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RETROSPECTIVE OBSERVATIONAL STUDY TO DETERMINE THE INCIDENCE OF METABOLIC DERANGEMENTS AND KETOSIS IN CHILDREN UNDERGOING CRANIOFACIAL SURGERY

T. M. Zhande, Alder Hey Children's Hospital, Liverpool, UK

Introduction

Paediatric craniofacial surgery is a highly specialised area of expertise aimed at correcting congenital or acquired anomalies of the facial and cranial bones in children.

We completed an audit on metabolic markers in the blood of 30 children who underwent either Fronto-Orbital Remodelling (FOAR) or Total Vault surgery between November 2021 and November 2023 at Alder Hey Children’s Hospital. On the pre-incision arterial baseline gas samples

that are taken routinely, we observed that these patients predominantly have a low base excess (less than 2mEq/L, mean base excess was –2.4mEq/L) and yet display normal lactate levels (< 1mmol/L), and normal pH levels (pH 7.35-7.45). Considering their age and weight and the

fact that they do not have the glucose reserves of older children, we hypothesised these patients may be exhibiting starvation ketosis.

Elevated ketones are correlated with metabolic acidosis, disruptions in electrolyte balances, cardiovascular, respiratory and neurological complications and an impaired oxygen delivery to tissues. Additionally, it can lead to prolonged emergence or delayed awakening after general anaesthesia and a higher incidence of nausea and vomiting.1

Method

We measured ketone levels in 30 patients using a point-of-care ketone monitoring device. In 20 patients the ketosis was actively managed with a dextrose infusion. The effects of the treatment were observed.

Results

25 patients showed elevated ketone levels (above 0.6 mmol/L) perioperatively. Children with weight less than 12.5 kg were more like to develop ketosis as compared to children with weight above 12.5 kg (19 and 6 respectively). In the patient group where the ketosis was not treated, or treated with 5 or 10% dextrose, the ketone levels increased further (highest observed value was 2.9 mmol/L). 1 patient was treated with 20% dextrose but no change in ketone levels was observed. In the 10 patients where 50% dextrose was given, only 50% showed a decrease in ketone levels.

Conclusion

Despite the small sample size, we believe our observations to be relevant to the clinical practice. There is limited research or evidence regarding preoperative starvation ketosis in children. This abstract highlights the importance of developing clinical protocols addressing the intricate relationship between paediatric craniofacial surgery, metabolic acidosis and ketosis. It also underscores the need to determine the optimal approach for correcting ketones in this context.

Reference:

1. Kidwell R, Tobias JD. Anaesthetic care of a child receiving a ketogenic diet. Paediatric Anaesthesia & Critical Care Journal (PACCJ). 2021 Jul 1;9(2).