Background:
Functional changes in the myocardium secondary to increased intracranial pressure (ICP) are studied sparingly. Direct echocardiographic changes in patients with supratentorial tumors have not been documented. The primary aim was to assess and compare the transthoracic echocardiography changes in patients with supratentorial tumors presenting with and without raised intracranial pressure for neurosurgery.
Methods:
Patients were divided into two groups based on preoperative radiological and clinical evidence of midline shift of <6 mm without features of raised ICP (Group 1) or greater than 6mm with features of raised ICP (Group 2). Hemodynamic, echocardiographic, and optic nerve sheath diameter (ONSD) parameters were obtained during the preoperative period and 48 h after the surgery.
Results:
Ninety patients were assessed, 88 were included for analysis. Two were excluded based on a poor echocardiographic window (1) and change in the operative plan (1). Demographic variables were comparable. About 27% of the patients in Group 2 had ejection fraction <55% and 21.2% had diastolic dysfunction in Group 2 in the preoperative period. There was a decrease in the number of patients with a left ventricular (LV) function <55% from 27% before surgery to 19% in the postoperative period in group 2. About 5.8% patients with moderate LV dysfunction in the preoperative period had normal LV function postoperatively. We found a positive correlation between ONSD parameters and radiological findings of raised intracranial pressure.
Conclusion:
The study demonstrated that in patients with supratentorial tumors with ICP, cardiac dysfunction might be present in the preoperative period.
An 8-year-old boy with a past medical history of scoliosis presented for elective percutaneous growth rod distraction. General anaesthesia was induced uneventfully and positive pressure ventilation commenced with an anaesthetic machine ventilator (Dr€ ager Medical GmbH, L€ ubeck, Germany). The capnography waveform displayed an abnormal phase three, but immediately returned to baseline at the beginning of the phase. There was also an overall low end-tidal carbon dioxide concentration (ETCO 2 ) of around 2.5 kPa. A large difference in measured inspiratory and expiratory oxygen and nitrous oxide concentrations of 35 % and 50 %, respectively, was also noted. There was an audible air leak near the Y-piece of the breathing circuit, thus the circuit was changed. However, there was no improvement in the capnography waveform and there was a persistent leak alarm on the anaesthetic machine. We checked and eliminated a blocked water trap or a loose connection as the cause. Finally, we decided to replace the gas sampling line (Dragerwerk AG & Co. KGaA, Lubek, Germany) with a new one. The capnography waveform and ETCO 2 concentration gradually returned to normal. On careful inspection of the replaced gas sampling line, we found the male-to-male luer lock connector at both ends to be defective. The inner small tubular prolongation was missing at both ends (Fig. 1).Figure 1 Defective male luer lock connectors with absence of tubular prolongation.
Long QT syndrome (LQTS) is a myocardial repolarisation disorder caused by cardiac ion channelopathy and one of its common presentations is recurrent syncope. This reduced repolarisation reserve in LQTS can be unmasked by perioperative factors like electrolyte imbalance, drugs, hypothermia and changes in cardiac autonomic tone. We report the anaesthetic management of left thoracoscopic sympathectomy in a 5-year-old child with LQTS and epicardial pacemaker in situ. It is very challenging to isolate the lung on one hand and prevent the predisposition to torsadogenic potential on the other.
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