|Year : 2016 | Volume
| Issue : 1 | Page : 134-135
An unusual perioperative event in a complex pediatric surgery
Gaurav Chopra DA, MD, FELLOW (UWO, Canada) , Gulam M Parihar
Department of Anaesthesiology and Pain Management, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
|Date of Submission||06-Aug-2014|
|Date of Acceptance||21-Sep-2014|
|Date of Web Publication||17-Mar-2016|
Department of Anaesthesiology and Pain Management, Swami Rama Himalayan University, Jolly Grant, Dehradun, Uttarakhand, 248001
Source of Support: None, Conflict of Interest: None
Sacrococcygeal teratomas are tumors that arise in the sacrococcygeal area containing tissue from all three germ layers. Sacrococcygeal teratoma has an incidence of ~one in 27 000 live births, with malignant transformation with increasing age. We report a unique case of a 6-year-old child with a large sacrococcygeal mass with rudimentary genitals with an intraoperative intraoral misplacement of the endotracheal tube during positioning.
Keywords: pediatric anesthesia, prone position, sacrococcygeal teratoma, uncuffed endotracheal tube
|How to cite this article:|
Chopra G, Parihar GM. An unusual perioperative event in a complex pediatric surgery
. Ain-Shams J Anaesthesiol 2016;9:134-5
| Introduction|| |
Germ cell tumors (GCTs) that arise outside the testes or the ovaries are classified as extragonadal. Extragonadal GCTs typically arise in midline locations and specific sites vary with age. In adults, the most common sites are the anterior mediastinum, retroperitoneum, and the pineal and suprasellar regions. In infants and young children, sacrococcygeal teratomas (SCTs) are most common. SCT are tumors that arise in the sacrococcygeal area containing tissues from all three germ layers. SCT has an incidence of ~one in 27 000 live births, with malignant transformation with increasing age. SCT is more common in females with a male: female ratio of 1: 3. SCT may present in three categories - fetal, neonatal, and children. Prenatal ultrasound can detect fetal tumors with or without maternal symptoms. Those presenting at birth are usually mature or immature teratoma. A large sacral mass that has been increasing progressively is the most common type of presentation in children.
| Case report|| |
A 6-year-old boy presented with a sacral mass in the perianal area since birth as reported by his mother. The mass had been growing slowly and progressively to reach the present size. It had also grown to the extent that he could not sleep in the supine position. He also had a history of constipation on and off. There was no history of altered bladder habits or weakness of the legs. On examination, the child was alert and adequately built, with a large solid-cystic mass of 28 × 30 cm in the sacrum, with the anus grossly pushed anteriorly [Figure 1]. No weakness of the lower limbs or intrabdominal mass was palpable. The ultrasound of the abdomen did not indicate any genitourinary abnormality. MRI indicated a fatty mass with a bony and cystic component in the perineal region that was extrapelvic in origin, with the right testis in the inguinal region and the left testis in the normal position. Preoperative investigations showed hemoglobin 11.79 g/dl, hematocrit 37.25, platelets 363 × 09/l, sodium 138 mmol/l, potassium 3.86 mmol/l, serum creatinine 0.34 mg/dl, blood urea nitrogen 8.9 mg/dl, bilirubin total 0.32 mg/dl, direct bilirubin 0.06 mg/dl, alkaline phosphatase 221 IU/l, and α-fetoprotein 0.69 ng/ml. The patient was admitted early in the morning as the first case after applying cardio respiratory monitors and securing intravenous access with a 20 G canulla. Coinduction was performed using thiopentone 40 mg and inhalational agent sevoflurane 6%, and fentanyl 40 mg as an analgesic. Atracurium 10 mg was used as a muscle relaxant. After 3 min of intermittent positive pressure ventilation, endotracheal intubation was performed using a 4.5 mm internal diameter noncuffed endotracheal tube. As we intubated the patient's trachea and fixed the endotracheal tube with adhesive bandage, a resident was instructed to cut the length of the tube to decrease the dead space. While surgeons asked to turn the patient prone, after turning the patient and applying monitors we found a decrease in SpO 2 to 80%, no end-tidal CO 2 (EtCO 2 ) tracing, and tachycardia with heart rate 116/min; we checked the tube placement and found the circuit lying disconnected. Immediately, the patient was turned supine and we started looking for the endotracheal tube and immediately, laryngoscopy was performed; we found the endotracheal tube lying deep in the posterior pharyngeal wall. The endotracheal tube was taken out with Magill forceps, the patient was ventilated with 100% O 2 for 1 min; as the SpO 2 , which had decreased to 60%, returned to 100, the patient was reintubated with a new 4.5 mm noncuffed endotracheal tube. The patient was maintained on oxygen, nitrous oxide, and sevoflurane. Intraoperative monitoring included ECG, heart rate, noninvasive blood pressure, EtCO 2 , pulse oximetry, temperature, and esophageal stethoscope. The patient was revived from anesthesia with neostigmine 1 mg and glycopyrolate 0.2 mg.
|Figure 1: (a) SCT. (b) MRI of SCT. (c) SCT. (d) ET tube after shortening. (e) After excision of SCT. ET, endotracheal tube; SCT, sacrococcygeal teratoma|
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| Discussion|| |
SCT is the most common GCT of childhood. Its cause remains unknown.
It is one of the most common fetal neoplasms. Teratomas are often comprised of cells that represent all three germ cell layers. They have solid, cystic, or mixed components. Most adult SCTs are intrapelvic, whereas most are external in infants. SCT generally presents either in utero, as a mass extending off the caudal end of the fetus, or as a tumor of infancy that may be asymptomatic or may present with signs of obstruction of the rectum or the bladder  . A small number of children present with weakness, pain, or paralysis. As SCT has the potential for malignant transformation, which increases with age  , early detection and management are important  . Examination by computed tomography and MRI can enable evaluation of the relationship of the tumor with the surrounding structures and define the excisional plane for surgery  . MRI is superior for evaluation of the anatomical relationship with adjacent organs, such as spinal canal invasion. This case falls into the category of mature huge SCT. This type of case is a challenge for the anesthesiologist as, in a pediatric surgical case with a large mass, the risk for blood loss is very high and also positioning for intubation as well as prone position for surgery represent additional risks. In this case, SpO 2 decreased because of a change in position because of an iatrogenic cause. A resident, by mistake, instead of cutting the tube at 16 mm, cut it at 14 mm. Thus, because of such shortening of the endotracheal tube, the chances of misplacement/dislodgment of the tube from the rest of the circuit are high as occurred in our case during shifting of the patient from the supine to the prone position. Although the management of this case was simple, such minor mistakes can lead to very catastrophic events perioperatively; even a tube of such a short length can be a foreign body in the tracheobronchial tree. By minimal monitoring (SpO 2 , EtCO 2 , etc.), we could detect tube misplacement early.
| Conclusion|| |
The carry home message is that if at all there is a need to shorten the length of the endotracheal tube to decrease the dead space, especially in pediatric cases, judicious attention should be paid while cutting the tube and the connection of the endotracheal tube should be attached firmly and cross checked for any loose connections.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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