Manikandan Sethuraman

Superior vena cava syndrome after pulsatile bidirectional Glenn shunt procedure: Perioperative implications

Bidirectional superior cavopulmonary shunt (bidirectional Glenn shunt) is generally performed in many congenital cardiac anomalies where complete two ventricle circulations cannot be easily achieved. The advantages of BDG shunt are achieved by partially separating the pulmonary and systemic venous circuits, and include reduced ventricular preload and long-term preservation of myocardium. The benefits of additional pulsatile pulmonary blood flow include the potential growth of pulmonary arteries, possible improvement in arterial oxygen saturation, and possible prevention of development of pulmonary arteriovenous malformations. However, increase in the systemic venous pressure after BDG with additional pulsatile blood flow is known. We describe the peri-operative implications of severe flow reversal in the superior vena cava after pulsatile BDG shunt construction in a child who presented for surgical interruption of the main pulmonary artery.

Sinus venosus atrial septal defect closure in an achondroplastic dwarf: anesthetic and cardiopulmonary bypass management issues.

1 Nunnelee JD. Superior vena cava syndrome. J Vasc Nurs 2007; 25: 2–5. 2 Economopoulos G, Kimitrakakis G, Brountzos E et al. Superior vena cava stenosis: a delayed BioGlue complication. J Thorac Cardiovasc Surg 2004; 127: 1819–1821. 3 Garcia-Delgado M, Navarrete-Sanchez I, Colmenero M et al. Superior vena cava syndrome after cardiac surgery: early treatment by percutaneous stenting. J Cardiothora Vasc Anesth 2007; 21: 417–419. 4 Ro PS, Hill SL, Cheatham JP. Congenital superior vena cava obstruction causing anasarca and respiratory failure in a newborn: successful transcatheter therapy. Catheter Cardiovasc Interv 2005; 65: 60–65. 5 Mert M, Saltik L, Gunay I. Remodelling of the superior caval vein after angioplasty in an infant with superior caval vein syndrome. Cardiovasc Intervent Radiol 2004; 27: 402–404. Sinus venosus atrial septal defect closure in an achondroplastic dwarf: anesthetic and cardiopulmonary bypass management issues

Mainstream Time-Capnography: An Aid to Select an Appropriate Uncuffed Endotracheal Tube in Small Children

Uncuffed endotracheal tubes are commonly used in children in an attempt to decrease the potential for pressure induced tracheal injury. However, uncuffed endotracheal tube may increase the risk of aspiration and lead to erratic delivery of preset tidal volume during mechanical ventilation. Therefore, it is desirable to intubate trachea with an appropriate but not an oversized endotracheal tube. In children, for selecting an endotracheal tube, a variety of formulas and techniques are used to find the endotracheal tube size that minimizes both pressure induced tracheal injury and aspiration potential or variable ventilation. Air-leak following tracheal intubation can be recognized by the presence of audible leak, by auscultation over the trachea, by palpation over the trachea and by observing effects of positive end-expiratory pressure on inspiratory expiratory tidal volume difference during mechanical ventilation. We describe mainstream time-capnograph as an aid to recognize leak around the endotracheal tube and its utility to determine appropriate endotracheal tube size in small children.

Combined monitored anesthesia care and femoral nerve block for muscle biopsy in children with myopathies.

1 Wheeler M. Proseal laryngeal mask airway in 20 paediatric surgical patients: a prospective evaluation of characteristics and performance. Paediatr Anaesth 2006; 16: 297–301. 2 Marttinez-Pons V, Madrid V. Ease of placement of LMA Proseal with a gastric tube insert. Anesth Analg 2004; 98: 1816–1817. 3 Lopez Gil M, Brimacombe J. The Proseal laryngeal mask airway in children. Paediatr Anaesth 2005; 15: 229–234. 4 LMA. LMA ProsealTM Instruction Manual, Ist edn. San Diego: LMA North America Inc 2000. 5 Lopez Gil M, Brimacombe J, Barragan L et al. Bougie guided insertion of Proseal laryngeal mask airway has higher first attempt success rate than the digital technique in children. Br J Anaesth 2006; 96: 238–241. 6 Howath A, Brimacombe J, Keller C. Gum elastic bougie guided insertion of PLMA: a new technique. Anaesth Intensive Care 2002; 30: 818.

Takotsubo cardiomyopathy in a patient with pituitary adenoma and secondary adrenal insufficiency

We describe a case of Takotsubo cardiomyopathy in a case of pituitary macroadenoma in acute adrenal crisis. A 48-year-old man presented with acute onset altered sensorium, vomiting, and gasping. On admission, he was unresponsive and hemodynamically unstable. He was intubated and ventilated and resuscitated with fluids and inotropes. The biochemical evaluation revealed hyponatremia, hyperkalemia, and hypocortisolism. Hyponatremia was corrected with 3% hypertonic saline. Contrast enhanced computed tomography (CT) scan of the brain revealed a sellar-suprasellar mass with hypothalamic extension with no evidence of pituitary apoplexy. A diagnosis of invasive pituitary adenoma with the Addisonian crisis was made and steroid replacement was initiated. Despite volume resuscitation, he had persistent refractory hypotension, recurrent ventricular tachycardia, and metabolic acidosis. Electrocardiogram (ECG) showed ST elevation and T-wave inversion in lateral leads; cardiac-enzymes were increased suggestive of acute coronary syndrome. Transthoracic echocardiography showed severe regional wall motion abnormalities (RWMAs) involving left anterior descending territory and low ejection fraction (EF). Coronary angiogram revealed normal coronaries, apical ballooning, and severe left ventricular dysfunction, consistent with a diagnosis of Takotsubos cardiomyopathy. Patient was managed with angiotensin-converting enzyme inhibitors and B-blockers. He improved over few days and recovered completely. At discharge, ECG changes and RWMA resolved and EF normalized to 56%. In patients with Addisonian Crisis with persistent hypotension refractory to optimal resuscitation, possibility of Takotsubos cardiomyopathy should be considered. Early recognition of association of Takotsubos cardiomyopathy in neurological conditions, prompt resuscitation, and supportive care are essential to ensure favorable outcomes in this potentially lethal condition.

Acute Hemodynamic Instability in an Infant After Pulsatile Bidirectional Cavopulmonary (Glenn Shunt) Anastomosis: Mechanisms and Resolution

Bidirectional superior cavopulmonary shunt (bidirectional Glenn shunt [BDG]) generally is performed as a firstor secondstage procedure in situations of leftor right-heart hypoplasia (eg, hypoplastic but potentially partially usable right ventricle,1 and patients with tricuspid atresia having single-ventricle physiology).2,3 The antegrade flow (if present) to the pulmonary artery (PA) is either interrupted or preserved. In selected patients, the preservation of antegrade flow results in better palliation in terms of improvement of atrioventricular valve regurgitation and the reduction of ventricle size.4 However, xcessive antegrade flow and pressures may lead to the develpment of pulsatile BDG and superior vena cava (SVC) synrome.5 We describe the pathophysiology of unstable hemodynamics and low oxygen saturation with the preservation of antegrade pulmonary blood flow (PBF) and the mechanism of improved hemodynamics with controlled PA banding. A 1-year-old infant presented with cyanosis and sweating during feeding. The developmental milestones were slightly delayed. The heart rate (HR), arterial blood pressure (ABP), and peripheral saturation (SpO2) were 120 bpm, 100/60 mHg, and 80%. His laboratory study results were normal. ransthoracic echocardiography showed situs solitus, levoardia, normally-related great vessels, tricuspid atresia with estrictive atrial septal defect, and a 7-mm ventricular septal efect (VSD). There was no pulmonary stenosis. The child as receiving digoxin and furosemide for congestive heart ailure. The patient was scheduled for BDG shunt construcion and atrial septectomy. Anesthesia was induced with evoflurane in O2, fentanyl, and pancuronium and mainained with O2, isoflurane, fentanyl, morphine, and pancuonium. The femoral artery and right internal jugular vein IJV) were cannulated for ABP and central venous pressure onitoring. The ABP, HR, and SpO2 during the prebypass eriod were about 100 mmHg, 134 bpm, and 88%. The PA ressure measured before cardiopulmonary bypass (CPB) as 29/12 (15) mmHg. BDG was constructed under partial PB, and atrial septectomy was performed under total CPB, ortic clamp, and cardioplegic myocardial protection. After he aortic clamp release, sinus rhythm resumed spontaneusly. Separation from CPB was achieved with elective notropic support by epinephrine, 0.03 g/kg/min. After separation from CPB, ABP was 60/30 mmHg, and SpO2 ranged between 75% and 78%. The PA pressure monitored i

Pericardial tamponade after left posterolateral thoracotomy for left upper lobectomy for pulmonary aspergilloma.

Pericardial tamponade limits diastolic filling of the heart; therefore, a high venous pressure is required to fill the ventricle. In presence of cardiac tamponade, therapeutic agents and manoeuvres that results in venodilation or vasodilation can severely compromise diastolic filling of the heart and might result in rapid cardiac decompensation. Equalization of central venous pressure and pulmonary artery diastolic pressure or equalization of pressures in all four chambers during diastole confirms cardiac tamponade. Transthoracic echocardiography can detect the site of tamponade and assist in pericardiocentesis. We describe acute pericardial tamponade in a young man who underwent left posterolateral thoracotomy for left upper lobectomy. Intraoperatively, mobilization of the left upper lobe was frequently associated with hypotension. Postoperatively, the patient suffered two more episodes of hypotension. The episodes of hypotension were attributed to surgical manipulation and epidural blockade. Hemodynamics normalized after discontinuing epidural infusion, volume resuscitation and lobectomy. On third postoperative day, the patient developed cardiovascular collapse; arterial blood pressure and central venous pressure were 70/50 and 12 mmHg. Investigations showed haziness of left lung, and severe respiratory acidosis. On opening of the left thoracotomy wound, pericardial tamponade was diagnosed. A pericardial window was created and tamponade was released with that the hemodynamics normalized. Episodes of unexplained hypotension after left upper lobectomy suggest a cardiac etiology and acute pericardial tamponade is a possibility which should be released immediately otherwise it can result in fatal outcome.

Anesthetic Challenges in the Management of Distal Posterior Cerebral Artery Aneurysm for Surgical Clipping: A Report of 2 Cases.

tilation, a videolaryngoscope (Glide Scope GVL) was sought and readied for better visualization. Using the videolaryngoscope, it was possible to visualize the structures better (Fig. 1) and a gum elastic bougie could be negotiated inside the glottic opening. Through the bougie, a 7.5-mm endotracheal tube was railroaded over and the trachea could be intubated. Rest of the surgery proceeded uneventfully. Because of the relative rarity and recent recognition of NF type 2 (acoustic neurofibromatosis) as a distinct identity, most of the literature concerning anesthetic implications relates to NF type 1.4 Likewise, cases and series describing intraoral involvement, too have preponderance of patients suffering from NF type 1.5 Through this correspondence we would like to alert the neuroanesthesiologists regarding the possibility of coexisting mucocutaneous neurofibromas in obscure intraoral locations in patients with NF type 2 (acoustic neurofibromatosis). In view of their remote locations, these lesions might often be overlooked during routine airway examination and subsequently complicate the airway management. Therefore history taking and airway examination should be meticulous in this subset of patients. Pertinent points like history of dyspnea, stridor, dysphagia, loss or change of voice should warn the neuroanesthesiologists regarding the existence of intraoral growths. Indirect laryngoscopy, fibreoptic examination, and detailed radiologic review should be routinely included in the preanesthetic assessment of these patients to rule out such lesions. Moreover as neurofibromatosis is a progressive disease, the history of previous uneventful anesthetics should not generate complacency1 and presently existing intraoral afflictions should be diligently excluded preoperatively.

Entropy score, patent ductus arteriosus (PDA), and cardiopulmonary bypass (CPB): ligation of PDA on CPB can compromise cerebral blood flow.

A patent ductus arteriosus (PDA) is often present in patients undergoing correction of congenital heart disease. It is well appreciated that during cardiopulmonary bypass (CPB), a PDA steals arterial inflow into pulmonary circulation, and may lead to systemic hypoperfusion, excessive pulmonary blood flow (PBF) and distention of the left heart. Therefore, PDA is preferably ligated before initiation of CPB. We describe acute decreases of arterial blood pressure and entropy score with the initiation of CPB and immediate increase in entropy score following the PDA ligation in a child undergoing intracardiac repair of ventricular septal defect and right ventricular infundibular stenosis. The observation strongly indicates that a PDA steals arterial inflow into pulmonary circulation and if the PDA is dissected and ligated on CPB or its ligation on CPB is delayed the cerebral perfusion is potentially compromised.

Extremely narrow airway in a child undergoing intracardiac repair of tetralogy of Fallot: perioperative implications

neonate, as there may be no suitably small tracheal tube. We solved the problem by inserting an 18-gauge intravenous catheter into the trachea. One problem with this method is that it is difficult to connect the catheter to the breathing system. To solve the problem, we inserted the laryngeal mask (while the catheter was kept in place in the trachea), and successfully ventilated the lungs, during attempts at emergency tracheostomy. In conclusion, we believe that in a neonate with subglottic stenosis, insertion of an intravenous catheter through the glottis and insertion of the laryngeal mask (with the catheter in place) may be useful as a rescue airway management. Takeshi Umegaki Takashi Asai Kentaro Kojima Kohei Murao Koh Shingu Department of Anaesthesiology, Kansai Medical University, Moriguchi City, Osaka, Japan (email: asait@takii.kmu.ac.jp)