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LETTER TO EDITOR
Year : 2018  |  Volume : 19  |  Issue : 2  |  Page : 101-102
 

Unusual cause of respiratory distress postoperatively in neonate operated for intestinal duplication cyst


Department of Anaesthesia, B J M C and Sassoon General Hospital, Pune, Maharashtra, India

Date of Web Publication15-Nov-2018

Correspondence Address:
Dr. Sanyogita Vijay Naik
Department of Anaesthesia, B J M C and Sassoon General Hospital, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_42_18

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How to cite this article:
Tandale SR, Naik SV, Abhade SR, Birnale CD. Unusual cause of respiratory distress postoperatively in neonate operated for intestinal duplication cyst. Indian Anaesth Forum 2018;19:101-2

How to cite this URL:
Tandale SR, Naik SV, Abhade SR, Birnale CD. Unusual cause of respiratory distress postoperatively in neonate operated for intestinal duplication cyst. Indian Anaesth Forum [serial online] 2018 [cited 2022 Aug 13];19:101-2. Available from: http://www.theiaforum.org/text.asp?2018/19/2/101/245549




Sir,

An 8-day-old male child, born at 38th gestational weeks, weighing 3.2 kg was referred to our institute with provisional diagnosis of intestinal obstruction as suggested by abdominal ultrasound. Physical examination of child revealed tachypnea, heart rate 160 bpm, blood pressure of 68/48 mmHg, and pulse oximetry reading 98% with 2 L O2. Emergency laparotomy was planned under general anesthesia and caudal analgesia. Preoperative hemogram, renal function test, liver function test, serum electrolytes, and arterial blood gas (ABG) analysis were normal. Chest X-ray (CXR) revealed normal cardiac size. General anesthesia was induced with intravenous ketamine 3.2 mg, inhalation of sevoflurane 8% with oxygen, and atracurium followed by orotracheal intubation. Caudal analgesia was given with 3.2 cc of 0.1% bupivacaine with sterile technique. Anesthesia was maintained with 100% oxygen (as air not available at our institute), isoflurane, and incremental dose of fentanyl and atracurium. Intraoperatively, small intestinal duplication cyst was noted with evidence of obstruction. Excision of cyst was performed followed by resection of bowel and stoma. Vital signs remained stable intraoperatively. A volume of 45 ml blood loss was replaced with whole blood and 1% dextrose ringer lactate was used for maintenance and replacement of evaporative losses. Postextubation, the neonate was maintaining his expiratory blast, heart rate, and reflex activity and was given oxygen by nasal prongs at 2 lit/min. On postoperative 2nd day, neonate developed tachypnea and chest indrawing required nasal continuous positive airway pressure with oxygen 5 L/min and pressure 5 cm H2O. Heart rate and blood pressure were 173/min and 70/50 mmHg, respectively. CXR, ABG, and abdominal ultrasound were done and were normal. Hemoglobin, metabolic screening, and serum electrolytes were normal. Analgesia was given with intravenous paracetamol 30 mg three times a day. Two-dimensional echocardiography was advised by pediatrician in view of persistent chest indrawing. Echocardiography revealed nonobstructive cardiac total anomalous pulmonary venous connection (TAPVC) with four pulmonary veins draining into coronary sinus, small 3-mm ostium secundum defect with right-to-left shunt, severe pulmonary hypertension (55 mmHg), and normal systemic venous drainage with right atrial and ventricular dilatation. Cardiothoracic opinion was sought for same and they advised intracardiac repair. We lost follow-up after referral as patient's relative took discharge against medical advice.

Respiratory distress is a common problem in neonates and causes may be respiratory, cardiovascular, central, metabolic, hematological, and surgical.[1] TAPVC represents 1% of congenital heart disease in which pulmonary veins drain into the right atrium either directly or indirectly.[2] Based on connection, they are divided into four types: supracardiac (50%) draining into innominate vein, infra diaphragmatic (20%) draining into hepatic and portal vein, cardiac (20%) draining into coronary sinus, and mixed (10%) is combination of any of type.[2] Various associated congenital malformation seen with TAPVC are asplenia, polysplenia, midline liver, and intestinal malrotation.[3] Patients with TAPVC with obstruction present with progressive cyanosis and respiratory distress soon after birth.[4] Patients with TAPVC without pulmonary venous obstruction are usually asymptomatic at birth (as in our case), but at least 50% become symptomatic within 1st month of life.[4] Clinical presentation depends on the degree of pulmonary venous obstruction and extent of mixing of blood between right and left atrium. Here, the autism spectrum disorder allows the free communication between two atria and mixing of the venous blood. Postnatal decrease in pulmonary vascular resistance along with significantly decreased left side compliance promotes the delivery of mixed systemic and pulmonary venous blood to pulmonary circuit.[4] Further increase in pulmonary blood flow can be seen with perioperative fluid shifts due to intestinal surgery and vigorous intravenous fluid therapy[5] which could have happened in our patient. Excessive pulmonary blood flow can result in pulmonary hypertension or may progress to pulmonary edema. This increases the work of breathing and hence appearance of tachypnea and persistent chest indrawing. This explains the delayed presentation of TAPVC in our neonate, although the condition was present since birth.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dey PK, Mondal B, Bagchi NR. Atypical respiratory distress in a newborn: A diagnostic dilemma. Acta Med Iran 2014;52:575-7.  Back to cited text no. 1
    
2.
Yun SW. Congenital heart disease in the newborn requiring early intervention. Korean J Pediatr 2011;54:183-91.  Back to cited text no. 2
    
3.
Obinata H, Nishibe S, Ishihara Y. Atypical perioperative management for duodenal obstruction in an infant with heterotaxy syndrome: A case report. JA Clin Rep 2018;4:16.  Back to cited text no. 3
    
4.
Samyn MM, Plymale JM, Cousineau AJ, Tweddell JS. TAPVR in a kindergartner presenting with fatigue. BMJ Case Rep 2014:(1-3).  Back to cited text no. 4
    
5.
Khanna S, Choudhury M, Kiran U. Total anomalous pulmonary venous connection: Post operative problems and management. Indian J Anaesth 2009;53:71-4.  Back to cited text no. 5
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