Anesthetic management of a child with corrected transposition of great vessels undergoing non-cardiac surgery
A 14-year-old girl weighing 30 kg presented with deformity of right foot following trauma and gait abnormality for 3 years. During childhood she suffered frequent from respiratory tract infections. Further assessment revealed her to have TGA for which she underwent pulmonary artery banding twice followed by a double switch procedure in childhood. Currently, she was on tablets, ramipril 2.5 mg and hydrochlorothiazide 12.5 mg for afterload reduction.\nPre-anesthetic check-up showed stable vitals except for mild peripheral cyanosis with SpO2 90% on room air. Cardiovascular evaluation revealed sternotomy scar, apex beat on right 5th intercostal space lateral to midclavicular line. No raised jugular venous pressure or parasternal heave was evident. Heart sounds were heard on the right chest and there was no murmur. She had a good effort tolerance.\nLaboratory investigations including haematocrit and electrolytes were normal. Electrocardiogram (ECG) showed heart rate 84 per minute, T wave inversion in V1, V2, and V3. Chest X-ray revealed dextrocardia. 2-D echocardiogram showed dextrocardia, situs inversus, atrioventricular-ventriculoatrial concordance, mild atrioventricular valve regurgitation on both left and right side. A 2.5 mm size ostium secundum atrial septal defect with bidirectional shunt, normal biventricular systolic function, and intact interventricular septum was found. Arterial blood gas on room air revealed pH 7.48, PaCO2 26 mmHg, PaO2 59 mmHg, and HCO3 19 mEq/L. Tab ramipril was continued and hydrochlorthiazide were skipped in the morning during surgery. Once the child was on operating table, baseline monitoring established (NIBP, SpO2, ECG on right side). Intravenous (IV) access 20 G canula left hand and left radial artery cannulated with 22 G canula and hep-locked with precautions not to inject/avoid air-bubbles. Infective endocarditis prophylaxis given with IV ampicillin 1.5 G and gentamycin 40 mg. Induction involved pre-oxygenation, fentanyl 50 μg, etomidate 8 mg, and sevoflurane 2-2.5% in O2. A proseal LMA (PLMA) size 2.5 was inserted following atracurium 15 mg. Controlled ventilation was initiated with tidal volume 250 mL, respiratory rate 13/min, and anesthesia maintained with sevoflurane 1.5-2%, air: O2 mixture with FiO2 40%. The procedure involved repair of tendoachillis tendon under tourniquet. Throughout the procedure (50 min) patient remained stable, maintaining SpO2 94-96%. The patient received 375 mL crystalloids. At the end of the procedure, the neuromuscular blockade was antagonized with neostigmine 1.5 mg and glycopyrrolate 0.3 mg. PLMA was removed once the patient was awake. The postoperative course was uneventful.