Aim & Objective: To highlight the importance of anesthetic management in a small neonate with cleft lip, cleft palate, single kidney, atrial septal defect, posted for trachea-oesophageal stula repair. Case description:Afemale baby born at 35 weeks of gestation to a 23-year-old primigravida mother by caesarean section in view of foetal distress with breech presentation .Baby had difculty in breathing and froathing from mouth. Cleft lip and cleft palate was present. Anasogastric tube was not going beyond 11 cm per oral route. Chest x ray showed coiling of tube in upper esophagus.F/S/O Type C Tracheo esophageal stula. . Plain Xray abdomen showed presence of bowel gas. Ultrasonography of the abdomen showed right renal agenesis. The left kidney was normal. Echocardiography showed presence of atrial septal defect with left to right shunt, tiny patent ductusarteriosus, mild pulmonary arterial hypertension, mild tricuspid regurgitation. Based on the presence of tracheoesophagealstula, atrialseptal defect, unilateral renal agenesis and absence of features, suggestive of alternative diagnosis infant, meet criteria of vacteral association. Discussion: VACTERL is a cluster of congenital malformations based on the non-random association of various congenital malformations in a single patient. Here “V” denotes vertebral defects or vascular anomalies (single umbilical artery), “A” anal atresia, “C” cardiac abnormalities, “TE” tracheoesophageal stula, “R"renal (kidney) abnormalities and “L” for limb anomalies) Diagnosis of VACTERL association is done only when at least three of the above mentioned congenital malformations are identied in a patient. Although 80% of these cases have vertebral defects, our case is unique as patient does not have one of the commonest occuring association i.e., vertebral anomalies. The other highlight of this case is although reports say that VACTERL babies with ipsilateral renal disorder have the same side limb defects, our case has a renal anomaly with no limb anomaly. Conclusion: Anaesthetic challenges were difcult airway, endotracheal tube placement, low respiratory reserve, small maximum allowable blood loss, long duration of surgery, risk of hypothermia, aspiratedlungs, risk of right to left shunt, difculty in securing intravenous line and intra arterialline. this case needs continuous monitoring of ECG, invasive blood.
INTRODUCTION: Pheochromocytoma is pharmacologically volatile, potentially lethal catecholamine- Containing tumor of chromafn tissues 1 . Pediatric pheochromocytomas, although rare, have an increased incidence of bilateral, multifocal, and familial preponderance when compared to 2 adults. It occurs in less than 2% of pediatric patients with hypertension and is a diagnosis of exclusion . They are usually located in adrenal medulla 3 or sympathetic paraganglia but may be found anywhere chromafn tissue exists. These locations extend from the base of skull to anus . Traditionally it was thought that 90% of pheochromocytoma are found in adrenal medulla and 10% occuredelse where. Prevalence of extra adrenal 4 tumorsis now thought to be as high as 20%.theseare commonly called paragangliomas . RESULT: The child was premedicated with midazolam 30mcg/kg intravenously and was transferred to the operating room on an infusion of normal saline 60 mL/hr and hydrocortisone 10mg/hr according to the endocrinologist's advice. After instituting electrocardiogram (ECG), noninvasive blood pressure (NIBP), and pulse oximeter (SpO2) monitors, the child was pre-oxygenated and anesthesia was induced with propofol2 mg/Kg and fentanyl 2 mcg/Kg. Endotracheal intubation was facilitated with vecuronium0.1 mg/Kg. Right internal juglar vein and right radial artery were cannulated for continuous invasive pressure monitoring. A19G epidural catheter was inserted in T8-T9 interspace for analgesia. CONCLUSION: On the basis of these case reports, we want to emphasize that while dealing with surgeries of pheochromocytomahaemodynamic instability should be kept in mind. Preoperative blood pressure optimization is necessity along with intraoperative beat to beat monitoring and use of titrated doses of antihypertensive accordingly. Persistent hypertension after removal of pheochromocytoma occasionally signies that a residual tumor is present, so post operative biochemical assay and imaging studies are repeated for conrmation and further management.
Background: To observe the correlation of central venous oxygen saturation (ScvO 2 ), serum lactate, standard base excess (SBE), and anion gap (AG) in septic and septic shock patients resuscitated with early goal-directed therapy (EGDT). Materials and Methods: A review was made of 130 severe septic shock patients (15–65 years) according to the consensus conference criteria admitted in intensive care unit. Blood samples were obtained from arterial and central venous line for ScvO 2, serum lactate, SBE, and AG on admission and after achieving all aims of EGDT i.e.; mean arterial pressure >65 mmHg, central venous pressure = 8–12 mmHg, ScvO 2 >70%, and urine output >0.5 mL.kg −1 .h −1 , and on 12 and 24 h. The statistical analysis was done using SPSS for windows version 16 software. For comparison, Pearson test was used. A P < 0.05 was considered as statistically significant. Results: There were a positive correlation between ScvO 2 and SBE, a negative correlation between ScvO 2 and AG, a negative correlation between ScvO 2 and lactate, a negative correlation between SBE and AG, a negative correlation between AG and lactate, and a negative correlation between SBE and lactate. The ScvO 2 was initially low but was in an improving trend after a resuscitative period, SBE was initially low and correction of SBE was linear. AG was high in the beginning and goes on decreasing after resuscitation. Lactate level was also high initially and in decreasing trend after a resuscitative period. Conclusions: ScvO 2 and SBE are correlated and can be used as a surrogate marker. ScvO 2 and AG are related but not absolutely codependent. ScvO 2 and lactate are correlated but they are not absolutely codependent. SBE and AG are correlated and can be used as a surrogate marker. AG and lactate are not related to each other. Hence, AG cannot be considered as a surrogate for lactate testing. SBE and lactate are related and can be used as a surrogate marker.
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