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has rare cardiovascular adverse effects such as atrial fibrillation, bigeminy, sinus bradycardia, ventricular tachycardia, QT prolongation, cardiac arrest.[1,2] Bradycardia and cardiac arrest (asystole)[3] is also reported with ranitidine. The adverse cardiac effects of ranitidine may be due to H2 receptor antagonism in coronary smooth muscle, through vasoconstriction or a rise in plasma histamine levels.[4] Other mechanisms may include a cholinergic action mediated by cholinesterase inhibition.

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DOI: 10.4103/0970-9185.119136

Ondansetron has submicromolecular affinity for K + channels encoded by “human ether‑a go‑go related gene,” which is possibly responsible for the prolongation of cardiac repolarization, thus resulting in conduction disturbances like QT/QTc interval prolongation.[5] Presence of 5‑ hydroxytryptamine (5‑HT) receptors in left ventricle usually precipitate the von Bezold Jarisch reflex and use of 5‑HT3 antagonist usually block this effect. However, the cardiovascular effect of ondansetron will depend on pre‑existing serotonergic activity in both arms of the autonomic nervous system. The additional finding that this hemodynamic response was reversed by atropine emphasizes its likely parasympathomimetic origin.

Patent ductus arteriosus ligation: Do not take it easy

The mechanism of cardiac arrest in this case is not clear either it is due to the combination of drug or ondensetron alone. Ondansetron and ranitidine both can cause bradycardia and cardiac arrest, so one should be careful when using the combination of two drugs.

An 8‑month old infant weighing 5 kg was diagnosed to have a large PDA of 5  mm size with left to right shunting and gradient of 18/2 mm Hg on 2D transthoracic echocardiography as the sole cardiac problem. A plan for direct ligation of the PDA through the left thoracotomy was made. Pre‑operatively, the only abnormal finding was a continuous murmur on his left second intercostals space. Anesthesia management was as per the standard protocol in our institute. His airway was secured with an uncuffed 4.5 size endotracheal tube. The procedure went uneventful and the blood pressures were maintained between systolic 85‑90 Hg and diastolic of 50‑60  mmHg. Arterial blood gas was normal except for an increase in PaCO2  (45 mmHg), which was managed by adjusting the ventilator settings and endotracheal suctioning. Trachea was extubated at 1st post‑operative hour and he had a normal arterial blood gas at 30 min post‑extubation. At 2nd h post‑extubation, he developed severe laryngospasm. At this time, arterial blood gas showed PaCO2 of 65  mmHg. His airway was secured immediately and the child was mechanically ventilated. Chest‑ X ray revealed gross cardiomegaly, which was not present in the pre‑operative and immediate post‑operative period. [Figures 1and 2] A 2‑D transthoracic echocardiogram revealed the presence of ventricular dilation and dysfunction. An additional arterial line was inserted in the right radial artery to rule out any possibilities of missed coarctation of the aorta. Injection dobutamine was started at a rate of 5 mickg/min to maintain hemodynamic. The child was gradually weaned off from the ventilator after 24 h and extubated after obtaining a

Vinit K. Srivastava, Parineeta Jaisawal, Sanjay Agrawal1, Diwakar Kumar Department of Anaesthesia, Apollo Hospitals Bilaspur, Chhattisgarh, 1 Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India Address for correspondence: Dr. Vinit K. Srivastava, Department of Anaesthesia, Apollo Hospitals Bilaspur, Chhattisgarh ‑ 495 006, India. E‑mail: [email protected]

References 1. Havrilla PL, Kane‑Gill SL, Verrico MM, Seybert AL, Reis SE. Coronary vasospasm and atrial fibrillation associated with ondansetron therapy. Ann Pharmacother 2009;43:532‑6. 2. Moazzam MS, Nasreen F, Bano S, Amir SH. Symptomatic sinus bradycardia: A rare adverse effect of intravenous ondansetron. Saudi J Anaesth 2011;5:96‑7. 3. Hart AM. Cardiac arrest associated with ranitidine. BMJ 1989;299:519. 4. Parkin JV, Ackroyd EB, Glickman S, Hobsley M, Lorenz W. Release of histamine by H2‑receptor antagonists. Lancet 1982;2:938‑9. 5. Weissenburger J, Funck‑Brentano C, Jaillon P, Charbit B. Droperidol and ondansetron in vitro electrophysiological drug interaction study. Fundam Clin Pharmacol 2009;23:719‑26. 564

Sir, Ligation of patent ductus arteriosus (PDA) is one of the simplest cardiac surgery performed with negligible incidence of complications. [1] We describe a case of severe laryngospasm followed by acute ventricular dysfunction during the immediate post‑operative periodinan 8‑month‑old infant who underwent PDA ligation.

Journal of Anaesthesiology Clinical Pharmacology | October-December 2013 | Vol 29 | Issue 4

Letters to Editor

normal blood gas analysis. Injection dobutamine was tapered after 2  days. A  repeat 2D echocardiography revealed an improvement of ventricular dysfunction. A repeat chest X‑ray showed a decrease in cardiomegaly [Figure 3] and the child maintained stable hemodynamic without inotropic support. He

Figure 1: Post‑operative chest X‑ray

was discharged on the 5th post‑operative day. PDA ligation is a common closed heart surgery performed in neonates and infants and complications are minimal. In our case, the child developed laryngospasm and ventricular dysfunction during the immediate post‑operative period. Mc Namara et al. analyzed echocardiography findings before and after PDA ligation in premature infants and found PDA ligation is associated with impaired left ventricular systolic performance attributable to altered loading conditions.[2] In our case, the ventricular dysfunction occurred after extubation and there was no abnormal finding in the pre‑operative echocardiography. Galal et al. studied left ventricular dimensions and performance in 43 patients after surgical ligation of PDA based on ductal diameter and concluded that closure of large ductus arteriosus in children can lead to significant immediate deterioration of left ventricular performance. [3] In our case, the ductus arteriosus was large 5‑6 mm size and could have been the cause of immediate ventricular dysfunction. This dysfunction was attributable to the regression of left ventricular end diastolic diameter and decrease in ejection fraction. Laryngospasm and respiratory distress usually are found in infants under going PDA ligation due to iatrogenic vocal cord paralysis. Zabar et al. reported six cases of vocal cord paralysis who underwent PDA ligation and he noted that premature neonates were at greater risk. [4] In our case, the child developed immediate laryngospasm after extubation, but subsequently was normal after weaning off from the ventilator on next post‑operative day, which rules out any vocal cord paralysis.

Figure 2: Pre‑operative chest X‑ray

Valletta et al. reported the event of acute myocardial dysfunction following acute airway obstruction in a10‑year‑old girl. They attributed acute hypoxia as a causative agent.[5] The above literature studies have shown that PDA ligation is associated with complications such as laryngospasm and ventricular dysfunction. In our case, whether the ventricular dysfunction was a separate entity or it is related to the laryngospasm could not be determined. We believe that, even the incidence of this complication is extremely low it should not be ignored because of its grave prognosis. Bhuvana Vijayakanthi, Minati Choudhury, Milind P Hote, Usha Kiran Department of Cardiac Anaesthesia, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India

Figure 3: Repeat postoperative chest X-ray

Address for correspondence: Dr. Minati Choudhury, Department of Cardiac Anaesthesia, 7th Floor, Room No. 8, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, New Delhi ‑ 110 029, India. E‑mail: [email protected]

Journal of Anaesthesiology Clinical Pharmacology | October-December 2013 | Vol 29 | Issue 4

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References 1. Murray‑Calderon P, Connolly MA. Laryngospasm and non cardiogenic pulmonary edema. J Perianesth Nurs 1997;12:89‑94. 2. McNamara PJ, Stewart L, Shivananda SP, Stephens D, Sehgal A. Patent ductus arteriosus ligation is associated with impaired left ventricular systolic performance in premature infants weighing less than 1000 g. J Thorac Cardio vasc Surg 2010;140:150‑7. 3. Galal MO, Amin M, Hussein A, Kouatli A, Al‑Ata J, Jamjoom A. Left ventricular dysfunction after closure of large patent ductus arteriosus. Asian Cardiovasc Thorac Ann 2006;14:90. 4. Zbar RI, Chen AH, Behrendt DM, Bell EF, Smith RJ. Incidence of vocal fold paralysis in infants undergoing ligation of patent ductus arteriosus. Ann Thorac Surg 1996;61:814‑6. 5. Valletta ME, Haque I, Al‑Mousily F, Udassi J, Saidi A. Transient ventricular dysfunction after an asphyxiation event: Stress or hypoxia? Pediatr Crit Care Med 2008;9:e47‑50. Access this article online Quick Response Code:

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DOI: 10.4103/0970-9185.119138

Difficult airway rescued by a gamjee Sir, Difficult airway has forever posed a challenge to the anesthesiologists. By definition, it is the difficulty posed to either the bag mask ventilation or intubation or both.[1] We present a case after a written informed parental consent in which a seemingly difficult airway was made relatively easy by the use of an alternative device (gamjee pads). A 10‑year‑old, 25 kg boy presented to the operating room with maxillofacial injury minutes after road traffic accident posted for faciomaxillary repair. On examination, his blood pressure (BP) was 90/60 mm, heart rate was 129/min and oxygen saturation (SpO2) was 95% on room air, Glasgow Coma scale E4V5M6. Local examination of the wound revealed 5 cm × 3 cm laceration on the forehead extending up to the left side of the scalp; the cheek was avulsed from the corner of the right ala nasi, including the right sided angle of the mouth to the middle of the right cheek. The lacerated tissue was edematous, friable and actively bleeding. Inside the oral cavity, the right ramus of the mandible was exposed and teeth were missing on the right maxilla and right half of 566

mandible. The right upper incisor was loose. The systemic examination was within normal limits. Patient had a 20 G intravenous access in situ. The parents gave a history of oral intake (chapatti) 8 h back. He was scheduled for repair of the faciomaxillary wound on an emergent basis. We anticipated the following problems:. Potential aspiration of blood; Poor candidate for awake intubation; Difficult Bag and mask ventilation; Difficult Laryngoscopy (loose incisor). The difficult airway cart was kept ready and consent for tracheostomy taken. With the patient in trendelenburg position, we preoxygenated him with 100% oxygen. We planned to follow the modified rapid sequence intubation. Injection Fentanyl thirty micrograms IV and injection midazolam one milligram IV were given as premedication. General anesthesia was induced with titrated doses of injection propofol sixty milligram along with sevoflurane inhalation, injection fentanyl and O2. The spontaneous respiration, however, was maintained. After giving Sellick’s maneuver, a Guedel’s oropharyngeal airway of appropriate size was placed in the mouth and the cheek gap was filled with two equal sized gamjees [Figure 1]. An appropriate sized mask was chosen and positive pressure was given and a fresh gas flow of at least 6 L was maintained. Patient could be ventilated with a leak of only 250 ml. After protecting the loose incisor with another gamjee, laryngoscopy was performed with a left molar approach (by inserting the right sided blade from the left corner of the mouth, directing the tip of the blade posteromedially, such that the view was provided by the flange, the lingual surface of the blade and the tongue bulge on the right) for intubation and suction of the oropharynx was also performed under the guidance. A 6.0 mm cuffed endotracheal tube was inserted and secured on the left angle of the mouth. Following this, the cricoid pressure was released and orogastric tube sized 10 French.

Figure 1: The defect sealed by a gamjee roll and an oropharyngeal airway placed in situ

Journal of Anaesthesiology Clinical Pharmacology | October-December 2013 | Vol 29 | Issue 4

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Patent ductus arteriosus ligation: Do not take it easy.

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