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LETTERS TO EDITOR
Year : 2021  |  Volume : 22  |  Issue : 2  |  Page : 187-188
 

The dilemma of extubation of a patient with congenital cyanotic heart disease


1 Department of Anesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan, India
2 Department of Trauma and Emergency (Anesthesiology), AIIMS, Jodhpur, Rajasthan, India

Date of Submission19-Feb-2021
Date of Decision03-Apr-2021
Date of Acceptance04-Apr-2021
Date of Web Publication29-Sep-2021

Correspondence Address:
Dr. Ankur Sharma
58, Subhash Nagar-2, Jodhpur - 342 008, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_25_21

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How to cite this article:
Ramalingam HP, Sharma A, Ayyawar H, Bhatia PK, Kothari N. The dilemma of extubation of a patient with congenital cyanotic heart disease. Indian Anaesth Forum 2021;22:187-8

How to cite this URL:
Ramalingam HP, Sharma A, Ayyawar H, Bhatia PK, Kothari N. The dilemma of extubation of a patient with congenital cyanotic heart disease. Indian Anaesth Forum [serial online] 2021 [cited 2021 Dec 7];22:187-8. Available from: http://www.theiaforum.org/text.asp?2021/22/2/187/326972




Sir,

Patients with congenital cyanotic heart disease (CCHD) generally present during the early years of life, and it is not uncommon for CCHD to manifest in adulthood. In such an undiagnosed patients, it may be difficult to determine the oxygenation target, if they require mechanical ventilation.

A 37-year-old female patient with brain abscess was intubated because of low Glasgow Coma Scale (6/15) and oxygen saturation (SpO2) of 70% on room air. Although lungs were compliant, even on FiO2 of 1, the PaO2 was only 40 mmHg (P: F ratio 40), the patient was hemodynamically stable. On the 4th day, the patient started improving neurologically, but because of the high oxygen requirement, weaning from ventilator could not be started. On a thorough review of the case, the relatives gave the history of breathlessness and chest pain 15 years back during her antenatal period, followed by a misconception. During further workup, her transthoracic echocardiography showed large ventricular septal disease (VSD) of 30 mm in size, both great vessels arising from the right ventricle, with severe pulmonary stenosis with PV pressure gradient 104 mmHg, and an ejection fraction of 55% [Figure 1]. A weaning trial was given by gradually decreasing FiO2 from 1 to 0.3, while oxygen saturation remained constant.[1] She was extubated and put on a nonrebreathing face mask with an oxygen flow of 12 L/min, and oxygen support was gradually withdrawn. Post extubation, her SpO2 remained 70% on air, which was same as during mechanical ventilation. She was referred to a cardiothoracic surgeon for corrective cardiac surgery.[2]
Figure 1: Two-dimensional echocardiogram: Apical 4 chamber view. Note the large ventricular septal disease. IVS: Inter-ventricular septum; RA: Right atrium; LA: Left Atrium

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Although the patient improved neurologically by the fourth day, extubation was not tried because of persisting hypoxemia which was due to right to left shunting of blood rather than the respiratory cause. Large VSD was functioning as a single ventricle with severe pulmonary stenosis. Due to CCHD, tissues had been chronically exposed to a low level of PaO2 since her birth leading to the acclimatization of cells to low PaO2. This led to the right shift of the oxygenhaemoglobin dissociation curve to increase oxygen's tissue delivery [Figure 2]. Positive pressure ventilation decreases preload to the right atrium, increase pulmonary vascular resistance, and decreases left ventricle afterload. Though this effect helps a failing heart, it is detrimental for a cardiac lesion with low pulmonary circulation.[3],[4] Based on this concept, FiO2 was gradually decreased to 0.3, with monitoring of other parameters (PaO2, PaCO2, SpO2, and lactate). Nevertheless, of low FiO2, they were in the normal range with no signs of anaerobic cell metabolism or respiratory distress.
Figure 2: Oxygen dissociation curve: Red line graph is oxygen saturation of patients with ventricular septal disease with PS, showing the right shift indicating decreased affinity of hemoglobin to oxygen. Right shift increased the oxygen delivery to tissues. The blue line is for a normal patient

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There are no recommendations for target SpO2 in adult patients with CCHD presenting with pulmonary hypertension. Target saturation may be different for every patient, and it has to be titrated by clinical correlation. In these patients, early extubation based on clinical parameters could have been done if the diagnosis of CCHD was known to us.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ruckdeschel E, Kim YY. Pulmonary valve stenosis in the adult patient: Pathophysiology, diagnosis and management. Heart 2019;105:414-22.  Back to cited text no. 1
    
2.
Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM, et al. 2018 AHA/ACC guideline for the management of adults with congenital heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019;73:e81-192.  Back to cited text no. 2
    
3.
Shekerdemian L, Bohn D. Cardiovascular effects of mechanical ventilation. Arch Dis Child 1999;80:475-80.  Back to cited text no. 3
    
4.
Corredor C, Jaggar SI. Ventilator management in the cardiac intensive care unit. Cardiol Clin 2013;31:619-36.  Back to cited text no. 4
    


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