Anaesthetic management in a child with an atypical triad for reconstructive scoliosis surgery
An 11-year-old, 26-kg female patient was admitted in orthopaedic unit with complains of backache, difficulty in walking and deformity of spine and was diagnosed case of G6PD deficiency and CP. She had severe thoracolumbar scoliosis (Cobb's angle - 55°) and was planned for surgical correction of the deformity. She had a history of premature delivery with low birth weight (1500 g) and epilepsy on oral carbamazepine for the last 5 years. On chest auscultation, bilateral coarse crepitations in lower zones and a pansystolic murmur in precordial area were heard.\nPulmonary function tests (PFT) and echocardiography with colour Doppler were advised, but the patient was not able to perform PFT. Echocardiography showed moderate pulmonary artery hypertension (pulmonary artery pressure - 32 mmHg) with left ventricular ejection fraction of 70%and grade-3 mitral regurgitation. Patient was scheduled for surgery after optimizing chest condition with full course of antibiotics and bronchodilators. On the day of surgery, infective endocarditis prophylaxis was instituted (amoxicillin 1 g PO and Inj.Gentamicin 40 mg 1 h prior to the surgery) in view of severe regurgitant lesion.\nAfter obtaining written informed parental consent the child was transferred to the operating room and all baseline monitors (non-invasive blood pressure, continuous electrocardiogram, oxygen saturation-pulse oximeter and bispectral index) were attached. Child was pre-medicated with glycopyrrolate (125 μg IV) and fentanyl (60 μg IV). Anaesthesia was induced with propofol (60 mg IV) and muscle relaxation was achieved by administration of atracurium besylate (15 mg IV). Trachea was intubated with cuffed endotracheal tube and anaesthesia was maintained with rate controlled infusion of propofol (6 mg/kg/h, following the 10-8-6 regimen to achieve effective plasma concentration).[] Atracurium (0.5 mg/kg/h) and fentanyl (1 μg/kg/h) with 50% O2 in air. Left radial artery and ultrasound guided right internal jugular vein cannulation were carried out for continuous haemodynamic and central venous pressure monitoring respectively. Peripheral nerve stimulator was applied and urinary catheter and nasopharyngeal temperature probe were inserted. Appropriate measures to maintain normothermia were employed including warming blankets and warm fluids infusion. Intraoperatively, wake-up test was performed successfully. Tranaexemic acid (loading dose of 10 mg/kg just before surgical incision followed by continuous infusion of 1 mg/kg/h until closure of skin incision) was also administered to minimise intra-operative blood loss. Surgery lasted for nearly 7 h with approximate blood losses of 1200 ml, which was adequately replaced.\nPost-operatively, patient was transferred to intensive care unit (ICU) for elective ventilation in view of hypothermia (32°C) following prolonged surgery, which was not responding to aforementioned warming measures. Patient was electively ventilated for next 24 h on continuous infusion of fentanyl (2 μg/kg/h IV) and dexmedetomidine (0.2 μg/kg/h IV). Trachea was extubated next day uneventfully. On day 3, patient was shifted to high dependency unit and subsequently discharged on the 7th day without any complication.