Anesthetic Considerations in Patients With Cerebral Palsy

Function

Formulating a safe and effective anesthetic plan for patients with cerebral palsy requires the anesthesiologist to have a thorough understanding of how this spectrum of disorders affects the physiology of multiple organ systems.

Neurologic

Approximately two-thirds of patients with cerebral palsy have some degree of intellectual disability. Visual and hearing impairments are also common.[6] These conditions can pose challenges for effective communication between the patient and clinician. In patients with severe intellectual disability, preoperative anxiety can be particularly challenging to assess and may manifest as irritability or combativeness. Seizure disorders are common, with as many as 50% of patients with cerebral palsy also carrying a diagnosis of epilepsy.[7] Results from several studies suggest that general anesthesia places these patients at greater risk of developing seizures in the perioperative setting; however, this has not been shown in the literature.[8]

Patients with cerebral palsy have a lower minimum alveolar concentration for volatile anesthetic agents and also frequently have delayed emergence from general anesthesia. The exact explanation for this is unknown, but it is likely multifactorial and related to increased baseline sensitivity to anesthetic agents, use of anticonvulsant and antispasmodic medications, and perioperative hypothermia.[9] Furthermore, assessment of pain in patients with cerebral palsy can be particularly difficult in the setting of intellectual disability and poor communication skills. The patient's primary caregiver is often a valuable source of information in this context, as the caregiver is often very familiar with the patient's behaviors and mannerisms.

Musculoskeletal

Patients with cerebral palsy typically have a thin body habitus, with little subcutaneous fat and an increased surface area-to-body weight ratio.[8] This low body fat percentage makes them extremely susceptible to hypothermia in the intraoperative period.[9] Chronic contractures and spasticity of the extremities can pose significant challenges for postinduction positioning, obtaining adequate venous access, placing both invasive and noninvasive monitors, and performing regional techniques.[6] 

Neuromuscular blockers are not contraindicated in patients with cerebral palsy. These patients have a slightly increased sensitivity to depolarizing neuromuscular blockers such as succinylcholine. However, they appear to exhibit relative resistance to nondepolarizing neuromuscular blockers, such as rocuronium, with both a delayed onset and a prolonged duration of neuromuscular blockade.[10] This resistance is likely due to upregulation of extrajunctional acetylcholine receptors and interactions between neuromuscular blockers and anticonvulsant medications.[6][11][12][13]

Respiratory and Airway

Respiratory complications remain the most common cause of morbidity and mortality in patients with cerebral palsy. Underlying chronic lung diseases, such as bronchopulmonary dysplasia, may be present from birth. Recurrent respiratory infections are extremely common and are due to various factors, including oromotor dysfunction leading to aspiration, poor immune function, and chronic carriage of pathogenic bacteria.[14] Concomitant scoliosis of the spine can cause restrictive lung physiology, predisposing these patients to hypoxemia and the development of pulmonary hypertension in more severe cases.[6][9][15] 

Involuntary sustained muscle contractions in the neck, along with scoliotic curvature, may cause decreased mobility of the cervical spine. Loose teeth and temporomandibular joint dysfunction may also be present, potentially presenting a substantial challenge during airway management. An adequate preoperative airway examination may not be feasible due to cognitive impairment. The clinician should be prepared for difficulty establishing a definitive airway, and backup airway equipment and additional assistance should be readily available.[6] 

Patients with cerebral palsy often have pooling of saliva in the upper airway, caused by overproduction by salivary glands and motor dysfunction such as pseudobulbar palsy, which can impair swallowing.[16][17] Hypotonia of the respiratory muscles may lead to an inability to cough and clear secretions from the airway adequately. Increased oral secretions may pose difficulty with both mask ventilation and adequate visualization of the glottic structures during intubation.[9] Consequently, these patients are at an increased risk of aspiration. Preoperative or intraoperative administration of an anticholinergic such as glycopyrrolate may be beneficial on a case-by-case basis. Please see StatPearls' companion resource, "Glycopyrrolate," for further information.

Cardiovascular

Hypotension is one of the most common complications encountered in the intraoperative setting in patients with cerebral palsy. The explanation for this phenomenon is unknown and may be related to either increased sensitivity to anesthetic agents or a diminished central adrenergic response.[9] Clinicians may have difficulty adequately assessing cardiovascular reserve in patients with more severe manifestations of cerebral palsy who are chronically immobile. Permanent coexisting pulmonary complications may lead to pulmonary hypertension or cor pulmonale in extreme cases.[6][14] If any of these conditions are known or suspected, a more thorough interdisciplinary cardiovascular evaluation may be warranted before undergoing general anesthesia.

Patients with cerebral palsy are often malnourished and have a thin body habitus. Pseudobulbar palsy and oromotor dysfunction are common, predisposing patients to sialorrhea and poor feeding with resultant dehydration, malnourishment, and a weakened immune system that predisposes the patient to recurrent infections.[18] Poor nutrition and frequent use of laxatives for chronic constipation place these patients at risk for significant electrolyte derangements.[19] Decreased lower esophageal sphincter tone increases the risk of gastroesophageal reflux disease and aspiration of gastric or oropharyngeal contents.[14] Patients may have a percutaneous feeding tube, and the feeding schedule should be obtained from the primary caregiver before anesthesia is administered.

Allergies

An increased incidence of latex allergy has been reported in patients with cerebral palsy, partly due to recurrent and prolonged exposures to the healthcare setting. A thorough list of allergies should be obtained from the patient's chart or caregiver during the preoperative assessment.[6]

Issues of Concern

Preoperative assessment should be comprehensive, and an interdisciplinary approach may be beneficial depending on the severity of a patient’s symptoms. Caregivers are a crucial source of information for obtaining an adequate history. Medications for seizures, spasticity, and gastroesophageal reflux disease should be continued perioperatively. Preoperative anxiety should be carefully assessed, and premedication with an anxiolytic may be administered if indicated.

Establishing intravenous access can be difficult due to dehydration, chronic spasticity, and cognitive impairment. Topical application of a eutectic mixture of local anesthetics cream may be helpful, and an additional assistant may be required. Inhalational induction followed by postinduction vascular access can be a reasonable option if clinically indicated. Ultrasonography guidance can be a valuable tool if persistent difficulty is encountered.[6]

When positioning patients with cerebral palsy, great care should be taken to prevent dislocations and pressure sores.[6] Hypotension and hypothermia remain the most common complications encountered in the perioperative setting. Warming of intravenous fluids may be warranted, and perioperative use of forced air warmers should be used to minimize the risk of hypothermia.[9] Perioperative chest physiotherapy, bronchodilators, or antibiotics may be used individually to optimize a patient’s lung function and minimize the risk of pulmonary complications postoperatively.[14] Emergence may be delayed and accompanied by agitation or irritability.[6][9]

Assessment of postoperative pain can be especially difficult in the setting of intellectual disability, poor communication skills, and residual effects of anesthetic agents, and subjective indicators such as groaning, grimacing, and irritability can be difficult to interpret. The presence of a caregiver in the postanesthesia care unit can help interpret the patient’s manifested emotions and provide a familiar, calming presence. Regional and epidural anesthesia techniques are commonly used in these patients and can effectively provide prolonged postoperative analgesia while significantly reducing opioid requirements.[20] A multimodal, opioid-sparing regimen involving nonsteroidal anti-inflammatory drugs, acetaminophen, and antispasmodic and antineuropathic agents is recommended.[6]

Patients with neurodevelopmental disabilities are nearly twice as likely to experience respiratory depression compared to patients without such disabilities.[21] Judicious use of opioids is therefore recommended along with close vigilance postoperatively to monitor for adverse effects. Further caution should be exercised in patients with chronic constipation, and augmentation of their normal bowel regimen may be necessary.

Clinical Significance

The incidence of cerebral palsy has remained stable or slightly increased over the last 50 years.[3] Whereas cerebral palsy was historically considered a childhood disorder, life expectancy for patients with cerebral palsy now extends well into adulthood. Please see StatPearls' companion resource, "Cerebral Palsy," for further information.[22] Anesthesiologists will likely encounter patients with cerebral palsy throughout their careers. Therefore, it is prudent that the practicing anesthesiologist has a comprehensive understanding of this broad spectrum of disorders and can provide exceptional and personalized perioperative care.

Enhancing Healthcare Team Outcomes

Cerebral palsy is a group of permanent neurodevelopmental disorders that affect muscle tone, movement, posture, and motor function. The condition often presents with multisystem involvement, including neurologic, musculoskeletal, respiratory, and cardiovascular complications, as well as intellectual disabilities and seizure disorders. Patients frequently require surgical or diagnostic procedures, making perioperative management particularly complex. Clinicians must consider altered anesthetic sensitivity, airway challenges, malnutrition, and risks of hypotension, hypothermia, and aspiration. Effective care requires individualized planning, careful monitoring, and collaboration with caregivers who provide essential insight into patient behaviors, communication abilities, and baseline functional status.

Physicians, advanced practitioners, and general practitioners are responsible for thorough preoperative assessment, identifying comorbidities, and developing tailored anesthetic and pain management strategies. Nurses and pharmacists play a key role in monitoring vital signs, administering medications safely, and supporting postoperative care. Interprofessional communication and coordination with therapists, caregivers, and other health professionals are critical to optimizing positioning, airway management, and postoperative monitoring. By working collaboratively, the healthcare team enhances patient safety, minimizes complications, and delivers personalized, patient-centered perioperative care for individuals with cerebral palsy.