Praveen Kumar Neema

Anomalous pulmonary venous connection to superior vena cava: Warden technique.

OBJECTIVE Repair of anomalous pulmonary venous connection (APVC) to superior vena cava (SVC) with internal pericardial patch may be complicated by the obstruction of the SVC or pulmonary veins and sinus node dysfunction. Moreover, the shrinkage of the pericardium may lead to late obstruction. Various techniques are practiced, which have reduced the incidence of obstruction to the venous drainage, but sinus node dysfunction continues to be an issue. We reviewed our experience with the Warden technique, predominantly in children, for various types of APVC to the SVC. METHODS Between 2006 and 2010, 32 patients with anomalous drainage of the pulmonary veins to SVC underwent repair by the Warden technique in our institute. The median age at operation was 4 years (range 3 months-34 years). Partial anomalous pulmonary venous connection (PAPVC) was present in 28 patients, while four patients had total anomalous pulmonary venous connection (TAPVC) to the SVC, where one or more pulmonary veins joined the SVC separately from the entry of the common chamber. Clinical data, echocardiography and operative details were collected from our database, retrospectively. RESULTS At a median follow-up of 24 months, there was no mortality. One patient had transient rhythm disturbance. On follow-up, it was revealed that all patients are in sinus rhythm with no evidence of systemic or pulmonary venous obstruction. CONCLUSION The Warden technique is a simple and effective surgical option, which should be preferred for patients with anomalous drainage of the pulmonary veins to SVC. Though arrhythmias are rare in the early follow-up, longer follow-up is required to rule out their late development.

Severe seizures during propofol induction in a patient with syringomyelia receiving baclofen.

We report the occurrence of recurrent severe generalized seizures during induction of anesthesia with propofol in a patient with syringomyelia receiving baclofen for flexor spasms undergoing neurosurgery. We discuss the possible epileptogenic interaction between baclofen and propofol in our patient.

Partial atrioventricular canal defect with cor triatriatum sinister: Report of three cases

Cor triatriatum is an uncommon but surgically correctable cause of pulmonary venous hypertension and congestive cardiac failure, with a reported incidence of 0.1% among children with congenital heart diseases. Association with partial atrioventricular canal defect (PAVCD) is even rarer, with only anecdotal reports appearing in the literature. In the classic form, cor triatriatum is characterized by the presence of a fibromuscular diaphragm that subdivides the left atrium into a proximal accessory chamber and a distal true chamber.

Reverse herniation of brain: a less recognized complication in a patient with midline posterior fossa tumor postendoscopic third ventriculostomy.

To JNA Readership:A 57-year-old diabetic male weighing about 59 kg was referred to our hospital with an episode of projectile vomiting and generalized tonic clonic seizure with complaints of severe headache and gait unsteadiness since from last 2 months. Previous computed tomography (CT) brain revea

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.

Airway problems caused by hypogonadism in male patients undergoing neurosurgery.

Unanticipated difficult endotracheal intubations can pose challenges for the anesthesiologist. Risks include airway injury, hypoxemia, and death. There is intubation difficulty in various conditions including Downs syndrome, achondroplasia, acromegaly, and dwarfism. We describe difficulty in intubating the trachea with an appropriate sized endotracheal tube in two young male patients with hypogonadism presenting for neurosurgical procedures under general anesthesia. We discuss the role of hypogonadism and the effects of gonadotropin hormones on pubertal laryngeal growth in male patients.

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.

Resolution of Airway Compression Induced by Transesophageal Echocardiography Probe Insertion in a Pediatric Patient After Repair of an Atrial Septal Defect and Partial Anomalous Pulmonary Venous Connection

S d RANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) is routinely used in the operating room to assess surgical epairs in children with congenital heart disease (CHD). In a tudy of TEE examinations involving 1,650 children, Stevenon1 described airway obstruction in 14 patients (1%), right ainstem advancement of the endotracheal tube (ETT) in 3 atients (0.2%), inadvertent tracheal extubation in 8 patients 0.5%), vascular compression in 10 patients (0.6%), and addiional complications in 4 patients (0.2%). In another intraopertive TEE study of 200 pediatric cardiac patients undergoing urgical repair of CHD, complications associated with probe nsertion occurred in 11 patients (5.5%) and included airway bstruction in 6, inability to pass the probe in 4, and vascular ompression in 1 patient.2 The authors now report resolution of airway compression rom a TEE probe after surgical closure of an atrial septal efect (ASD) and rerouting of partial anomalous pulmonary enous connection (PAPVC) in a child. The patient had shown igns of airway compression after TEE probe insertion that ecessitated its removal shortly after initial endotracheal intuation. The mechanisms and the risk factors associated with irway compression by TEE probe insertion are discussed.