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LETTERS TO EDITOR
Year : 2018  |  Volume : 19  |  Issue : 1  |  Page : 30-32
 

Severe pulmonary hypertension in a preterm for retinal surgery - An anaesthetists challenge


Senior Consultant, Department of Anaesthesia, Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India

Date of Web Publication22-May-2018

Correspondence Address:
Dr. Shobha Ravishankar
Department of Anaesthesia, Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_48_17

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How to cite this article:
Ravishankar S. Severe pulmonary hypertension in a preterm for retinal surgery - An anaesthetists challenge. Indian Anaesth Forum 2018;19:30-2

How to cite this URL:
Ravishankar S. Severe pulmonary hypertension in a preterm for retinal surgery - An anaesthetists challenge. Indian Anaesth Forum [serial online] 2018 [cited 2019 Oct 22];19:30-2. Available from: http://www.theiaforum.org/text.asp?2018/19/1/30/232912




Sir,

Pulmonary hypertension (PH) is a common complication of neonatal respiratory diseases including bronchopulmonary dysplasia (BPD), and recent studies have increased the awareness that PH worsens the clinical course, morbidity, and mortality of BPD.

A 2-month-old female infant weighing 2700 g presented to our institution for lens-sparing vitrectomy for Grade IV retinopathy of prematurity. The baby was born to a primigravida at 27 weeks of gestation, and the birth weight was 720 g. Soon after birth, the baby developed severe tachypnea and was intubated and ventilated. An echo done at that time showed patent foramen ovale (L-R) and severe PH of 65 mmHg with good biventricular function. The baby had a stormy neonatal period. On the 16th day of life, the baby developed sepsis which was treated with antibiotics, packed cell, and platelet transfusion. On the 21st day of birth, she developed bronchopneumonia which was appropriately treated. When attempts were made to wean the baby from ventilator, the baby's oxygen saturation dropped to 80%–82% with room air and heart rate dropped to 50–52/min. Hence, continuous positive airway pressure was continued. Altogether, the baby was ventilated for 56 days (invasive and noninvasive). At the time of discharge, the baby was on 0.5 L/min of nasal oxygen and a SaO2 was 93%–94%.

On examination, this 60-day-old baby at our institution was on nasal oxygen (0.5 L/min) and was highly irritable with incesstant cry. She also had microcephaly, macroglossia, and retrognathia [Figure 1]. On auscultation, heart rate was 160/min with systolic murmur. Respiratory system examination revealed conducted sounds on both sides. Hemogram was normal. Chest X-ray revealed cardiomegaly [Figure 2]. Echocardiogram showed severe PH (65 mmHg), tricuspid regurgitation pressure gradient was 65 mmHg, and pulmonary regurgitation pressure gradient was 30 mmHg. There was patent foramen ovale with left-to-right shunt and normal biventricular function [Figure 3] and [Figure 4].
Figure 1: Patient after intubation

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Figure 2: Chest X-ray showing cardiomegaly

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Figure 3: Echocardiogram

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Figure 4: Echocardiogram

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Sildenafil (0.5 mg orally, twice a day) and theophylline (1 mg/kg orally, twice a day) were given for 3 days preoperatively. After obtaining the informed consent from parents, the baby was scheduled for surgery.

After preoperative fasting, the patient was premedicated with glycopyrrolate (4 mcg/kg, intramuscular) and was induced with oxygen and sevoflurane (6% dial concentration) using bag and mask. Monitoring included electrocardiography, noninvasive blood pressure, SaO2, and EtCo2. An intravenous (iv) access was established and 0.45% normal saline with dextrose was started. After 3 min of assissted ventilation, direct laryngoscopy was performed (anticipating difficult intubation). Only the posterior part of vocal cords was visualized with external cricoid pressure. The trachea was intubated in the first attempt with 2.5 mmID endotracheal tube with Stillete. Anesthesia was maintained with O2:N2O (50:50) and 2% sevoflurane with assissted ventilation for the duration of surgery which lasted for an hour. Intraoperative analgesia included 1 mcg/kg iv fentanyl and parabulbar block with 2% xylocaine. Intraoperative vitals remained stable. The baby was extubated completely awake and was maintained on nasal oxygen postoperatively, and SaO2 was maintained between 97% and 98%.

There are an increasing number of patients (especially preterm) presenting for noncardiac surgeries, including ophthalmic procedures. Echocardiography remains the primary method for evaluation for BPD-associated PH.[1] Retrospective studies of infants with BPD-associated PH have reported mortality rates ranging from 14% to 38%.[2],[3] Recent evidence indicates that up to 18% of all extremely low-birth-weight infants will develop some degree of PH during their hospitalization and the incidence rises to 25%–40% of infants with established BPD. Risk factors are not yet well understood, but new evidence shows that fetal growth restriction is a significant predictor of PH. The use of pulmonary vasodilator medications such as nitric oxide and phosphodiesterase 5 inhibitors (sildenafil and tadalafil) in the BPD population is steadily growing. The phosphodiesterase 5 inhibitors elevate cyclic guanosine monophosphate by blocking its decomposition, thereby inhibiting calcium entry and consequently enabling pulmonary vasodilatation. The successful management requires a multidisciplinary team approach and thorough preoperative risk assessment. Correct diagnosis, optimization of patient's functional status and hemodynamics, and management of comorbidities are vital. Anesthetic management is dependent on an understanding of pathophysiology and avoidance of pulmonary hypertensive crisis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Slaughter JL, Pakrashi T, Jones DE, South AP, Shah TA. Echocardiographic detection of pulmonary hypertension in extremely low birth weight infants with bronchopulmonary dysplasia requiring prolonged positive pressure ventilation. J Perinatol 2011;31:635-40.  Back to cited text no. 1
[PUBMED]    
2.
An HS, Bae EJ, Kim GB, Kwon BS, Beak JS, Kim EK, et al. Pulmonary hypertension in preterm infants with bronchopulmonary dysplasia. Korean Circ J 2010;40:131-6.  Back to cited text no. 2
[PUBMED]    
3.
Kim DH, Kim HS, Choi CW, Kim EK, Kim BI, Choi JH, et al. Risk factors for pulmonary artery hypertension in preterm infants with moderate or severe bronchopulmonary dysplasia. Neonatology 2012;101:40-6.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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