Anesthesia: Essays and Researches  Login  | Users Online: 476 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size
Home | About us | Editorial board | Ahead of print | Search | Current Issue | Archives | Submit article | Instructions | Copyright form | Subscribe | Advertise | Contacts

Table of Contents  
Year : 2017  |  Volume : 11  |  Issue : 4  |  Page : 1109-1111  

Difficult airway in a case of gross hydrocephalus for shunt surgery

Department of Anaesthesiology and Critical Care, Sanjay Gandhi Postgraduate Institute of Medical Science, Lucknow, Uttar Pradesh, India

Date of Web Publication28-Nov-2017

Correspondence Address:
Raghavendra Vagyannavar
Room No. 336, New P.G. Hostel, Sanjay Gandhi Postgraduate Institute of Medical Science Campus, Raebareli Road, Lucknow - 226 014, Uttar Pradesh
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aer.AER_201_16

Rights and Permissions

Children with gross hydrocephalus for emergency ventriculoperitoneal (VP) shunt present challenges to anesthesiologist due to increase in circumference of head, associated congenital anomalies. Here is a case report of child with gross hydrocephalus with Type 2 Arnold chiari malformation posted for emergency VP shunt placement possessed a difficult airway.

Keywords: Difficult airway, gross hydrocephalus, ventriculoperitoneal shunt

How to cite this article:
Vagyannavar R, Bharti V, Hashim M. Difficult airway in a case of gross hydrocephalus for shunt surgery. Anesth Essays Res 2017;11:1109-11

How to cite this URL:
Vagyannavar R, Bharti V, Hashim M. Difficult airway in a case of gross hydrocephalus for shunt surgery. Anesth Essays Res [serial online] 2017 [cited 2023 Jan 31];11:1109-11. Available from:

   Introduction Top

Hydrocephalus is a Greek word hydro means water and cephalus means head, a condition in which there is an excessive accumulation of cerebrospinal fluid (CSF) resulting from increased production or decreased absorption of CSF. Hydrocephalus may be of two types, it may be communicating or noncommunicating (obstructive) hydrocephalus. Hydrocephalus cases require thorough preoperative anaesthetic assessment to rule out the congenital defects, delayed milestones, difficult airway assessment.

   Case Report Top

A 9-month-old second born child by normal delivery and cried immediately after birth with no perinatal complications presented with history of increasing size of head sine 4 months. On examination vitals were stable and drowsy with no cry Sun setting sign present, occipitofrontal circumference 65 cm, and (normal 32–35 cm conclusion hydrocephalus), weight 10 kg, dilated scalp veins. Both pupils were 3 mm reacting to light; visual acuity could not be assessed. No sensorimotor deficit except for spontaneous activity present in upper limbs more than lower limbs. Lower limbs moving against gravity on pain stimuli [Figure 1]. Magnetic resonance imaging suggestive of tethered cord syndrome with Arnold  Chiari malformation More Details Type II gross hydrocephalus with dilation of bilateral lateral ventricle, third ventricle and brain matter seen as mantle around ventricle [Figure 2] other investigations were normal. This baby posted for ventriculoperitoneal shunt surgery. In our case, the problems we anticipated were difficult intubation [1],[2] due to presence of gross hydrocephalus, positioning of the baby for intubation and probability of hypothermia.[3]
Figure 1: Gross hydrocephalus (sun set sign, dilated scalp veins)

Click here to view
Figure 2: Magnetic resonance imaging of head (dilated ventricles, atrophy brain)

Click here to view

This baby has gross hydrocephalus so the difficult airway cart was kept ready. Though here the chances of difficult intubation were likely due to head size and positioning was difficult for intubation. After attaching all basic monitors induction done with sevoflurane 8% in incremental dial settings maintaining spontaneous respiration. Towel is kept below the shoulders to easy for intubation positioning. After checking for effective bag mask ventilation intravenous IV injection succinylcholine 2 mg/kg body weight given. Direct laryngoscopy done with Macintosh blade number 1, Cormack and Lehane grade (CLG) 3 with floppy epiglottis noted which was unable to lift up. First intubation attempt was failed. Bag mask ventilation was done along with deepening the plane of anesthesia with sevoflurane. We immediately concluded it to be difficult airway. Second attempt of intubation was taken by the senior anesthesiologist along with the change of Macintosh blade number 2 and optimal external laryngeal maneuver, again there was no glottic visibility with similar difficulty. We continued with bag mask ventilation successfully in between ensuring oxygenation. Afterwards intubation attempt done with keeping towels below the shoulders properly and successful intubation achieved with 4 mm i.d. endotracheal tube (ETT) with little difficulty while negotiation [Figure 3]. Anesthesia was maintained on O2, air, sevoflurane, injection atracurium. 2.5 mg. Hemodynamic maintained stable, SpO2 100, EtCO2 35 mmHg. Surgery lasted for 2 h. After the initiation of spontaneous respiration patient reversed with neostigmine and glycopyrrolate and was extubated carefully once the patient had protective airway reflexes and fully conscious [Figure 4]. Shifted to postoperative Intensive Care Unit for monitoring.
Figure 3: After intubation

Click here to view
Figure 4: Postextubation

Click here to view

   Discussion Top

Hydrocephalus is a clinical condition which occurs as a result of CSF accumulation resulting from complex mechanisms and cerebrospinal shunt procedures are life-saving. Management of patients presenting for shunt surgery can be challenging especially in children with congenital anomalies and will require thorough planning.

Congenital Hydrocephalus is capable of producing brain atrophy hence poor prognosis and may also be associated with severe mental retardation. Usually mental assessment together with other systems should be monitored cautiously because the birth asphyxia is associated with multi-organ damage. However in our case baby was having a possibility of severe mental retardation and delayed milestones due to brain cortical growth failure, if the surgical procedures were delayed, causes poor prognosis.

Therefore an urgent need to resolve this issue as failure rates is high particularly for complex shunt systems. Major complications of shunt surgery are like blockage, infection, shunt malfunction and hence the need for shunt revisions. Shunt failures occur due to catheter obstruction proximally or distally, migration of the catheter, disconnection, valve malfunction, hematomas and infection.

The anesthetic management includes careful planning and can be challenging given the fact that many procedures are done as emergency surgeries and expert help may not be available. A thorough preoperative examination is very crucial in conduction of anaesthesia. Induction of anaesthesia depends on the IV access if IV access is available then thiopentone or propofol can be used. If not then a volatile induction like sevoflurane can be used. An ETT should fix properly because migration of tube can occur easily in young children with changes in position. Cardiac function may be altered by persistent vomiting resulting in hypovolemia, hypotension and electrolyte abnormalities.

The goals of fluid management include maintaining adequate cerebral perfusion and normovolemia with isotonic fluids without hyperglycemia. Small children will require extended monitoring in the postoperative period to identify problems early to enable early treatment.[4]

   Conclusion Top

The anaesthetic management in a gross hydrocephalic child can be particularly challenging due to complex issues like difficulties related to airway management, cardiovascular dysfunction, age-related needs of positioning and congenital anomalies. Proper positining of childerns is mandatory for successful intubation.

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


Conflicts of interest

There are no conflicts of interest.

   References Top

Bissonette B, Sadeghi P. Anaesthesia for neurosurgical procedures. In: Gregory GA, editor. Pediatric Anesthesia. 4th ed., Vol. 393. Edinburgh: Churchill Livingstone; 2002. p. 4411-3.  Back to cited text no. 1
Wheeler M. Management strategies for the difficult pediatric airway. Anesthesiol Clin North America 1998;16:753.  Back to cited text no. 2
Hooper VD, Chard R, Clifford T, Fetzer S, Fossum S, Godden B, et al. ASPAN's evidence-based clinical practice guideline for the promotion of perioperative normothermia. J Perianesth Nurs 2009;24:271-87.  Back to cited text no. 3
Nienaber J. Anaesthesia for ventriculoperitoneal shunts. South Afr J Anaesth Analg 2011;17:73-5.  Back to cited text no. 4


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

This article has been cited by
Ankita Yadav,Gurjinder Singh,Parasmani Parasmani
[Pubmed] | [DOI]
2 An infant with hydrocephalus and lumbar meningomyelocele for ventriculoperitoneal shunt insertion: Concerns of an anesthesiologist
Amoolya Kamalnath,Ramyavel Thangavelu,Mamie Zachariah,RanjanR Venkatesh
Indian Journal of Health Sciences and Biomedical Research (KLEU). 2020; 13(1): 50
[Pubmed] | [DOI]
3 Airway Considerations in Pediatric Neurosurgical Patients
Hemant Bhagat,Summit Dev Bloria,Sonia Kapil,Narender Kaloria
Indian Journal of Neurosurgery. 2020; 9(03): 179
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
   Case Report
    Article Figures

 Article Access Statistics
    PDF Downloaded133    
    Comments [Add]    
    Cited by others 3    

Recommend this journal