Abstract SNACC-95

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Anesthetic management of children with tetralogy of Fallot undergoing craniotomy and evacuation of brain abscess

Mishra N, Dube S, Kapoor I, Rath G, Bithal P
All India Institute of Medical Sciences, New Delhi, , India

INTRODUCTION: Intracranial abscess is one of the most serious complications of uncorrected congenital heart disease in children. Most of our current knowledge on the management of these children is based on case reports that emphasizes on the surgical aspects of the problem. However, the reports on anesthetic management of the children with tetralogy of Fallot (TOF) undergoing craniotomy for evacuation of intracranial abscess are rare. Hence, this retrospective study was undertaken to analyze the anesthetic management of children of TOF with brain abscess.
METHODS: Approval from the Institutional ethics committee was taken. The preoperative, intraoperative and postoperative data of children presenting with TOF and brain abscess who underwent craniotomy and evacuation, in between Apr 2011 and Mar 2013 were collected, by reviewing the patient’s medical records and anesthesia notes. Appropriate statistical analysis was done and results were presented as mean±SD and/ or percentage.
RESULTS: Total 10 children (6 male and 4 female) of TOF complicated with brain abscess were reviewed. The mean age was 4.5 years (Range: 1 month to 9 years). Two children presented with associated atrial septal defect and one with transposition of great arteries. Febrile illness was the commonest mode of presentation (60%). Headache (40%), seizures (40%), vomiting (30%) and hemiparesis (20%) were the other presenting complaints. Frontal lobe was, the commonest site, affected by brain abscess (70%). One child underwent correction for cardiac defect before abscess drainage, and three children underwent abscess drainage for more than once. The mean hemoglobin concentration of the cohort was 15.2 gm/dl. Three children presented with electrolyte abnormality, three had coagulopathy, and another two had preoperative metabolic acidosis which was corrected prior to surgery. Four patients received propranolol prior to surgery. All patients underwent either burrhole craniotomy for abscess drainage (9 children) except in one child who underwent flap craniotomy. The mean duration of anesthesia and surgery was 102.5 min and 82 min, respectively. Intravenous anesthetic induction was carried out in nine children with ketamine, thiopentone, or propofol in five, three and one children, respectively along with fentanyl and rocuronium. One child underwent inhalational induction with sevoflurane. Anesthesia was maintained with sevoflurane (nine children) and isoflurane (one) along with intermittent boluses of fentanyl and rocuronium. The patient who underwent craniotomy and abscess drainage had intraoperative hypotension and hypercyanotic spell which was successfully managed. All other patients had a stable intraoperative course.
CONCLUSION: Intravenous technique was the preferred mode of anesthetic induction in children of TOF with brain abscess with ketamine or thiopentone being the most common choices. However, anesthesia was maintained with sevoflurane in most of such children. The incidence of intraoperative hypercyanotic spell was 10% in this series.

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