Staged surgical anesthesia in pediatric disseminated cystic echinococcosis: A case report

Staged surgical anesthesia in pediatric disseminated cystic echinococcosis: A case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Staged surgical anesthesia in pediatric disseminated cystic echinococcosis: A case report Yu Li, Pengzui Bai, Yuhai Xie, Xiangqing Song, Menglong Zhu, Yong Deng, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9047045/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Cystic echinococcosis remains endemic in pastoral regions; however, evidence guiding perioperative anesthetic management in very young children with concomitant multi-organ (hepatic–pulmonary) involvement is limited. We report the anesthetic management of a 2-year-old girl with disseminated hepatic and bilateral pulmonary echinococcosis who underwent three staged operations within a short period, and we summarize practical perioperative considerations. Case presentation: The patient initially presented with abdominal distension and discomfort, followed by fever, productive cough, and hemoptysis. Imaging revealed multiple cystic hepatic lesions and multiple hydatid cysts in both lungs. A staged surgical strategy was adopted: open hepatic hydatid cystectomy with endocyst removal/pericyst management was performed first, followed by left and right thoracotomies for pulmonary hydatid cyst excision with closed thoracic drainage. Anesthetic management focused on dynamic evaluation of hepatic synthetic function and coagulation/albumin status, lung-protective ventilation under pediatric small-airway conditions, and protocolized preparedness for potential anaphylaxis associated with cyst fluid exposure. Pressure-controlled ventilation was used. Total intravenous anesthesia based on propofol was combined with a low concentration of inhalational anesthetic, remifentanil-based analgesia, and multimodal monitoring including arterial waveform analysis. No catastrophic events related to cyst rupture occurred; hemodynamics and ventilation remained stable throughout all procedures. Postoperative recovery was uneventful, and the patient was discharged on postoperative days 13, 29, and 8 after the three surgeries, respectively. Conclusions For pediatric patients with disseminated hepatic–pulmonary echinococcosis, staged surgery supported by iterative organ-function assessment, proactive anaphylaxis preparedness, and lung-protective ventilation may facilitate safe anesthetic care across multiple high-risk procedures. This case provides a transferable perioperative strategy for similar patients in endemic settings. Cystic echinococcosis Pediatric anesthesia Staged surgery Hepatopulmonary involvement Lung-protective ventilation case report Figures Figure 1 Background Echinococcosis, also known as cystic echinococcosis (CE), is a major parasitic disease endemic in pastoral regions, where transmission is sustained through close contact between humans, dogs, and livestock such as sheep [ 1 ]. Although symptomatic CE in very young children is relatively rare, pediatric cases continue to occur in areas with high disease burden. However, evidence specifically addressing peri-anesthesia management in infants and toddlers with CE remains limited [ 2 ], particularly regarding multi-organ involvement. Involvement of both the liver and lungs compounds anesthesia risks due to the combination of organ dysfunction, invasive surgical approaches (laparotomy and thoracotomy), and the limited physiological reserve of young children. Therefore, reporting the anesthesia management of a 2-year-old patient who underwent one laparotomy and two thoracotomies in stages can provide actionable clinical insights for physicians practicing in endemic areas [ 1 , 2 ]. Hepatic echinococcosis imposes multiple risks from an anesthetic perspective. Large or strategically located hydatid cysts can lead to hepatocellular injury, biochemical abnormalities, and biliary tract involvement, which raise concerns regarding altered drug metabolism and clearance, impaired synthetic function, and perioperative coagulation disorders. In addition, abdominal distension and increased intra-abdominal pressure elevate the risks of gastroesophageal reflux and aspiration [ 3 ]. Pulmonary involvement introduces additional challenges, including ventilation–perfusion mismatch, hypoxemia, and the potential need for lung isolation or one-lung ventilation during thoracic surgery. In very young patients, these techniques are constrained by small airway size and limited device availability, increasing the risk of intraoperative respiratory compromise [ 4 ]. One of the most serious anesthetic complications across both hepatic and pulmonary procedures is anaphylaxis caused by cyst rupture or leakage. Although the reported incidence varies, the potential for rapid bronchospasm, severe hypotension, and cardiovascular collapse necessitates constant vigilance and preemptive preparedness during all stages of care [ 5 ]. Staged surgery management, consisting of sequential hepatic and thoracic procedures, represents a pragmatic approach to distributing physiological stress and procedural risk over time. This strategy also facilitates iterative reassessment of hepatic and pulmonary reserve and refinement of anesthetic planning between operations. In this report, we describe the anesthetic management of a 2-year-old child with disseminated hepatic and bilateral pulmonary CE who underwent one laparotomy and two-stage thoracotomies. This case provides transferable insights into risk stratification, airway and ventilation planning, and proactive anaphylaxis preparedness in a high-risk pediatric population. Case Presentation A female toddler aged 2 years old at the first admission (2 years and 6 months on subsequent follow-up) with a body weight of 10–12.5 kg presented with progressive abdominal distension and discomfort for approximately 3 weeks. She was later readmitted, presenting with fever, cough, expectoration for 2 weeks, and hemoptysis for 4 days. Imaging examinations conducted at another hospital and our institution revealed multiple cystic lesions in both lungs, suggestive of pulmonary echinococcosis. Contrast-enhanced computed tomography (CT) and ultrasonography further revealed multiple cystic lesions in the liver, consistent with hepatic echinococcosis (CE1–CE2 type). Based on the extent of thoracic and abdominal involvement, the patient’s young age, and the anticipated physiological burden of multiple procedures, a simultaneous thoracic and abdominal approach was deemed inappropriate. A staged surgical strategy was adopted, consisting of one laparotomy for hepatic hydatid cyst management, followed by two thoracotomies for staged bilateral pulmonary cyst resection. This approach was selected to reduce perioperative risk and allow interval reassessment of the patient’s clinical and physiological status. A summary of the perioperative evaluations and anesthetic management is presented in Table 1 . Representative imaging findings at initial presentation are shown in Fig. 1 . Table 1 Peri-anesthetic Management Across Three Consecutive Surgeries in a 2-Year-Old Child with Disseminated Cystic Echinococcosis (CE) Item Surgery #1 (hepatic CE) Surgery #2 (left lung CE) Surgery #3 (right lung CE) Date / Weight 2020-09-29 / 10 kg 2021-04-30 / 12.5 kg 2021-07-02 / 13 kg Procedure (approach; key steps; time) GA; upper midline laparotomy; hepatic endocystectomy + pericystectomy; 24 lesions; 205 min GA; R anterolateral thoracotomy (4–5th ICS); exploration + L lung hydatid cystectomy + CTTD; 6 endocysts; 255 min GA; L anterolateral thoracotomy (4–5th ICS); R lung hydatid cystectomy + CTTD; 4 endocysts (UL1/LL3); 110 min Imaging summary CT: bilateral lung cysts; liver multiple cystic lesions w/ vascular/biliary involvement ; US: liver cystic mass, CE2 CT: bilateral lung CE (largest RLL 4.6×2.5 cm), partial emptying/cavities; LLL inflammation; liver S7 lesion similar ; US: S6 3.7×3.6 cm, CE1 CT: post-L lung surgery improved inflammation; RLL lesion 3.4×1.9 cm; liver lesions markedly smaller; US: post-treatment changes (2.2×1.6 cm; 1.2×0.9 cm) Key labs (pre-op) ALT/AST 159/115 U·L⁻¹; Alb 37.7 g·L⁻¹ ; coag normal ALT/AST 45/47; Alb 35.5 ; Plt 494×10⁹·L⁻¹ (others normal) ; Hb 10.8 g·dL⁻¹ LFT/coag/ABG: within normal range Infection / inflammation hs-CRP 38.67 mg·L⁻¹ (mild others↑) WBC 16×10⁹·L⁻¹; eos 4.93×10⁹·L⁻¹ Normal range Pre-op optimization / blood prep NRS 2 (moderate risk); nutrition support; no IV albumin; standby blood products: FFP 600 mL, RBC 2U, cryo 8U NRS 0; albendazole + ceftriaxone + iron; standby RBC 3U + plasma 400 mL NRS 0; albendazole + cefuroxime (prophylaxis); standby RBC 2U + plasma 400 mL Induction MID 0.4 mg + Fent 20 µg + Atrac 1.5 mg Adjuncts (peri-induction / intra-op) Warming blanket; Dexa 2 mg (pre-op); Atrop 0.2 mg (induction); MPS 4 mg (pre-cyst removal); ABG pre-cyst removal Dexa-P 10 mg (pre-op); Penehyclidine 35 µg (induction); ABG post-induction & pre-cyst removal Airway Oral ETT 4.5; depth 12.5–13 cm Ventilation PCV; Pinsp 10–15 cmH₂O; RR 15–20; I:E 1:1.5; PEEP 0; FGF 1–1.5 L·min⁻¹; Vt 70–110 mL; ETCO₂ monitoring Intra-op monitoring / access US-guided A-line (L radial, 24G); CVC (R IJV, 7F, 7 cm); core T°; MostCare (PRAM) Maintenance (hypnosis / analgesia / NMB) Sevo 1–2% ; Prop 120–150 mg·h⁻¹ ; Remi 160 µg·h⁻¹ ; BIS 40–60 ; Cis 0.3–0.5 mg q30min, TOF (T4/T1) < 0.7 Fluids / blood products (guided) MostCare-guided (CI 2.5–4; PPV ~ 7.5%; SVR 900–1500); + 4-2-1 rule; plasma 100 mL; LR 45 mL Same guidance; total 310 mL (electrolyte-glucose 50 + LR 260); 5% Alb 200 mL (20% Alb 40 + NS 80 + D5W 80) Same guidance; total 400 mL (mainly LR); plasma 100 mL (type B, Rh+) Cyst rupture/anaphylaxis prevention No rupture; prophylactic MPS; close observation; irrigation; hypertonic saline-soaked gauze around endocyst Prophylactic surveillance; thoracic irrigation after endocyst removal; hypertonic saline gauze coverage to limit spillage Operative duration 4 h 6 h 30 min 2 h 55 min Post-op outcome Discharged POD 13 Discharged POD 29 Discharged POD 8 Abbreviations：A-line: Arterial line; ABG: Arterial blood gas; Alb: Albumin; Atrac: Atracurium; BIS: Bispectral index; CE: Cystic echinococcosis; CI: Cardiac index; CTTD: Closed thoracic tube drainage; CVC: Central venous catheter; Dexa: Dexamethasone; Dexa-P: Dexamethasone phosphate; Eos: Eosinophils; ETT: Endotracheal tube; Fent: Fentanyl; FFP: Fresh frozen plasma; FGF: Fresh gas flow; GA: General anesthesia; Hb: Hemoglobin; hs-CRP: High-sensitivity C-reactive protein; ICS: Intercostal space; IJV: Internal jugular vein; I:E: Inspiratory:expiratory ratio; LR: Lactated Ringer’s solution; LFT: Liver function test; MAC: Minimum alveolar concentration; MostCare (PRAM): Pressure recording analytical method hemodynamic monitoring; MPS: Methylprednisolone; NMB: Neuromuscular blockade; NRS: Nutritional risk screening; NS: Normal saline; PCV: Pressure-controlled ventilation; PEEP: Positive end-expiratory pressure; Pinsp: Inspiratory pressure; POD: Postoperative day; PPV: Pulse pressure variation; PRAM: Pressure recording analytical method; Prop: Propofol; Remi: Remifentanil; RR: Respiratory rate; Sevo: Sevoflurane; SVR: Systemic vascular resistance; TOF: Train-of-four; US: Ultrasound; Vt: Tidal volume; WBC: White blood cell count; D5W: 5% dextrose in water. Discussion This case report describes a rare presentation of disseminated CE in a 2-year-old child who underwent three complex surgical procedures for combined hepatic and pulmonary disease within a short timeframe. Safe anesthetic management required careful decision-making under the “triple burden” of physiological stressors: impaired organ function, limited airway and ventilation options inherent to young age, and a high risk of hypersensitivity reactions. Therefore, anesthetic planning focused on the interaction between hepatic dysfunction and drug handling, the technical constraints of thoracic ventilation and lung isolation in a pediatric airway, and continuous preparedness for perioperative anaphylaxis related to hydatid cyst fluid exposure [ 3 – 5 ]. Preoperative Assessment and Optimization Hepatic Synthetic Function and Drug Binding While routine liver enzyme measurements (ALT/AST) determine hepatocellular injury, they do not reliably reflect hepatic metabolic or synthetic capacity. Thus, perioperative assessment prioritizing markers of hepatic synthetic function was conducted, particularly serum albumin concentration and coagulation parameters. Hypoalbuminemia is clinically important in pediatric anesthesia, as many anesthetic and perioperative drugs, e.g., propofol, opioids, and some antibiotics, are highly protein-bound. Reduced albumin levels may increase the unbound fraction of these drugs, potentially amplifying pharmacodynamic effects and increasing the risk of adverse events, especially if concurrent with hepatic dysfunction or unstable intravascular volume status [ 8 – 10 ]. In the present case, albumin levels were optimized preoperatively (target > 35 g/L) to increase colloid oncotic pressure and reduce pharmacokinetic variability. Coagulation abnormalities were addressed with preoperative vitamin K supplementation to correct potential prothrombin deficiency. When laboratory abnormalities were clinically significant, plasma and/or cryoprecipitate were administered to achieve coagulation parameters considered acceptable for surgery [ 3 , 8 ]. Pulmonary Function Assessment Under Mass Effect The mass effect exerted by pulmonary hydatid cysts critically determines anesthetic safety. Preoperative evaluation combining thoracic CT imaging and arterial blood gas analysis was performed to assess airway patency, compensatory respiratory reserve, and hypoxemia risk during induction and one-lung ventilation. In young children, lung isolation strategies are constrained by a small airway diameter and limited device availability; therefore, multidisciplinary planning and predefined rescue strategies are essential. These included contingency bronchoscopy to manage airway obstruction or clear cyst contents if required [ 4 ]. Furthermore, aggressive treatment of respiratory infections and interval imaging reassessment prior to each staged procedure were integral to optimizing pulmonary status and minimizing perioperative respiratory complications [ 4 ]. Anaphylaxis Preparedness Given the high antigenicity of hydatid cyst fluid, perioperative preparation should focus on standardized, rapid-response protocols rather than on ad hoc decision-making. Anaphylaxis drills were performed, emergency medications were prepared in advance, and clear recognition and treatment algorithms were established. Epinephrine (1:10,000) was immediately available at the anesthesia workstation. In the event of suspected anaphylaxis, characterized by unexplained hypotension, bronchospasm, or cardiovascular instability, efforts were made to minimize further antigen exposure and to initiate guideline-based management immediately. International guidelines identify epinephrine as the first-line therapy and recommend early administration with repeat dosing as required. Adjunctive measures include rapid crystalloid resuscitation, delivery of high-concentration oxygen, and escalation of positive-pressure ventilation to support oxygenation [ 6 , 7 ]. For persistent bronchospasm, nebulized β₂-agonists may be administered. If epinephrine remains refractory, additional vasopressors, such as norepinephrine or vasopressin, may be considered, whereas corticosteroids and antihistamines serve as second-line adjunct therapies [ 6 , 7 ]. Anesthetic Induction and Airway Management: Individualized Selection Pharmacological Basis of Induction Agents Esketamine vs midazolam: Experimental and animal studies have raised concerns regarding the potential neurotoxicity of ketamine-class agents, particularly with repeated exposure during early neurodevelopment [ 24 – 27 ]. In children who may require multiple anesthetic episodes, this issue warrants caution when considering repeated exposure to ketamine-class drugs. Midazolam, a benzodiazepine acting via GABAA receptor modulation, provides sedation, anxiolysis, and anticonvulsant effects and is generally associated with modest cardiovascular impact during induction. These properties are advantageous in young children with limited intravascular reserve or potential hemodynamic instability. Although midazolam lacks the intrinsic bronchodilatory properties of esketamine, its established clinical use and predictable sedative profile made it a reasonable choice in this case, where repeated procedures were anticipated and the baseline risk of severe bronchospasm was low. Sufentanil vs fentanyl: Both agents are commonly used during pediatric anesthetic induction to attenuate stress responses associated with airway manipulation and surgical incision. However, opioid pharmacokinetics in young children are influenced by age, body composition, and hepatic function, increasing the risk of accumulation with repeated dosing or continuous infusion. Careful titration and close clinical monitoring are therefore essential, particularly in the setting of hepatic dysfunction or reduced metabolic capacity [ 9 , 10 ]. The higher potency of sufentanil allows effective blunting of stress responses at lower administered doses, which may help maintain hemodynamic stability when titrated carefully. Regardless of opioid selection, rapid bolus administration should be avoided, as infants and toddlers are at increased risk of opioid-induced chest wall rigidity and subsequent ventilation difficulties. Immediate availability of neuromuscular blockade and ventilatory support is essential for rescue [ 11 , 12 ]. Airway Management and Lung Isolation Strategies One-lung ventilation (OLV) was among the most technically challenging aspects of anesthetic management in this 2-year-old patient. Appropriately sized double-lumen tubes are generally unavailable for toddlers; therefore, pediatric thoracic anesthesia relies on alternative lung isolation techniques, including bronchial blockers (e.g., an Arndt blocker) or fiberoptic bronchoscopy approaches. Current evidence suggests that fiberoptic bronchoscopy-guided bronchial blockade improves positioning accuracy and surgical lung control and permits the application of continuous positive airway pressure to the nonventilated lung to mitigate hypoxemia when necessary [ 4 ]. Given equipment availability and predefined emergency protocols, blind mainstem intubation with a single-lumen tube was retained as a rescue option for rapid lung isolation when cyst rupture or spillage became imminent. To minimize complications, such as unintended upper-lobe obstruction, ventilation was continuously assessed using airway pressure trends and auscultation, alongside heightened intraoperative monitoring and communication with the surgical team during critical phases [ 4 ]. Ventilation Strategy Lung-protective ventilation was employed with a tidal volume of 6–8 mL/kg and a positive end-expiratory pressure of 4–5 cmH2O. In pulmonary echinococcosis, limiting airway pressure is particularly important to reduce the risk of cyst rupture before surgical decompression. During thoracic surgery requiring OLV, pressure-controlled ventilation was favored to limit peak inspiratory pressure and reduce the risk of barotrauma. Pediatric OLV principles emphasize the use of the gentlest ventilatory settings compatible with adequate oxygenation, with continuous reassessment and adjustment performed throughout the procedure to monitor dynamic changes in lung compliance and surgical conditions [ 4 , 28 ]. Intraoperative Maintenance and Risk Control TIVA vs. Inhalational Anesthesia A propofol-based total intravenous anesthesia (TIVA) strategy was used for intraoperative maintenance. Although prolonged or high-dose propofol infusion in children has been associated with propofol infusion syndrome (PRIS), available evidence indicates that PRIS is reported predominantly in the setting of prolonged, high-dose infusion, often during critical care sedation. In contrast, propofol use in the operating room for limited durations at controlled doses remains a viable option, provided that unnecessary dose escalation is avoided and vigilant monitoring is maintained [ 13 , 14 ]. In the present case, low-dose propofol infusion (6–8 mg/kg/h) was combined with low-concentration sevoflurane (0.8–1.0 minimum alveolar concentration) to achieve stable anesthetic depth while limiting exposure to either modality alone. This balanced approach facilitated stress suppression and hemodynamic stability across repeated procedures. Management of Cyst Rupture and Anaphylaxis Intraoperative rupture of a hydatid cyst poses the well-known risk of type I hypersensitivity reactions and anaphylactic shock. Management was guided by international recommendations for anaphylaxis treatment, which emphasize rapid reduction of antigen exposure when feasible, immediate administration of high-concentration oxygen, aggressive fluid resuscitation, and prompt use of epinephrine as first-line therapy. Corticosteroids and antihistamines were reserved as adjunctive, second-line treatments [ 6 , 7 ]. Close coordination with the surgical team was integral to risk mitigation. In the present case, surgical precautions included gentle tissue handling, controlled decompression of cyst contents when appropriate, and coordinated communication during cyst manipulation to reduce the likelihood and consequences of accidental rupture. Circulatory Monitoring: Application of MostCare and Pressure Recording Analytical Method Algorithm Continuous hemodynamic monitoring was performed using the MostCare system with the Pressure Recording Analytical Method (PRAM). PRAM is a minimally invasive arterial waveform-based technique that provides continuous estimates of cardiac output, stroke volume, and dynamic indices of fluid responsiveness. Previous clinical experience has demonstrated its feasibility and consistency in pediatric settings, establishing its use as an adjunct for hemodynamic trend assessment and fluid management guidance [ 15 – 17 ]. In the present case, PRAM was performed primarily for trend monitoring and decision support rather than absolute value interpretation. This approach reduced the risk of pulmonary edema associated with empiric fluid loading and enabled earlier detection of circulatory instability during periods of potential risk for anaphylaxis-related distributive shock [ 15 – 17 ]. Anesthetic Depth Monitoring The reliability and clinical benefits of bispectral index (BIS) monitoring in toddlers remain controversial. Available evidence suggests that BIS-guided anesthesia in children may improve certain recovery parameters, such as extubation time. However, significant heterogeneity exists across studies, and performance in very young children is less consistent. Accordingly, in the present case, clinical signs remained the primary guide for anesthetic depth, with BIS trends used as a supplementary reference rather than a standalone determinant of drug titration [ 18 ]. Perioperative Temperature Management Strategy Perioperative temperature control is particularly critical in young children, who are highly susceptible to unintentional hypothermia during anesthesia and surgery. Hypothermia is associated with adverse outcomes, including impaired coagulation, cardiac arrhythmias, delayed drug metabolism, and increased infection risk [ 19 ]. Active warming strategies were therefore implemented immediately after induction, including application of pre-warmed intravenous fluids and forced-air warming devices. Core body temperature was maintained at approximately 36.5℃, with continuous monitoring and adjustment of warming measures throughout the procedure [ 19 ]. Despite the favorable outcome in the current case, recent literature suggests several opportunities to refine and update the surgical-anesthetic strategy. Advancements in Lung Isolation Although blind mainstem intubation with a single-lumen tube was effective in this case, contemporary pediatric thoracic anesthesia increasingly favors fiberoptic bronchoscopy-guided placement of a bronchial blocker. This approach improves positioning accuracy, enhances control of the operative lung, and facilitates hypoxemia management, including the application of continuous positive airway pressure to the nonventilated lung when required [ 4 ]. Pharmacologic Precision in Liver Disease In patients with significant hepatic dysfunction, anesthetic agents with minimal dependence on hepatic metabolism may provide pharmacokinetic advantages. Remifentanil, which is metabolized by nonspecific plasma and tissue esterases, is largely independent of hepatic and renal function, enabling predictable clearance and rapid recovery. Reviews support this pharmacologic rationale in patients with liver disease or impaired organ function and in settings where rapid titration and recovery are desirable [ 8 , 10 , 20 ]. Advanced Hemodynamic Assessment Point-of-care ultrasound (POCUS) represents an increasingly valuable adjunct for intraoperative hemodynamic assessment in pediatric anesthesia. Perioperative literature describes its application for focused cardiac evaluation, volume status assessment, and lung ultrasound. By providing real-time physiologic information, POCUS may reduce reliance on empiric fluid administration, support early detection of circulatory instability, and facilitate individualized fluid and cardiovascular management, particularly in patients at risk of pulmonary edema or distributive shock [ 21 ]. Integration of Regional Anesthesia The erector spinae plane (ESP) block is increasingly used for pediatric thoracic and chest wall surgery. Randomized trials and reviews indicate that ESP blocks reduce perioperative opioid requirements, improve postoperative analgesia, and are technically straightforward with a low complication rate. Thus, they can serve as an alternative or adjunct to epidural analgesia [ 22 , 23 ]. Conclusions In toddlers with disseminated hepatopulmonary CE, a staged surgical approach supported by iterative reassessment of organ function, proactive anaphylaxis preparedness, and lung-protective ventilation strategies may facilitate safe anesthetic management across multiple-stage high-risk procedures. Abbreviations BIS Bispectral index CE Cystic echinococcosis CT Computed tomography ESP Erector spinae plane OLV One-lung ventilation POCUS Point-of-care ultrasound PRAM Pressure Recording Analytical Method PRIS Propofol infusion syndrome TIVA Total intravenous anesthesia Declarations Ethics approval and consent to participate Written informed consent was obtained from the patient. This study was approved by the Biomedical Ethics Review Committee of Qinghai Red Cross Hospital. Consent for publication Written informed consent for publication of this case report and any accompanying images was obtained from the patient’s legal guardians. All potentially identifying information has been anonymized. Availability of data and materials No datasets were generated or analysed during the current study. Competing interests The authors declare no competing interests. Funding This research was funded by Qinghai University 2025 Graduate Student Scientific Research and Practical Innovation Project (NO.2025-GPKY-7), Shanghai Jiading District Health Commission Traditional Chinese Medicine Project (Youth) (NO.2022-QN-ZYY-03),Qinghai Red Cross Hospital Self-Selected Research Project (No. ZX-2025-01). Authors’ contributions YL drafted the manuscript. PZB collected the case-related clinical information and was responsible for the anesthetic management of the patient. YHX and MLZ organized the case materials and critically reviewed the manuscript. YD,WL and XJW performed the final review and approved the final version of the manuscript. All authors read and approved the initial draft and agreed to the publication of this report. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9047045","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":617701109,"identity":"bf8b053f-9bf7-4ff3-8563-be3d600c876a","order_by":0,"name":"Yu Li","email":"","orcid":"","institution":"Qinghai University School of Clinical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Li","suffix":""},{"id":617701110,"identity":"0dc57134-41f5-419d-b824-43dc75760549","order_by":1,"name":"Pengzui Bai","email":"","orcid":"","institution":"Qinghai Red Cross Hospital","correspondingAuthor":false,"prefix":"","firstName":"Pengzui","middleName":"","lastName":"Bai","suffix":""},{"id":617701111,"identity":"fd35e4e7-ddff-4ba6-89ba-710c36663dc7","order_by":2,"name":"Yuhai Xie","email":"","orcid":"","institution":"Qinghai Red Cross Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yuhai","middleName":"","lastName":"Xie","suffix":""},{"id":617701112,"identity":"3286c703-6843-463e-b594-5df2ae563456","order_by":3,"name":"Xiangqing Song","email":"","orcid":"","institution":"Qinghai Red Cross Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiangqing","middleName":"","lastName":"Song","suffix":""},{"id":617701113,"identity":"fe4bf2b1-9778-49d9-8c9e-3d938fdb7c86","order_by":4,"name":"Menglong Zhu","email":"","orcid":"","institution":"Qinghai University School of Clinical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Menglong","middleName":"","lastName":"Zhu","suffix":""},{"id":617701114,"identity":"bd0a7531-8f81-421e-8d81-c45c50a76d5b","order_by":5,"name":"Yong Deng","email":"","orcid":"","institution":"Research Center of High Altitude Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yong","middleName":"","lastName":"Deng","suffix":""},{"id":617701115,"identity":"2eed4382-e373-4631-8c5b-3ecc04ea6910","order_by":6,"name":"Wen li","email":"","orcid":"","institution":"Daping Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wen","middleName":"","lastName":"li","suffix":""},{"id":617701116,"identity":"de60f336-f5f2-4653-8377-fa2c41e04a38","order_by":7,"name":"Xuejun Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABD0lEQVRIiWNgGAWjYBADZgYGHiBVIcHDxt7Y+PAD8VrOWMjw8RxuNpYgziKgFsa2Chs5ifQ2AR486gyOnz38mrfNht3gdu/hjz/bgA6TfNjGIMFgJ6fbgEPLmbw0y5ltacwGd86lSUicA2qRTmx7UMCQbGx2ALsWswM5ZgYf2w4zG9zIMWMwKANraTeQYDiQuA2XlvNvzAwS2/6DtBh/SGADOewg0Hn4tABVPvjYdgCkxUDiAMgvEoz4tdjfeGPGOONcMrMk0GGSDWeAWngSgYFsgNsvkv05xp95yuyS+YDWffxRUWcv33784cMPFXZyuLQAARso3pLRBA1wKgcBZlDqsMOrZBSMglEwCkY2AAAp5Fq7Q9onQQAAAABJRU5ErkJggg==","orcid":"","institution":"Qinghai Red Cross Hospital","correspondingAuthor":true,"prefix":"","firstName":"Xuejun","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2026-03-06 06:54:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9047045/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9047045/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106540815,"identity":"a653c65c-845e-4bad-938c-6f64a8046fb7","added_by":"auto","created_at":"2026-04-09 16:02:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":326576,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative computed tomography (CT) images of the patient showing overall involvement and organ-specific lesions.\u003cbr\u003e\n(A) Whole-body CT overview.\u003cbr\u003e\n(B) Chest CT demonstrating pulmonary cystic echinococcosis.\u003cbr\u003e\n(C) Abdominal CT demonstrating hepatic cystic echinococcosis.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9047045/v1/f985d3d5e8be5d8df45011c4.png"},{"id":109081284,"identity":"4b9e817c-7975-44f2-8f78-74e4deb3eb6a","added_by":"auto","created_at":"2026-05-12 12:13:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":576643,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9047045/v1/80356748-f82b-4d42-ac90-1ceff3e4113f.pdf"},{"id":106540814,"identity":"5b98dc74-a71e-4db6-88ef-ab0631013692","added_by":"auto","created_at":"2026-04-09 16:02:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":69556,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklistEnglish2013filledpageline20260306135459.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9047045/v1/e673a17908d53e974e08c2f6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Staged surgical anesthesia in pediatric disseminated cystic echinococcosis: A case report","fulltext":[{"header":"Background","content":"\u003cp\u003eEchinococcosis, also known as cystic echinococcosis (CE), is a major parasitic disease endemic in pastoral regions, where transmission is sustained through close contact between humans, dogs, and livestock such as sheep [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although symptomatic CE in very young children is relatively rare, pediatric cases continue to occur in areas with high disease burden. However, evidence specifically addressing peri-anesthesia management in infants and toddlers with CE remains limited [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], particularly regarding multi-organ involvement.\u003c/p\u003e \u003cp\u003eInvolvement of both the liver and lungs compounds anesthesia risks due to the combination of organ dysfunction, invasive surgical approaches (laparotomy and thoracotomy), and the limited physiological reserve of young children. Therefore, reporting the anesthesia management of a 2-year-old patient who underwent one laparotomy and two thoracotomies in stages can provide actionable clinical insights for physicians practicing in endemic areas [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHepatic echinococcosis imposes multiple risks from an anesthetic perspective. Large or strategically located hydatid cysts can lead to hepatocellular injury, biochemical abnormalities, and biliary tract involvement, which raise concerns regarding altered drug metabolism and clearance, impaired synthetic function, and perioperative coagulation disorders. In addition, abdominal distension and increased intra-abdominal pressure elevate the risks of gastroesophageal reflux and aspiration [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePulmonary involvement introduces additional challenges, including ventilation\u0026ndash;perfusion mismatch, hypoxemia, and the potential need for lung isolation or one-lung ventilation during thoracic surgery. In very young patients, these techniques are constrained by small airway size and limited device availability, increasing the risk of intraoperative respiratory compromise [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne of the most serious anesthetic complications across both hepatic and pulmonary procedures is anaphylaxis caused by cyst rupture or leakage. Although the reported incidence varies, the potential for rapid bronchospasm, severe hypotension, and cardiovascular collapse necessitates constant vigilance and preemptive preparedness during all stages of care [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStaged surgery management, consisting of sequential hepatic and thoracic procedures, represents a pragmatic approach to distributing physiological stress and procedural risk over time. This strategy also facilitates iterative reassessment of hepatic and pulmonary reserve and refinement of anesthetic planning between operations. In this report, we describe the anesthetic management of a 2-year-old child with disseminated hepatic and bilateral pulmonary CE who underwent one laparotomy and two-stage thoracotomies. This case provides transferable insights into risk stratification, airway and ventilation planning, and proactive anaphylaxis preparedness in a high-risk pediatric population.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA female toddler aged 2 years old at the first admission (2 years and 6 months on subsequent follow-up) with a body weight of 10\u0026ndash;12.5 kg presented with progressive abdominal distension and discomfort for approximately 3 weeks. She was later readmitted, presenting with fever, cough, expectoration for 2 weeks, and hemoptysis for 4 days. Imaging examinations conducted at another hospital and our institution revealed multiple cystic lesions in both lungs, suggestive of pulmonary echinococcosis. Contrast-enhanced computed tomography (CT) and ultrasonography further revealed multiple cystic lesions in the liver, consistent with hepatic echinococcosis (CE1\u0026ndash;CE2 type). Based on the extent of thoracic and abdominal involvement, the patient\u0026rsquo;s young age, and the anticipated physiological burden of multiple procedures, a simultaneous thoracic and abdominal approach was deemed inappropriate.\u003c/p\u003e \u003cp\u003eA staged surgical strategy was adopted, consisting of one laparotomy for hepatic hydatid cyst management, followed by two thoracotomies for staged bilateral pulmonary cyst resection. This approach was selected to reduce perioperative risk and allow interval reassessment of the patient\u0026rsquo;s clinical and physiological status. A summary of the perioperative evaluations and anesthetic management is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Representative imaging findings at initial presentation are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePeri-anesthetic Management Across Three Consecutive Surgeries in a 2-Year-Old Child with Disseminated Cystic Echinococcosis (CE)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgery #1\u003c/p\u003e \u003cp\u003e(hepatic CE)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurgery #2\u003c/p\u003e \u003cp\u003e(left lung CE)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSurgery #3\u003c/p\u003e \u003cp\u003e(right lung CE)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDate / Weight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2020-09-29 / 10 kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2021-04-30 / 12.5 kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2021-07-02 / 13 kg\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcedure (approach; key steps; time)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGA; upper midline laparotomy; hepatic endocystectomy\u0026thinsp;+\u0026thinsp;pericystectomy; 24 lesions; 205 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGA; R anterolateral thoracotomy (4\u0026ndash;5th ICS); exploration\u0026thinsp;+\u0026thinsp;L lung hydatid cystectomy\u0026thinsp;+\u0026thinsp;CTTD; 6 endocysts; 255 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGA; L anterolateral thoracotomy (4\u0026ndash;5th ICS); R lung hydatid cystectomy\u0026thinsp;+\u0026thinsp;CTTD; 4 endocysts (UL1/LL3); 110 min\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImaging summary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCT: bilateral lung cysts; liver multiple cystic lesions w/ vascular/biliary involvement ; US: liver cystic mass, CE2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCT: bilateral lung CE (largest RLL 4.6\u0026times;2.5 cm), partial emptying/cavities; LLL inflammation; liver S7 lesion similar ; US: S6 3.7\u0026times;3.6 cm, CE1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCT: post-L lung surgery improved inflammation; RLL lesion 3.4\u0026times;1.9 cm; liver lesions markedly smaller; US: post-treatment changes (2.2\u0026times;1.6 cm; 1.2\u0026times;0.9 cm)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKey labs (pre-op)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eALT/AST 159/115 U\u0026middot;L⁻\u0026sup1;; Alb 37.7 g\u0026middot;L⁻\u0026sup1; ; coag normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eALT/AST 45/47; Alb 35.5 ; Plt 494\u0026times;10⁹\u0026middot;L⁻\u0026sup1; (others normal) ; Hb 10.8 g\u0026middot;dL⁻\u0026sup1;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLFT/coag/ABG: within normal range\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfection / inflammation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ehs-CRP 38.67 mg\u0026middot;L⁻\u0026sup1; (mild others\u0026uarr;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWBC 16\u0026times;10⁹\u0026middot;L⁻\u0026sup1;; eos 4.93\u0026times;10⁹\u0026middot;L⁻\u0026sup1;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNormal range\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-op optimization / blood prep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNRS 2 (moderate risk); nutrition support; no IV albumin; standby blood products: FFP 600 mL, RBC 2U, cryo 8U\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNRS 0; albendazole\u0026thinsp;+\u0026thinsp;ceftriaxone\u0026thinsp;+\u0026thinsp;iron; standby RBC 3U\u0026thinsp;+\u0026thinsp;plasma 400 mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNRS 0; albendazole\u0026thinsp;+\u0026thinsp;cefuroxime (prophylaxis); standby RBC 2U\u0026thinsp;+\u0026thinsp;plasma 400 mL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eMID 0.4 mg\u0026thinsp;+\u0026thinsp;Fent 20 \u0026micro;g\u0026thinsp;+\u0026thinsp;Atrac 1.5 mg\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjuncts (peri-induction / intra-op)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWarming blanket; Dexa 2 mg (pre-op); Atrop 0.2 mg (induction); MPS 4 mg (pre-cyst removal); ABG pre-cyst removal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eDexa-P 10 mg (pre-op); Penehyclidine 35 \u0026micro;g (induction); ABG post-induction \u0026amp; pre-cyst removal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAirway\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eOral ETT 4.5; depth 12.5\u0026ndash;13 cm\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVentilation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003ePCV; Pinsp 10\u0026ndash;15 cmH₂O; RR 15\u0026ndash;20; I:E 1:1.5; PEEP 0; FGF 1\u0026ndash;1.5 L\u0026middot;min⁻\u0026sup1;; Vt 70\u0026ndash;110 mL; ETCO₂ monitoring\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntra-op monitoring / access\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eUS-guided A-line (L radial, 24G); CVC (R IJV, 7F, 7 cm); core T\u0026deg;; MostCare (PRAM)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaintenance (hypnosis / analgesia / NMB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eSevo 1\u0026ndash;2% ; Prop 120\u0026ndash;150 mg\u0026middot;h⁻\u0026sup1; ; Remi 160 \u0026micro;g\u0026middot;h⁻\u0026sup1; ; BIS 40\u0026ndash;60 ; Cis 0.3\u0026ndash;0.5 mg q30min, TOF (T4/T1)\u0026thinsp;\u0026lt;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFluids / blood products (guided)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMostCare-guided (CI 2.5\u0026ndash;4; PPV\u0026thinsp;~\u0026thinsp;7.5%; SVR 900\u0026ndash;1500); + 4-2-1 rule; plasma 100 mL; LR 45 mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSame guidance; total 310 mL (electrolyte-glucose 50\u0026thinsp;+\u0026thinsp;LR 260); 5% Alb 200 mL (20% Alb 40\u0026thinsp;+\u0026thinsp;NS 80\u0026thinsp;+\u0026thinsp;D5W 80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSame guidance; total 400 mL (mainly LR); plasma 100 mL (type B, Rh+)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCyst rupture/anaphylaxis prevention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo rupture; prophylactic MPS; close observation; irrigation; hypertonic saline-soaked gauze around endocyst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eProphylactic surveillance; thoracic irrigation after endocyst removal; hypertonic saline gauze coverage to limit spillage\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative duration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 h 30 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 h 55 min\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-op outcome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDischarged POD 13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDischarged POD 29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDischarged POD 8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003eAbbreviations：A-line: Arterial line; ABG: Arterial blood gas; Alb: Albumin; Atrac: Atracurium;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBIS: Bispectral index; CE: Cystic echinococcosis; CI: Cardiac index; CTTD: Closed thoracic tube\u0026nbsp;\u003c/p\u003e\n\u003cp\u003edrainage; CVC: Central venous catheter; Dexa: Dexamethasone; Dexa-P: Dexamethasone phosphate;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEos: Eosinophils; ETT: Endotracheal tube; Fent: Fentanyl; FFP: Fresh frozen plasma; FGF: Fresh gas\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eflow; GA: General anesthesia; Hb: Hemoglobin; hs-CRP: High-sensitivity C-reactive protein; ICS:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIntercostal space; IJV: Internal jugular vein; I:E: Inspiratory:expiratory ratio; LR: Lactated Ringer\u0026rsquo;s\u0026nbsp;\u003c/p\u003e\n\u003cp\u003esolution; LFT: Liver function test; MAC: Minimum alveolar concentration; MostCare (PRAM):\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePressure recording analytical method hemodynamic monitoring; MPS: Methylprednisolone; NMB:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNeuromuscular blockade; NRS: Nutritional risk screening; NS: Normal saline; PCV:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePressure-controlled ventilation; PEEP: Positive end-expiratory pressure; Pinsp: Inspiratory pressure; POD: Postoperative day; PPV: Pulse pressure variation; PRAM: Pressure recording analytical method; Prop: Propofol; Remi: Remifentanil; RR: Respiratory rate; Sevo: Sevoflurane; SVR: Systemic vascular resistance; TOF: Train-of-four; US: Ultrasound; Vt: Tidal volume; WBC: White blood cell count; D5W: 5% dextrose in water.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case report describes a rare presentation of disseminated CE in a 2-year-old child who underwent three complex surgical procedures for combined hepatic and pulmonary disease within a short timeframe. Safe anesthetic management required careful decision-making under the \u0026ldquo;triple burden\u0026rdquo; of physiological stressors: impaired organ function, limited airway and ventilation options inherent to young age, and a high risk of hypersensitivity reactions. Therefore, anesthetic planning focused on the interaction between hepatic dysfunction and drug handling, the technical constraints of thoracic ventilation and lung isolation in a pediatric airway, and continuous preparedness for perioperative anaphylaxis related to hydatid cyst fluid exposure [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003ePreoperative Assessment and Optimization\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eHepatic Synthetic Function and Drug Binding\u003c/h2\u003e \u003cp\u003eWhile routine liver enzyme measurements (ALT/AST) determine hepatocellular injury, they do not reliably reflect hepatic metabolic or synthetic capacity. Thus, perioperative assessment prioritizing markers of hepatic synthetic function was conducted, particularly serum albumin concentration and coagulation parameters. Hypoalbuminemia is clinically important in pediatric anesthesia, as many anesthetic and perioperative drugs, e.g., propofol, opioids, and some antibiotics, are highly protein-bound. Reduced albumin levels may increase the unbound fraction of these drugs, potentially amplifying pharmacodynamic effects and increasing the risk of adverse events, especially if concurrent with hepatic dysfunction or unstable intravascular volume status [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In the present case, albumin levels were optimized preoperatively (target\u0026thinsp;\u0026gt;\u0026thinsp;35 g/L) to increase colloid oncotic pressure and reduce pharmacokinetic variability. Coagulation abnormalities were addressed with preoperative vitamin K supplementation to correct potential prothrombin deficiency. When laboratory abnormalities were clinically significant, plasma and/or cryoprecipitate were administered to achieve coagulation parameters considered acceptable for surgery [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePulmonary Function Assessment Under Mass Effect\u003c/h3\u003e\n\u003cp\u003eThe mass effect exerted by pulmonary hydatid cysts critically determines anesthetic safety. Preoperative evaluation combining thoracic CT imaging and arterial blood gas analysis was performed to assess airway patency, compensatory respiratory reserve, and hypoxemia risk during induction and one-lung ventilation. In young children, lung isolation strategies are constrained by a small airway diameter and limited device availability; therefore, multidisciplinary planning and predefined rescue strategies are essential. These included contingency bronchoscopy to manage airway obstruction or clear cyst contents if required [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Furthermore, aggressive treatment of respiratory infections and interval imaging reassessment prior to each staged procedure were integral to optimizing pulmonary status and minimizing perioperative respiratory complications [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eAnaphylaxis Preparedness\u003c/h3\u003e\n\u003cp\u003eGiven the high antigenicity of hydatid cyst fluid, perioperative preparation should focus on standardized, rapid-response protocols rather than on ad hoc decision-making. Anaphylaxis drills were performed, emergency medications were prepared in advance, and clear recognition and treatment algorithms were established. Epinephrine (1:10,000) was immediately available at the anesthesia workstation. In the event of suspected anaphylaxis, characterized by unexplained hypotension, bronchospasm, or cardiovascular instability, efforts were made to minimize further antigen exposure and to initiate guideline-based management immediately. International guidelines identify epinephrine as the first-line therapy and recommend early administration with repeat dosing as required. Adjunctive measures include rapid crystalloid resuscitation, delivery of high-concentration oxygen, and escalation of positive-pressure ventilation to support oxygenation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. For persistent bronchospasm, nebulized β₂-agonists may be administered. If epinephrine remains refractory, additional vasopressors, such as norepinephrine or vasopressin, may be considered, whereas corticosteroids and antihistamines serve as second-line adjunct therapies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAnesthetic Induction and Airway Management: Individualized Selection\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003ePharmacological Basis of Induction Agents\u003c/h2\u003e \u003cp\u003eEsketamine vs midazolam: Experimental and animal studies have raised concerns regarding the potential neurotoxicity of ketamine-class agents, particularly with repeated exposure during early neurodevelopment [\u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In children who may require multiple anesthetic episodes, this issue warrants caution when considering repeated exposure to ketamine-class drugs. Midazolam, a benzodiazepine acting via GABAA receptor modulation, provides sedation, anxiolysis, and anticonvulsant effects and is generally associated with modest cardiovascular impact during induction. These properties are advantageous in young children with limited intravascular reserve or potential hemodynamic instability. Although midazolam lacks the intrinsic bronchodilatory properties of esketamine, its established clinical use and predictable sedative profile made it a reasonable choice in this case, where repeated procedures were anticipated and the baseline risk of severe bronchospasm was low.\u003c/p\u003e \u003cp\u003eSufentanil vs fentanyl: Both agents are commonly used during pediatric anesthetic induction to attenuate stress responses associated with airway manipulation and surgical incision. However, opioid pharmacokinetics in young children are influenced by age, body composition, and hepatic function, increasing the risk of accumulation with repeated dosing or continuous infusion. Careful titration and close clinical monitoring are therefore essential, particularly in the setting of hepatic dysfunction or reduced metabolic capacity [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The higher potency of sufentanil allows effective blunting of stress responses at lower administered doses, which may help maintain hemodynamic stability when titrated carefully. Regardless of opioid selection, rapid bolus administration should be avoided, as infants and toddlers are at increased risk of opioid-induced chest wall rigidity and subsequent ventilation difficulties. Immediate availability of neuromuscular blockade and ventilatory support is essential for rescue [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eAirway Management and Lung Isolation Strategies\u003c/h3\u003e\n\u003cp\u003eOne-lung ventilation (OLV) was among the most technically challenging aspects of anesthetic management in this 2-year-old patient. Appropriately sized double-lumen tubes are generally unavailable for toddlers; therefore, pediatric thoracic anesthesia relies on alternative lung isolation techniques, including bronchial blockers (e.g., an Arndt blocker) or fiberoptic bronchoscopy approaches. Current evidence suggests that fiberoptic bronchoscopy-guided bronchial blockade improves positioning accuracy and surgical lung control and permits the application of continuous positive airway pressure to the nonventilated lung to mitigate hypoxemia when necessary [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Given equipment availability and predefined emergency protocols, blind mainstem intubation with a single-lumen tube was retained as a rescue option for rapid lung isolation when cyst rupture or spillage became imminent. To minimize complications, such as unintended upper-lobe obstruction, ventilation was continuously assessed using airway pressure trends and auscultation, alongside heightened intraoperative monitoring and communication with the surgical team during critical phases [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eVentilation Strategy\u003c/h2\u003e \u003cp\u003eLung-protective ventilation was employed with a tidal volume of 6\u0026ndash;8 mL/kg and a positive end-expiratory pressure of 4\u0026ndash;5 cmH2O. In pulmonary echinococcosis, limiting airway pressure is particularly important to reduce the risk of cyst rupture before surgical decompression. During thoracic surgery requiring OLV, pressure-controlled ventilation was favored to limit peak inspiratory pressure and reduce the risk of barotrauma. Pediatric OLV principles emphasize the use of the gentlest ventilatory settings compatible with adequate oxygenation, with continuous reassessment and adjustment performed throughout the procedure to monitor dynamic changes in lung compliance and surgical conditions [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eIntraoperative Maintenance and Risk Control\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003eTIVA vs. Inhalational Anesthesia\u003c/h2\u003e \u003cp\u003eA propofol-based total intravenous anesthesia (TIVA) strategy was used for intraoperative maintenance. Although prolonged or high-dose propofol infusion in children has been associated with propofol infusion syndrome (PRIS), available evidence indicates that PRIS is reported predominantly in the setting of prolonged, high-dose infusion, often during critical care sedation. In contrast, propofol use in the operating room for limited durations at controlled doses remains a viable option, provided that unnecessary dose escalation is avoided and vigilant monitoring is maintained [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In the present case, low-dose propofol infusion (6\u0026ndash;8 mg/kg/h) was combined with low-concentration sevoflurane (0.8\u0026ndash;1.0 minimum alveolar concentration) to achieve stable anesthetic depth while limiting exposure to either modality alone. This balanced approach facilitated stress suppression and hemodynamic stability across repeated procedures.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eManagement of Cyst Rupture and Anaphylaxis\u003c/h2\u003e \u003cp\u003eIntraoperative rupture of a hydatid cyst poses the well-known risk of type I hypersensitivity reactions and anaphylactic shock. Management was guided by international recommendations for anaphylaxis treatment, which emphasize rapid reduction of antigen exposure when feasible, immediate administration of high-concentration oxygen, aggressive fluid resuscitation, and prompt use of epinephrine as first-line therapy. Corticosteroids and antihistamines were reserved as adjunctive, second-line treatments [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Close coordination with the surgical team was integral to risk mitigation. In the present case, surgical precautions included gentle tissue handling, controlled decompression of cyst contents when appropriate, and coordinated communication during cyst manipulation to reduce the likelihood and consequences of accidental rupture.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eCirculatory Monitoring: Application of MostCare and Pressure Recording Analytical Method Algorithm\u003c/h2\u003e \u003cp\u003eContinuous hemodynamic monitoring was performed using the MostCare system with the Pressure Recording Analytical Method (PRAM). PRAM is a minimally invasive arterial waveform-based technique that provides continuous estimates of cardiac output, stroke volume, and dynamic indices of fluid responsiveness.\u003c/p\u003e \u003cp\u003ePrevious clinical experience has demonstrated its feasibility and consistency in pediatric settings, establishing its use as an adjunct for hemodynamic trend assessment and fluid management guidance [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In the present case, PRAM was performed primarily for trend monitoring and decision support rather than absolute value interpretation. This approach reduced the risk of pulmonary edema associated with empiric fluid loading and enabled earlier detection of circulatory instability during periods of potential risk for anaphylaxis-related distributive shock [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eAnesthetic Depth Monitoring\u003c/h2\u003e \u003cp\u003eThe reliability and clinical benefits of bispectral index (BIS) monitoring in toddlers remain controversial. Available evidence suggests that BIS-guided anesthesia in children may improve certain recovery parameters, such as extubation time. However, significant heterogeneity exists across studies, and performance in very young children is less consistent. Accordingly, in the present case, clinical signs remained the primary guide for anesthetic depth, with BIS trends used as a supplementary reference rather than a standalone determinant of drug titration [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003ePerioperative Temperature Management Strategy\u003c/h2\u003e \u003cp\u003ePerioperative temperature control is particularly critical in young children, who are highly susceptible to unintentional hypothermia during anesthesia and surgery. Hypothermia is associated with adverse outcomes, including impaired coagulation, cardiac arrhythmias, delayed drug metabolism, and increased infection risk [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Active warming strategies were therefore implemented immediately after induction, including application of pre-warmed intravenous fluids and forced-air warming devices. Core body temperature was maintained at approximately 36.5℃, with continuous monitoring and adjustment of warming measures throughout the procedure [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the favorable outcome in the current case, recent literature suggests several opportunities to refine and update the surgical-anesthetic strategy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eAdvancements in Lung Isolation\u003c/h2\u003e \u003cp\u003eAlthough blind mainstem intubation with a single-lumen tube was effective in this case, contemporary pediatric thoracic anesthesia increasingly favors fiberoptic bronchoscopy-guided placement of a bronchial blocker. This approach improves positioning accuracy, enhances control of the operative lung, and facilitates hypoxemia management, including the application of continuous positive airway pressure to the nonventilated lung when required [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003ePharmacologic Precision in Liver Disease\u003c/h2\u003e \u003cp\u003eIn patients with significant hepatic dysfunction, anesthetic agents with minimal dependence on hepatic metabolism may provide pharmacokinetic advantages. Remifentanil, which is metabolized by nonspecific plasma and tissue esterases, is largely independent of hepatic and renal function, enabling predictable clearance and rapid recovery. Reviews support this pharmacologic rationale in patients with liver disease or impaired organ function and in settings where rapid titration and recovery are desirable [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eAdvanced Hemodynamic Assessment\u003c/h2\u003e \u003cp\u003ePoint-of-care ultrasound (POCUS) represents an increasingly valuable adjunct for intraoperative hemodynamic assessment in pediatric anesthesia. Perioperative literature describes its application for focused cardiac evaluation, volume status assessment, and lung ultrasound. By providing real-time physiologic information, POCUS may reduce reliance on empiric fluid administration, support early detection of circulatory instability, and facilitate individualized fluid and cardiovascular management, particularly in patients at risk of pulmonary edema or distributive shock [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eIntegration of Regional Anesthesia\u003c/h2\u003e \u003cp\u003eThe erector spinae plane (ESP) block is increasingly used for pediatric thoracic and chest wall surgery. Randomized trials and reviews indicate that ESP blocks reduce perioperative opioid requirements, improve postoperative analgesia, and are technically straightforward with a low complication rate. Thus, they can serve as an alternative or adjunct to epidural analgesia [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn toddlers with disseminated hepatopulmonary CE, a staged surgical approach supported by iterative reassessment of organ function, proactive anaphylaxis preparedness, and lung-protective ventilation strategies may facilitate safe anesthetic management across multiple-stage high-risk procedures.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBIS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Bispectral index\u003c/p\u003e\n\u003cp\u003eCE\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Cystic echinococcosis\u003c/p\u003e\n\u003cp\u003eCT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Computed tomography\u003c/p\u003e\n\u003cp\u003eESP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Erector spinae plane\u003c/p\u003e\n\u003cp\u003eOLV\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;One-lung ventilation\u003c/p\u003e\n\u003cp\u003ePOCUS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Point-of-care ultrasound\u003c/p\u003e\n\u003cp\u003ePRAM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Pressure Recording Analytical Method\u003c/p\u003e\n\u003cp\u003ePRIS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Propofol infusion syndrome\u003c/p\u003e\n\u003cp\u003eTIVA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Total intravenous anesthesia\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient. This study was approved by the Biomedical Ethics Review Committee of Qinghai Red Cross Hospital.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eWritten informed consent for publication of this case report and any accompanying images was obtained from the patient\u0026rsquo;s legal guardians. All potentially identifying information has been anonymized.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research was funded by Qinghai University 2025 Graduate Student Scientific Research and Practical Innovation Project (NO.2025-GPKY-7), Shanghai Jiading District Health Commission Traditional Chinese Medicine Project (Youth) (NO.2022-QN-ZYY-03),Qinghai Red Cross Hospital Self-Selected Research Project (No. ZX-2025-01).\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; contributions\u003c/h2\u003e\n\u003cp\u003eYL drafted the manuscript. PZB collected the case-related clinical information and was responsible for the anesthetic management of the patient. YHX and MLZ organized the case materials and critically reviewed the manuscript. YD,WL\u0026nbsp;and XJW performed the final review and approved the final version of the manuscript. All authors read and approved the initial draft and agreed to the publication of this report.\u003c/p\u003e\n\u003ch2\u003eAcknowledgments\u003c/h2\u003e\n\u003cp\u003eThe authors thank Dr. SaiRenmucuo for assistance in retrieving and reviewing the relevant medical records.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWen H, Vuitton L, Tuxun T, et al. Echinococcosis: advances in the 21st century. 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Sci Rep. 2022;12(1):2242. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/s41598-022-06394-9\u003c/span\u003e\u003cspan address=\"10.1038/s41598-022-06394-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cystic echinococcosis, Pediatric anesthesia, Staged surgery, Hepatopulmonary involvement, Lung-protective ventilation, case report","lastPublishedDoi":"10.21203/rs.3.rs-9047045/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9047045/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCystic echinococcosis remains endemic in pastoral regions; however, evidence guiding perioperative anesthetic management in very young children with concomitant multi-organ (hepatic\u0026ndash;pulmonary) involvement is limited. We report the anesthetic management of a 2-year-old girl with disseminated hepatic and bilateral pulmonary echinococcosis who underwent three staged operations within a short period, and we summarize practical perioperative considerations.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eThe patient initially presented with abdominal distension and discomfort, followed by fever, productive cough, and hemoptysis. Imaging revealed multiple cystic hepatic lesions and multiple hydatid cysts in both lungs. A staged surgical strategy was adopted: open hepatic hydatid cystectomy with endocyst removal/pericyst management was performed first, followed by left and right thoracotomies for pulmonary hydatid cyst excision with closed thoracic drainage. Anesthetic management focused on dynamic evaluation of hepatic synthetic function and coagulation/albumin status, lung-protective ventilation under pediatric small-airway conditions, and protocolized preparedness for potential anaphylaxis associated with cyst fluid exposure. Pressure-controlled ventilation was used. Total intravenous anesthesia based on propofol was combined with a low concentration of inhalational anesthetic, remifentanil-based analgesia, and multimodal monitoring including arterial waveform analysis. No catastrophic events related to cyst rupture occurred; hemodynamics and ventilation remained stable throughout all procedures. Postoperative recovery was uneventful, and the patient was discharged on postoperative days 13, 29, and 8 after the three surgeries, respectively.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eFor pediatric patients with disseminated hepatic\u0026ndash;pulmonary echinococcosis, staged surgery supported by iterative organ-function assessment, proactive anaphylaxis preparedness, and lung-protective ventilation may facilitate safe anesthetic care across multiple high-risk procedures. This case provides a transferable perioperative strategy for similar patients in endemic settings.\u003c/p\u003e","manuscriptTitle":"Staged surgical anesthesia in pediatric disseminated cystic echinococcosis: A case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-09 16:02:27","doi":"10.21203/rs.3.rs-9047045/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-16T09:06:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-15T10:57:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"13124511434383414083459189247051862768","date":"2026-04-14T11:47:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31879985629050551585544707975428945196","date":"2026-04-14T06:05:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-04T13:55:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"130986476284203809437448704811654009985","date":"2026-04-03T04:52:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-03T04:20:03+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-09T18:04:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-06T10:52:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-06T10:46:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Anesthesiology","date":"2026-03-06T06:45:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"31d6c0f6-e5a0-4bf8-97cf-b06c436f694c","owner":[],"postedDate":"April 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-09T16:02:27+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-09 16:02:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9047045","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9047045","identity":"rs-9047045","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}