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LETTER TO EDITOR
Year : 2018  |  Volume : 19  |  Issue : 2  |  Page : 102-103
 

Anesthesia concerns in neonate with large ventricular septal defect with bidirectional shunt undergoing tracheoesophageal fistula repair


Department of Anaesthesia, B J Medical College and Sassoon General Hospital, Pune, Maharashtra, India

Date of Web Publication15-Nov-2018

Correspondence Address:
Dr. Sanyogita V Naik
Department of Anaesthesia, B J Medical College and Sassoon General Hospital, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_53_18

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How to cite this article:
Tandale SR, Naik SV, Abhade SR, Hatgaonkar RK. Anesthesia concerns in neonate with large ventricular septal defect with bidirectional shunt undergoing tracheoesophageal fistula repair. Indian Anaesth Forum 2018;19:102-3

How to cite this URL:
Tandale SR, Naik SV, Abhade SR, Hatgaonkar RK. Anesthesia concerns in neonate with large ventricular septal defect with bidirectional shunt undergoing tracheoesophageal fistula repair. Indian Anaesth Forum [serial online] 2018 [cited 2019 Oct 22];19:102-3. Available from: http://www.theiaforum.org/text.asp?2018/19/2/102/245554




Sir,

A 2-day-old neonate, weighing 1.9 kg, gestational age of 38.1 weeks was posted for tracheoesophageal fistula (TEF) repair. Neonate was intubated and on controlled ventilation with synchronized intermittent-mandatory ventilation mode. General examination revealed tachypnea, heart rate 172/min, blood pressure of 62/40 mmHg, pulse oximetry reading 88%, and pansystolic murmur over precordium. Echocardiography revealed 6.5-mm subaortic ventricular septal defect (VSD) with bidirectional shunt, 3-mm atrial septal defect with left to right shunt, and moderate pulmonary hypertension. Cardiovascular thoracic surgeon opinion was sought and was decided to operate TEF first followed by VSD closure as neonate would not have tolerated both procedures simultaneously. Abdominal ultrasound revealed a dilated renal pelvis bilaterally. Neonate was on intravenous (IV) sildenafil infusion 0.12 mg/h, dopamine, and dobutamine infusion 1 mcg/kg/h. Preoperative blood investigation, including arterial blood gas analysis, was unremarkable. In the operating room, standard anesthesia monitors were applied. Endocarditis prophylaxis was given with IV ceftriaxone 100 mg. Premedication with IV glycopyrrolate 10 mcg and ondansetron 0.2 mg was given. General anesthesia was induced with intravenous ketamine 2 mg, inhalation of sevoflurane 8% with oxygen followed by atracurium bolus. Caudal analgesic block was avoided. Anesthesia was maintained with 100% oxygen (as air not available at our institute), isoflurane, and intermittent boluses of atracurium and fentanyl. Ligation of TEF with esophageal anastomosis was performed. Blood loss of 30 ml was replaced with 25 ml of packed cell volume. One percentage of dextrose in Ringer lactate was used for maintenance and evaporative losses. IV infusion of sildenafil, dobutamine, and dopamine was continued intraoperatively. Intraoperative course was uneventful with stable hemodynamics. The neonate was shifted to the intensive care unit for postoperative management. He succumbed on 5th postoperative day due to sepsis.

Anesthetic challenges associated with VSD and TEF are unique. Frequent problem with TEF surgery is hypoxemia. It occurs secondary to right endobronchial intubation, endotracheal tube obstruction due to the presence of secretions and blood, kinking of bronchus as well as trachea secondary to surgical manipulation, and atelectasis of retracted lung due to surgical exposure.[1] Hence, recruitment maneuvers are necessary to reexpand the lung and to improve oxygenation.[1] Hypoxia, hypercarbia, and acidosis result in increase pulmonary vascular resistance (PVR), leading to reversal of shunt.[2] There is a great interplay of systemic vascular resistance (SVR) and PVR in VSD. The shunt flows from left to right during systole and preferentially to pulmonary artery with the generation of great pressure leading to pulmonary hypertension.[3] At times, pulmonary hypertension may exceed aortic outflow pressure leading to right to left shunt with consequent desaturation, hypoxia, and cyanosis.[3] In our case, there was a possibility of worsening of pulmonary hypertension and shunt reversal in the presence of hypotension, high-inflation pressure during ventilation, and increased PVR.[4] The gentle, positive pressure ventilation (airway pressure <25 mmHg) was practiced. In the event of desaturation, surgeons were asked for the early removal of lung retractors. In addition to it, other precautionary measures, such as optimization of preload with 20 ml of isotonic fluid bolus before induction, meticulous fluid, and blood loss replacement to maintain SVR and to avoid hypovolemia, maintenance of adequate analgesia, and depth of anesthesia to avoid any sympathetic stimulation, were taken.[5] Meticulous attention was paid to avoid any bubbles in lines and syringes because of the risk of paradoxical embolus. IV ketamine and sevoflurane induction with avoidance of caudal block were performed to maintain SVR.

To conclude, avoiding high airway pressure during ventilation and hemodynamic stability leads to the uneventful intraoperative course.

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.
Fleisher LA. The paediatric patient. In: Doreen S, Franklyn PD, editors. Anaesthesia and Uncommon Diseases. 5th ed. Noida, India: Elsevier; 2009. p. 601-39.  Back to cited text no. 1
    
2.
Kaye AD, Stout TB, Padnos IW, Schwartz BG, Baluch AR, Fox CJ, et al. Left-to-right cardiac shunt: Perioperative anesthetic considerations. Middle East J Anaesthesiol 2012;21:793-806.  Back to cited text no. 2
    
3.
Yen P. ASD and VSD flow dynamics and anesthetic management. Anesth Prog 2015;62:125-30.  Back to cited text no. 3
    
4.
Patra C, Singh NG, Manjunatha N, Bhatt A. Anaesthetic management of an infant posted for ventricular septal defect closure with right-sided eventration of diaphragm. Indian J Anaesth 2018;62:136-8.  Back to cited text no. 4
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5.
Menghraj SJ. Anaesthetic considerations in children with congenital heart disease undergoing non-cardiac surgery. Indian J Anaesth 2012;56:491-5.  Back to cited text no. 5
    




 

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