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| CASE REPORT |
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| Year : 2023 | Volume
: 2
| Issue : 1 | Page : 62-64 |
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Spinal anesthesia for a neonate with complex congenital heart disease for lower limb surgery
Sunil Rajan, Niranjan Kumar Sasikumar, Dimple Elina Thomas, Jerry Paul, Lakshmi Kumar
Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| Date of Submission | 11-Nov-2022 |
| Date of Decision | 19-Jan-2023 |
| Date of Acceptance | 04-Feb-2023 |
| Date of Web Publication | 25-May-2023 |
Correspondence Address:
Dr. Sunil Rajan
Department of Anaesthesiology, Amrita Institute of Medical Sciences, Kochi - 682 041, Kerala
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jica.jica_36_22
A neonate with complex congenital heart disease was referred for patent ductus arteriosus (PDA) stenting, who had an ulceration of the dorsum of the foot secondary to extravasation injury. Echo showed situs solitus, levocardia, atrioventricular concordance, double-outlet right ventricle, large inlet with conoventricular ventricular septal defect, bidirectional shunt, D-posed aorta, pulmonary atresia, confluent good-sized branch pulmonary arteries, left arch, no coarctation, and tortuous PDA arising from the base of arch supplying the branch pulmonary artery confluence. Three days later, PDA stenting was done. As limb ulceration progressed to cellulitis, he was posted for debridement and VAC application 6 days after PDA stenting. It was performed under subarachnoid block with 0.5% bupivacaine heavy 0.6 ml through L4-L5 interspace using a 24G needle. Intraoperatively, saturation and hemodynamic variables remained stable. Skin grafting was performed 3 days later under spinal anesthesia with an unremarkable intraoperative and postoperative period.
Keywords: Congenital heart disease, neonate, spinal
How to cite this article:
Rajan S, Sasikumar NK, Thomas DE, Paul J, Kumar L. Spinal anesthesia for a neonate with complex congenital heart disease for lower limb surgery. J Ind Coll Anesth 2023;2:62-4 |
How to cite this URL:
Rajan S, Sasikumar NK, Thomas DE, Paul J, Kumar L. Spinal anesthesia for a neonate with complex congenital heart disease for lower limb surgery. J Ind Coll Anesth [serial online] 2023 [cited 2023 Jun 8];2:62-4. Available from: https://www.jicajournal.in//text.asp?2023/2/1/62/377596 |
| Introduction | |  |
Pediatric patients with congenital heart diseases (CHD) often require surgical procedures for abdominal conditions.[1] Neonates and infants undergoing noncardiac surgery have two times higher mortality rate in the presence of a CHD.[2] Spinal anesthesia is a well-tolerated regional anesthetic technique in the highly unstable newborns. It causes absent to minimal respiratory and cardiovascular disturbances. It has been shown that following subarachnoid block, the hemodynamic stability remains constant even in newborns with heart diseases.[3]
| Case Report | | |
We are reporting a case of a 15-day-old male child with complex CHD who was referred to our institute for patent ductus arteriosus (PDA) stenting. The child was delivered vaginally, weighed 3.35 kg, and was admitted in the neonatal intensive care unit (ICU) for decreased oxygen saturation levels. He was managed with continuous positive airway pressure, prostaglandin E1 (0.02 μg/kg/min), and injection piperacillin tazobactam and amikacin and was refereed after a few days of management from a local hospital.
On admission at our hospital, he had found to have ulceration of the dorsum of the foot secondary to extravasation injury. Echo showed situs solitus, levocardia, atrioventricular concordance, double-outlet right ventricle (DORV), large inlet with conoventricular ventricular septal defect (VSD), bidirectional shunt, D-posed aorta, pulmonary atresia, confluent good-sized branch pulmonary arteries, left arch, no coarctation, and tortuous PDA arising from the base of arch supplying the branch pulmonary artery (PA) confluence. Three days later, PDA stenting was done with 3.5 × 16 BioMime stent under general anesthesia with endotracheal intubation and positive pressure ventilation. The child received ketamine 2 mg/kg, glycopyrrolate 0.4 μg/kg, fentanyl 2 μg/kg, and vecuronium 0.1 mg/kg and was intubated with a 3.0 mm ID endotracheal tube. Anesthesia was maintained with sevoflurane in air–oxygen mixture. After the procedure, which lasted for 45 min, saturation improved to 89% from the baseline 71%. The procedure was uneventful. The child was shifted to the postoperative ICU and was ventilated and extubated on the same day. Echo was repeated 3 days later, which showed DORV, VSD, PA status post-PDA stenting, PDA stent in situ, good stent flows, good branch PA flows, and good biventricular function with no pericardial effusion. He was started on aspirin 15 mg orally once daily.
As limb ulceration progressed to cellulitis, he was posted for debridement and wound vacuum assisted closure application 6 days after PDA stenting. Our plan of anesthesia was subarachnoid block. Following adequate fasting, the child was taken to the operation theater, and preinduction monitors were attached. Intravenous glycopyrrolate 0.025 mg and ketamine 5 mg were administered, and under sterile precautions, the subarachnoid block was given with 0.5% bupivacaine heavy 0.35 ml through L4-L5 interspace using a 24G needle [Figure 1]. The level of block was up to T10. Intraoperatively, oxygen saturation remained 87%–90%, heart rate 130–170/min, and systolic blood pressure 70–80 mmHg. Surgery lasted for 45 min, and during the period, 20 ml Ringer's lactate with 1% dextrose was given. The child was not moving both the lower limbs intraoperatively. However, ketamine 2 mg was repeated intravenously during the procedure to keep the child sedated. The child was breathing spontaneously throughout the procedure and did not require any additional maneuvers to maintain the airway patent. The child did not vomit or regurgitate.
Postoperatively, the child was shifted back to the neonatal ICU, and paracetamol (70 mg) suppository was kept for analgesia. Skin grafting was performed 3 days later under spinal anesthesia using 0.5% bupivacaine heavy 0.6 ml. During that time also, the intraoperative hemodynamic parameters remained stable, and the child had an unremarkable postoperative recovery.
| Discussion | | |
The subarachnoid block is infrequently practiced in infants and neonates, though it is considered a safe technique of anesthesia. While administering spinal anesthesia for pediatric patients, a few points should always be remembered. As the spinal cord ends at lower border of L3 vertebra at birth and L1 vertebra by 6–12 months, it is the safest to perform lumbar puncture at or below the intercristal line.[4] The pediatric spinal requires a higher volume of local anesthetic compared to body weight due to a higher cerebrospinal fluid volume. However, the duration of block is usually shorter due to a higher uptake of the drug due to an increased blood flow to the spinal cord compared with adults.[5] Hence, it is recommended mainly for the abdominal or lower limb surgeries lasting <90 min.[6] Due to immature sympathetic system in children aged <5–8 years and the presence of less intravascular volume in the lower limb and splanchnic circulation for venous pooling, the degree of hypotension following spinal is minimal to absent.[7] When the hemodynamic parameters in infants with CHD undergoing noncardiac surgery who received awake spinal anesthesia for the procedures were compared with controls without CHD, it was found that the hemodynamic changes in both groups were comparable. Hence, it was postulated that the subarachnoid block could be a safe alternative to general anesthesia in infants with CHD.[8] During spinal anesthesia in children, preloading with intravenous fluids or intraoperative use of vasopressors is generally not required.[3]
It is concluded that in high-risk neonates, the subarachnoid block could be considered as a safe anesthetic technique for lower limb surgeries.
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 | | |
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| 2. | Baum VC, Barton DM, Gutgesell HP. Influence of congenital heart disease on mortality after noncardiac surgery in hospitalized children. Pediatrics 2000;105:332-5. |
| 3. | Hernández-Cortez E, Martínez-Barragán YM, Iñiguez-Lopéz KL. Spinal anesthesia in pediatrics. In: Whizar-Lugo VM, Saucillo-Osuna JR, Castorena-Arellano G, editors. Topics in Regional Anesthesia. London: IntechOpen; 2021. Available from: https://www.intechopen.com/chapters/78991. [Last accessed on 2022 Dec 22]. |
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| 5. | Frumiento C, Abajian JC, Vane DW. Spinal anesthesia for preterm infants undergoing inguinal hernia repair. Arch Surg 2000;135:445-51. |
| 6. | Verma D, Naithani U, Gokula C, Harsha. Spinal anesthesia in infants and children: A one year prospective audit. Anesth Essays Res 2014;8:324-9. [Full text] |
| 7. | Sethna NF, Berde CB. Pediatric regional anesthesia. In: Gregory GA, editor. Pediatric Anesthesia. 4 th ed. New York: Churchill Livingstone Inc.; 2002. p. 267-316. |
| 8. | Kachko L, Birk E, Simhi E, Tzeitlin E, Freud E, Katz J. Spinal anesthesia for noncardiac surgery in infants with congenital heart diseases. Paediatr Anaesth 2012;22:647-53. |
[Figure 1]
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