Early in the course, infants and young children often do not exhibit

the traditional signs of intracranial hypertension such as bradycardia,

elevated systemic blood pressure, dilation of the pupils, and
papilledema. If present, these signal severe progression with poor
outcomes. Neonates and infants may present with increased head
circumference, bulging fontanelles, widened cranial sutures,
sundowning of the eyes, irritability, lethargy, poor feeding, or lower
motor deficits. The limits of cerebral autoregulation may be shifted to
significantly lower values (mean arterial pressure (MAP) 20-60
mmHg) in the neonates and infants. The margin of safety is
narrower as the infant is less well able to compensate for acute hypoor hypertension. Low MAP presents the risk of ischemia while
hypertension in infants may present risk of intracranial hemorrhage.
Response to hyperventilation (low PaCO2) in infants may be brisk,
with a risk of inducing cerebral ischemia with extremely low PaCO2 (

 Cerebral blood flow (CBF) affects the cerebral blood volume and
the intracranial volume, thereby affecting the intracranial pressure
(ICP).
premature infants (12 ml/100 g/min) and full-term neonates (2340 ml/100 g/min) and higher in infants and older children than in
adults (50 ml/100 g/min).From 6 months to 3 years of age, CBF is
90 ml/100 g/min; and from 3 to 12 years of age, the CBF is 100
ml/100 g/min.
CBF is coupled tightly with the metabolic demand known as
cerebral metabolic rate of oxygen (CMRO 2), and both increase
proportionally after birth.
In children, the CMRO2is higher at 5.2 ml/100g/min than the
adults (3.5 ml/100 g/min) and hence, less tolerant to hypoxia.
Neonates have a lower CMRO2(3.5 ml/100 g/ min) with a relative
tolerance to hypoxaemia.

 Premedication
Sedative and narcotic premedication
should be avoided in all the children
suspected of increased ICP as these
medications decrease respiratory
drive which may result in
hypercapnia and further increase in
ICP.

 Induction

The goal of anaesthetic induction is to avoid increase in ICP owing to

associated hypoxia, hypercapnia and volatile anaesthetic-induced
increases in CBF.
An intravenous (IV) induction with thiopentone or propofol and
neuromuscular block to facilitate endotracheal intubation is ideal in
children with raised ICP.
However, in children without IV access or with difficult IV access,
inhalational induction by facemask with sevoflurane should be preferred
as crying or struggling may lead to further increase in ICP.
After the IV access is secured, a bolus of thiopentone (1-2 mg/ kg) or
propofol may be given to prevent the pressure responses of tracheal
intubation.
Allvolatile anaesthetics cause an increase in CBF, and thence the ICP.
Therefore, ventilation should be controlled as early as possible and mild
hyperventilation be instituted to prevent rise in ICP

 Maintenance of anaesthesia

Anaesthesia is maintained either with low end-tidal

volatile agents (minimum alveolar concentration (MAC)
< 1) or with total IV anaesthesia (TIVA), along with
short-acting opioids (fentanyl and controlled ventilation.
Sevoflurane provides smooth induction followed by a
rapid recovery. Fentanyl is the most commonly used
opioids, but its half-life increases with repeated dosing.
It requires hepatic metabolism which is immature in
premature infants. Hence, the sedative and respiratory
depressive effects of fentanyl may be prolonged in
these children.

position
unobstructed view of the part of
child, proper padding of pressure
points, protection of the eyes from
surgical cleaning solutions, and the
access to IV line, airway and
breathing circuits before
commencement of surgery

 Monitoring
Intracranial surgery may be associated with haemodynamic
changes owing to sudden blood loss, VAE and manipulation
of cranial nerves. A part from the routine monitors,
placement of an arterial cannula permits continuous
monitoring of blood pressure, occasional estimation of
arterial blood gas, electrolytes and haematocrit values. A
central venous catheter provides large-bore access and
aspiration of air during occurrence of VAE in sitting position.
Precordial Doppler and trans-oesophageal echocardiography
are sensitive monitors used to detect of VAE, but not
available everywhere. Hence, the end-tidal CO 2is
commonly used in India for this purpos

 Fluid management
The intraoperative goal is to maintain normovolaemia, and thus the
haemodynamic stability. Normal saline is the most commonly administered
crystalloid during paediatric neurosurgical procedures as it is mildly
hyperosmolar and hence prevents cerebral oedema.
However, infusion of large quantities (>60 ml/kg) of normal saline may
cause hyperchloraemic metabolic acidosis and hypernatraemia.Ringer's
lactate is slightly hypo-osmolar and infusion of large quantities may
increase cerebral oedema.
Glucose-containing fluids should not be used during these procedures as
hyperglycaemia worsens reperfusion injury. However, in neonates and
premature infants, the danger of hypoglycaemia should be borne in mind.
Blood glucose should be closely monitored in these patients, along with
continuous infusion of glucose at 5-6 mg/kg/min.
Blood transfusion should be guided by the degree of blood loss and initial
haematocrit values.

anaesthetic considerations for

craniosynostosis
Difficult airway associated with syndromic craniosynostosis
Hydrocephalus and elevated ICP due to abnormal shape of skull; ICP reduction
manoeuvres are to be undertaken
Sudden and massive blood loss may occur, as the surgery is carried out in close
proximity to major venous sinuses. Hence, large bore venous catheters must be
secured before skin incision. Presence of an arterial cannula may help for
continuous measurement of blood pressure, serial haematocrit and blood gas
Venous air embolism: The reported incidence in children undergoing
craniosynostosis repair is 82.6% with use of precordial Doppler, [21]whereas it is
4.2% with the use of end-tidal CO2monitoring[22]
The Ocular (corneal) injury can be prevented by lubricating the eyes with wetting
agents or antibiotic ointments
Postoperative oozing of blood from the surgical site may need further transfusion
of blood and blood components
In children operated below the orbital ridge, a possible airway compromise owing
to facial oedema should defer tracheal extubation by 24-48 h until resolution of
oedema.[6]

Induksi

Induksi harus mulus

Barbirturat merupakan agen yang ideal untuk
menurunkan ICP, CBF dfan metabolic rate
Pada anak yang tidak kooperatif perlu
dipertimbangkan induksi per rectal
Pada pasien dengan anomali craniofascial
lebih baik diinduksi inhalasi atau awake
intubasi.
Vecuronium lebih disukai

Intubasi
ETT not kinking dipakai pada posisi yang
ekstrim
Untuk anak < 6 tahun digunakan ETT non
cuff untuk mencegah trauma subglotis
Gastric tube digunakan untuk mencegah
distensi lambung
Lidokain 1-1.5 mg/kg digunakan untuk
mencegah reflek simpatis dan mencegah
peningkatan ICP

 Crouzons dan Aperts syndrome

Pasien ini mengalami deformitas midface yang
berat dan displasia sehingga mengalami gangguan
pertumbuhan dari jalan napas dan cenderung
untuk apnea karena obstruksi. Hal ini
menyebabkan sulitnya intubasi terutama intubasi
nasal
Tanda-tanda yang lain : exopthalmus dengan
hypertelorism, mata yang sangat lebar dan
proptosis, tulang-tulang yang abnormal
Pasien ini diterapi dengan midface Le Fort
advancements.

 RANIOSYNOSTOSIS:
Adalah akibat fusi sutura kranii yang prematur'
Sutura yang terlibat termasuk korona dextra dan sinistra
(anterior plagiocephaly),metopik(trigonocephaly),sagital
(scaphycephaly),lambdoida dextra dan sinistra(posterior
plagiocephaly),korona bilateral(anterior brachicephaly).
lambdoida bilateral(posterior brachicephaly)
SAGITAL SYNOSTOSIS:
Hampir separoh dari kejadian craniosynostosis diduga pre
disposisi genetik dan pria lebih dominan.
Bentuk kepala lonjong antroposterior(scaphocepahalic),
fontanella anterior mengecil atau hilang
Kebanyakan perkembangan otak dan pemeriksaan neurolo
gi normal dan biasanya intervensi pembedahan diarahkan
untuk pembebasan sutura yang menyatu pada umur dibawah6 bulan.

 CORONALSYNOSTOSIS:
Meliputi 20% dari seluruh kejadian craniosynostosis bila
unilateral maka kening disisi yang terkena akan mendatar
dan meningginya pinggir orbita ipsilateral sebaliknya
keningdisisikontralateral akan menonjol
Khasnya hidung menyimpang jauh dari sutura yang menyempit.Bilateral
coronal synostosis sering bersamaan dengancraniofacial dysmorphism
(Apert,Crouzon dan Saethre Chotsen syndrome).

Penyatuan sutura frontoethmoidalis bisa menimbulkan

penyempitan nasal airway
Rekontruksi pada unilateral coronalsynostosis dilakukan di
bawah umur 6 bulan sedangkan pada bilateral synostosis diatas umur 6
bulan,prosedur ini memakan waktu yang lamadan perdarahan yang lebih
banyak daripada yang
unilateral.

MULTIPLE SUTURE SYNOSTOSIS:

Kejadiannya 7% dari seluruh kasus craniosynostosis.
Bentuk kepala tergantung pada sutura mana saja yang ter
libat,pada kasus ini diperlukan total rekonstruksi tulang
kepala untuk kosmetik terbaik,dimana posisi pasien teng
kurap dan leher sangat extensi kemungkinan pipa endotra
keal tertarik dan perdarahan yang banyak.(5)
Pertimbangan anestesi:
Termasuk perhatian terhadap :(5,7,9)
1.ICP yang meninggi.
2.Problema airway
3.Hilang darah yang massif.
4.Emboli udara vena.

 ad.1.Peninggian ICP berkaitan dengan cepatnya

pertumbuhanotak didalam rongga tengkorak yang
kaku yang bisaterjadi tergantung jumlah sutura yang
terlibat dan berapa cepat problem ini diketahui.
Hidrosepalus ditemukan pada 5-10% pasien dengan
anomali craniofacial mungkin karena stenosis basis
kranii.
Penurunan ICP sangat penting untuk mempermudah
akses intrakranial ke struktur facialis dan mengu
rangi kompressi terutama pada lobus temporalis
yang dapat meneyebabkan odema serebral post ope
ratif hal ini bisa dicapai dengan hiperventilasi dan
osmotik/loop diuretik untuk menurunkan volume
isi intrakranial
Induksi anestesi harus mulus,gunakan barbiturat,nar
kotik dan batasi pemakaian inhalasi anestesi.(6)

 Penyempitan nasal airway sering dijumpai padahal

bayihanya bisa bernafas lewat hidung.
Karena kemungkinan kesulitan intubasi terutama
pada anak dengan anomali facialis dengan man
dibula hipoplasia,leher dan trakea yang immobil,mak
roglossi dan mulut yang sulit dibuka maka sebaiknya
bronchoscope fiberoptik tersedia dan ahli bedah siap
dengan trakeostomi..Beberapa anak bisa mento
lerir awake laringoskopi dan fiberoptik intubasi.
Tehnik induksi utama pada kesulitan jalan nafas ada
lah tehnik inhalasi dan assisted ventilasi dapat mem
pertahankan atau mengurangi PaCO2 sehingga bisa
membatasi kenaikan ICP
Bila bisa dintubasi maka pipa trakea diamankan de
ngan dijahit karena kemungkinan bergeser besar
sekali.Pasien dengan prosedur facial terutama diba
wahorbita sering dengan odem jalan nafas atas
untukitu sebaiknya pasien tetap terintubasi dan ter
sedasidan diventilasi selama 24-48 jam post opera
tif dengan subarachnoid drain untuk mengurangi
kebocoranCSF melalui dura sebelum extubasi.

 alaupun prosedur adalah extradural namun

hilangnyadarah bisa massif dan mendadak bila
intervensi pembedahan mengenai sinus venous
mayor.

Semakin banyak sutura dan semakin tebal tulang

yang direkonstruksi semakin banyak darah yang hi
lang untuk itu cross match darah selalu tersedia di
kamar operasi dan persiapan darah harus ada sebe
lum operasi.Akses intravena harus dijamin lancar
untuk persiapan pergantian cairan/darah dan moni
toring tekanan intra arterial,CVP,produksi urine dan
temperatur otak adalah penting.
Bila hilangnya darah sama dengan volume darah efek
tif kemungkinan gangguan pembekuan darah terjadi.


Ahli anestesi haruslah serius mengamati pasien wak
tu ahli bedah memisahkan sutura yang menyatu dari
sinus sagitalis dimana perdarahan vena yang hebat
dan emboli udara terjadi.Emboli udara vena didetek
si dengan echocardiography dan precordial Doppler
dimana craniectomi pada bayi resiko terjadinya
emboli udara vena sekitar 66-83% yang dapat dimi
nimalisir dengan deteksi dini dengan precordial Dop
pler dan mempertahankan euvolumia.