1 - Interna Formação Específica do Hospital Professor Dr. Fernando Fonseca
2 - Interna Formação Específica do Hospital Professor Dr. Fernando Fonseca
3 - Assistente Hospitalar do Centro Hospitalar Universitário Lisboa Central, Hospital Dona Estefânia
- 12th European Congress for Pediatric Anesthesiology, September 29 – October 1 2022, Lisbon, Portugal
Introduction: The exstrophy-epispadias complex is a rare congenital malformation affecting 1 in 50.000 live births, with involvement of the genitourinary system, abdominal wall musculature and pelvic structures. Corrective surgery is very complex and time-consuming, making the anaesthetic approach extremely challenging. Case description: We present a case of a 8-month-old male patient submitted to a 15-hours surgery consisting in bladder and abdominal wall closure, pelvis approximation with iliac osteotomies and external fixation, and epispadias and bilateral inguinal hernia repair. A combined anaesthetic technique with a continuous infusion of ropivacaine 0,1% through a lumbar epidural catheter was performed. The epidural catheter was tunnelled in 4 sites in order to prevent dislodgement in the postoperative period, and a central venous catheter and an arterial line were employed. Neuromonitoring was performed with BIS and fluid therapy was guided by hemodynamic parameters such as arterial pressure, heart rate, pulse pressure variation, fluid responsiveness, blood losses and subjective evaluation of urinary losses. Patient blood management was performed through blood analysis, tranexamic acid perfusion and restrictive blood transfusion. A latex-free protocol was performed.
Discussion: Bladder exstrophy repair need a well-established multidisciplinary team in order to achieve a successful outcome. The blood losses can be considerable and fluid therapy management is challenging. A multimodal analgesic approach is essential for pain control during and after the procedure. Sedation is necessary to maintain patient immobilization several days after the procedure in order to promote pelvic ring integrity. Epidural analgesia allows excellent pain control as well as motor block to minimize prolongued deep sedation and invasive ventilation with minimal physiological impact, however the risk of infection, and catheter dislodgement are a concern. Efficient communication between the anaesthesia, paediatric surgerons and intensive care unit is a pre-requisite for the perioperative period.
Palavras Chave: Bladder e«Extrophy, Epidural Anesthesia, Pediatric Anesthesia