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 Table of Contents    
LETTER TO EDITOR
Year : 2015  |  Volume : 59  |  Issue : 11  |  Page : 756-758  

Repair of late-presenting right Bochdalek hernia in a patient with uncorrected tetralogy of Fallot: Anaesthetic management


Department of Anaesthesiology and Critical Care, Gauhati Medical College and Hospital, Guwahati, Assam, India

Date of Web Publication20-Nov-2015

Correspondence Address:
Priyam Saikia
Department of Anaesthesiology and Critical Care, Gauhati Medical College and Hospital, Guwahati - 781 032, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.170041

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How to cite this article:
Saikia P, Talukdar FA, Phukan B, Chakraborty K. Repair of late-presenting right Bochdalek hernia in a patient with uncorrected tetralogy of Fallot: Anaesthetic management. Indian J Anaesth 2015;59:756-8

How to cite this URL:
Saikia P, Talukdar FA, Phukan B, Chakraborty K. Repair of late-presenting right Bochdalek hernia in a patient with uncorrected tetralogy of Fallot: Anaesthetic management. Indian J Anaesth [serial online] 2015 [cited 2019 Sep 21];59:756-8. Available from: http://www.ijaweb.org/text.asp?2015/59/11/756/170041

Sir,

Anaesthesia for patients with isolated tetralogy of Fallot (TOF) or late presenting congenital diaphragmatic hernia (Lp-CDH) can be challenging. [1],[2],[3] No publications on anaesthetic care of patients with concurrent TOF and Lp-CDH were found on thorough literature search.

During pre-anaesthetic evaluation, the patient, a male baby (1-year-old, weighing 7 kg) with TOF was conscious, but irritable and crying, with a regular pulse rate of 150/min, blood pressure (BP) of 90/50 mmHg and peripheral oxygen saturation (SpO 2) of 70% on room air. Results of investigations carried out in the pre-operative as well as intra-operative period are shown in [Table 1].
Table 1: Result of laboratory and imaging studies of the patient

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On the morning of surgery, prophylaxis against infective endocarditis and scheduled dose of oral propranolol were administered. Premedication was achieved with ketamine 5 mg, glycopyrrolate 70 μg and midazolam 1 mg through the pre-existing 24 G peripheral intravenous (IV) catheter. Mask ventilation and subsequent tracheal intubation were carried out 3 min after administration of ketamine 15 mg, fentanyl 15 μg and vecuronium 1.0 mg IV. End tidal CO 2 (ETCO 2 ) was maintained in the range of 27-40 mmHg (tidal volume 60 ml, respiratory rate 22-26/min) with peak airway pressure of 20-24 hPa. A few minutes into the tracheal intubation, his heart rate (HR) increased to 170/min and SpO 2 rapidly decreased to 63% and invasive BP (measured at right radial artery) was 100/56 mmHg. At this point of time, ETCO 2 was 40 mmHg with normal waveform and auscultation of bilateral lung fields suggested equal ventilation. Isoflurane concentration was increased with not much improvement but subsequent esmolol 3.5 mg IV bolus administration improved SpO 2 to 90% and HR settled at 148/min. Anaesthesia was supplemented further with another bolus of fentanyl and regular top up of vecuronium; a nasogastric tube was inserted nasally. Another intra-operative episode of low SpO 2 and ETCO 2 with tachycardia and normotension did not respond to supplemental dose of fentanyl 15 μg IV. It subsequently responded to RL 70 ml and esmolol 3.5 mg IV bolus administration. The right-sided Bochdalek hernia was repaired through a right subcostal incision and ropivacaine 0.2% (10 ml) was infiltrated in the subcutaneous tissue of the incision site. He was extubated tracheally at the end of surgery. The results of arterial blood gas analysis at different points of time are shown in [Table 1]. Immediate post-operative period was complicated by another episode of desaturation with tachycardia and normotension that responded to esmolol 3.5 mg and RL 60 ml IV administration. He was discharged in stable condition on the ninth post-operative day, no significant improvement of SpO 2 was noted.

Peri-operative haemodynamic goals (e.g., maintenance of normovolaemia, avoidance of decrease in systemic vascular resistance and increase in pulmonary vascular resistance) and management of hypercyanotic spell in patients with TOF has been well described. [1],[2],[3] The first and the last hypercyanotic spell in this case was presumed to be because of increased sympathomimetic activity arising from tracheal intubation and extubation, respectively, leading to right ventricular tract (RVOT) obstruction. As sudden decrease of ETCO 2 may be seen in both RVOT obstruction and myocardial depression, we did not increase the concentration of isoflurane during the second hypercyanotic spell. Instead, we administered fluid bolus and supplementary dose of fentanyl. In all the instances, esmolol was used due to persistent tachycardia.

Although pre-operative aspiration of stomach contents in patients with Lp-CDH has been recommended, it was not used and we proceeded with gentle mask ventilation, as stomach was intra-abdominal [Figure 1]a. [4] Moreover, there was a high chance of precipitating a hypercyanotic spell during its insertion. Use of double lumen endotracheal tube has been suggested, but we proceeded with single lumen endotracheal tube as pre-operative chest X-ray [Figure 1]b showed a comparatively well aerated right lung. [5]
Figure 1: (a) Barium upper gastrointestinal tract radiography (1) Stomach at normal intra-abdominal position (red thin arrow), (2) Few segments of small bowel loops are seen in the right hemithorax (green thin arrow), (3) Cardiac shadow (blue thin arrow). (b) Chest X-ray shows: (1) Well aerated right lung (red thick arrow), (2) There is evidence of bowel loops in the right hemithorax ( green thick arrow), (3) Homogenous opacities are also noted in the right lower thorax (blue thick arrow), (4) No demonstrable air containing loops noted in the visualised part of the abdomen

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We hope that description of this unusual clinical situation and our management strategies will help to identify key clinical management issues and serve to compare outcome in patients who may suffer from similar comorbidities.

Acknowledgements

The authors would like to acknowledge the help of Dr. Manoj Saha, Assistant Professor, Department of Paediatric Surgery; Dr. Mriduplaban Nath, Assistant Professor, Department of Anaesthesiology and Critical Care; Dr. Manoj Hazarika, Assistant Professor, Department of Radiology of Gauhati Medical College and Hospital, Guwahati, Assam, India, during peri-operative management of this patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Wajekar AS, Shetty AN, Oak SP, Jain RA. Anaesthetic management for drainage of frontoparietal abscess in a patient of uncorrected tetralogy of Fallot. Indian J Anaesth 2015;59:244-6.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Singh A, Sarkar D, Kansara B, Sharma KK. Bipolar hip arthroplasty in an adult patient with uncorrected tetralogy of Fallot: Anesthetic management. Ann Card Anaesth 2011;14:158-61.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Twite MD, Ing RJ. Tetralogy of Fallot: Perioperative anesthetic management of children and adults. Semin Cardiothorac Vasc Anesth 2012;16:97-105.  Back to cited text no. 3
    
4.
James JP, Josephine JJ, Ponniah M. Late-presenting bilateral congenital diaphragmatic hernia: An extremely rare confluence of two rarities. Indian J Anaesth 2014;58:768-70.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.
Juwarkar CS, Kamble DS, Sawant V. A late presenting congenital diaphragmatic hernia misdiagnosed as spontaneous pneumothorax. Indian J Anaesth 2010;54:464-6.  Back to cited text no. 5
[PUBMED]  Medknow Journal  


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