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<meta name="robots" content="INDEX,FOLLOW,NOARCHIVE" /><meta name="citation_inbook_title" content="StatPearls [Internet]" /><meta name="citation_title" content="Anesthetic Considerations in Patients With Cerebral Palsy" /><meta name="citation_publisher" content="StatPearls Publishing" /><meta name="citation_date" content="2023/08/05" /><meta name="citation_author" content="Brady Miller" /><meta name="citation_author" content="Bryan Rondeau" /><meta name="citation_pmid" content="34283423" /><meta name="citation_fulltext_html_url" content="https://www.ncbi.nlm.nih.gov/books/NBK572057/" /><link rel="schema.DC" href="http://purl.org/DC/elements/1.0/" /><meta name="DC.Title" content="Anesthetic Considerations in Patients With Cerebral Palsy" /><meta name="DC.Type" content="Text" /><meta name="DC.Publisher" content="StatPearls Publishing" /><meta name="DC.Contributor" content="Brady Miller" /><meta name="DC.Contributor" content="Bryan Rondeau" /><meta name="DC.Date" content="2023/08/05" /><meta name="DC.Identifier" content="https://www.ncbi.nlm.nih.gov/books/NBK572057/" /><meta name="description" content="Cerebral palsy is a group of permanent neurodevelopmental disorders that affects an individual’s muscle tone, motor functions, movement, and posture.[1][2] It encompasses a broad spectrum of clinical symptoms affecting multiple organ systems, with clinical presentation varying widely between individuals.[2] It occurs in approximately 2 per 1,000 live births, and incidence has remained stable, or slightly increased, over the last 50 years.[1][3] " /><meta name="og:title" content="Anesthetic Considerations in Patients With Cerebral Palsy" /><meta name="og:type" content="book" /><meta name="og:description" content="Cerebral palsy is a group of permanent neurodevelopmental disorders that affects an individual’s muscle tone, motor functions, movement, and posture.[1][2] It encompasses a broad spectrum of clinical symptoms affecting multiple organ systems, with clinical presentation varying widely between individuals.[2] It occurs in approximately 2 per 1,000 live births, and incidence has remained stable, or slightly increased, over the last 50 years.[1][3] " /><meta name="og:url" content="https://www.ncbi.nlm.nih.gov/books/NBK572057/" /><meta name="og:site_name" content="NCBI Bookshelf" /><meta name="og:image" content="https://www.ncbi.nlm.nih.gov/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-statpearls-lrg.png" /><meta name="twitter:card" content="summary" /><meta name="twitter:site" content="@ncbibooks" /><meta name="bk-non-canon-loc" content="/books/n/statpearls/article-132887/" /><link rel="canonical" href="https://www.ncbi.nlm.nih.gov/books/NBK572057/" /><link rel="stylesheet" href="/corehtml/pmc/css/figpopup.css" type="text/css" media="screen" /><link rel="stylesheet" href="/corehtml/pmc/css/bookshelf/2.26/css/books.min.css" type="text/css" /><link rel="stylesheet" href="/corehtml/pmc/css/bookshelf/2.26/css/books_print.min.css" type="text/css" /><style type="text/css">p a.figpopup{display:inline !important} .bk_tt {font-family: monospace} .first-line-outdent .bk_ref {display: inline} </style><script type="text/javascript" src="/corehtml/pmc/js/jquery.hoverIntent.min.js"> </script><script type="text/javascript" src="/corehtml/pmc/js/common.min.js?_=3.18"> </script><script type="text/javascript">window.name="mainwindow";</script><script type="text/javascript" src="/corehtml/pmc/js/bookshelf/2.26/book-toc.min.js"> </script><script type="text/javascript" src="/corehtml/pmc/js/bookshelf/2.26/books.min.js"> </script>
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<div class="pre-content"><div><div class="bk_prnt"><p class="small">NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.</p><p>StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. </p></div></div></div>
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<div class="main-content lit-style" itemscope="itemscope" itemtype="http://schema.org/CreativeWork"><div class="meta-content fm-sec"><h1 id="_NBK572057_"><span class="title" itemprop="name">Anesthetic Considerations in Patients With Cerebral Palsy</span></h1><p class="contrib-group"><h4>Authors</h4><span itemprop="author">Brady Miller</span><sup>1</sup>; <span itemprop="author">Bryan Rondeau</span><sup>2</sup>.</p><h4>Affiliations</h4><div class="affiliation"><sup>1</sup> Baylor Scott and White</div><div class="affiliation"><sup>2</sup> Baylor Scott & White</div><p class="small">Last Update: <span itemprop="dateModified">August 5, 2023</span>.</p></div><div class="body-content whole_rhythm" itemprop="text"><div id="article-132887.s1"><h2 id="_article-132887_s1_">Continuing Education Activity</h2><p>Cerebral palsy encompasses a broad spectrum of permanent neurodevelopmental disorders that affects an individual’s muscle tone, motor functions, movement, and posture. The anesthesiologist will often encounter patients with cerebral palsy for a variety of surgical procedures. In order to provide exceptional perioperative care, the provider must have advanced knowledge of this group of disorders. This activity reviews the evaluation and management of patients with cerebral palsy and highlights the role of the interprofessional team in managing patients with this condition.</p><p>
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<b>Objectives:</b>
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<ul><li class="half_rhythm"><div>Describe the typical physical exam findings associated with cerebral palsy.</div></li><li class="half_rhythm"><div>Outline the anticipated challenges for airway management in patients with cerebral palsy.</div></li><li class="half_rhythm"><div>Identify common intraoperative complications associated with cerebral palsy.</div></li><li class="half_rhythm"><div>Summarize anesthetic management considerations taken by the interprofessional team for patients with cerebral palsy.</div></li></ul>
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<a href="https://www.statpearls.com/account/trialuserreg/?articleid=132887&utm_source=pubmed&utm_campaign=reviews&utm_content=132887" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Access free multiple choice questions on this topic.</a>
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</p></div><div id="article-132887.s2"><h2 id="_article-132887_s2_">Introduction</h2><p>Cerebral palsy is a group of permanent neurodevelopmental disorders that affects an individual’s muscle tone, motor functions, movement, and posture.<a class="bk_pop" href="#article-132887.r1">[1]</a><a class="bk_pop" href="#article-132887.r2">[2]</a> It encompasses a broad spectrum of clinical symptoms affecting multiple organ systems, with clinical presentation varying widely between individuals.<a class="bk_pop" href="#article-132887.r2">[2]</a> It occurs in approximately 2 per 1,000 live births, and incidence has remained stable, or slightly increased, over the last 50 years.<a class="bk_pop" href="#article-132887.r1">[1]</a><a class="bk_pop" href="#article-132887.r3">[3]</a> </p><p>Patients with cerebral palsy are often encountered in the perioperative setting for a variety of indications, including orthopedic or neurosurgical procedures, gastrostomy tubes or tracheostomy, dental extractions, and imaging, to name a few.<a class="bk_pop" href="#article-132887.r4">[4]</a> Cerebral palsy poses a particular challenge to the anesthesiologist. Appropriate perioperative management requires a meticulous understanding of the etiology, pathophysiology, and clinical implications of this group of disorders.</p></div><div id="article-132887.s3"><h2 id="_article-132887_s3_">Function</h2><p>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.</p><p>
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<b>Neurologic</b>
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</p><p>Approximately two-thirds of patients with cerebral palsy have some degree of intellectual disability. Visual and hearing impairments are also common.<a class="bk_pop" href="#article-132887.r4">[4]</a> This can pose challenges for effective communication between the patient and provider. In patients with more severe intellectual disability, pre-operative anxiety can be particularly challenging to assess and may manifest as irritability or combativeness. Seizure disorders are common as well, with approximately 30% of patients with cerebral palsy also carrying a diagnosis of epilepsy. It has been suggested 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.<a class="bk_pop" href="#article-132887.r5">[5]</a></p><p>Patients with cerebral palsy have a lower minimum alveolar concentration (MAC) to volatile anesthetic agents and also frequently have delayed emergence from general anesthesia. The exact explanation for this is unknown but is likely multifactorial and related to increased baseline sensitivity to anesthetic agents, usage of anti-convulsant and anti-spasmodic medications, and perioperative hypothermia.<a class="bk_pop" href="#article-132887.r6">[6]</a></p><p>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.</p><p>
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<b>Musculoskeletal</b>
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</p><p>Patients with cerebral palsy typically have a thin body habitus with little subcutaneous fat and an increased surface area to body weight ratio.<a class="bk_pop" href="#article-132887.r5">[5]</a> This makes them extremely susceptible to hypothermia in the intra-operative period.<a class="bk_pop" href="#article-132887.r6">[6]</a> Chronic contractures and spasticity of the extremities can pose great difficulty with post-induction positioning, obtaining adequate venous access, placement of both invasive and non-invasive monitors, and regional techniques.<a class="bk_pop" href="#article-132887.r4">[4]</a> </p><p>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 display relative resistance to non-depolarizing neuromuscular blockers such as vecuronium. This is likely due to the up-regulation of extra-junctional acetylcholine receptors and interactions of neuromuscular blockers with anticonvulsant medications.<a class="bk_pop" href="#article-132887.r4">[4]</a><a class="bk_pop" href="#article-132887.r7">[7]</a><a class="bk_pop" href="#article-132887.r8">[8]</a><a class="bk_pop" href="#article-132887.r9">[9]</a></p><p>
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<b>Respiratory and Airway</b>
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</p><p>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 oro-motor dysfunction leading to aspiration, poor immune function, and chronic carriage of pathogenic bacteria.<a class="bk_pop" href="#article-132887.r10">[10]</a> 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.<a class="bk_pop" href="#article-132887.r4">[4]</a><a class="bk_pop" href="#article-132887.r6">[6]</a><a class="bk_pop" href="#article-132887.r11">[11]</a> 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 great challenge during airway management. An adequate pre-operative airway exam may not be feasible due to a patient’s lack of cooperation. The provider should be prepared for difficulty establishing a definitive airway and backup airway equipment, and additional assistance should be readily available.<a class="bk_pop" href="#article-132887.r4">[4]</a> </p><p>Patients with cerebral palsy often have a pooling of saliva in the upper airway. This is caused by overproduction by salivary glands as well as motor dysfunction such as pseudo-bulbar palsy, which can lead to an impaired ability to swallow.<a class="bk_pop" href="#article-132887.r12">[12]</a><a class="bk_pop" href="#article-132887.r13">[13]</a> Hypotonia of the respiratory muscles may lead to an inability to adequately cough and clear secretions from the airway. Increased oral secretions may pose difficulty with both mask ventilation and adequate visualization of the glottic structures during intubation.<a class="bk_pop" href="#article-132887.r6">[6]</a> Naturally, these patients are at an increased risk of aspiration. Pre-operative or intra-operative administration of an anticholinergic such as glycopyrrolate may be beneficial on a case-by-case basis.<a class="bk_pop" href="#article-132887.r14">[14]</a></p><p>
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<b>Cardiovascular</b>
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</p><p>Hypotension is one of the most common complications encountered in the intra-operative setting in patients with cerebral palsy. The explanation for this phenomenon is unknown and may be related to either the increased sensitivity to anesthetic agents or a diminished central adrenergic response.<a class="bk_pop" href="#article-132887.r6">[6]</a> It can be difficult to adequately assess cardiovascular reserve in patients with more severe manifestations of cerebral palsy who are chronically immobile. If severe enough, permanent co-existing pulmonary complications may lead to pulmonary hypertension or cor pulmonale in extreme cases.<a class="bk_pop" href="#article-132887.r4">[4]</a><a class="bk_pop" href="#article-132887.r10">[10]</a> If any of these conditions are known or suspected, a more thorough multi-disciplinary cardiovascular evaluation may be warranted prior to undergoing general anesthesia.</p><p>
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<b>Gastrointestinal</b>
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</p><p>As mentioned previously, patients with cerebral palsy are often malnourished and have a thin body habitus. Pseudo-bulbar palsy and oro-motor 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.<a class="bk_pop" href="#article-132887.r15">[15]</a></p><p>Poor nutrition and frequent use of laxatives for chronic constipation place these patients at risk for potentially significant electrolyte derangements.<a class="bk_pop" href="#article-132887.r16">[16]</a> Decreased lower esophageal sphincter tone leads to a high risk of gastroesophageal reflux disease (GERD) and aspiration of gastric or oropharyngeal contents.<a class="bk_pop" href="#article-132887.r10">[10]</a> Patients may have a percutaneous feeding tube, and the patient’s feeding schedule should be elicited from the primary caregiver before undergoing anesthesia.</p><p>
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<b>Allergies</b>
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</p><p>An increased incidence of latex allergy has been reported in patients with cerebral palsy. This may be in part due to recurrent and prolonged exposures to the healthcare setting. A thorough list of allergies should be elicited from the patient’s chart or caregiver during the preoperative assessment.<a class="bk_pop" href="#article-132887.r4">[4]</a></p></div><div id="article-132887.s4"><h2 id="_article-132887_s4_">Issues of Concern</h2><p>Preoperative assessment should be comprehensive, and a multidisciplinary 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 GERD 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 lack of patient cooperation. Topical application of a eutectic mixture of local anesthetics (EMLA) cream may be helpful for the uncooperative patient, and an additional assistant may be required. Inhalational induction followed by post-induction vascular access can be a reasonable option if clinically indicated. Ultrasound guidance can be a valuable tool if persistent difficulty is encountered.<a class="bk_pop" href="#article-132887.r4">[4]</a></p><p>When positioning patients with cerebral palsy, great care should be taken to prevent dislocations and pressure sores.<a class="bk_pop" href="#article-132887.r4">[4]</a> 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 utilized to minimize the risk of hypothermia.<a class="bk_pop" href="#article-132887.r6">[6]</a> Perioperative chest physiotherapy, bronchodilators, or antibiotics may be used on an individual basis to optimize a patient’s lung function and minimize risks of pulmonary complications postoperatively.<a class="bk_pop" href="#article-132887.r10">[10]</a> Emergence may be delayed and accompanied by combativeness or irritability.<a class="bk_pop" href="#article-132887.r4">[4]</a><a class="bk_pop" href="#article-132887.r6">[6]</a></p><p>Assessment of pain postoperatively 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 post-anesthesia care unit can help interpret the patient’s manifested emotions and be a familiar, calming presence for the patient. Regional anesthetic techniques are commonly utilized in these patients and can effectively provide prolonged postoperative analgesia. It is recommended to use a multimodal opioid-sparing regimen involving nonsteroidal anti-inflammatory drugs, acetaminophen, and anti-spasmodic and anti-neuropathic agents.<a class="bk_pop" href="#article-132887.r4">[4]</a> </p><p>Patients with neurodevelopmental disabilities are nearly twice as likely to experience respiratory depression compared to patients without such disabilities.<a class="bk_pop" href="#article-132887.r17">[17]</a> 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.</p></div><div id="article-132887.s5"><h2 id="_article-132887_s5_">Clinical Significance</h2><p>The incidence of subjects with cerebral palsy has remained stable or slightly increased over the last 50 years.<a class="bk_pop" href="#article-132887.r3">[3]</a> Whereas cerebral palsy was historically considered a childhood disorder, life expectancy for these patients now extends well into adulthood.<a class="bk_pop" href="#article-132887.r18">[18]</a> This makes it increasingly likely that anesthesiologists will 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.</p></div><div id="article-132887.s6"><h2 id="_article-132887_s6_">Enhancing Healthcare Team Outcomes </h2><p>Patients with cerebral palsy can have several complex health issues managed by different healthcare providers.  An interprofessional and multidisciplinary team can help achieve the best outcomes in patients with cerebral palsy in the perioperative setting. A collaborative approach should be employed between all healthcare workers, including providers, occupational and physical therapists, social workers, nursing staff, nutritionists, speech and language pathologists, and the patient’s primary caregiver to optimize the patient’s recovery after surgical procedures. Effective communication and transparency between the healthcare team and the patient’s primary caregiver are crucial to achieving a favorable outcome. [Level 5]</p></div><div id="article-132887.s7"><h2 id="_article-132887_s7_">Nursing, Allied Health, and Interprofessional Team Interventions</h2><p>Nurses routinely provide care across multiple settings for patients with cerebral palsy. Providers rely on nursing staff to perform a multitude of crucial tasks in the perioperative setting, including obtaining venous access, assessing pain scores, administering medications, and detecting and intervening on complications. Allied health professionals are similarly of the utmost importance in the postoperative rehabilitation of patients with cerebral palsy. Therefore, all healthcare professionals must understand cerebral palsy and its broad spectrum of clinical manifestations and be able to provide an individualized approach to each patient to ensure the best outcomes.</p></div><div id="article-132887.s8"><h2 id="_article-132887_s8_">Review Questions</h2><ul><li class="half_rhythm"><div>
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</div></li></ul></div><div id="article-132887.s9"><h2 id="_article-132887_s9_">References</h2><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="article-132887.r1">Wimalasundera N, Stevenson VL. Cerebral palsy. <span><span class="ref-journal">Pract Neurol. </span>2016 Jun;<span class="ref-vol">16</span>(3):184-94.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/26837375" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26837375</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="article-132887.r2">Vitrikas K, Dalton H, Breish D. Cerebral Palsy: An Overview. <span><span class="ref-journal">Am Fam Physician. </span>2020 Feb 15;<span class="ref-vol">101</span>(4):213-220.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/32053326" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32053326</span></a>]</div></dd><dt>3.</dt><dd><div class="bk_ref" id="article-132887.r3">Reddihough DS, Collins KJ. The epidemiology and causes of cerebral palsy. <span><span class="ref-journal">Aust J Physiother. </span>2003;<span class="ref-vol">49</span>(1):7-12.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/12600249" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 12600249</span></a>]</div></dd><dt>4.</dt><dd><div class="bk_ref" id="article-132887.r4">Shaikh SI, Hegade G. Role of Anesthesiologist in the Management of a Child with Cerebral Palsy. <span><span class="ref-journal">Anesth Essays Res. </span>2017 Jul-Sep;<span class="ref-vol">11</span>(3):544-549.</span> [<a href="/pmc/articles/PMC5594763/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC5594763</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/28928544" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28928544</span></a>]</div></dd><dt>5.</dt><dd><div class="bk_ref" id="article-132887.r5">Benish SM, Cascino GD, Warner ME, Worrell GA, Wass CT. Effect of general anesthesia in patients with epilepsy: a population-based study. <span><span class="ref-journal">Epilepsy Behav. </span>2010 Jan;<span class="ref-vol">17</span>(1):87-9.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/19910260" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19910260</span></a>]</div></dd><dt>6.</dt><dd><div class="bk_ref" id="article-132887.r6">Wass CT, Warner ME, Worrell GA, Castagno JA, Howe M, Kerber KA, Palzkill JM, Schroeder DR, Cascino GD. Effect of general anesthesia in patients with cerebral palsy at the turn of the new millennium: a population-based study evaluating perioperative outcome and brief overview of anesthetic implications of this coexisting disease. <span><span class="ref-journal">J Child Neurol. </span>2012 Jul;<span class="ref-vol">27</span>(7):859-66.</span> [<a href="/pmc/articles/PMC3561730/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3561730</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/22190505" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22190505</span></a>]</div></dd><dt>7.</dt><dd><div class="bk_ref" id="article-132887.r7">Moorthy SS, Krishna G, Dierdorf SF. Resistance to vecuronium in patients with cerebral palsy. <span><span class="ref-journal">Anesth Analg. </span>1991 Sep;<span class="ref-vol">73</span>(3):275-7.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/1678256" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 1678256</span></a>]</div></dd><dt>8.</dt><dd><div class="bk_ref" id="article-132887.r8">Theroux MC, Brandom BW, Zagnoev M, Kettrick RG, Miller F, Ponce C. Dose response of succinylcholine at the adductor pollicis of children with cerebral palsy during propofol and nitrous oxide anesthesia. <span><span class="ref-journal">Anesth Analg. </span>1994 Oct;<span class="ref-vol">79</span>(4):761-5.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/7943788" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 7943788</span></a>]</div></dd><dt>9.</dt><dd><div class="bk_ref" id="article-132887.r9">Theroux MC, Akins RE, Barone C, Boyce B, Miller F, Dabney KW. Neuromuscular junctions in cerebral palsy: presence of extrajunctional acetylcholine receptors. <span><span class="ref-journal">Anesthesiology. </span>2002 Feb;<span class="ref-vol">96</span>(2):330-5.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/11818764" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 11818764</span></a>]</div></dd><dt>10.</dt><dd><div class="bk_ref" id="article-132887.r10">Marpole R, Blackmore AM, Gibson N, Cooper MS, Langdon K, Wilson AC. Evaluation and Management of Respiratory Illness in Children With Cerebral Palsy. <span><span class="ref-journal">Front Pediatr. </span>2020;<span class="ref-vol">8</span>:333.</span> [<a href="/pmc/articles/PMC7326778/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC7326778</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32671000" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32671000</span></a>]</div></dd><dt>11.</dt><dd><div class="bk_ref" id="article-132887.r11">Boel L, Pernet K, Toussaint M, Ides K, Leemans G, Haan J, Van Hoorenbeeck K, Verhulst S. Respiratory morbidity in children with cerebral palsy: an overview. <span><span class="ref-journal">Dev Med Child Neurol. </span>2019 Jun;<span class="ref-vol">61</span>(6):646-653.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/30320434" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30320434</span></a>]</div></dd><dt>12.</dt><dd><div class="bk_ref" id="article-132887.r12">National Guideline Alliance (UK). <span class="ref-journal">Cerebral palsy in under 25s: assessment and management.</span> National Institute for Health and Care Excellence (NICE); London: Jan, 2017. [<a href="https://pubmed.ncbi.nlm.nih.gov/28151611" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28151611</span></a>]</div></dd><dt>13.</dt><dd><div class="bk_ref" id="article-132887.r13">Jan BM, Jan MM. Dental health of children with cerebral palsy. <span><span class="ref-journal">Neurosciences (Riyadh). </span>2016 Oct;<span class="ref-vol">21</span>(4):314-318.</span> [<a href="/pmc/articles/PMC5224428/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC5224428</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/27744459" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27744459</span></a>]</div></dd><dt>14.</dt><dd><div class="bk_ref" id="article-132887.r14">Gallanosa A, Stevens JB, Quick J. <span class="ref-journal">StatPearls [Internet].</span> StatPearls Publishing; Treasure Island (FL): Jun 8, 2023. Glycopyrrolate. 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Metabolic disturbances in patients with cerebral palsy and gastrointestinal disorders. <span><span class="ref-journal">Clin Nutr ESPEN. </span>2016 Feb;<span class="ref-vol">11</span>:e67-e69.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/28531429" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28531429</span></a>]</div></dd><dt>17.</dt><dd><div class="bk_ref" id="article-132887.r17">Jay MA, Thomas BM, Nandi R, Howard RF. Higher risk of opioid-induced respiratory depression in children with neurodevelopmental disability: a retrospective cohort study of 12 904 patients. <span><span class="ref-journal">Br J Anaesth. </span>2017 Feb;<span class="ref-vol">118</span>(2):239-246.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/28100528" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28100528</span></a>]</div></dd><dt>18.</dt><dd><div class="bk_ref" id="article-132887.r18">Hutton JL. Cerebral palsy life expectancy. <span><span class="ref-journal">Clin Perinatol. </span>2006 Jun;<span class="ref-vol">33</span>(2):545-55.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/16765736" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 16765736</span></a>]</div></dd></dl></div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_top_margin">
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<b>Disclosure: </b>Brady Miller declares no relevant financial relationships with ineligible companies.</p></div></dd><dt></dt><dd><div><p class="no_top_margin">
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<b>Disclosure: </b>Bryan Rondeau declares no relevant financial relationships with ineligible companies.</p></div></dd></dl></div></div></div>
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