Pediatric neurosurgery, special attention is required!

Pediatric neurosurgical operations carry a considerable risk of bleeding in the perioperative period. This risk is related to several factors, such as, the nature of surgery, preoperative hemoglobin level, and body weight of the patient.

Bleeding is a major risk intra- and postoperatively, affecting the hemodynamic stability, oxygen carrying capacity, and consequently morbidity and mortality.

The anesthetist has to have a clear plan regarding the perioperative management of blood loss, including preoperative autologous blood donation, erythropoietin administration, and normovolemic hemodilution. Intraoperative management during surgery should include precise evaluation of blood losses, hematocrit measurements at regular intervals, autologous blood transfusion and homologous blood transfusion, which has to extend into the postoperative phase.[1]

In this issue, a case report of craniosynostosis undergoing a corrective surgery has been reported.[2] Difficult intubation due to high larynx was encountered. The surgery was quite complicated: Pansynostosis orbital bar advancement, frontal expansion, and right optic canal deroofing. The operation lasted for 10 hours with blood loss of about 90% of the patient's estimated red cell mass.

Apart from postoperative blood loss in the Intensive Care Unit, the postoperative course was complicated with sever lung atelectases and ventilatory difficulties, respiratory acidosis, and sepsis.

Bonhomme et al., reported a hematocrit threshold of 21%, below which transfusion is indicated, but the above-mentioned blood salvage techniques should be appropriately implemented, to avoid or reduce homologous blood transfusion.[3]

It is very important to build up an anesthesia management plan before surgery; this plan has to consider the perioperative risk factors related to the operation in this specific child, evaluation of the preoperative condition, airway assessment, and invasive management techniques, such as, arterial line and central venous catheter. Important information can be obtained from the surgeon about the surgical plan, which may affect the anesthetic plan. Finally, the parents of the child have to be informed about the possible intra- and postoperative anesthesia risks.

Good preoperative assessment, correct intraoperative and ICU management plan, and teamwork with the surgeon and intensivist are the key issues to achieve a successful end result.