References 1 Kamra K, Hammer GB. Central venous catheter placement in children: ‘How good is good enough?’. Pediatr Anesth 2013; 23: 971–973. 2 Breschan C, Platzer M, Jost R et al. Comparison of catheter-related infection and tip colonization between internal jugular and subclavian central venous catheters in surgical neonates. Anesthesiology 2007; 107: 946–953.
3 Pirotte T, Veyckemans F. Ultrasound-guided subclavian vein cannulation in infants and children: a novel approach. Br J Anaesth 2007; 98: 509–514. 4 Rhondali O, Attof R, Combet S et al. Ultrasound-guided subclavian vein cannulation in infants: supraclavicular approach. Pediatr Anesth 2011; 21: 1136–1141.
5 Breschan C, Platzer M, Jost R et al. Consecutive, prospective case series of a new method for ultrasound-guided supraclavicular approach to the brachiocephalic vein in children. Br J Anaesth 2011; 106: 732–737.
Reply to Breschan et al, re ‘Central venus catheter placement in children’ SIR—We appreciate the comments by Drs. Breschan and Marhofer pursuant to our editorial, ‘Central venous catheter placement in children: How good is good enough?’ The authors take issue with our statement, ‘the subclavian vein is generally more difficult to visualize via ultrasound’ than the internal jugular vein in children. We certainly respect the expertise of the authors and others using ultrasound to identify a variety of central venous cannulation sites. On the other hand, our statement is not controversial in the context of anesthesia practice. In the hands (and eyes) of most anesthesiologists performing central venous catheter insertion in children, the internal jugular vein is easier to visualize than the subclavian vein. To a significant extent, this accounts for the widespread use of the former in anesthesia practice. In our practice of cardiac anesthesia in infants and children, as well as in other sites with which
we are familiar in the United States, the UK, Europe, and Asia, the internal jugular vein is used almost exclusively during anesthesia. That the internal jugular vein is easier to visualize by ultrasound accounts for the relative safety of central venous catheter insertion in this site compared to the subclavian vein. We appreciate the authors’ reference to additional citations describing the use of the full range of central venous structures. For purposes of brevity in our editorial; however, we limited the number of citations commensurate with limiting our overall word count. Komal Kamra & Greg Hammer Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA Email: [email protected]
Epidural blood patch relieves positional diplopia following lumbar punctures SIR—Significant positional headache after lumbar punctures (spinal headache) refractory to conservative measures such as hydration, bed rest, caffeine, acetaminophen, and nonsteroidal antiinflammatory drugs (NSAIDs) is often treated with epidural blood patch with immediate and good symptom relief. Positional diplopia in the absence of headache is an atypical manifestation of intracranial hypotension due to cerebrospi© 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 339–357
nal fluid leak following lumbar puncture (1). We report the first case of an adolescent patient who had positional horizontal diplopia following multiple lumbar puncture attempts which was relieved by an epidural blood patch. A 13-year-old, 104 kg, obese girl was initially presented with fever, headache, vomiting, and a finding of papilledema. A diagnostic lumbar puncture ruled out 345
meningitis. A head computerized tomogram obtained was normal without any signs of increased intracranial pressure, and additional eye examinations did not find papilledema ruling out the possibility of pseudotumor cerebri. Subsequently, the patient was discharged home on antibiotics with follow-up with neurology. Although her vomiting and fever improved, she continued to have headaches. After a week at home, her headache worsened along with vomiting. She came to the emergency room again. At this point, another diagnostic lumbar puncture was attempted in the emergency room without success. Following hospital admission, because of initial diagnosis of papilledema, a third diagnostic lumbar puncture was attempted with interventional radiology guidance, which was also unsuccessful despite fluoroscopic guidance. As her other symptoms improved except mild headache with hydration, ondansetron and NSAIDs, she was discharged home on chronic headache management and an outpatient magnetic resonance (MR) imaging of head to rule out potential intracranial causes of headache such as venous sinus thrombosis. Subsequently at home, she developed significant blurry vision, double vision, dizziness, and worsening headache. She was seen by an ophthalmologist for diplopia; there was a subtle esophoria in extreme gaze, good extraocular movements, and no papilledema on examination. Upon review of the MR images of head, she was found to have signs of intracranial hypotension including engorged dural venous sagittal and transverse sinuses, midbrain sagging into the posterior fossa causing decreased pontine midbrain angle, prominent epidural venous plexus enhancement in the upper cervical canal (Figure 1), diffuse smooth dural enhancement, convex superior margin of the pituitary gland, and a sagging optic chiasm draping over the pituitary gland (Figure 2). There was no sinus thrombosis, intracranial lesions, or significant herniation at foramen magnum (Figures 1 and 2). Upon second hospitalization to treat symptoms of intracranial hypotension with hydration, caffeine, acetaminophen, and NSAIDs, her headache resolved completely and she continued to have intermittent diplopia. Her diplopia was improved by closing her eyes and supine position, and it was worsened by walking and erect posture. Because of persistent positional diplopia and MR signs of intracranial hypotension, after discussions with neurologist, the patient and family about the benefits and risks of epidural blood patch, a total of 40 ml of sterile blood was obtained from her upper extremity and was slowly administered in her lumbar epidural space (10 ml at a time) under fentanyl and 346
Figure 1 Sagittal contrast enhanced T1 weighted Magnetic Resonance image demonstrates signs of intracranial hypotension including engorged dural venous sinuses (white arrows), midbrain sagging into the posterior fossa causing decreased pontine midbrain angle (open arrow) and prominent epidural venous plexus enhancement in the upper cervical canal (small arrowheads).
Figure 2 Coronal contrast enhanced Magnetic Resonance demonstrates other findings of intracranial hypotension such as diffuse smooth dural enhancement (arrows), convex superior margin of the pituitary gland (*), and a sagging optic chiasm (arrowheads) draping over the pituitary gland. © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 339–357
midazolam conscious sedation with the patient in sitting position, arms rested on a table. When she reported fullness in her back and easing of pressure behind her eyes, further injection of blood in the epidural space was stopped. After the blood patch, she reported that her double vision resolved completely in standing position and she was discharged home without any complications. Abducens nerve, which has a long intracranial course, is often stretched with caudal sagging of brain structures due to intracranial hypotension. Prolonged stretching of abducent nerve can result in ischemia, palsy, and persistent diplopia despite correction of intracranial hypotension. Although adult literature reports that epidural blood patch consistently fails to relieve diplopia when performed more than 1 day after the onset of sixth cranial nerve palsy (2), we report an adolescent who developed diplopia for 3 days without positional headache following multiple lumbar punctures, having complete resolution of diplopia immediately after epidural blood patch. Clinicians need to be aware of atypical symptoms of intracranial hypotension such as positional diplopia in the absence of spinal headache following intentional (e.g. diagnostic lumbar punctures) or accidental (e.g. epidural catheter placement) dural punctures as these procedures are frequently carried out in children and adolescents. In children, lumbar epidural blood patches might be useful in relieving diplopia following intracranial hypotension due to CSF leak following dural punctures.
Learning points 1. In addition to positional headache, double vision in erect postures is a sign of intracranial hypotension due to CSF leak following lumbar (dural) punctures. 2. In the absence of classical positional spinal headache, radiological evidences of intracranial hypotension may help decide the potential benefits of epidural blood patch. 3. Epidural blood patch is an effective strategy in treating positional diplopia following dural puncture in children.
Disclosures There is no funding for this article besides institutional salary support for authors. Authors believe that there is no need for ethics board approval as no patient identifying information is included in the letter. Parental consent was obtained for this report. There is no conflict of interests and financial support for this article. Ryan Mills1, Rupa Radhakrishnan2, David L. Moore1 & Senthilkumar Sadhasivam1 1 Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA 2 Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA Email: [email protected]
References 1 Sudhakar P, Trobe JD, Wesolowski J. Dural puncture-induced intracranial hypotension causing diplopia. J Neuroophthalmol 2013; 33: 106–112.
2 Bechard P, Perron G, Larochelle D et al. Case report: epidural blood patch in the treatment of abducens palsy after
a dural puncture. Can J Anaesth 2007; 54: 146–150.
The need for preoperative a-adrenergic blockade for ganglioneuroma excision SIR—Ganglioneuromas (GNs) are rare, benign, fully differentiated tumors that arise most commonly from the sympathetic ganglia in the posterior mediastinum in adolescents and young adults. The treatment involves complete surgical excision and has an excellent prognosis. Compared with malignant neuroblastomas and ganglioneuroblastomas, which frequently produce catecholamines, GNs secrete catecholamines only © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 339–357
occasionally. The release of catecholamines during surgery, which is one of the most feared complications, can be catastrophic and difficult to manage. For this reason, the British Paediatric Society of Endocrinology and Diabetes (BPSED) (1) and the panel of experts at the First International Symposium on Pheochromocytoma (2) have recommended that all patients with a biochemically positive pheochromocytoma should receive 347