Cerebral palsy: Anesthesia management

Cerebral Palsy represents a large spectrum of symptoms usually stemming from an injury to the developing brain which impairs various neurological functions and has wide ranging sequelae across many organ systems (e.g. mild monoplegia to spastic quadriplegia; normal cognition to severe MR). CP is often classified as spastic, dyskinetic, ataxic and mixed. Most commonly these patient undergo general anesthesia for imaging, neurosurgery (VP shunt), orthopedic surgery (hip spica, tenotomy, arthrodesis, fusion), dental extractions, and general surgery (GI, hernias)

Preoperative assessment should additionally focus on seizure type and history, spasticity, swallowing impairment/home suction needs/aspiration hx and risk, esophageal dysfunction, G-tube, scoliosis severity (c/f pulm htn), chronic lung disease, tracheostomy, cognitive/communication impairment, prior anesthetic needs/outcomes (difficult airway?). Also consider the implications of polypharmacy on your intra and post-operative medication management.

Consider the implications of using drugs that lower seizure threshold (volatiles, methohexital, etomidate, ketamine, tramadol, etc.) and most importantly ensure patient has received their normal anti-convulsant regimen preoperatively as appropriate and have a contingency treatment plan if seizures occur. Consider the use of regional anesthesia where appropriate to reduce post-op pain, spasm and respiratory complications. Consider RSI and ETT if significant aspiration risk, hypersalivation, esophageal dysfunction, etc.

These patients have lower MAC due to anticonvulsant use. CP patients tend to have increased resistance of Non-Depolarizer

Muscle Relaxants (NDMRs) and increased sensitivity to depolarizers (i.e. shorter duration of action of NDMRs and increased duration of action of depolarizers due to mild upregulation of peri-junctional ACh receptors). Quantitative neuromuscular blockade monitoring should be employed when available due to potential for altered response. Additionally, it should be noted that these patients are not prone to succinylcholine induced hyperkalemia in the way other upper motor neuron diseases are. They are however prone to hypothermia due to hypothalamic dysfunction (use pre-operative warming and ensure adequately warmed OR as well as plan for intra-op warming). They are also similarly prone to hypotension possibly due impaired adrenergic response.

Most common intraoperative complications include hypothermia, hypotension, delayed emergence, seizure, obstruction, PNA, stridor, bronchospasm, neuropathy, reintubation, aspiration, and laryngospasm (with the first two categories encompassing the vast majority of complications).