Background: Anesthesia for Dandy-Walker syndrome (DWS) child may be challenging due to difficult airway. We report a case of bradycardia and asystole occurring at intubation in a child with DWS undergoing shunt revision, in which cause of cardiac arrest was difficult to determine.
Case Report: The patient was 18-month-old female with DWS diagnosed at birth. Cyst-peritoneal shunt was placed at 4 months old. This time, she was undergoing emergency cyst drainage because of shunt obstruction and increased posterior fossa intracranial pressure (ICP). She had episodes of bradycardia while being taken care of in ward in supine position. Thus, she was placed in the supine position with the head turned to the left on OR table for induction of anesthesia. After induction, airway management turned out to be difficult because of enlarged head size. She was then placed in the supine position facing midline. During laryngoscopy, sudden bradycardia developed. Atropine was injected and intubation was done. However, cardiac arrest ensued. Chest compression was initiated and epinephrine was given. End-tidal carbon dioxide was not detected. Reintubation was attempted twice. Placement of the endotracheal tube was finally confirmed fiberoptically. She was positioned in a lateral position to decrease the ICP. Return of spontaneous circulation was noted 23 minutes later. The operation proceeded uneventfully thereafter. At the end of the operation, she was able to move all limbs while breathing spontaneously. She remained intubated in the PICU, but did not require mechanical ventilation.
Discussion: The possible causes of bradycardia and cardiac arrest in this child may be increased ICP as well as esophageal intubation. This case highlights the importance of thorough preoperative evaluation, atropine premedication, and adjusting the body position, even for an emergency operation at night, in order to prevent ICP increase and asystole, bradycardia, and difficult airway.
Learning points: The anesthesiologists should be well prepared to manage ICP and airway difficulties by positioning in patients with DWS for an emergency operation.

04 / Bradycardia and asystole during intubation in a child with Dandy-Walker syndrome for an emergency operation at night: The possible causes