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Year : 2019  |  Volume : 63  |  Issue : 7  |  Page : 604-605  

Anaesthetic management of a child with pulmonary agenesis for laparoscopic inguinal hernia repair


Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication12-Jul-2019

Correspondence Address:
Dr. Ganga Prasad
Department of Anaesthesiology, Pain Medicine and Critical Care, Room No. 5011, 5th Floor, Teaching Block, All India Institute of Medical Sciences, New Delhi -110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_167_19

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How to cite this article:
Pangasa N, Prasad G, Singh G, Nair PR. Anaesthetic management of a child with pulmonary agenesis for laparoscopic inguinal hernia repair. Indian J Anaesth 2019;63:604-5

How to cite this URL:
Pangasa N, Prasad G, Singh G, Nair PR. Anaesthetic management of a child with pulmonary agenesis for laparoscopic inguinal hernia repair. Indian J Anaesth [serial online] 2019 [cited 2019 Oct 15];63:604-5. Available from: http://www.ijaweb.org/text.asp?2019/63/7/604/262608



Sir,

Pulmonary agenesis is a rare congenital malformation in which there is total absence of the bronchial tree, alveolar parenchyma, pulmonary and bronchial vasculature.[1]

A 20-month-old 10-kg male child, known case of left pulmonary agenesis, was scheduled for right inguinal hernia repair. He had undergone open right inguinal hernia repair last month. Due to recurrence, the surgeons now opted for laparoscopic repair as they wanted to approach through fresh surgical planes. On pre-anaesthetic evaluation, the child was active with room air oxygen saturation of 100%. Blood investigations were within normal limits. Recent chest X-ray was suggestive of(s/o) absent left lung with hyperinflated right lung with no mediastinal shift [Figure 1]. On contrast-enhanced computed tomography(CECT) chest, left lung, left main bronchus, left main pulmonary artery and left pulmonary vein were absent. CECT abdomen was s/o absent left kidney and DMSA scan revealed normal functioning right kidney. CECT neck revealed segmentation anomalies in cervical and proximal dorsal spine. On two-dimensional echocardiography, a small patent ductus arteriosus was detected with left-to-right shunt.
Figure 1: Chest X-ray of child with left pulmonary agenesis

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Parental consent and 6-hour fasting was ensured. He had an intravenous(iv) cannula insitu. Midazolam 0.5 mg iv was given and the child was wheeled in to the operating room with oxygen and pulse oximetry monitoring. Three-lead electrocardiography and noninvasive blood pressure monitors were attached. Intravenous induction of anaesthesia was done with fentanyl 20 μg, propofol 20mg and atracurium 5mg. Laryngoscopy was done using C-MAC video laryngoscope and trachea was intubated with size 4.0 cuffed endotracheal tube.

Pressure control mechanical ventilation was initiated with the following settings: inspiratory pressure 14 cmH2O, respiratory rate 24/min, positive end-expiratory pressure(PEEP) 5 cmH2O and 0.5 FiO2, delivering a tidal volume of 50mL and end-tidal carbon-dioxide(EtCO2) 42mmHg. Carbon dioxide was gradually insufflated to attain a pneumoperitoneum, and intra-abdominal pressure(IAP) was not allowed to exceed 10mmHg. The delivered tidal volume decreased after creating pneumoperitoneum and EtCO2 increased to 62mmHg. Inspiratory pressure was then increased to 17 cmH2O and respiratory rate to 28/min. Anaesthesia was maintained with isoflurane in air/oxygen(50/50), maintaining a MAC (Minimum Alveolar Concentration)of 1.1. Boluses of fentanyl 10 μg and atracurium 2mg were given along with paracetamol 100mg iv. The child's blood pressure and heart rate were maintained throughout the procedure and no episode of desaturation was recorded. Neuromuscular blockade was reversed, and the child was extubated and shifted to the recovery area with oxygen by face mask and monitoring of vitals. He was allowed orally after 4 hours and discharged home on the second postoperative day.

In patients with pulmonary agenesis, positive pressure ventilation poses a higher risk of barotrauma, pneumothorax, pneumomediastinum and interstitial emphysema to the single lung tissue.[2] Laparoscopic surgery can further increase the risk, as the respiratory changes due to pneumoperitoneum are subjected to single delicate lung tissue. The co-malformations associated with pulmonary agenesis can further result in anaesthetic challenges.[2]

We used C-MAC video laryngoscope for intubation, to avoid neck extension as the child had segmentation anomalies of cervical spine. Since the child had no respiratory compromise, we planned to proceed with laparoscopic surgery. Slow and gradual carbon dioxide insufflation was ensured to avoid vagal response to pneumoperitoneum which is predominant in children.[3] IAP was not allowed to exceed 10mmHg to avoid excessive cardiorespiratory changes. Various authors recommend restriction of IAP to 6mmHg in infants and 12mmHg in older children as these pressures have minimal effects on cardiac index.[3],[4] Amin etal. recommended the use of lung protective ventilation and proposed the requirement of higher peak pressures to overcome airway resistance and prevent shunting and hypoxemia in such patients.[2] We used similar ventilation strategy. Pennant proposed that children have a low functional residual capacity(FRC) which quickly falls below the closing capacity due to the pneumoperitoneum in laparoscopic surgery, producing small airway closure, atelectasis, intrapulmonary shunting and hypoxaemia.[4] Hence, the use of PEEP was recommended and thus applied.

In conclusion, laparoscopic surgery in a patient with pulmonary agenesis poses a great challenge for the anaesthesiologist, as the strain of respiratory changes associated with pneumoperitoneum is subjected to single lung tissue.

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.
GabarreJA, Galindo IzquierdoA, Rasero PonferradaM, Orbea GallardoC, Puente AguedaJM, de la Fuente Pérez P. Isolated unilateral pulmonary agenesis: Early prenatal diagnosis and long-term follow-up. JUltrasound Med 2005;24:865-8.  Back to cited text no. 1
    
2.
AminMD, ChinDT, AminS, PatelA. Anesthetic challenges in a child with pulmonary agenesis: Acase report and review of literature. JAnesth Clin Res 2018;9:833.  Back to cited text no. 2
    
3.
GuptaR, SinghS. Challenges in paediatric laparoscopic surgeries. Indian J Anaesth 2009;53:560-6.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
PennantJH. Anaesthesia for laparoscopy in paediatric patients. Anaesth Clin N Am 2001;19:69-88.  Back to cited text no. 4
    


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