Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 25475

AbstractCase ReportDiscussionConclusionAcknowledgementReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case report
Year : 2023 | Month : January | Volume : 17 | Issue : 1 | Page : UD01 - UD03 Full Version

Unravelling the Convoluted Story of Perioperative Care in Three-year-old Child with Tetralogy of Fallot Undergoing Repair Surgery


Published: January 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/58065.17254
Aishwarya Nayak, Sanjot Ninave, Dhawal Wadaskar, Prasad Panbude, Amol Bele

1. Junior Resident, Department of Anaesthesia, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharastra, India. 2. Professor, Department of Anaesthesia, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharastra, India. 3. Associate Professor, Department of Anaesthesia, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharastra, India. 4. Assistant Professor, Department of Anaesthesia, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharastra, India. 5. Assistant Professor, Department of Anaesthesia, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharastra, India.

Correspondence Address :
Dr. Sanjot Ninave,
Professor, Department of Anaesthesia, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharastra, India.
E-mail: drsusann02@rediffmail.com

Abstract

Tetralogy of Fallot (TOF), one of the most prevalent cyanotic congenital heart diseases in children. Single step corrective surgery, early on in life, provides a fair expectation of favourable outcome in these individuals. However, complex, and skilled anaesthetic management is required by experienced team of healthcare providers. Preoperative surgical preparation, intraoperative key anaesthesia principles and postoperative care Intensive Care Unit (ICU) are all perioperative considerations in these patients. The present article reports challenges faced in the perioperative anaesthesic management of a 3-year-old male child having uncorrected TOF, who underwent Waterston shunt and later Intracardiac Repair (ICR). He presented with postoperative complication like cyanotic spell, gastrointenstinal bleeding, sepsis; but later, recovered successfully.

Keywords

Anaesthesia, Congenital cyanotic heart disease, Cyanotic spell, Intracardiac repair, Waterston shunt

Case Report

A 3-year-old male child having congenital heart disease of tetralogy of fallot (diagnosed at birth) was posted for one step corrective surgery and preanaesthetic check-up was requested. He had chief complaints of bluish discolouration of lips and nail beds, breathlessness, and intermittent loss of consciousness after crying or excessive playing. The child became limp off and on after any rigorous activity. These episodes lasted for 3-5 minutes and occurred 5-6 times in a month. Increased frequency of these episodes was observed since last 3-4 months, which subsided after maintaining a knee-chest position or on reassurance by the mother. The child was born vaginally, at term gestation and was admitted in Neonatal Intensive Care Unit (NICU) for difficulty in breathing and had a birth weight of 1.5 kg. There was delay in achieving developmental milestones with a reported ability to sit at age of 1.5 years. The child is not able to stand and/or walk at the age of three years and can speak only in monosyllables. He was receiving tablet propranolol 5 mg twice daily since birth.

The weight and height of the child was 6.1 kg and 77 cm, respectively, with a body surface area of 0.36 m2. He was afebrile, with a pulse of 102 bpm (beats per minute), respiratory rate of 26/min. There was no pallor, icterus, lymphadenopathy, or oedema on the feet. Jugular venous pressure was normal. Cyanosis was present on lips, tongue, fingers and toes, there was grade 3 clubbing and oxygen saturation was 40% on room air. On inspection of the precordium, there was visible apical impulse, and thrill was palpable at second intercostal space along the sternal border. Parasternal heave was present. S1 and S2 heart sound were heard normally. Pansystolic murmur was present on lateral border of sternum in 2nd intercostal space. There was no chest wall deformity and accessory muscle for respiration were not used.

The ejection fraction was 65% on 2D echocardiography examination. There was a large, bidirectional, Ventricular Septal Defect (VSD) of 12 mm size. The pulmonary arteries were grossly hypoplastic with a severe infundibular pulmonary stenosis with pressure gradient of 68 mmHg. The pulmonary valve annulus was 6 mm. The superior vena cava was grossly dilated and Tetralogy of Fallot (TOF) was seen. Boot-shaped heart was seen on chest x-ray (Table/Fig 1).

As a part of preoperative preparation, the baby was kept nil by mouth for 4 hours, intravenous (i.v.) cannula was secured, and i.v. fluids Dextrose Normal Saline (DNS) (2 mL/kg) was started to maintain adequate hydration. Adequate blood and blood products were cross matched and kept ready. Informed consent was obtained from patient’s father after counselling, about risk of anaesthesia, postoperative complications of surgery and chance of prolonged Intensive Care Unit (ICU) stay. Precaution was taken to avoid hypothermia. Initially, Blalock-Taussig (BT) shunt was planned, but because of unfavourable anatomy, the surgical team had opted to perform Waterston’s shunt. During preinduction of anaesthesia, the child went into a cyanotic spell, blood pressure dropped to 60 mmHg and SpO2 (oxygen saturation) fell to 10%. To increase the systemic vascular resistance, the anaesthetic team tried to calm the child and make him comfortable in knee-chest position and 100% O2 was given. A fluid bolus was given, and acidosis was corrected after injecting sodium bicarbonate in bolus dose as per body weight. Injection phenylephrine was given as per requirement to treat hypotension. Patient responded to the given treatment and became vitally stable.

Anaesthesia was induced with inj. midazolam (0.05 mg/kg), inj. fentanyl (1 mcg/kg), inj. ketamine (2 mg/kg), inj. vecuronium (0.1 mg/kg) as per calculated dose per kg body weight in i.v. route and the child was intubated with No.5 uncuffed endotracheal tube and maintained on oxygen and air. Injection vecuronium was used for topping up of anaesthesia. Central Venous Pressure (CVP), Invasive Blood Pressure, temperature was monitored as per standard American Heart Association (AHA) monitoring. Normothermia and normocapnia was maintained. Intravascular fluid volume with attention to blood sugar monitoring was done.

Meticulous care was taken to avoid air bubbles entering the tube used to deliver intravenous fluid. Waterston Shunt was done using pericardial tube. Waterson shunt is side-side anastomosis of right pulmonary artery to ascending aorta. Anastomosis of Right Pulmonary Artery (RPA) to aorta was done. Postoperatively, the patient was shifted to intensive care unit on ventilatory and ionotropic (noradrenaline and adrenaline) support. In postoperative period, good analgesia was achieved with Inj. dexmedetomidine infusion and Inj. paracetamol as per body weight. The child was extubated on Postoperative Day (POD) 4, was vitally stable and maintained saturation of 80% on two litres of oxygen and was shifted to regular ward on POD 8.

On POD 10, the child suddenly desaturated and SpO2 fell to 20%. He was shifted to ICU and was diagnosed to have a cyanotic spell and severe metabolic acidosis as per Arterial Blood Gas (ABG) report {pH-6.8, (partial pressure of carbon dioxide) pCO2-48, pO2-25, (partial pressure of oxygen) lactate-15 ) (Table/Fig 2). He was managed conservatively (knee-chest position). On Transthoracic Echocardiography (TTE), good flow across the shunt was noted. He was shifted to ICU and intubated. Intravenous heparin 500 IU was given followed by 100 IU per hour, intravenous infusion. In view, of the deteriorating condition and haemodynamics, the patient was taken up for Intracardiac Repair (ICR) under high risk.

Intracardiac repair was done under anaesthesia and the child was managed postoperatively in ICU, ventilated mechanically, and kept on ionotropic support. He was extubated on POD 2 of ICR. On POD 3 of ICR, there was sudden fall in saturation, and we suspected aspiration due to Gastrointestinal (GI) bleed, secondary to thrombocytopaenia as platelet was 32000 cells/μL. Ryle’s tube bleed and melena was present. Cold saline irrigation was done. The child was again intubated and shifted to mechanical ventilation in view of drop in saturation and suspected aspiration. Dexamethasone and heparin were stopped to avoid steroid or heparin induced thrombocytopenia. Multiple Packed Red Cells (PRC), Fresh Frozen Plasma (FFP) and platelets were transfused as per body weight to maintain haemoglobin and platelet within normal range.

On post operative day 4 of ICR, the child developed with sepsis i.e high grade fever, tachycardia, hypotension, high total leucocyte counts (22600 cumm) and low platelet count (32000 cells/μL); so blood culture, Endotracheal Tube (ET) culture and urine culture were immediately sent. Blood investigations- Complete Blood Count (CBC), C-Reactive Protein (CRP), serum lactate and chest 2X-ray was done. It was found that Total Leucocyte Count (TLC) (18000 cumm) and CRP (47.28 mg/L) values were higher than normal values. Platelet count was low (28,000 cells/μL). In x-ray, there was bilateral haziness present in lower lobes. The antibiotics were escalated and Inj. colistin 90,000 IU TDS and Inj. meropenem 200 mg TDS were started, within the 1st hour of recognising sepsis. Fluid challenge was given and multiple inotropes started in view of persistent hypotension. Chest physiotherapy and nebulisation were given to manage the secretion overload.

In postoperative period, anaesthesia team maintained the child, with adequate filling and started phosphodiesterase inhibitors (sildenafil) and ionodilators (milrinone, dobutamine). The child responded well to the treatment and was extubated on POD 6 of ICR and managed conservatively (Inj. digoxin 0.06 mg i.v. once a day, Inj. furosemide 3 mg i.v., Inj. pantoprazole). Then he was shifted to step-down ward and discharged from hospital on POD 10 in stable condition. The 2D echocardiography on discharge showed signs of TOF repair. The Ventricular Septal Defect (VSD) patch was in-situ and there was no residual VSD. There was mild residual Pulmonary Stenosis (PS) with pressure gradient of 34 mmHg. Free pulmonary regurgitation was present with normal biventricular function.

Discussion

Tetralogy of Fallot (TOF) is one of the most prevalent cyanotic congenital heart disorders (1). Four main characteristics of TOF include (2):

1. Ventricular Septal Defect (VSD)
2. Right Ventricular Outflow Tract Blockage (RVOTO), which is often dynamic
3. Over-riding aorta and
4. Right Ventricular Hypertrophy (RVH).

The presentation and prognosis of this disease are determined by the degree of RVOTO, relative pressures in the right and left ventricles and the proportion of the aorta over-riding the VSD (2). Several perioperative risk factors need to be considered for patients with TOF, whose presentations might vary in complexity. The first factor is the severity of disease, which is assessed by the heart’s preoperative oxygenation and function.

In most circumstances, corrective surgery is performed in a single phase, and if done, quickly enough, positive results can be anticipated. Anaesthetists may encounter this condition before to or during repair, thus, they should be familiar with its relevant anatomy, physiology, and emergency care. Its presence increases the perioperative risk and mortality. Preoperative planning for surgery, managing the anaesthesia during surgery, and managing common postoperative problems in the critical care unit are all perioperative issues for these patients.

Anaesthesiologists face various challenges while managing a child undergoing repair surgery for uncorrected TOF. They must have a full understanding of the pathophysiology, events, and effects of drugs that can change the degree of right to left shunting. Maintaining normovolemia, minimising hypoxia, and avoiding changes in Systemic Vascular Resistance (SVR) and Peak Vascular Resistance should all be goals of. In the present case, during preinduction of anaesthesia, the child went into a cyanotic spell, blood pressure dropped to 60 mmHg and SpO2 fell to 10%. Cyanotic episodes are typically brought on by either a drop in SVR or a spasm of the heart muscle in the vicinity of the RVOT as a result of sympathetic activation (infundibular spasm) (3). Adrenergic agonists like phenylephrine or norepinephrine and intravenous (i.v.) fluids are used to treat any drop in SVR, whereas beta blockers like propranolol or esmolol are used to treat infundibular spasm.

In present case, on postoperative day 10, the child suddenly desaturated due to cyanotic spell and severe metabolic acidosis. He was managed medically and heparinised, however due to deteriorating condition and haemodynamics, he was taken up for ICR. As there was unfavourable anatomy for BT shunt i.e evidence of large 12 mm subaortic VSD, grossly hypoplastic Pulmonary Arteries (PA) (MPA-5 mm, LPA/RPA -4.2 MM), and severe infundibular pulmonary stenosis with pressure gradient 68 mmHg, surgeons decided to perform Waterston shunt. However, the child could not maintain oxygen saturation and had to be taken for intracardiac surgery. The Waterston shunt is preferred by for palliative treatment of cyanotic congenital heart disease with decreased pulmonary blood flow (4), though intracardiac repair surgery is definitive treatment.

However, on postoperative day 4 of ICR, the child developed sepsis i.e high grade fever, tachycardia, hypotension, high total leucocyte counts (22600 cumm) and low platelet counts (32000 cells/μL). Yaroustovsky M et al., suggested that one of the main issues with paediatric intensive care to this day is sepsis (5). Infants with chronic illnesses and congenital problems, as well as, low birth weight newborns, are particularly vulnerable. It is estimated that 15-30% of paediatric heart surgery patients would experience infection problems (5). As a result, early sepsis treatment reduces the length of ICU stays and increases the survival rate of children after cardiac surgery. According to Oliveira DC et al., sepsis after cardiac surgery is a rare occurrence, with a reported prevalence of 0.39% to 2.5%. Patients who develop severe sepsis following heart surgery, have a significant death rate, ranging from 65 to 79% (6). They also require prolong mechanical ventilation, as well as, intensive care and hospital stay. Early detection, aggressive fluid resuscitation, appropriate antibiotic therapy, source control and organ support should be done for sepsis management (7).

After intracardiac surgery, Gastrointestinal (GI) bleeding, is a serious and often fatal complication (8). Elgharably H et al., reported Gastrointestinal Complications (GICs) in 1037 patients (3.5%) out of 29,909 cardiac surgical procedures, with overall in-hospital mortality of 14% compared to 1.6% in those without GICs. Mesenteric ischaemia, Hepatopancreatobiliary (HPB) dysfunction, and gastrointestinal haemorrhage were the most fatal GICs (9). Welsh GF et al., reported that within 30 days after open-heart surgery, 16 (0.22%) of the 7,333 patients developed significant gastrointestinal bleeding (8). Early recognition and aggressive treatment of GI bleed are necessary to improve the postoperative outcomes (9).

The present case report, mainly focusses on expert anaesthesia management and excellent nursing care, which helped in managing the complicated case successfully. The patient response was positive to conservative management. The patient was recovered satisfactorily and discharged on 10th postoperative day of ICR.

Conclusion

Children with tetralogy of fallot are at high risk for anaesthesia management. Anaesthesiologists have to deal with TOF patient in cardiac catheterisation laboratory, TOF with cerebral abscess posted for Magnetic Resonance Imaging (MRI), neurosurgery, TOF with non cardiac surgery, TOF posted for BT shunt/ICR. Management starts with proper preanaesthesia check-up, preoperative advice and preparation for surgery. Postoperative monitoring and care is equally important as intraoperative care management. Cyanotic spells may prove life-threatening and deserve prompt treatment. Sepsis is another life-threatening condition, which may adversely affect the outcome of children affected by RVOTO and needs prompt recognition and aggressive management to save life. Multidisciplinary approaches involving anaesthesiologists, surgeons, paediatric cardiologists and neonatologist is essential in managing these patients.

Acknowledgement

The authors are thankful to the Department of CVTS, Cardiology and Paediatrics at AVBRH, Jawaharlal Nehru Medical College, Sawangi (M), Wardha, Maharashtra, India.

References

1.
Yi K, Wang D, Xu J, Zhang X, Wang W, Gao J, et al. Surgical strategies for preservation of pulmonary valve function in a radical operation for tetralogy of fallot: A systematic review and meta-analysis. Front Cardiovasc Med. 2022;9:888258. [crossref] [PubMed]
2.
Wilson R, Ross O, Griksaitis MJ. Tetralogy of fallot. BJA Educ. 2019;19(11):362-69. [crossref] [PubMed]
3.
https://johnsonfrancis.org/professional/cyanotic-spell-or-tet-spells/Cyanotic spells – All About Cardiovascular System and Disorders (johnsonfrancis.org).
4.
Lansing AM. A simplified technique for performing the Waterston shunt. Ann Thorac Surg. 1971;11(4):385-7. [crossref] [PubMed]
5.
Yaroustovsky M, Abramyan M, Rogalskaya E, Komardina E. Selective polymyxin hemoperfusion in complex therapy of sepsis in children after cardiac surgery. Blood Purif. 2021;50(2):222-29. [crossref] [PubMed]
6.
Oliveira DC, Oliveira Filho JB, Silva RF, Moura SS, Silva DJ, Egypt ES, et al. Sepsis in the postoperative period of cardiac surgery: Problem description. Brazilian Archives of Cardiology. 2010;94:352-56. [crossref] [PubMed]
7.
Paternoster G, Guarracino F. Sepsis after cardiac surgery: From pathophysiology to management. J Cardiothorac Vasc Anesth. 2016;30(3):773-80. [crossref] [PubMed]
8.
Welsh GF, Dozois RR, Bartholomew LG, Brown Jr AL, Danielson GK. Gastrointestinal bleeding after open-heart surgery. J Thorac Cardiovasc Surg. 1973;65(5):738-43. [crossref] [PubMed]
9.
Elgharably H, Gamaleldin M, Ayyat KS, Zaki A, Hodges K, Kindzelski B, et al. Serious gastrointestinal complications after cardiac surgery and associated mortality. Ann Thorac Surg. 2021;112(4):1266-74. https://johnsonfrancis.org/ professional/cyanotic-spell-or-tet-spells/Cyanotic spells-All About Cardiovascular System and Disorders (johnsonfrancis.org). [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2023/58065.17254

Date of Submission: May 27, 2022
Date of Peer Review: Jul 11, 2022
Date of Acceptance: Nov 06, 2022
Date of Publishing: Jan 01, 2023

Author declaration:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: May 31, 2022
• Manual Googling: Oct 25, 2022
• iThenticate Software: Nov 04, 2022 (10%)

Etymology: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com