Abstracts / Free Papers
Dr Mahesh Venkata
Abstract:
Introduction :we present a case of 3 yr girl child with congenital complete heart block who underwent placement of permanent pacemaker insertion under general anaesthesia
History :
A 3 yr old girl child presented with fever, cough and cold for 7 days,breathlessness since 4 days and syncopal attacks since 1 day.
Examination :
Patient was tachypnoeic.Respiratory examination revealedb/lcrepts .She was thoroughly evaluated by Paediatrician and Cardiologist . She was diagnosed to have Congenital complete heart block
Vital data :
HR:44bpm: BP:60/40mmhg.
Temperature:101degrees F
Room air saturation :88%. RR:30/min .
Weight of the baby : 9 kgs.
2D Echo revealed Dilated Cardiomyopathy ,severe LV dysfunction ,dilated LA,LV. Ejection fraction was 30%.
TREATMENT :
Temporary pacemaker was placed on the first day of admission . She improved symptomatically over the next 1 week .She was planned for insertion of permanent pacemaker under General anaesthesia .
Anaesthetic management :
Patient was conscious and coherent . Heart rate was 110/min with temporary pacemaker and BP- 80/40 mmHg .
Premedication :
inj .Glycopyrolate 0.1mg .
inj .Fentanyl 15 micrograms i.v.
Induction :
Inj .ketamine 15mg.I.V
Sevofluraneand injRocuronium 8 mg
Intubation:
done with 4.5 uncuffed ET tube and fixed at 11 cm .
Maintenance :
sevofluraneinjRocuronium
Nitrous oxide and oxygen .
Reversal:
InjNeostimine 0.62 mg and Inj.Glycopyrolate 0.2mg
Total time taken for surgery was 2hrs.15 mins . Intra operatve blood loss was 40-50ml .
The baby was extubated and kept in icu for 3 days. post operative period uneventful.
Discussion :
The incidence of congenital high degree heart block either complete or with more than 50% of blocked atrial impulses has been estimated at 1 in 15000-20000 live births .
The most commonest cause of congenital heart block responsible for 70-90% of cases in neonatal lupus secondary to SLE.
Paced heart cannot compensate for hypotension by tachycardia so intra-operative fluid management and blood loss is important
Care should be taken during insertion of guide wire or central venous catheter as they are potentially arrhythmogenic
Skeletal myopotentials commonly encountered with succinylcholine , myoclonic movements, or direct muscle stimulation can inhibit or trigger pacemaker and should avoided
Induction in Dilated cardiomyopathy is with opioids and ketamine .
Both electrical and mechanical evidence of heart function should be monitored by manual palpation of pulse ,pulseoximetry ,precordial stethoscope and arterial line .
References :
Kaplans cardiac anaesthesia
Pergoffspediatric cardiology
Stolteing co-existing diseases
Millers anaesthesia 7 th edition
Introduction :
we present a case of 3 yr girl child with congenital complete heart block who underwent placement of permanent pacemaker insertion under general anaesthesia
History :A 3 yr old girl child presented with fever, cough and cold for 7 days,breathlessness since 4 days and syncopal attacks since 1 day.
Examination :Patient was tachypnoeic.Respiratory examination revealedb/lcrepts .She was thoroughly evaluated by Paediatrician and Cardiologist . She was diagnosed to have Congenital complete heart block Vital data : HR:44bpm: BP:60/40mmhg. Temperature:101degrees F Room air saturation :88%. RR:30/min . Weight of the baby : 9 kgs. 2D Echo revealed Dilated Cardiomyopathy ,severe LV dysfunction ,dilated LA,LV. Ejection fraction was 30%.
TREATMENT :Temporary pacemaker was placed on the first day of admission . She improved symptomatically over the next 1 week .She was planned for insertion of permanent pacemaker under General anaesthesia .
Anaesthetic management :Patient was conscious and coherent . Heart rate was 110/min with temporary pacemaker and BP- 80/40 mmHg .
Premedication :inj .Glycopyrolate 0.1mg . inj .Fentanyl 15 micrograms i.v. Induction : Inj .ketamine 15mg.I.V Sevofluraneand injRocuronium 8 mg
Intubation:done with 4.5 uncuffed ET tube and fixed at 11 cm .
Maintenance :sevofluraneinjRocuronium Nitrous oxide and oxygen .
Reversal:InjNeostimine 0.62 mg and Inj.Glycopyrolate 0.2mg Total time taken for surgery was 2hrs.15 mins . Intra operatve blood loss was 40-50ml . The baby was extubated and kept in icu for 3 days. post operative period uneventful. Discussion : The incidence of congenital high degree heart block either complete or with more than 50% of blocked atrial impulses has been estimated at 1 in 15000-20000 live births . The most commonest cause of congenital heart block responsible for 70-90% of cases in neonatal lupus secondary to SLE. Paced heart cannot compensate for hypotension by tachycardia so intra-operative fluid management and blood loss is important Care should be taken during insertion of guide wire or central venous catheter as they are potentially arrhythmogenic Skeletal myopotentials commonly encountered with succinylcholine , myoclonic movements, or direct muscle stimulation can inhibit or trigger pacemaker and should avoided Induction in Dilated cardiomyopathy is with opioids and ketamine . Both electrical and mechanical evidence of heart function should be monitored by manual palpation of pulse ,pulseoximetry ,precordial stethoscope and arterial line .
References :Kaplans cardiac anaesthesia Pergoffspediatric cardiology Stolteing co-existing diseases Millers anaesthesia 7 th edition