Airway Management with ProSeal LMA in a Patient with Osteogenesis Imperfecta

Comprehensive risk assessments and anesthetic management for children with osteogenesis imperfecta: A retrospective review of 252 orthopedic procedures over 5 years

BACKGROUND

Major anesthetic risks arise in orthopedic surgeries for children with osteogenesis imperfecta, a rare genetically inherited condition presenting diverse skeletal issues.

AIM

We aimed to investigate anesthetic risks, including difficult airway, hypo- and hyperthermia, blood loss, and pain, in connection with patient, anesthetic, and surgical factors.

METHODS

Both descriptive and inferential statistics were employed to study the anesthetic risks and their predictors. Data of 252 surgeries for 132 Chinese osteogenesis imperfecta patients aged 18 or below were retrieved from the authors' hospital between 2015 and 2019.

RESULTS

Two thirds of the cohort were Sillence type IV patients, with types I, III, and V accounting for 7.6%, 14.4%, and 11.4%, respectively. Video and direct laryngoscopy were used. No case of difficult airway was identified. Due to a careful management strategy, intraoperative temperature varied on average between -0.38°C and +0.89°C from the initial temperature. Fifty-two and 18 cases of hyper- and hypothermia were encountered, respectively. The use of sevoflurane for maintenance resulted in a mean increase of +0.24°C [95% CI 0.05 ~ 0.42] in the maximum temperature. Massive blood losses (>20% of estimated total blood volume) were observed in 18.3% of the cases. Neither intraoperative temperature changes nor blood loss was found to be related to Sillence classification. Regional anesthesia techniques were applied to 72.6% of the cases. Ultrasound guidance was used per the judgment of anesthesiologists or when in case of difficult landmarks. The incidence of difficult regional anesthesia was low (4 out of 252). For postoperative analgesia, 154 neuraxial blocks (including 77 caudal and 77 lumbar epidural) and 29 peripheral nerve blocks were performed.

CONCLUSION

Anesthesia for children with osteogenesis imperfecta undergoing complex orthopedic procedures was challenging. Proper anesthesia planning was essential for both intraoperative management and postoperative analgesia. Age, surgical duration, and use of sevoflurane for maintenance impacted the intraoperative temperature most, and massive blood loss was not uncommon. The risks for airway or regional anesthesia difficulties were low. Pain scores could be controlled to be ≤3 via multiple techniques.

The Anesthetic Management of a Parturient With Osteogenesis Imperfecta Type I Undergoing Cesarean Delivery

Osteogenesis imperfecta (OI) is a rare disorder of bone fragility caused by mutations in the COL1A1/2 genes, which encode type I procollagen. It commonly manifests with bone fractures, joint dislocations, and easy bruising. OI patients presenting for surgery may pose multiple challenges to the anesthesiologist such as management of a potentially difficult airway and heightened positional fracture risks. We present a case detailing the spinal anesthetic management of a 28-year-old woman with type I OI requiring cesarean delivery for a 32-week intrauterine pregnancy with fetal cardiac anomalies.

Anesthesia in children with osteogenesis imperfecta: Retrospective chart review of 83 patients and 205 anesthetics over 7 years

BACKGROUND

Osteogenesis imperfecta is the collective term for a heterogeneous group of connective tissue syndromes characterized by bone fragility with multisystem involvement and perioperative implications.

AIMS

Literature review of anesthetic management of patients with osteogenesis imperfecta revealed a paucity of data on the incidence of perioperative challenges. We sought to determine the rates of these challenges in our study cohort.

METHODS

Data were collected in a specialty orthopedic hospital from 2008 to 2015 for 83 osteogenesis imperfecta patients undergoing 205 surgeries: 203 orthopedic surgeries and 2 mid-face reconstructive surgeries. Airway management, intravenous access, surgical blood loss, use of peripheral nerve blockade and/or neuraxial techniques, presence of perioperative fracture, and peak intraoperative temperature were evaluated and analyzed.

RESULTS

Difficult airway was encountered in 3/205 (1.5%) cases and perioperative fracture in 2/205 (1%) cases. Neuraxial anesthesia was attempted in 64/205 cases with an 87.5% success rate. All peripheral nerve block attempts (33/205 cases) were successful. Difficult intravenous catheter placement was noted in 8/205 (4%) cases. Estimated blood loss >10% of estimated blood volume was considered significant, and occurred in 35/205 (17%) cases. Significant blood loss occurred more often in severe osteogenesis imperfecta types: 18/76 (23.7%) in Type III and 11/65 (16.9%) in Type IV, whereas only 4/47 (8.5%) occurred in mild Type I. In our 205 case cohort, osteogenesis imperfecta Type III had 5.6 times the odds [(95% CI = 1.8-17.2) P = 0.003] of having an anesthetic complication as compared to osteogenesis imperfecta Type I.

CONCLUSION

Patients with osteogenesis imperfecta undergo frequent anesthetic exposures, but anesthetic challenges in our series were uncommon. Odds of challenges are greater in severe osteogenesis imperfecta Type III, with significant blood loss and difficulty placing intravenous catheters more likely encountered in the more severe types.

Anesthetic Management in a Gravida with Type IV Osteogenesis Imperfecta

Osteogenesis imperfecta (OI) is an inherited disorder of the connective tissues caused by abnormalities in collagen formation. OI may present many challenges to the anesthesiologist. A literature review reveals a wide range of implications, from basic positioning to management of the difficult airway. We present the anesthetic management of a 25-year-old gravid woman with OI, fetal demise, and possible uterine rupture, admitted for an exploratory laparotomy.

Anesthesia management in a child with osteogenesis imperfecta and epidural hemorrhage

Osteogenesis Imperfecta (OI) results from gene mutation that causes defective or insufficient collagen formation. It may cause various anesthetic complications due to the difficulty in airway management, existence of spinal deformity, respiratory disorders, cardiac anomalies, thrombocyte function disorder, risk of hyperthermia, bacillary invagination, bone deformities and metabolic disorders. The anesthesia management of OI patients should be exercised with caution given certain risks of respiratory disorders. These risks are due to thorax deformity, bone fractures during moving or changing position, mandibular and cervical fractures related with intubation, difficult intubation and malignant hyperthermia. The anesthetic technique using Total Intravenous Anesthesia (TIVA) and laryngeal mask airway is suitable for pediatric patient care with OI. However, these techniques have not yet been reported as useful in neurosurgery case reports. In this study, we present the use of TIVA and ProSeal Laringeal Mask in a child with OI and epidural hemorrhage. We came to the conclusion that LMA and TIVA can safely be used in the anesthetic management of OI patients with severe anesthetic problems.

Neonatal Upper Airway Obstruction in Osteogenesis Imperfecta: Series of Three Cases and Review of the Literature

Objectives:

Osteogenesis imperfecta (OI) is a genetic disorder characterized by variable degrees of dysfunction in type I collagen formation. We sought to explore an association between OI and upper airway obstruction (UAO) in light of our recent experience.

Methods:

We performed a retrospective chart audit and a review of the literature.

Results:

Three consecutive cases of OI at our institution required otolaryngological evaluation for UAO. The first patient had the mildest mutation type and did well until he developed severe reflux-triggered laryngospasm that improved with Nissen fundoplication and gastrostomy tube placement. He had mild hypotonia on endoscopy. The second patient had severe OI and the greatest acute fracture burden at birth. He required tracheotomy after early respiratory failure, and some mild bronchomalacia was noted. The third patient had severe OI and underwent cesarean section delivery. She developed respiratory failure after 1 month, requiring tracheotomy; mild tracheomalacia and glottic narrowing were noted on endoscopy.

Conclusions:

The UAO consisted of mild hypotonia or malacia in 3 consecutive cases of OI, and may have contributed to pulmonary and mechanical causes of tracheotomy requirement. The greatest predictors of tracheotomy requirement appear to be the severity of the OI mutation and the fracture burden. Elective cesarean section should be considered in severe cases of OI.