been found to produce haemodynamic instability even without embolism.[9] Major complication of intraoperative rupture of hydatid cyst is life threatening anaphylaxis. Rupture of hydatid cyst releases highly antigenic contents into the circulation which causes IgE mediated Anaphylactic reactions with severe hypotension and increased airway pressure due to bronchospasm. [10] A high index of suspicion and early aggressive therapy with intravenous epinephrine along with administration of 100% oxygen are vital in the management of life‑threatening anaphylaxis. Hydrocortisone is used for prophylaxis as well for treatment of refractory hypotension. [10] Other complications include development of subdural effusion, epidural haematoma and pneumocephalus.[11]
CONCLUSION We successfully managed a case of giant intracranial hydatid cyst in a 4‑year‑old child in which cyst ruptured just at the time of extrusion. Relaxed brain, Indian Journal of Anaesthesia | Vol. 58 | Issue 4 | Jul-Aug 2014
Brief Communications
clean surgical field and smooth anaesthesia are essential for a good outcome. Various complications are expected during different stages of surgery, therefore, anaesthesiologist should remain alert and be prepared to prevent and treat any complications during surgery.
Nidhi Bidyut Panda, YK Batra, Ajay Mishra, SS Dhandapani1 Departments of Anaesthesia and Intensive Care and 1Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India Address for correspondence: Dr. Nidhi Bidyut Panda, Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, H. No. 1030, Sec‑24B, Chandigarh ‑ 160 023, India. E‑mail: [email protected]
REFERENCES 1.
Ersahin Y, Mutluer S, Güzelbag E. Intracranial hydatid cysts in children. Neurosurgery 1993;33:219‑24. 2. Mussa T, Bijan Z, Mohammad HB, Zahra Z. Hydatid cyst of foramen magnum, Case report. Neurosurg Q 2005;15:110‑2. 3. Gupta S, Desai K, Goel A. Intracranial hydatid cyst: A report of five cases and review of literature. Neurol India 1999; 47:214‑7. 4. Duishanbai S, Jiafu D, Guo H, Liu C, Liu B, Aishalong M, et al. Intracranial hydatid cyst in children: Report of 30 cases. Childs Nerv Syst 2010;26:821‑7. 5. Caglar R, Yuzbasioglu MF, Bulbuloglu E, Gul M, Ezberci F, Kale IT. In vitro effectiveness of different chemical agents on scolices of hydatid cyst. J Invest Surg 2008;21:71‑5. 6. Carrea R, Dowling E Jr, Guevara JA. Surgical treatment of hydatid cysts of the central nervous system in the pediatric age (Dowling’s technique). Childs Brain 1975;1:4‑21. 7. Albi A, Baudin F, Matmar M, Archambeau D, Ozier Y. Severe hypernatremia after hypertonic saline irrigation of hydatid cysts. Anesth Analg 2002;95:1806‑8. 8. Ouerghi S, Abdelhafidh K, Merghli A, Smati B, Boudaya MS, Lamine K, et al. Iatrogenic gas embolism after use of hydrogen peroxide in the treatment of lung hydatid cyst: A report of 2 cases. Tunis Med 2010;88:851‑4. 9. Prabhakar H, Bithal PK, Pandia MP, Gupta MM, Rath GP. Bradycardia due to hydrogen peroxide irrigation during craniotomy for craniopharyngioma. J Clin Neurosci 2007;14:488‑90. 10. Zeynep NA, Erkan YA, Nermin G. An intraoperative anaphylactic shock due to a hydatid cyst. New J Med 2011;28:123‑5. 11. Tuzun Y, Solmaz I, Sengul G, Izci Y. The complications of cerebral hydatid cyst surgery in children. Childs Nerv Syst 2010;26:47‑51. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.139018
Indian Journal of Anaesthesia | Vol. 58 | Issue 4 | Jul-Aug 2014
Outcome of in‑hospital, out of intensive care and operation room cardiac arrests in a tertiary referral hospital in India: Comparison of outcomes of two audits INTRODUCTION Varied rates of survival to discharge after cardiac arrest are cited in the literature.[1‑4] Factors such as appropriate training for the medical and the paramedical staff, speed of response, early defibrillation, type of the ward, part of the shift and weekends have been implicated in varying outcomes.[1‑5] Code blue is the term used for the process of calling for assistance via phone. We published our data for the period of the years 2007-2009 and noted the survival to discharge rate of 30%.[5] However, the current audit spanned 5 years from January 2007 to December 2011. Data from two periods of time were compared. Despite on‑going training, several quality measures, the outcome of the recent batch of cardiac arrest victims was not encouraging. Survival to discharge decreased from 30% to 16%. This may be attributable to increasing incidence of comorbidities in the recent times.
METHODS The first set of data‑data A from 2007 to 2009 was compared with data B of 2009-2011. The procedure for initiating ‘code blue’ (‘code 555’) is in place at the hospital for treating individuals with cardio‑respiratory collapse. A phone call to 555 from any of the house phones by any of the staff (nurses, doctors or technicians) would automatically dial the emergency room staff, who by pressing buttons 1-4 would dial automatically dial the ‘code phone’ manned by a registrar from medical intensive care unit, coronary care unit, anaesthesiology and nursing supervisor who are all located within the hospital. This phone call also informs the phone holder from where the code has been raised. The receiver will immediately rush to the location from where the code has been raised and attend to the victim of cardio‑respiratory arrest. The co morbidities, the gender distribution, time to arrive 479
Copyright of Indian Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Heat and moisture exchange filter obstruction. Aust Ther Device Bull 1990;67. Prasad KK, Chen L. Complications related to the use of a heat and moisture exchanger. Anesthesiology 1990;72:958. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.139017
A giant intracranial hydatid cyst in a child: Intraoperative anaesthetic concerns
pressure, heart rate, oxygen saturation, end‑tidal CO2 (ETCO2), temperature, airway pressure and urine output throughout the intraoperative period. To decrease intracranial pressure (ICP) mannitol (1 g/kg) and hydrocortisone (5 mg/kg) were administered and keeping ETCO2 at 30-35 mm Hg. Apart from emergency drugs (epinephrine, atropine and sodium bicarbonate), injection pheniramine maleate, dexamethasone and salbutamol (inhaler) were kept to treat anaphylactic reaction if it presented intraoperatively. A fronto‑temporo‑parietal craniotomy was done. Brain was well relaxed. The cyst was large and soft to touch. It was semi‑transparent due to the presence of scolices and brood capsules [Figure 2]. Surgeon
INTRODUCTION Intracranial hydatid disease has predominance (50-75%) in the paediatric age group and is caused by the larval stage of Echinococcus granulosus or Echinococcus multilocularis.[1] Anaesthetic management of a child with huge intracranial hydatid cyst of the brain is a case of concern for the anaesthesiologist.
CASE REPORT A 4‑year‑old boy (weight 20 kg) presented with focal seizures in right arm since last 2 months and gradually increasing skull swelling on the left side since last 6 months. Computed tomography of the brain demonstrated a large, spherical, homogeneous cystic mass measuring 110 × 96 × 85 mm in the left frontoparietal region. The magnetic resonance imaging showed a well‑defined lesion, hypo‑intense on T1‑weighted images and hyper‑intense on T2‑weighted images. There was a mural nodule (daughter cyst) in the posterior wall and midline shift of the brain (24 mm) towards the right side [Figure 1]. Child was induced with sevoflurane‑oxygen and trachea was intubated after inj.atracurium (10 mg). Fentanyl (40 µg) was given for intraoperative analgesia. Anaesthesia was maintained with propofol infusion (4-6 mg/kg/h) along with O2:N2O (50:50) and atracurium. An arterial line was secured, and child was monitored for continuous invasive blood Indian Journal of Anaesthesia | Vol. 58 | Issue 4 | Jul-Aug 2014
Figure 1: Magnetic resonance image showing mural nodule attached to the posterior wall of the cyst
Figure 2: Giant intracranial hydatid cyst during the intraoperative period 477
Brief Communications
used hypertonic saline (3%) irrigation to separate the cyst from the surrounding brain parenchyma. Once cyst appeared free from the surrounding, head end of the operation table was lowered around 45° to extract the cyst with the help of gravitational force. During the extraction of the cyst from cranium to the collecting bowel, the cyst got ruptured. The cyst contents were aspirated immediately and hypertonic saline and hydrogen peroxide were administered into the remnants of cyst. Ruptured cyst was then resected completely. Child was monitored closely for anaphylaxis after rupture of the cyst. Child remained haemodynamically stable with no increase in airway pressure. He received hypertonic saline (200 ml) as irrigation fluid during surgery which was suctioned out continuously. Serum sodium was checked frequently to rule out hypernatremia. The blood loss during the surgery was approximately 200 ml which was replaced with packed red blood cells. Child was haemodynamically stable at the end of the surgery and was extubated. He was discharged on 10th postoperative day and was followed up regularly. After 1 year child was found to be normal and active with no h/o seizures.
DISCUSSION Intracranial hydatid cysts are more frequently located in the supratentorial compartment, especially in the watershed area of the middle cerebral artery.[2] They can be classified as primary (single) or secondary (multiple).[3] The patients present with headache, nausea and vomiting (due to increased ICP), neurological deficits, hemiparesis, visual deficit, diplopia and seizures as per the location of the cyst.[4] Features of a significant rise in ICP did not develop in our case because of progressive increase in size of the calvarium in the child. Hydrodissection of the cyst is recommended in which the cyst is separated from the brain gently by irrigating fluid between cyst wall and brain interface.[3] In our case, hypertonic saline (3%) was used for hydrodissection which decreases the tension inside the cyst by keeping the cyst in a hyperosmolar environment. It also acts as scolicidal agent.[5] The Dowling‑Orlando technique remains the preferred method of extruding the intracranial hydatid cyst, in which the cyst is delivered by lowering the head of the operating table by 45° using gravity.[6] Other surgical 478
options include puncture and aspiration of the cyst fluid and expulsion of the cyst by insufflations of air in the contralateral ventricle.[3] Providing adequate surgical field for excision of large intracranial cyst in a child is a challenge for anaesthesiologist. Aims of anaesthesia include keeping brain well relaxed throughout the intraoperative period and prevent any movement of the patient during surgery; surgical field should be free of bleeding to assist the surgeon to excise the cyst smoothly. Numerous scolicidal agents have been used to prevent recurrence of the cysts resulting from rupture of cyst and release of parasites’ protoscolices.[5] Hypertonic saline, although very effective scolicidal agent, may give rise to hypernatremia leading to seizure and dehydration of cerebral cells with shrinkage of the brain giving rise to subdural haematoma.[7] Therefore, frequent and regular monitoring of sodium is necessary. We used lesser concentration of hypertonic saline (3%) to prevent these complications and monitored serum sodium level regularly. Hydrogen peroxide is another scolicidal agent. It releases gaseous oxygen which has scolicidal property. Ouerghi et al. reported severe oxygen embolism after use of hydrogen peroxide in cases of thoracic hydatid cysts.[8] It has been found to produce haemodynamic instability even without embolism.[9] Major complication of intraoperative rupture of hydatid cyst is life threatening anaphylaxis. Rupture of hydatid cyst releases highly antigenic contents into the circulation which causes IgE mediated Anaphylactic reactions with severe hypotension and increased airway pressure due to bronchospasm. [10] A high index of suspicion and early aggressive therapy with intravenous epinephrine along with administration of 100% oxygen are vital in the management of life‑threatening anaphylaxis. Hydrocortisone is used for prophylaxis as well for treatment of refractory hypotension. [10] Other complications include development of subdural effusion, epidural haematoma and pneumocephalus.[11]
CONCLUSION We successfully managed a case of giant intracranial hydatid cyst in a 4‑year‑old child in which cyst ruptured just at the time of extrusion. Relaxed brain, Indian Journal of Anaesthesia | Vol. 58 | Issue 4 | Jul-Aug 2014
Brief Communications
clean surgical field and smooth anaesthesia are essential for a good outcome. Various complications are expected during different stages of surgery, therefore, anaesthesiologist should remain alert and be prepared to prevent and treat any complications during surgery.
Nidhi Bidyut Panda, YK Batra, Ajay Mishra, SS Dhandapani1 Departments of Anaesthesia and Intensive Care and 1Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India Address for correspondence: Dr. Nidhi Bidyut Panda, Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, H. No. 1030, Sec‑24B, Chandigarh ‑ 160 023, India. E‑mail: [email protected]
REFERENCES 1.
Ersahin Y, Mutluer S, Güzelbag E. Intracranial hydatid cysts in children. Neurosurgery 1993;33:219‑24. 2. Mussa T, Bijan Z, Mohammad HB, Zahra Z. Hydatid cyst of foramen magnum, Case report. Neurosurg Q 2005;15:110‑2. 3. Gupta S, Desai K, Goel A. Intracranial hydatid cyst: A report of five cases and review of literature. Neurol India 1999; 47:214‑7. 4. Duishanbai S, Jiafu D, Guo H, Liu C, Liu B, Aishalong M, et al. Intracranial hydatid cyst in children: Report of 30 cases. Childs Nerv Syst 2010;26:821‑7. 5. Caglar R, Yuzbasioglu MF, Bulbuloglu E, Gul M, Ezberci F, Kale IT. In vitro effectiveness of different chemical agents on scolices of hydatid cyst. J Invest Surg 2008;21:71‑5. 6. Carrea R, Dowling E Jr, Guevara JA. Surgical treatment of hydatid cysts of the central nervous system in the pediatric age (Dowling’s technique). Childs Brain 1975;1:4‑21. 7. Albi A, Baudin F, Matmar M, Archambeau D, Ozier Y. Severe hypernatremia after hypertonic saline irrigation of hydatid cysts. Anesth Analg 2002;95:1806‑8. 8. Ouerghi S, Abdelhafidh K, Merghli A, Smati B, Boudaya MS, Lamine K, et al. Iatrogenic gas embolism after use of hydrogen peroxide in the treatment of lung hydatid cyst: A report of 2 cases. Tunis Med 2010;88:851‑4. 9. Prabhakar H, Bithal PK, Pandia MP, Gupta MM, Rath GP. Bradycardia due to hydrogen peroxide irrigation during craniotomy for craniopharyngioma. J Clin Neurosci 2007;14:488‑90. 10. Zeynep NA, Erkan YA, Nermin G. An intraoperative anaphylactic shock due to a hydatid cyst. New J Med 2011;28:123‑5. 11. Tuzun Y, Solmaz I, Sengul G, Izci Y. The complications of cerebral hydatid cyst surgery in children. Childs Nerv Syst 2010;26:47‑51. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.139018
Indian Journal of Anaesthesia | Vol. 58 | Issue 4 | Jul-Aug 2014
Outcome of in‑hospital, out of intensive care and operation room cardiac arrests in a tertiary referral hospital in India: Comparison of outcomes of two audits INTRODUCTION Varied rates of survival to discharge after cardiac arrest are cited in the literature.[1‑4] Factors such as appropriate training for the medical and the paramedical staff, speed of response, early defibrillation, type of the ward, part of the shift and weekends have been implicated in varying outcomes.[1‑5] Code blue is the term used for the process of calling for assistance via phone. We published our data for the period of the years 2007-2009 and noted the survival to discharge rate of 30%.[5] However, the current audit spanned 5 years from January 2007 to December 2011. Data from two periods of time were compared. Despite on‑going training, several quality measures, the outcome of the recent batch of cardiac arrest victims was not encouraging. Survival to discharge decreased from 30% to 16%. This may be attributable to increasing incidence of comorbidities in the recent times.
METHODS The first set of data‑data A from 2007 to 2009 was compared with data B of 2009-2011. The procedure for initiating ‘code blue’ (‘code 555’) is in place at the hospital for treating individuals with cardio‑respiratory collapse. A phone call to 555 from any of the house phones by any of the staff (nurses, doctors or technicians) would automatically dial the emergency room staff, who by pressing buttons 1-4 would dial automatically dial the ‘code phone’ manned by a registrar from medical intensive care unit, coronary care unit, anaesthesiology and nursing supervisor who are all located within the hospital. This phone call also informs the phone holder from where the code has been raised. The receiver will immediately rush to the location from where the code has been raised and attend to the victim of cardio‑respiratory arrest. The co morbidities, the gender distribution, time to arrive 479
Copyright of Indian Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
