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BRIEF COMMUNICATION
Year : 2015  |  Volume : 59  |  Issue : 2  |  Page : 121-123  

Anaesthetic considerations in an infant with Beckwith-Weidemann syndrome and hepatoblastoma for partial hepatectomy


Department of Anaesthesia, St. John's Medical College Hospital, Bengaluru, Karnataka, India

Date of Web Publication13-Feb-2015

Correspondence Address:
Dr. Jui Y Lagoo
Elita Promenade, B7-1101, JP Nagar 7th Phase, Opp. RBI Water Tank, Bengaluru - 560 078, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.151377

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How to cite this article:
Lagoo JY, Shah VM. Anaesthetic considerations in an infant with Beckwith-Weidemann syndrome and hepatoblastoma for partial hepatectomy. Indian J Anaesth 2015;59:121-3

How to cite this URL:
Lagoo JY, Shah VM. Anaesthetic considerations in an infant with Beckwith-Weidemann syndrome and hepatoblastoma for partial hepatectomy. Indian J Anaesth [serial online] 2015 [cited 2019 Oct 18];59:121-3. Available from: http://www.ijaweb.org/text.asp?2015/59/2/121/151377


   Introduction Top


Beckwith-Weidemann syndrome (BWS) is a disorder of growth regulation with incidence of 1 in 13,700 [1] and anaesthetic implications such as difficult airway, hypoglycaemia and cardiac anomalies. Hepatoblastoma, constituting 1% of childhood malignancies [2] is frequently associated with BWS, but detailed guidelines for the management are not available in the literature.


   Case Report Top


A 4-month-old male infant weighing 6 kg and length 40 cm presented with an enlarging abdominal mass. He was a full term baby with birth weight 3.7 kg without significant family history. Patient initially presented with faecal discharge from the umbilicus for which excision of remnants of vitello-intestinal duct and anastomosis was performed on day 10. Persistent post-operative hypoglycaemia, syndromic face with macroglossia and high arched palate lead to clinical diagnosis of BWS [Figure 1]. At time of presentation, he was diagnosed of hepatoblastoma of the left lobe and was posted for partial hepatectomy. Current investigations revealed haemoglobin of 10 g/dl, raised alfa feto proteins, normal serum creatinine and liver function tests. Echocardiography revealed a patent foramen ovale with a left to right shunt.
Figure 1: Child with Beckwith-Wiedemann syndrome

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The child was kept nil orally for 6 h for formula feed and 2 h for water prior to surgery. Maintenance infusion with 0.45% dextrose normal saline was started. Difficult airway cart with laryngeal mask airway, different sizes of face masks, nasopharyngeal airway, stylet and bougie was kept ready. After premedication with glycopyrrolate and fentanyl, inhalational induction was carried out with sevoflurane. Initial difficulty in mask ventilation was overcome by inserting nasopharyngeal airway refashioned from the endotracheal tube. Tongue was deflected easily with Macintosh size 1 laryngoscope blade improving laryngoscopic view, and airway was secured with 3.5 ID uncuffed endotracheal tube. Right internal jugular vein and left radial artery were cannulated for invasive haemodynamic monitoring. Analgesia was provided with paracetamol suppository and titrated doses of morphine directed by haemodynamic parameters. We maintained central venous pressure (CVP) between 6 and 8 cm H 2 O and urine output of 1-2 ml/kg/h. Blood glucose was monitored hourly. Ringer's lactate was infused at 6 ml/kg/h. Care was taken to prevent air bubbles while infusing fluids. Nasopharyngeal temperature was monitored continuously and maintained between 35.5 and 37°C. Hypothermia was prevented by using fluid warmer set at 39°C and forced air warming device. Blood loss was 60 ml, replaced with packed red blood cells. At the end of surgery, arterial blood gases and electrolytes were within normal range. The patient was electively ventilated overnight in view of prolonged duration of surgery (7 h).


   Discussion Top


Beckwith-Weidemann syndrome was first described by Hans-Rudolf Wiedemann and J Bruce Beckwith. The constellation includes exomphalos, macroglossia, gigantism, macrosomia, visceromegaly, horizontal earlobe creases, renal medullary dysplasia, cardiac malformations, hypoglycaemia, hypothyroidism, hyperlipidemia, polycythemia, hypercalciuria and embryonal tumours. [3],[4] The presence of three major features will confirm the clinical diagnosis of BWS after ruling out clinical features of overgrowth syndromes such as Simpson-Golabi-Behmel, Costello, Solos, Perlman and mucopolysaccharoidosis and maternal diabetes. It is caused by genetic alterations on chromosome 11p15 region. Risk for embryonal tumor development namely hepatoblastoma, neuroblastoma, rhabdomyosarcoma, gonadoblastoma and adrenal carcinoma has been observed. [3],[4]

Hepatoblastoma is the most common primary malignant tumour of the liver in children. Increased incidence is reported with low birth weight, BWS, hemihypertrophy, familial adenomatosis polypi and precocious puberty. It commonly presents with enlarging abdominal mass and less commonly with anorexia, weight loss, and pain. [2],[5]

These children frequently require corrective surgical interventions in infancy. Major anaesthetic considerations in BWS are abnormal airway anatomy, hypoglycaemia and cardiac anomalies. A detailed pre-operative assessment of airway, cardiac and urinary system is mandatory. Visceromegaly may shift the diaphragm upwards reducing functional residual capacity. Associated congenital malformations, prematurity and interventions early in life may complicate anaesthetic management. [3],[4]

Macroglossia may manifest with difficulty in breathing, feeding, swallowing, speech articulation and malocclusion of mandible. Functional problems associated are risk of upper airway obstruction, difficult mask ventilation or intubation. [3],[4],[6] Administration of high concentration intravenous anaesthetics or neuromuscular blocker may result in tongue fall, into retrolingual space. [3] Anticipation of difficulty, planning, preparation and judicious use of airway aids result in successful difficult airway management.

Sevoflurane is the inhalational agent of choice for induction in children. [7] Isoflurane and desflurane are preferred for maintenance by virtue of lesser decrease in splanchnic and hepatic blood flow. [5] Neuromuscular blockers that are not metabolised or eliminated by liver have been recommended like atracurium. [5],[8]

Fentanyl has been used safely for hepatectomy as the pharmacokinetics remain unaltered. Titrated morphine can be safely used with close monitoring of respiratory depression and hepatotoxicity as residual liver tissue and function is normal in children [6],[8] though surgical handling may affect metabolism to some extent. Epidural analgesia has been used successfully in older children providing optimum analgesia, good operating conditions and decreased requirement of blood transfusion. We did not opt for it as it was against institutional protocol.

Risk of massive blood loss mandates invasive haemodynamic monitoring and good intravenous access. Restriction of fluid with maintenance of CVP <5 cm H 2 O till ligation of vessels and parenchymal resection is recommended to limit distension of hepatic vein and sinusoids. [5],[8],[9] This aids in minimising blood loss and morbidity associated with massive blood transfusion. However, it can be associated with a risk of inadequate perfusion of vital organs, lack of volume reserve in the event of bleeding and air embolism. [8] Thus, we preferred to maintain CVP between 6 and 8 cm H 2 O. The presence of left to right shunt mandated prevention of hypoxia, hypercarbia and acidosis to avoid a shift to foetal circulation.

Hypoglycaemia is reported in 30-50% of patients, most probably caused by islet cell hyperplasia and hyperinsulinaemia. Prevention of neurological sequelae mandates a careful intraoperative glucose homeostasis with infusion of glucose-containing solution along with hourly glucose checks. [3],[4],[6]

The large operative field exposure is associated with significant heat loss, and the risk is further increased due to paediatric age. Hypothermia inhibits the enzymes of the coagulation cascade and contributes to intraoperative blood loss. [5],[8],[9]

Elective ventilation following hepatectomy may be considered in the presence of other comorbidities, massive blood loss, hypothermia, coagulopathies, prolonged duration of surgery and acid-base imbalance. [9]


   Conclusion Top


Anaesthesia management in BWS is complicated by abnormal airway anatomy, cardiac defects, associated anomalies and persistent hypoglycaemia. Knowledge about the same will aid in a safe conduct of anaesthesia during various surgical procedures. Careful pre-operative evaluation, planning, appropriate anaesthesia technique and vigilant monitoring results in a successful outcome.

 
   References Top

1.
Weksberg R, Shuman C, Beckwith JB. Beckwith-Wiedemann syndrome. Eur J Hum Genet 2010;18:8-14.  Back to cited text no. 1
    
2.
Herzog CE, Andrassy RJ, Eftekhari F. Childhood cancers: Hepatoblastoma. Oncologist 2000;5:445-53.  Back to cited text no. 2
    
3.
Kim Y, Shibutani T, Hirota Y, Mahbub SF, Matsuura H. Anesthetic considerations of two sisters with Beckwith-Wiedemann syndrome. Anesth Prog 1996;43:24-8.  Back to cited text no. 3
    
4.
Whizar-Lugo V, Moreno AS, Morales PO, Ramνrez AG, Vallarino FA, Domνnguez J, et al. Anesthesia for partial glossectomy in a toddler with Beckwith Wiedemann syndrome. Pediatr Anesth 2004;14:53-9.Jacob R. Anaesthesia for biliary atresia and hepatectomy in paediatrics. Indian J Anaesth 2012;56:479-84.  Back to cited text no. 4
    
5.
Bicer C, Eskitascioglu T, Aksu R, Madenoglu H. The anesthetic management of a case of Beckwith-Weidemann syndrome presenting with a large tongue. Erciyes Tip Derg 2011;33:251-4.  Back to cited text no. 5
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6.
Redhu S, Jalwal GK, Saxena M, Shrivastava OP. A comparative study of induction, maintenance and recovery characteristics of sevoflurane and halothane anaesthesia in pediatric patients (6 months to 6 years). J Anaesthesiol Clin Pharmacol 2010;26:484-7.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.
Chevalier A. Anaesthesia and hepatic resection. Anaesthesiol Rounds 2005;4:122-9.  Back to cited text no. 7
    
8.
Redai I, Emond J, Brentjens T. Anesthetic considerations during liver surgery. Surg Clin North Am 2004;84:401-11.  Back to cited text no. 8
    


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