# Navigating Anesthesia for Thoracoscopic Biopsy in a Six-Year-Old Child With Eosinophilic Granulomatosis With Polyangiitis, Stroke Sequelae, and Pulmonary Collapse

## TL;DR

This paper discusses the anesthetic challenges and management of a six-year-old child with a rare condition undergoing surgery for lung complications.

## Contribution

The paper presents a novel case of anesthetic management for a pediatric EGPA patient with multiple comorbidities.

## Key findings

- A tailored anesthetic plan was used to avoid allergenic agents in a child with EGPA and stroke sequelae.
- Multimodal pain management and alternative airway techniques were successfully implemented.
- The case highlights the importance of multidisciplinary care for complex pediatric vasculitis patients.

## Abstract

Eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as Churg-Strauss syndrome, is a rare systemic vasculitis that affects small- to medium-sized vessels, characterized by asthma, hypereosinophilia, and multiorgan involvement. Pediatric cases are sporadic, and anesthetic management poses significant challenges due to airway hypersensitivity, allergy risk, and systemic complications. We describe the anesthetic management of a six-year-old girl with EGPA presenting with left-sided hemiparesis secondary to a prior intracerebral bleed, severe eosinophilia, and left lung collapse with pleural effusion. She was scheduled for video-assisted thoracoscopic surgery and pleural biopsy for persistent hypereosinophilia to confirm the probable diagnosis of EGPA. Considering her history of vasculitis, stroke, bronchial hyperreactivity, hypereosinophilia, and elevated IgE, the anesthetic plan prioritized avoidance of known allergenic agents such as neuromuscular blockers, opioids, non-steroidal anti-inflammatory drugs, and latex. General anesthesia was induced with propofol and sevoflurane. Although one-lung ventilation is often required, endotracheal intubation becomes a must, and it predisposes to pulmonary complications in such cases. A discussion with the surgical team was held to explore the use of both lung ventilation with low tidal volume and a supraglottic airway (i-gel®, Intersurgical Ltd, Berkshire, UK) to overcome the issues. Ultrasound-guided erector spinae block was administered as part of multimodal pain management. The procedure was limited to thoracoscopic biopsy as the need for further decortication was ruled out and was uneventful, and the patient had a stable recovery. This case underscores the importance of tailored anesthetic planning in pediatric EGPA patients with multisystem involvement. A multidisciplinary, individualized approach addressing hypersensitivity might ensure safe perioperative outcomes, even in complex cases involving the central nervous and respiratory systems.