Cerebral palsy

 

Disease:

Definition

·      Brain injury before, during or shortly after birth

·      Upper motor neuron effects are static

·      Muscle and bone effects evolve

Classification

Gross Motor Function Classification System (GMFCS)

·      From minimal impairment to wheelchair-bound

 

Human care:

Overall

·      Variable intellectual disability

·      Variable sensory deficit – vision, hearing

·      Good but not perfect correlation with physical abilities

·      Frequent episodes of anaesthesia

->Always address both child and parent

-> Ask child and parent what works

Pre-med

·      Variable utility

·      May facilitate pre-induction vascular access

·      May delay emergence

-> Ask child and parent what works

Pain

·      Difficult to assess

-> Clear analgesic plan

-> Ensure analgesic devices are in situ (e.g. long PIVC, epidurogram)

-> Suggest nurse-controlled PCA

-> Observe general appearance and vital signs

-> Ask parents for help

 

Procedures:

Airway

·      Contractures

·      Small dimensions

·      ±Bulbar palsy

·      ±GORD

-> Difficult intubation

-> Aspiration risk: suction PEG pre-op

Access

·      Atrophied limbs

·      Contractures

·      Small calibre vessels

-> Consider pre-induction vs post-induction: safety, ease, pain

-> Consider topicalization

-> Consider ultrasound

 

Drugs:

Hypnotic

·      ↓MAC -> slow wake-up

-> Fast-offset hypnotic: ***flurane

-> Fast-offset reflex suppressant: N2O, remifentanil

-> Titration to effect

Muscle relaxant

·      Sensitive to non-depolarising NMBD

·      Dangerous if depolarizing NMBD

-> Use roc & gamma

-> Don’t use sux

Opioid

·      Sensitive -> sedation, respiratory depression

-> Titration to effect

-> Short-acting agent if appropriate

-> Opioid-sparing analgesia

 

General care:

Pressure care

·      Atrophied muscles

·      Spasticity and contractures

·      Osteopaenia

-> Need meticulous limb pressure care

Temperature care

·      Low metabolic rate

·      Low heat capacity

·      Cold extremities

·      Propensity for intra-op hypothermia

-> Need peri-op forced air warmer

Bowel care

·      At risk of constipation

-> Opioid-sparing analgesics

-> Pair opioids with aperients

Medication

·      Multiple comorbidities

·      Multiple medications

-> Continue all peri-op incl psychoactives and anticonvulsants

-> Avoid proconvulsants – e.g. tramadol

 

Feedback welcome at ketaminenightmares@gmail.com