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• W2001058315 abstract "The Editor, Congenital cardiac diseases like isolated patent ductus arteriosus (PDA) and, atrial septal defect (left to right shunts) may lead to an increase in pressure of end tidal carbon dioxide (PEtCO2) and partial pressure of carbon dioxide in arterial blood (PaCO2). However, this occurs only if the pulmonary blood flow (PBF) is high enough to cause alveolar congestion and transudation into the alveolar spaces, compromising gas exchange. In infants and children with a left to right cardiac shunt, (a-Et) PCO2 gradient is not significantly different from children with normal circulation. Several studies have demonstrated the usefulness of EtCO2 pressures in assessing pulmonary blood flow in a variety of scenarios.[1,2] We hereby report a case of an 8 month old female child, weighing 3.75 kg, diagnosed with PDA and bicuspid aortic valve. The patient was taken for ligation of PDA under general anesthesia. Anesthesia was induced with sevoflurane (8%) and fentanyl (5 micg/kg) and muscle relaxation was achieved with rocuronium (1 mg/kg). The trachea was intubated with a 4 mm internal diameter uncuffed endotracheal tube. The child was ventilated with pressure control mode of ventilation using air oxygen 50-50%, with the inspiratory pressure set at 25 cm H2 O and ventilatory rate at 35 breaths per minute; generating a tidal volume of 30 ml. Anesthesia was maintained with fentanyl, midazolam and vecuronium bromide. After intubation, initially, the PEtCO2 was 53 mmHg, as expected. The patient was positioned in right lateral position for surgery. Following positioning, at the time of thoracotomy, the PEtCO2 suddenly rose to 82 mmHg and the oxygen saturation of hemoglobin decreased to 93% (on 50% FiO2). All probable causes of increased PEtCO2, like endobronchial intubation, leak in ventilatory circuit, bronchospasm, obstruction of endotracheal tube and rise in temperature, were ruled out. Intraoperatively, the surgeon discovered a tense left pulmonary artery (LPA), which is an unusual finding during this surgery. During dissection of PDA, suddenly, the PEtCO2 dropped from 82 mmHg to 41 mmHg even when the PDA was patent and flowing. On close inspection of the surgical field, it appeared that the surgeon has retracted the LPA and it was being compressed. The reduced blood flow through the LPA caused a fall in PEtCO2 but the LPA could only be released after the ligation of PDA. Following ligation of PDA, the PEtCO2 was still high, at 63 mmHg, which, in normal circumstances, drops to 35-40 mmHg after the PBF is normalized following PDA ligation. When the patient was turned to supine position, the PEtCO2 was still 56 mmHg. A provisional diagnosis of compromised ventilation of lung due to atelectasis was hypothesized and lung recruitment maneuvers were undertaken. A chest X-ray in the intensive care unit showed upper lobe collapse of the right lung. In the present case, the main cause of hypoventilation of the dependent right lung was compression of a compliant pediatric thorax by rolls and drapes used for positioning of the patient. A large roll of the entire width of the thorax must have caused the compression of the dependent lung due to suboptimal positioning.[3] This premise was further confirmed by the intraoperative finding of a tense LPA, as most of the pulmonary blood was being shunted through the LPA because of hypoxic vasoconstriction occurring in the dependent collapsed upper lobe of the right lung.[4,5] Moreover, when the LPA was occluded accidentally during dissection of the PDA, the blood flow to the functional part of the left lung dropped exponentially and so did the PEtCO2. If the right lung would have been functioning properly, the PEtCO2 should have risen instead of falling, as the blood flow would have been diverted to the normally ventilated lung and the alveoli necessarily have eliminated the CO2 efficiently. Furthermore, once the PDA was ligated, the PEtCO2 should have decreased to normal values, but it remained in a higher range because of ventilatory compromise of the right lung. Thus, congenital heart diseases with shunting of blood and lateral decubitus position along with pediatric physiology of respiratory mechanics all pose a great challenge to the working anesthesiologist. The interpretation of observed values should be carried out in the context of the clinical situation of the patient." @default.
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• W2001058315 date "2010-01-01" @default.
• W2001058315 modified "2023-09-22" @default.
• W2001058315 title "Anesthetic management of patent ductus arteriosus - Not always an easy option" @default.
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• W2001058315 doi "https://doi.org/10.4103/0971-9784.69061" @default.
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