Anesthetic management of a 2-day-old with complete congenital heart block
A 2-day-old-male baby, weighing 3 kg, born at full term by normal vaginal delivery presented to our facility with complaints of absent anorectal opening, abdominal distention, drooling of saliva and tachypnoea. On examination, he was found to have bradycardia with a heart rate (HR) of 65-75 beats/min. The electrocardiogram (ECG) performed for evaluation of bradycardia revealed CHB []. On the evaluation of the mother, she was diagnosed to have syphilis, which was considered as the probable cause of the congenital heart block.\nClinical examination revealed a lethargic neonate with abdominal distention and drooling from the mouth. The child was maintaining saturation of 85% on room air. On auscultation, the new born was found to have a HR of 50-55 beats/min with bilateral crepitations in the chest. The respiratory rate was 65/min. He was intubated with 3.5 mm internal diameter endotracheal tube using the midazolam 0.3 mg and mechanically ventilated. There was no hypothermia. The lab investigations revealed a hematocrit of 50%, platelet count of 3.2 lakh, total leukocyte count of 13,500, potassium 5.2 meq/L, creatinine of 1 mg/dL, bicarb of 20.5 meq/L, urea 30, Ca 4.5 meq/L, glucose of 80 mg/dL. An ECG was done, which showed wide QRS complexes and complete dissociation between the p-waves and QRS complexes. The echocardiography revealed a structurally normal heart with a small patent ductus arteriosus. The pediatric cardiologist diagnosed the new born to have a congenital CHB, advised to start dopamine (at 5 μg/kg/min) and isoprenaline (at 2 μg/kg/min) infusions were started to maintain the cardiac output. This increased the HR to about 75-80/min. No signs of cardiac failure were present in this neonate at this time.\nThe child was shifted to the operating room and attached to the ventilator. Oxygen and air were started. All the routine monitors were applied []. Isoprenaline and dopamine were continued. Adult size external adhesive pacemaker pads were applied antero-posteriorly and pacing was started in VOO mode with the pacing rate set to100 beats/min. The current was increased until a capture beat was detected. The threshold current was 60 mAmp. The patient was induced with fentanyl 4 μg, sevoflurane and atracurium 1.5 mg. The endotracheal tube was replaced with a rigid bronchoscope []. The TEF was identified and fogarty catheter was used to exclude the fistula. This was followed by palliative gastrostomy and sigmoid colostomy to relieve the intestinal obstruction. The vitals remained stable throughout the surgery with SpO2 fluctuating between 85% and 92%.