Letters to Editor
Extracorporeal membrane oxygenator for atrial septal defect!! The Editor, Sinus venosus atrial septal defect (SV‑ASD) with partial anomalous pulmonary venous connection (PAPVC) is one of the variants of atrial septal defect. Rarely, these cases develop severe biventricular dysfunction not responding to conventional inotropic agent in the post‑operative period. We describe the use of extracorporeal membrane oxygenator (ECMO) in a post‑operative case of SV‑ASD and PAPVC with severe biventricular dysfunction with a favorable outcome. The biventricular dysfunction was considered due to viral myocarditis. A 4‑year‑old male child, weighing 12 kg, was diagnosed to have SV‑ASD, with PAPVC to right atrium with normal biventricular function. The patient’s clinical features were exertional dyspnea, history of recurrent cough, cold and fever. Surgery was performed through midline sternotomy with standard perfusion protocol and Del‑Nido cardioplegic arrest. ASD closure with rerouting of PAPVC was carried out by two‑patch technique. The cardiopulmonary bypass (CPB) and aortic cross clamp times were 113 and 60 min, respectively. Dopamine 5 µg/kg/min was electively started to facilitate weaning from CPB. Transesophageal echocardiography in the post‑CPB period showed no residual ASD, no gradient across SVC‑RA area and normal biventricular function. The patient was transferred to pediatric cardiac intensive care unit (PCICU) for ventilatory support. The post‑ operative hemodynamic parameters remained stable and the child was extubated within 5 h of ICU stay. At 7 h after extubation, the patient developed high‑grade fever (103°F) and thrombocytopenia (66,000/µL) with total leucocytes count 20,790/µL. The peripheries became cold and arterial blood gases showed metabolic acidosis and high lactate level. The child was intubated and put back on controlled mode of ventilation and milrinone 0.5 µg/kg/min was started to support the circulation. Samples were sent to rule out infection and antibiotics Annals of Cardiac Anaesthesia Vol. 17:2 Apr-Jun-2014
were stepped up to meropenam. About 4 hours later, due to declining hemodynamic parameters adrenaline and noradrenaline were also started. Transthoracic echocardiography performed showed moderate left ventricular dysfunction and severe right ventricular dysfunction. In spite of maximal inotropic support and fluid management, hypotension and tachycardia persisted and the clinical condition of the child continued to deteriorate and it was decided to initiate an ECMO support. The child was immediately shifted to the operating room and placed on a Veno‑Arterial ECMO (Maquet Rota Flow, Maquet PLS Pediatric) and transferred to the PCICU with open sternum. On ECMO support, a blood flow of 2.4 l/min/m2 using a centrifugal pump with FiO2 of 60% and temperature of 35.5°C was maintained. During ECMO period, the inotropic agents and ventilatory supports were optimized. Child’s blood, endotracheal and urine cultures were negative and the serum was negative for dengue antibodies. The fever persisted in spite of optimal antibiotic therapy; therefore, a provisional diagnosis of viral myocarditis was considered and the child was treated with intravenous immunoglobulin (IVIG) in a dose of 2 g/kg over 24‑h infusion. The fever settled rapidly and the ventricular function improved within 2 days. The ECMO support was gradually weaned off over next 24 h. Total duration of ECMO support was 68 h. The child was extubated 3 days after chest closure with minimal inotropic support. Child was discharged from hospital on the 22 nd post‑operative day without having any neurological complication. Published data about the frequency of post‑operative fever in cardiovascular surgery are limited and the figure varies from 12% to 73% respectively.[1] Fever is associated with the metabolic response to trauma, systemic inflammatory response to CPB, hypothermia, presence of drainage tubes, drugs, blood transfusion and infections. In our patient, fever developed 12 h after surgery. The presence of fever 48 h after surgery should prompt a diligent search for deep‑seated infection.[2] Therefore, blood, endotracheal secretion and urine specimen were cultured to rule out infectious etiology, which came negative after 48 h. Dengue was also considered as the cause, which was negative. In view of negative culture for bacterial infections, viral myocarditis was strongly suspected in our case. Several diagnostic methods, such as cardiac magnetic resonance imaging and endomyocardial biopsy are useful for diagnosing it, but in most of the 175
Letters to Editor
cases, it is a clinical diagnosis based on exclusion of other infections.[3] Case reports and case series have described dramatic responses to IVIG in adults and children with presumed viral myocarditis. Administrations of IVIG have become common in the management of this condition and have dramatic and immediate response to it.[4] The ECMO was started to support the failing circulation and biventricular myocardial dysfunction. Data from case series suggest that ventricular assist devices or ECMO may provide a bridge to transplant or to recovery in patients with acute myocarditis.[5] In a case series, Chen et al.[6] reported that 80% of patients who received ECMO therapy were bridged to recovery. Finally, With the ECMO support and IVIG, we could prevent an adverse outcome in one of the simple procedure in current era of pediatric cardiac surgery.
Kamlesh B. Tailor, Shankar V. Kadam, Hari Bipin R. Kattana1, Suresh G. Rao1 1
Department of Pediatric Cardiac Anaesthesia and Intensive Care, Department of Pediatric Cardiac Surgery Children’s Heart Centre, Kokilaben Dhirubhai Ambani Hospital and Research Centre, Mumbai, Maharashtra, India Address for correspondence: Dr. Kamlesh B. Tailor, 802, Grace‑E, Vasant Oscar, LBS Marg, Mulund‑W, Mumbai ‑ 400 080, Maharashtra, India. E‑mail: [email protected]
REFERENCES 1. Andrade CL, Olvera S, Reyes PA. Fever and infection after heart surgery. A prospective study of 75 cases. Arch Inst Cardiol Mex 1989;59:487‑91. 2. Pien F, Ho PW, Fergusson DJ. Fever and infection after cardiac operation. Ann Thorac Surg 1982;33:382‑4. 3. Schultz JC, Hilliard AA, Cooper LT Jr, Rihal CS. Diagnosis and treatment of viral myocarditis. Mayo Clin Proc 2009;84:1001‑9. 4. Robinson J, Hartling L, Vandermeer B, Crumley E, Klassen TP. Intravenous immunoglobulin for presumed viral myocarditis in children and adults. Cochrane Database Syst Rev 2005;1:CD004370. 5. Bohn D, Macrae D, Chang AC. Acute viral myocarditis: Mechanical circulatory support. Pediatr Crit Care Med 2006;7:S22‑4. 6. Chen YS, Wang MJ, Chou NK, Han YY, Chiu IS, Lin FY, et al. Rescue for acute myocarditis with shock by extracorporeal membrane oxygenation. Ann Thorac Surg 1999;68:2220‑4.
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176
Labor analgesia in Eisenmenger syndrome: Peripartum concerns The Editor, Eisenmenger syndrome (ES) refers to a clinical condition that develops due to reversal of an initial left to right shunt in a patient with congenital intracardiac defect secondary to pulmonary hypertension and presents with cyanosis. Pregnancy in patients of ES is associated with high maternal mortality.[1,2] A 25‑year‑old woman (height 156 cm and body weight 52 kg), a known case of ES, presented with 34 weeks gestation along with cough, expectoration and breathlessness, bilateral ankle swelling for 15 days and palpitation for 2 months. She was treated with oral thyroxin 50 µg once daily for last 3 months. Her pulse rate was 102/min, regular, blood pressure 130/86 mmHg, respiratory rate 24/min and room air oxygen saturation (SpO2) 79‑81%. On auscultation, bilateral crepitations, loud second heart sound and a pansystolic murmur was present. Echocardiography revealed 18 mm inlet ventricular septal defect with a bidirectional shunt, grossly dilated right atrium and right ventricle, severe mitral regurgitation and ejection fraction 60%. Pulmonary artery systolic pressure was 64 mmHg. Investigations were unremarkable except arterial blood gas analysis showing severe hypoxemia on room air (PaO2 48 mmHg; SaO2 82%) with mixed acidosis; the SpO2 improved marginally to 85% on O2 supplementation. She was scheduled for induced labor and epidural analgesia to relieve pain. After administration of antibiotic prophylaxis, labor was induced by placing 25 µg misoprostol next to cervix at Bishop score of 4. The patient was monitored with electrocardiogram and SpO2. In addition, right internal jugular vein and right radial artery were cannulated for monitoring and access. An epidural catheter was inserted at L3‑4 intervertebral space in sitting position. After test dose of 3 ml of lignocaine with adrenaline, epidural infusion of bupivacaine 0.0625% with fentanyl 2 µg/ml was initiated at a rate of 5 ml/h (30 ml for 6 h) as labor was facilitated with oxytocin infusion, Annals of Cardiac Anaesthesia Vol. 17:2 Apr-Jun-2014
Copyright of Annals of Cardiac Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Extracorporeal membrane oxygenator for atrial septal defect!! The Editor, Sinus venosus atrial septal defect (SV‑ASD) with partial anomalous pulmonary venous connection (PAPVC) is one of the variants of atrial septal defect. Rarely, these cases develop severe biventricular dysfunction not responding to conventional inotropic agent in the post‑operative period. We describe the use of extracorporeal membrane oxygenator (ECMO) in a post‑operative case of SV‑ASD and PAPVC with severe biventricular dysfunction with a favorable outcome. The biventricular dysfunction was considered due to viral myocarditis. A 4‑year‑old male child, weighing 12 kg, was diagnosed to have SV‑ASD, with PAPVC to right atrium with normal biventricular function. The patient’s clinical features were exertional dyspnea, history of recurrent cough, cold and fever. Surgery was performed through midline sternotomy with standard perfusion protocol and Del‑Nido cardioplegic arrest. ASD closure with rerouting of PAPVC was carried out by two‑patch technique. The cardiopulmonary bypass (CPB) and aortic cross clamp times were 113 and 60 min, respectively. Dopamine 5 µg/kg/min was electively started to facilitate weaning from CPB. Transesophageal echocardiography in the post‑CPB period showed no residual ASD, no gradient across SVC‑RA area and normal biventricular function. The patient was transferred to pediatric cardiac intensive care unit (PCICU) for ventilatory support. The post‑ operative hemodynamic parameters remained stable and the child was extubated within 5 h of ICU stay. At 7 h after extubation, the patient developed high‑grade fever (103°F) and thrombocytopenia (66,000/µL) with total leucocytes count 20,790/µL. The peripheries became cold and arterial blood gases showed metabolic acidosis and high lactate level. The child was intubated and put back on controlled mode of ventilation and milrinone 0.5 µg/kg/min was started to support the circulation. Samples were sent to rule out infection and antibiotics Annals of Cardiac Anaesthesia Vol. 17:2 Apr-Jun-2014
were stepped up to meropenam. About 4 hours later, due to declining hemodynamic parameters adrenaline and noradrenaline were also started. Transthoracic echocardiography performed showed moderate left ventricular dysfunction and severe right ventricular dysfunction. In spite of maximal inotropic support and fluid management, hypotension and tachycardia persisted and the clinical condition of the child continued to deteriorate and it was decided to initiate an ECMO support. The child was immediately shifted to the operating room and placed on a Veno‑Arterial ECMO (Maquet Rota Flow, Maquet PLS Pediatric) and transferred to the PCICU with open sternum. On ECMO support, a blood flow of 2.4 l/min/m2 using a centrifugal pump with FiO2 of 60% and temperature of 35.5°C was maintained. During ECMO period, the inotropic agents and ventilatory supports were optimized. Child’s blood, endotracheal and urine cultures were negative and the serum was negative for dengue antibodies. The fever persisted in spite of optimal antibiotic therapy; therefore, a provisional diagnosis of viral myocarditis was considered and the child was treated with intravenous immunoglobulin (IVIG) in a dose of 2 g/kg over 24‑h infusion. The fever settled rapidly and the ventricular function improved within 2 days. The ECMO support was gradually weaned off over next 24 h. Total duration of ECMO support was 68 h. The child was extubated 3 days after chest closure with minimal inotropic support. Child was discharged from hospital on the 22 nd post‑operative day without having any neurological complication. Published data about the frequency of post‑operative fever in cardiovascular surgery are limited and the figure varies from 12% to 73% respectively.[1] Fever is associated with the metabolic response to trauma, systemic inflammatory response to CPB, hypothermia, presence of drainage tubes, drugs, blood transfusion and infections. In our patient, fever developed 12 h after surgery. The presence of fever 48 h after surgery should prompt a diligent search for deep‑seated infection.[2] Therefore, blood, endotracheal secretion and urine specimen were cultured to rule out infectious etiology, which came negative after 48 h. Dengue was also considered as the cause, which was negative. In view of negative culture for bacterial infections, viral myocarditis was strongly suspected in our case. Several diagnostic methods, such as cardiac magnetic resonance imaging and endomyocardial biopsy are useful for diagnosing it, but in most of the 175
Letters to Editor
cases, it is a clinical diagnosis based on exclusion of other infections.[3] Case reports and case series have described dramatic responses to IVIG in adults and children with presumed viral myocarditis. Administrations of IVIG have become common in the management of this condition and have dramatic and immediate response to it.[4] The ECMO was started to support the failing circulation and biventricular myocardial dysfunction. Data from case series suggest that ventricular assist devices or ECMO may provide a bridge to transplant or to recovery in patients with acute myocarditis.[5] In a case series, Chen et al.[6] reported that 80% of patients who received ECMO therapy were bridged to recovery. Finally, With the ECMO support and IVIG, we could prevent an adverse outcome in one of the simple procedure in current era of pediatric cardiac surgery.
Kamlesh B. Tailor, Shankar V. Kadam, Hari Bipin R. Kattana1, Suresh G. Rao1 1
Department of Pediatric Cardiac Anaesthesia and Intensive Care, Department of Pediatric Cardiac Surgery Children’s Heart Centre, Kokilaben Dhirubhai Ambani Hospital and Research Centre, Mumbai, Maharashtra, India Address for correspondence: Dr. Kamlesh B. Tailor, 802, Grace‑E, Vasant Oscar, LBS Marg, Mulund‑W, Mumbai ‑ 400 080, Maharashtra, India. E‑mail: [email protected]
REFERENCES 1. Andrade CL, Olvera S, Reyes PA. Fever and infection after heart surgery. A prospective study of 75 cases. Arch Inst Cardiol Mex 1989;59:487‑91. 2. Pien F, Ho PW, Fergusson DJ. Fever and infection after cardiac operation. Ann Thorac Surg 1982;33:382‑4. 3. Schultz JC, Hilliard AA, Cooper LT Jr, Rihal CS. Diagnosis and treatment of viral myocarditis. Mayo Clin Proc 2009;84:1001‑9. 4. Robinson J, Hartling L, Vandermeer B, Crumley E, Klassen TP. Intravenous immunoglobulin for presumed viral myocarditis in children and adults. Cochrane Database Syst Rev 2005;1:CD004370. 5. Bohn D, Macrae D, Chang AC. Acute viral myocarditis: Mechanical circulatory support. Pediatr Crit Care Med 2006;7:S22‑4. 6. Chen YS, Wang MJ, Chou NK, Han YY, Chiu IS, Lin FY, et al. Rescue for acute myocarditis with shock by extracorporeal membrane oxygenation. Ann Thorac Surg 1999;68:2220‑4.
Access this article online Quick Response Code:
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.129890
176
Labor analgesia in Eisenmenger syndrome: Peripartum concerns The Editor, Eisenmenger syndrome (ES) refers to a clinical condition that develops due to reversal of an initial left to right shunt in a patient with congenital intracardiac defect secondary to pulmonary hypertension and presents with cyanosis. Pregnancy in patients of ES is associated with high maternal mortality.[1,2] A 25‑year‑old woman (height 156 cm and body weight 52 kg), a known case of ES, presented with 34 weeks gestation along with cough, expectoration and breathlessness, bilateral ankle swelling for 15 days and palpitation for 2 months. She was treated with oral thyroxin 50 µg once daily for last 3 months. Her pulse rate was 102/min, regular, blood pressure 130/86 mmHg, respiratory rate 24/min and room air oxygen saturation (SpO2) 79‑81%. On auscultation, bilateral crepitations, loud second heart sound and a pansystolic murmur was present. Echocardiography revealed 18 mm inlet ventricular septal defect with a bidirectional shunt, grossly dilated right atrium and right ventricle, severe mitral regurgitation and ejection fraction 60%. Pulmonary artery systolic pressure was 64 mmHg. Investigations were unremarkable except arterial blood gas analysis showing severe hypoxemia on room air (PaO2 48 mmHg; SaO2 82%) with mixed acidosis; the SpO2 improved marginally to 85% on O2 supplementation. She was scheduled for induced labor and epidural analgesia to relieve pain. After administration of antibiotic prophylaxis, labor was induced by placing 25 µg misoprostol next to cervix at Bishop score of 4. The patient was monitored with electrocardiogram and SpO2. In addition, right internal jugular vein and right radial artery were cannulated for monitoring and access. An epidural catheter was inserted at L3‑4 intervertebral space in sitting position. After test dose of 3 ml of lignocaine with adrenaline, epidural infusion of bupivacaine 0.0625% with fentanyl 2 µg/ml was initiated at a rate of 5 ml/h (30 ml for 6 h) as labor was facilitated with oxytocin infusion, Annals of Cardiac Anaesthesia Vol. 17:2 Apr-Jun-2014
Copyright of Annals of Cardiac Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
