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Intraoperative problem during surgery for Chiari malformation

London, Ontario

To the Editor:

I read with interest the paper by Williams et al.¹ who discussed Chiari Type I malformation and postoperative respiratory failure. The authors note that the surgical procedure proceeded uneventfully. I recently provided anesthesia care for a similar case except that the procedure was not uneventful.

An obese but otherwise healthy anesthetized female was positioned in the prone position on bolsters and the head stabilized. She had had surgery for this condition 14 yr before but her symptoms had recurred, necessitating a revision.

The procedure was uneventful until the dura was incised to explore the fourth ventricle. Cerebrospinal fluid poured out and all monitors developed flat lines. No retractor was in place compressing the brain stem but some change had occurred to affect the vital centres. Atropine was administered immediately. A stretcher was prepared so that she could be turned supine. Fortunately, the heart rate returned after about a 20-sec interval. With a small dose of ephedrine the heart rate returned to normal and the blood pressure rose to acceptable levels. The patient was carefully monitored postoperatively and had no sequelae from the bout of asystole.

It was a valuable experience for the operating room staff because the first indication of a problem was the silence of the oximeter. There was no ECG, pulse oxymeter trace nor CO₂ trace, but only the flashing red light and alarm indicating asystole.

This case demonstrates again that surgery, especially involving the posterior fossa and areas around the brain stem, requires constant attention.

Reference

1 Williams DL, Umedaly H, Martin IL, Boulton A. Chiari type I malformation and postoperative respiratory failure. Can J Anesth 2000; 47: 1220–3.[Abstract]

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