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LETTERS TO EDITOR
Year : 2019  |  Volume : 20  |  Issue : 1  |  Page : 55-56
 

Customized doughnut with foam cushion: Facilitates laryngoscopy position for neonate with occipital encephalocele


Department of Anaesthesia, BJGMC and SGH, Pune, Maharashtra, India

Date of Web Publication6-May-2019

Correspondence Address:
Dr. Sushama Raghunath Tandale
Department of Anaesthesia, BJGMC and SGH, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_65_18

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How to cite this article:
Abhade SR, Tandale SR, Naik SV, Chavan MA. Customized doughnut with foam cushion: Facilitates laryngoscopy position for neonate with occipital encephalocele. Indian Anaesth Forum 2019;20:55-6

How to cite this URL:
Abhade SR, Tandale SR, Naik SV, Chavan MA. Customized doughnut with foam cushion: Facilitates laryngoscopy position for neonate with occipital encephalocele. Indian Anaesth Forum [serial online] 2019 [cited 2019 Aug 26];20:55-6. Available from: http://www.theiaforum.org/text.asp?2019/20/1/55/257687




Sir,

A 16-day-old, full-term neonate, weighing 2.8 kg was referred to our institute for excision of huge occipital encephalocele. The physical examination of neonate was unremarkable except for microcephaly and huge pedunculated cystic swelling measuring 13 cm × 8.5 cm × 5 cm, arising from the occipital region with skin ulceration. Spontaneous limb movements were present in all the four limbs. There was no other associated congenital malformation. Hematological and biochemical investigations of the patients were unremarkable. The neonate was lying in lateral position due to huge swelling. We prepared a doughnut made up from roller bandage, after taking the measurement of swelling in such a way that swelling should lie within the doughnut space with 1 cm free margin from all sides. The depth of doughnut space was also kept more than measured value, so as to accommodate the head and swelling during neck extension without any undue pressure over swelling [Figure 1]a. Floor and side walls of doughnut were covered by cotton for cushioning effect. Doughnut was placed above the foam cushion on operating room table. Foam cushion was of the same height as of doughnut. Neonate's head along with cystic swelling was placed over doughnut, and remaining part of the body was placed over foam cushion. This arrangement made the neonate to lie in the supine position with neck extension. The standard anesthesia monitors were used. Difficult airway cart was kept ready. Neonate was premedicated with intravenous glycopyrrolate 15 μg. After preoxygenation, the anesthetic plane was deepened with gradually increasing sevoflurane concentration up to 8 volume percentage with 100% oxygen through Jackson Rees Circuit. Gentle laryngoscopy was performed with miller size 0 blade, and Cormack–Lehane Grade II was observed followed by endotracheal intubation with 3.0 uncuffed tube [Figure 1]b. The surgery was uneventful with minimal blood loss. At the completion of surgery, the neuromuscular block was reversed, and the trachea was extubated. The neonate was shifted to intensive care unit for further management.
Figure 1: (a) Neonate having huge occipital encephalocele. (b) Neonate placed in supine position with customized doughnut and foam cushion

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Encephalocele is a neural tube defect where meninges and brain tissue protrudes out through a bony defect on the skull. Occipital encephalocele is a common presentation.[1] Incidence is 1 in 5000 live births.[2] Early excision is recommended to prevent rupture and infection. Associated congenital anomalies are club foot, hydrocephalus and Arnold  Chiari malformation More Details, exstrophy of bladder, prolapsed uterus, Klippel Feil syndrome, and cardiac defects.[3] Apart from difficult positioning for laryngoscopy, other intraoperative concerns are prone positioning, hemodynamic disturbances, and difficulty in assessing blood loss.

Proper positioning of neonate is essential for laryngoscopy as the presence of huge occipital encephalocele and restricted neck movement makes it difficult. Inadequate positioning may lead to frequent attempts to intubation, possible airway trauma, rise in intracranial pressure, and rupture of encephalocele. Our method of positioning neonate over customized doughnut and foam cushion offers certain advantages such as it is inexpensive as it can be made up of easily available resources, neonate can be placed in supine position with neck extension for mask ventilation and laryngoscopy, neck manipulations are possible in doughnut space without any pressure on sac and requires very less workforce for airway management.

Alternative options include intubation in a lateral position which requires expertise, placing the neonate's head beyond the edge of the table, which requires help from additional workforce and gradual decompression of encephalocele sac under sterile conditions.[4],[5]

We wish to highlight the importance of customized doughnut made up from roller bandage, and foam cushion for supine positioning of neonates with huge occipital encephalocele with successful airway management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rath GP, Dash HH. Anaesthesia for neurosurgical procedures in paediatric patients. Indian J Anaesth 2012;56:502-10.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Shende SY. Anaesthetic management of a huge occipital encephalocele in a neonate. Int J Healthc Sci 2014;2:126-8.  Back to cited text no. 2
    
3.
Creighton RE, Relton JE, Meridy HW. Anaesthesia for occipital encephalocoele. Can Anaesth Soc J 1974;21:403-6.  Back to cited text no. 3
    
4.
Goel V, Dogra N, Khandelwal M, Chaudhri R. Management of neonatal giant occipital encephalocele: Anaesthetic challenge. Indian J Anaesth 2010;54:477-8.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Gautham AK, Mariappan R, Singh G. Lessons learnt in the anaesthetic management of a neonate with giant occipital meningomyelocoele. J Neuroanaesthesiol Crit Care 2017;4:127-8.  Back to cited text no. 5
  [Full text]  


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