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LETTER TO EDITOR Table of Contents   
Year : 2008  |  Volume : 11  |  Issue : 1  |  Page : 54-55
Arterial inflow cannula obstruction during paediatric cardiac surgery


1 Department of Cardiac Anaesthesia, Cardiothoracic Center, All India Institute of Medical Sciences, New Delhi - 110 029, India
2 Department of Cardio Thoracic and Vascular Surgery, Cardiothoracic Center, All India Institute of Medical Sciences, New Delhi - 110 029, India
3 Department of Perfusion, Cardiothoracic Center, All India Institute of Medical Sciences, New Delhi - 110 029, India

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How to cite this article:
Das S, Kakani M, Kiran U, Bisoi AK, Airan R. Arterial inflow cannula obstruction during paediatric cardiac surgery. Ann Card Anaesth 2008;11:54-5

How to cite this URL:
Das S, Kakani M, Kiran U, Bisoi AK, Airan R. Arterial inflow cannula obstruction during paediatric cardiac surgery. Ann Card Anaesth [serial online] 2008 [cited 2019 Nov 22];11:54-5. Available from: http://www.annals.in/text.asp?2008/11/1/54/38454


Sir,

The developments in cardiac surgery are dependent on the continuous refinements in the use of cardiopulmonary bypass (CPB). The major complications encountered during the placement of aortic cannula and aortic cross-clamp (ACC) are the dissection of the aortic wall, cannula malposition and disruption of atheromatous plaques. [1] As a result, cerebral injuries and acute renal failure may occur in the postoperative period. [1],[2] Here, we describe a case of arterial inflow cannula (AIC) obstruction due to the placement of the ACC during Senning operation.

A 19-month-old male child (7.5 kg) was diagnosed to have d-transposition of the great arteries, atrial septal defect and intact ventricular septum. The child was scheduled to undergo Senning operation. Anaesthesia was induced and maintained with ketamine, sufentanil, midazolam and pancuronium. Electrocardiogram, pulse oximeter, end-tidal carbon dioxide, bispectral index (BIS), femoral artery invasive pressure and central venous pressure were monitored. After heparinization, the ascending aorta was cannulated with a 10-F cannula (Biomedicus, Medtronic Inc., Minneapolis, USA). Bicaval venous cannulation was established with 18-F and 16-F angled cannulae.

Arterial inflow line pressure (AILP) and femoral artery mean pressure (FAMP) were monitored according to the institutional protocol. At the onset of CPB, the AILP value was 120 mmHg and FAMP, 30 mmHg. Cardioplegia cannula was inserted into the aortic root. ACC was placed between the AIC and cardioplegia cannula, and cardioplegia was commenced. Immediately, the FAMP value decreased to 10 mmHg. The pump flow was increased up to 200 ml/kg and a high dose of norepinephrine (5-20 g) was introduced into the pump, presuming that the systemic vascular resistance in the patient had decreased grossly. The FAMP value decreased to 0 mmHg in a period of 3-4 min. The BIS value decreased to 20 from 40. The anaesthesiologist noticed the AILP value more than 500 mmHg on the pressure gauge of the heart-lung machine (Sarns 7000 roller pump, Sarns Inc., Ann Arbor, Michigan, USA). The surgeon and perfusionist were informed. A quick check of the CPB circuitry did not reveal a kink on the arterial limb of the circuit. Since we were unable to find any cause for this systemic hypoperfusion, we suspected an inadvertent partial obstruction of AIC by ACC. ACC was released and an immediate reversal of the complication was noted, with a decrease in AILP up to 150 mmHg and increase in FAMP and BIS values to 36 mmHg and 46, respectively. The patient was cooled to 24C. Empirically, methyl prednisolone, 225 mg; 20% mannitol, 35 ml; magnesium, 0.5 gm and ketamine, 5 mg were administered in the venous reservoir of the oxygenator, presuming that it would provide neuroprotection. Acid-base abnormalities and hyperglycemia were corrected.

The ACC was reapplied without any events. Senning operation was performed according to the plan and the patient was transferred to the intensive care unit. In the postoperative period, the child was conscious and recognizing the parents. The patient was electively ventilated for two days. After extubation, he was examined by a neurologist and his neuropsychological behavior and motor function was found to be normal. The patient was discharged on the 8 th postoperative day.

During CPB, the obstruction to the AIC produces cerebral ischemia and other organ dysfunctions due to absence of systemic perfusion. [1],[2] We suspected the possible obstruction to AIC because of an abrupt decrease in the FAMP and increase in AILP. The ACC was assumed to have partially occluded the AIC. Had the ACC obstructed the AIC completely, the pressure changes would have been observed earlier, and the effects of a lack of systemic perfusion may have been severe. A 'blowout' of the CPB circuit tubing on the arterial side can occur, if this complication is not rectified and CPB continues. The other possible causes of such an abrupt increase in the AILP and decrease in the peripheral arterial pressure are kinks in either the AIC or the CPB circuit tubing on the arterial side and occlusion of the AIC tip by the aortic wall.

An audible high-pressure alarm (provided by the manufacturer of the heart-lung machine) probably remained unnoticed. The use of bilateral near-infrared spectroscopy and BIS have been used in the detection of AIC malposition. [3],[4] Early detection of the AIC obstruction by vigilant monitoring of AILP and FAMP during CPB may prevent an adverse outcome due to the absence of systemic perfusion.

 
   References Top

1.Ruchat P, Hurni M, Stumpe F, Fischer AP, Segesser LK. Acute ascending aortic dissection complicating open heart surgery. Eur J Cardiothorac Surg 1998;14:449-52.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Murakami J, Yamaura K, Akata T, Takahashi S. Acute renal failure in an infant attributable to arterial cannula malposition during cardiopulmonary bypass via ministernotomy. Masui 2002;51:264-9.  Back to cited text no. 2  [PUBMED]  
3.Gottlieb EA, Fraser CD Jr, Andropoulos DB, Diaz LK. Bilateral monitoring of cerebral oxygen saturation results in recognition of aotic cannula malposition during pediatric congenital heart surgery. Paediatr Anaesth 2006;16:787-9.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Ellenberger C, Diaper J, Licker M, Panos A. Bispectral index and detection of acute brain injury during cardiac surgery. Eur J Anaesth 2007;24:807-9.  Back to cited text no. 4    

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Correspondence Address:
Sambhunath Das
Department of Cardiac Anaesthesia, 7th Floor, CN Center, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.38454

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