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      Respiratory depression during VP shunting in Arnold Chiari malformation Type-II, a rare complication (Case reports and review of literature)

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          Abstract

          The VP Shunt is a common pediatric surgical procedure in our country. Hydrocephalus is commonly associated with meningomyelocele in Arnold Chiari malformation-II and the ventriculoperitoneal shunt insertion is the common surgical procedure for the management of hydrocephalus. The standard protocol is to rule out any hydrocephalus by preoperative MRI. If associated with hydrocephalus, insertion of the VP shunt is indicated before the repair of MMC whereas the absence of hydrocephalus indicates that the surgical repair of MMC is to be undertaken immediately. Anesthetic management of the patient during the insertion of ventriculoperitoneal shunt may pose problems. We report here two cases of ACM-II (lumbar MMC with associated hydrocephalus) who had respiratory depression / delayed emergence after an otherwise uneventful procedure. Although the VP shunt (first procedure) required postoperative ventilation which improved later, the phenomena of respiratory depression / delayed emergence did not occur after the MMC repair (second surgery). The possible mechanisms involved in these events and their various clinical aspects are discussed below.

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          Most cited references 13

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          Chiari I malformation: potential role for intraoperative electrophysiologic monitoring.

          Intraoperative electrophysiologic monitoring can diminish the risk of neurologic injury by enabling the detection of injury at a time when it can be reversed or minimized. Although it is clear that in patients with cervical spine disease monitoring during surgery reduces the incidence of neurologic injury, almost no data are available regarding its utility in patients undergoing suboccipital decompression for Chiari I malformation. Patients with Chiari I malformation have caudal displacement of the cerebellar tonsils below the skull base, thereby creating a tight foramen magnum and cervical canal. Although the majority of pediatric neurosurgeons perform a bony decompression with duraplasty for symptomatic patients, there is much controversy regarding the amount of bony decompression required for clinical improvement and whether a duraplasty is essential. The authors therefore conducted a prospective, observational study using intraoperative brainstem auditory evoked potentials (BAEPs) and somatosensory evoked potentials in pediatric patients undergoing suboccipital decompressions for Chiari I malformations to determine whether there were consistent changes in intraoperative BAEPs that could help the operating surgeon decide how extensive a decompression was needed in these patients, and whether changes in BAEPs or somatosensory evoked potentials occurred during operative positioning that could be modified to reduce the risk of neurologic injury.
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            Prolonged emergence and failure to regain consciousness

             JK Denlinger (1983)
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              Prolonged emergence and failure to regain consciousness

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                Author and article information

                Journal
                J Pediatr Neurosci
                JPN
                Journal of Pediatric Neurosciences
                Medknow Publications (India )
                1817-1745
                1998-3948
                Jan-Jun 2009
                : 4
                : 1
                : 44-46
                Affiliations
                Department of Anaesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
                Author notes
                Address for Correspondence: Dr Sandeep Sahu, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E-mail: drsandeepsahu@ 123456yahoo.co.in
                Article
                JPN-4-44
                10.4103/1817-1745.49109
                3162838
                21887176
                © Journal of Pediatric Neurosciences

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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