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Anesthesia for pediatric epilepsy surgery
Rebecca Jacob, Sanjib Das Adhikary, Roy Thomas Daniel1
Departments of Anaesthesia and 1Neurological Sciences, Christian Medical College, Vellore, India
Address for Correspondence: Prof. Rebecca Jacob, Department of Anaesthesia, Christian Medical College, Vellore - 632 004,
Tamil Nadu, India. E-mail: rebeccajacob@hotmail.com
ABSTRACT
Epilepsy surgery for the child is increasingly being offered as a management option even in infants, due
to advances in neurosurgery and pediatric neuro-anesthesia, coupled with a better understanding of
neurophysiological evaluation/monitoring. Anesthesia for children in the setting of a major surgery like epilepsy
surgery presents a variety of challenges. This article deals with the physiology of electroencephalogram and
the effects of anesthetic agents on neurophysiology, sedation and anesthesia for investigative procedures and
definitive surgery with major blood loss and fluid shifts, with special emphasis on the small child and awake
craniotomy in the older child.
Key words: Anesthesia, electrocorticogram, epilepsy surgery
Physiology of Electroencephalogram
The electroencephalogram (EEG) is used to help identify
conditions like epilepsy, infarction of the brain, consciousness
and unconsciousness. However, the correlation of EEG with
anesthetic agents is less clear. The EEG signals contain three
parameters: amplitude, frequency and time. Amplitude is
the height of the wave, frequency is the number of cycles
per second the wave crosses the zero voltage line and time
is the duration of epileptic activity. In cases of deeply placed
epileptic foci, the spread of epileptiform activity is also of
significance. The usual base frequency in a normal conscious
patient is in the beta wave range (>13 Hz), and this comes to
alpha range (8-13 Hz) with closure of eyes or mild sedation.
The events that lead to the production of higher frequency
is termed activation, and the events that lead to slower
frequencies like theta or delta (<4-7 Hz) are referred to as
depression of EEG. Epilepsy is recognized by high-voltage
seizure induction during electrical stimulation, a dose of fastacting barbiturates is always kept ready to treat the seizure.
Warming
Keep the ambient temperature up, as once the scalp is retracted
temperature loss from the raw surfaces is rapid. An underbody
hot air warmer, intravenous (IV) fluid warmers and airway
heat-moisture exchangers are useful in maintaining the childs
body temperature. Hypothermia leads to increased wound
infection[17] and coagulopathy.[18,19] It may also suppress EEG
waves. Hyperthermia should also be avoided as it leads to
neuronal death. Now, air blowers are available for the underbody
blankets, which can be made to cool the baby by blowing cool
air through the blankets in case of hyperthermia.
Anesthesia goals
An ideal anesthetic regime would rapidly induce sleep without
interfering with the EEG, provide analgesia when required,
provide cerebral protection with a stable ICP, provide
hemodynamic stability and end with a rapid awakening
to a safe state when the procedure is finished. The ideal
anesthetic does not quite exist, and the choice of anesthetic
depends on the experience of the anesthetist with each agent,
the procedure contemplated and the patient himself. The
smaller the patient and the more complex the surgery, the
more difficult it is to manage the blood loss, hemodynamics
and temperature. Intracranial pressure should be maintained
normal or low to help surgical access. Though a raised ICP
is not usually a problem in these cases, increased ICP can
result from positive end expiratory pressure, poor positioning
obstructing venous drainage, lack of muscle relaxation
and elevated CO2.[10] Isoflurane and sevoflurane with mild
hyperventilation may be used.[20] Propofol will produce a
consistent reduction in cerebral blood volume and ICP.
Neuroprotection is done best by ensuring adequate cerebral
perfusion. Mild hypothermia and anesthetic drugs have also
been reported to be neuroprotective.[10]
Blood and fluid management
Some epilepsy surgeries, such as hemispherectomy, are
associated with very large blood loss. This should be
anticipated, adequate monitoring in place and large-bore
IV lines available for transfusion. The target for fluid therapy
is normovolemia. Normal saline is the commonly used
crystalloid. Large volumes of normal saline will cause acidosis.
Ringer lactate decreases osmotic pressure and can cause brain
swelling. Colloids such as voluven are an option. The child
may tolerate low hematocrit; but if transfusion is done after
filling him with colloids, then there is the risk of overfilling
the intravascular volume. If on the other hand, transfusion
is left till too late on a relatively hypovolemic child, then the
rapid transfusion could lead to hyperkalemia, acidosis and
hypocalcemia, which may result in cardiac arrest. Transfusion
should therefore be started early and volume maintained.[10]
There is also a need to check coagulation profile and get
specific blood products like FFP and cryoprecipitate, if
required, as in cases of massive transfusion.
Awake Craniotomy
Intracranial procedures requiring a conscious patient are
challenging to the anesthesiologist, especially when the patient
is a child. The challenges associated with this technique are
to provide adequate sedation, analgesia, with respiratory and
hemodynamic control while keeping the patient conscious
and cooperative for neurological testing. Resection of lesions
near eloquent areas of brain, such as speech and language,
mandates the use of this technique for excision of the lesion.
Different types of anesthetic techniques for awake craniotomy
have been described in the literature.[21-25] However, most of
these are for adult patients. There have been few case reports
recently where these techniques have been modified for use
in children down to 11 years of age. Compared to the adult,
where the patient is fully awake and conscious throughout the
surgery, in the pediatric patient a sleep-awake-sleep technique
is usually preferred. All the reports of awake craniotomy in
children have emphasized one single point that of proper
patient selection for the procedure.[26-28]
Complications during these procedures are often related
to airway obstruction, agitation, drowsiness and respiratory
depression. These problems are very difficult to treat once
the patient is positioned for a craniotomy, the skull opened
or the procedure started. Even though different reports
suggest different agents during the management, not a single
anesthetic agent has proven ideal by randomized trial; and
every drug has its advantages and disadvantages. There
are different agents that have been tried as anesthetics in
these cases, such as sevoflurane, propofol, remifentanil,
dexmedetomidine, droperidol and fentanyl alone or in
combination. The most commonly used for sleep-awakesleep technique, as reported in the literature, are propofol
with fentanyl. The advantage of propofol is that if used
properly, the patient can breathe spontaneously and no active
airway management is necessary. However, in higher doses,
respiratory depression and hypotension are seen. Sevoflurane,
on the other hand, has to be administered through an
LMA or ETT, which requires manipulation of the airway
during the procedure. Dexmedetomidine has recently been
introduced. It is an effective sedative, but it has a propensity
for bradycardia and hypotension even though it does not
have depressive effects on the respiratory system. There are
no large clinical trials to date comparing different anesthetic
agents in children during awake craniotomy; so it is left to
the neuroanesthesiologists to decide on the technique and
agents with which they are most familiar and which will suit
the specific patient. We describe here, broadly, the steps
of an awake (conscious) craniotomy with advantages and
disadvantages of the particular agent or technique.
Awake craniotomy with intraoperative cortical stimulation
is most commonly done in patients where the lesions affect
the eloquent areas of the brain. This technique allows the
excision of the lesion without significant neurological deficits
such as aphasia. The prerequisite on the part of the patient
is his/her psychological stability. The patient should be old
Conclusion
It is now increasingly being recognized that the treatment of
epilepsy in the child needs to be prioritized in order to not lose
the crucial phase of brain development when the plasticity of
the brain is maximal. Allowing a child to grow to adulthood
with normal cognition and capability to earn a livelihood
contributes immensely to the family and society. Thus younger
children are now presenting for major surgery on the brain in
the hope that early treatment will ameliorate their epilepsy
without increasing morbidity and enhance brain development.
The anesthetic management of these cases is widely different
and challenging in its own right. The anesthetist is thus called
upon to play a major role in the management of the very young
child who presents for epilepsy surgery or the older child who
undergoes an awake craniotomy. With marked improvement
in the understanding of neurophysiology, newer techniques of
surgery and anesthesia, more children with epilepsy can now
be offered the benefit of a curative surgery.
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Acknowledgement
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