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 Table of Contents  
Year : 2019  |  Volume : 6  |  Issue : 4  |  Page : 470-471

Anaesthetic management of a child with tetralogy of Fallot for dental extraction: a modified technique

Department of Anesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India

Date of Submission27-Dec-2018
Date of Acceptance20-Aug-2019
Date of Web Publication06-Jan-2020

Correspondence Address:
DNB Sunil Rajan
Department of Anesthesiology, Amrita Institute of Medical Sciences, Koch 682041i
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/roaic.roaic_118_18

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How to cite this article:
Rajan S, Tosh P, Sudevan M, Rahman AA, Kumar L. Anaesthetic management of a child with tetralogy of Fallot for dental extraction: a modified technique. Res Opin Anesth Intensive Care 2019;6:470-1

How to cite this URL:
Rajan S, Tosh P, Sudevan M, Rahman AA, Kumar L. Anaesthetic management of a child with tetralogy of Fallot for dental extraction: a modified technique. Res Opin Anesth Intensive Care [serial online] 2019 [cited 2020 Apr 6];6:470-1. Available from: http://www.roaic.eg.net/text.asp?2019/6/4/470/275135

A 3-year-old girl, known case of uncorrected tetralogy of Fallot, weighing 7 kg, was posted for dental caries extraction and filling, before a corrective cardiac repair. A history of cyanotic spells was present. The child had cyanosis and clubbing of toes, and oxygen saturation on room air was 83%. Investigations revealed hemoglobin of 17 g/dl, and ECHO showed a large conoventricular ventricular septal defect (VSD) and long-segment pulmonary atresia, with multiple major aorto-pulmonary collateral arteries.

On the day of surgery, the child was kept fasting 6 h for solids and 2 h for clear fluids. Before taking to the theater, we attempted giving intravenous ketamine, but the child cried and resisted, and it was found that the venous access had bulged. So, ketamine 35 mg was given intramuscularly. The child was immediately taken to the operation room, and when pulse oximeter probe was attached, saturation was found to be 65%. Mask ventilation was initiated with 100% oxygen. Although the bag was moving well, the child continued desaturating to 40%. There was no bradycardia, and on auscultation, chest was found to be clear. A diagnosis of cyanotic spell was made, and both knees were brought to the chest. With adoption of knee-to-chest position, saturation picked up to 90%. However, the child desaturated again when put back in supine position. So knee-to-chest position was maintained, and the saturation remained in 85–90% range. Meanwhile venous access was secured, additional dose of ketamine 10 mg and atracurium 3.5 mg were given. Airway was secured nasally with an uncuffed four-size Ring–Adair–Elwyn tube. Anesthesia was maintained with oxygen in air (50 : 50) and sevoflurane (1.5–2%). As keeping the child in knee-to-chest position would not interfere with the surgical procedure planned, it was decided to keep the child with legs flexed at hip and strapped to the table ([Figure 1]).
Figure 1 Child in knee-to-chest position.

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Intraoperative period was uneventful with stable vitals, saturation of 85–95%, and end tidal carbon dioxide of 30–35 mmHg. The patient was adequately hydrated with 250-ml Ringer lactate. Procedure was completed with the child in knee-to-chest position. At the end of the procedure, the patient was reversed and extubated. Postoperatively, heart rate was 150/min, blood pressure 90/60 mmHg, and SPO2 of 90% with oxygen with facemask at 4 l/min. The child was shifted to ICU and had an uneventful recovery.

Cynotic spell is characterized by a sudden and striking decrease in oxygen saturation owing to acute and complete, or near complete, obstruction of subpulmonary outflow tract precipitated usually with agitation or dehydration, which exacerbates the dynamic infundibular obstruction. The treatment was focused on decreasing pulmonary and increasing systemic vascular resistance [1],[2]. Knee-to-chest position increased systemic vascular resistance. Management included intravenous fluids, oxygen, morphine, propranolol to relieve infundibular spasm, and phenylephrine to increase systemic vascular resistance [3],[4].

For our patient, phenylephrine and propranolol were not used, as initially there was no venous access and later adoption of knee chest position had corrected cyanotic spell. The child underwent definite cardiac correction 2 months later uneventfully. We can conclude that knee-to-chest position may be safely tried to treat a Tet spell in children, and the position may be maintained if it does not interfere with the surgical procedure perioperatively.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Menghraj SJ. Anaesthetic considerations in children with congenital heart disease undergoing non-cardiac surgery. Indian J Anaesth 2012; 56:491–495.  Back to cited text no. 1
Tandale SR, Kelkar KV, Ghude AA, Kambale PV. Anesthesia considerations in neonate with tetralogy of Fallot posted for laparotomy. Ann Card Anaesth 2018; 21:465–466.  Back to cited text no. 2
[PUBMED]  [Full text]  
Bailliard F, Anderson RH. Tetralogy of Fallot. Orphanet J Rare Dis 2009; 4:2.  Back to cited text no. 3
Ahmed T, Sanil Y, Heidemann SM. Hypercyanotic spells. In: Sarnaik A, Ross R, Lipshultz S, Walters H, editors. Cardiac emergencies in children. Cham: Springer. 2018.  Back to cited text no. 4


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