Anaesthesia for a “Scalped” Patient

Abstract

A 52-year-old female presented to the Neurosurgery outpatient department for a painless, extensive ulcerative lesion of the scalp, in the occipital region [Table/ Fig-1,2]. The patient had this lesion for the past two years, initially it was the size of a coin however, it gradually progressed to the present size. A provisional diagnosis of Trichilemmal carcinoma of scalp was established after FNAC and the plan was to give a flap cover to the exposed area, along with clearing the Duramater of adhesions and a cranioplasty. Neurosurgeons and Plastic surgeons were involved in the management of the case. Initial lab workup of the case showed a baseline Haemoglobin of 12.2 gm%. Other relevant investigations were within normal limits. Spiral CT scan with 3D reconstruction image [Table/ Fig-3&4] showed that the lesion had invaded into the skull and there was a huge defect in the skull and the brain was lying unprotected in the region of the tumour (without bony skull to protect it).The Duramater could be seen pulsating, reflecting cerebral pulsations. Her weight was 55 kg and relevant airway examination was done, and did not reveal any difficulty in airway management as mouth opening was adequate, full range of neck movements were possible and the Modified Mallampatti Grade was I. Patient was pre-medicated with alprazolam 0.5mg PO, the night before surgery and advised a fast of eight hours for solids and two hours for clear liquids. After wheeling the patient into the operation theatre, standard monitoring was placed as per American Society of Anaesthesiologists (ASA) guidelines (ECG, NIBP, SPO 2 , ETCO 2 after induction, Temperature probe after intubation). The patient was placed in the left lateral position, which she preferred on her own and intravenous access was acquired under local anaesthesia. Preoxygenation was done with 100% oxygen for three minutes prior to induction of anaesthesia. She was co-induced with intravenous midazolam 1mg followed by intravenous Fentanyl 100mcgs and thiopentone 5mg/kg titrated, to eyelash reflex. Prior to administration of vecuronium 0.1mg/kg, adequate bag and mask ventilation (BMV) was confirmed. After administration of vecuronium, patient was ventilated for 5 minutes, to attain good intubating conditions. After this, direct laryngoscopy was done in the lateral position, revealing a Cormack and Lehane Grade I of the glottis. The trachea was intubated smoothly and swiftly with a flexo-mettallic endotracheal tube (7.5 ID). Tracheal intubation was confirmed with auscultation and end-tidal capnography (ETCO 2 ).Endotracheal tube was secured nicely with tincture benzoin and Dura pore adhesive tape. A Central venous catheter (CVC) 7 French, triple lumen was placed in the right internal jugular vein under ultrasonography (USG) guidance in the lateral position, as the surgery was presumed to be quite extensive and lengthy. Left radial artery was cannulated and arterial blood pressure was obtained by means of transducer. A Foley's catheter was passed aseptically and urine output was monitore...