Neurosurgery in a Child with Cyanotic Congenital Heart Disease (CCHD): Is Cardiac Grid Formulation the Panacea?

Cyanotic congenital heart disease (CCHD) is often associated with more than one cardiac anomaly with unique hemodynamic pattern, hence presenting a plethora of challenges to non-cardiac anesthesiologists. Understanding the pathophysiology of the cardiac lesion and constructing a cardiac grid can help in determining intraoperative hemodynamic goals and facilitate smooth perioperative management of such patients. This case report describes the anesthetic management of an infant with dextro-transposition of great arteries (dTGA) with a large atrial septal defect, ventricular septal defect, severe pulmonary stenosis, and patent ductus arteriosus posted for excision and repair of occipital meningocele and highlights the role of cardiac grid in clarifying anesthetic goals and ensuring better outcomes.

Can Echocardiographic Right Ventricular Function Parameters Predict Vasoactive Support Requirement After Tetralogy of Fallot Repair?

OBJECTIVE: To evaluate the role of echocardiographic right ventricular function parameters in predicting postoperative vasoactive inotrope requirement after tetralogy of Fallot repair. DESIGN: Prospective observational study. SETTING: A tertiary care hospital. PARTICIPANTS: Fifty-two children undergoing elective intracardiac repair. INTERVENTIONS: Comprehensive transesophageal echocardiography was performed before and after surgery. Fractional shortening, fractional area change, tricuspid annular plane systolic excursion (TAPSE), right ventricular myocardial performance index, tricuspid annular velocities (S', E', A'), and right ventricular global longitudinal strain and strain rate (RV Gls and RV Glsr) were measured. The ratio of peak systolic pressure of the right and left ventricles (Prv/lv) was measured directly from the surgical field pre- and post-repair. The inotrope requirement during first 24 postoperative hours was calculated using the mean Vasoactive-Inotropic Score (VIS). Pearson correlation analysis was used to study the relation between echocardiographic parameters and VIS as well as Prv/lv and VIS. Receiver operating characteristic analysis was used to study the predictive strength of parameters. MEASUREMENTS AND MAIN RESULTS: Among the measured parameters, both pre- and post-repair TAPSE had significant negative correlation with the mean VIS (p < 0.05). Both pre- and post-repair right ventricular myocardial performance index and S', E', A', RV Gls, RV Glsr, Prv/lv also had significant correlation with the mean VIS (p < 0.05). Of these, TAPSE, RV Gls, RV Glsr, and Prv/lv had significant predictive strength (p < 0.05) and reasonable sensitivity and specificity (area under the curve > 0.6) for predicting high mean VIS (VIS > 20). CONCLUSION: Tricuspid annular plane systolic excursion, RV Gls, RV Glsr, and Prv/lv could predict a postoperative high mean VIS with significant strength and reasonable sensitivity and specificity.

Bilateral Erector Spinae Plane Block for Acute Post-Surgical Pain in Adult Cardiac Surgical Patients: A Randomized Controlled Trial.

OBJECTIVES: To examine the analgesic efficacy of bilateral erector spinae plane (ESP) block compared with conventional treatment for pain after cardiac surgery in adult patients. DESIGN: A prospective, randomized, controlled, single-blinded study. SETTING: Single-center tertiary teaching hospital. PARTICIPANTS: One hundred and six adult patients undergoing elective cardiac surgery with cardiopulmonary bypass. INTERVENTIONS: Patients were randomized into 2 groups. Patients in group 1 (ESP block group, n = 53) received ultrasound-guided bilateral ESP block with 3 mg/kg of 0.375% ropivacaine before anesthesia induction at the T6 transverse process level. Patients in group 2 (paracetamol and tramadol group, n = 53) received paracetamol (1 gm every 6 hours) and tramadol (50 mg every 8 hours) intravenously in the postoperative period. The primary study outcome was to evaluate pain at rest using an 11-point numeric rating scale (NRS). Mann-Whitney U test was used for comparing NRS scores. MEASUREMENTS AND MAIN RESULTS: The postoperative pain level after extubation and duration of analgesia during which NRS was < 4 of 10 was compared between the groups. The median pain score at rest after extubation in group 1 was 0 of 10 until hour 6, 3 of 10 at hour 8, and 4 of 10 at hours 10 and 12 postextubation. These were significantly less in comparison with group 2 (p = 0.0001). Patients in group 1 had a significantly higher mean duration of analgesia (8.98 ± 0.14 hours), during which NRS was < 4 of 10, compared with group 2 (4.60 ± 0.12 hours) (p = 0.0001). CONCLUSION: ESP block safely provided significantly better pain relief at rest for longer duration as compared to intravenous paracetamol and tramadol.