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CASE REPORT |
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| Ahead of print
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Anesthetic management of brain abscess with cyanotic congenital heart disease: Two case reports
Vinitha Narayan1, Sanjay Jaswal1, Vidhya Narayanan2, Raghuraman M Sethuraman2, Shalvi Mahajan1
1 Department of Anaesthesiology and Intensive Care, Post-graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
2 Department of Anaesthesiology, Sree Balaji Medical College and Hospital, BIHER, Chennai, Tamil Nadu, India
| Date of Submission | 27-Jan-2022 |
| Date of Decision | 29-Mar-2022 |
| Date of Acceptance | 07-Apr-2022 |
| Date of Web Publication | 30-Jan-2023 |
Correspondence Address:
Vidhya Narayanan,
Department of Anaesthesiology, Sree Balaji Medical College and Hospital, BIHER, Chennai 600044, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/jpn.JPN_20_22
 Abstract | | |
Dextro transposition of great arteries (dTGA) and tricuspid atresia (TA) are rare causes of cyanotic congenital heart disease (cCHD). Brain abscess is a dreaded complication in these patients due to high rates of morbidity and mortality. We present the anesthetic management of two pediatric patients with dTGA and TA, who developed brain abscess, for which burr-hole and drainage were done under general anesthesia. Anesthetic management included a thorough preoperative assessment and optimization, careful selection of anesthetic agents, and close intraoperative and postoperative monitoring. Both of our patients recovered and were discharged from the hospital. Although several cases of brain abscess in cCHD have been reported, both dTGA and TA are rare conditions and this is the first case report of brain abscess in untreated TA, to the best of our knowledge.
Keywords: Brain abscess, transposition of great arteries, tricuspid atresia
| Introduction | |  |
Anesthetizing patients with cyanotic congenital heart disease (cCHD) for brain abscess surgery presents unique challenges to the anesthesiologist due to the complex cardiovascular abnormalities, superimposed with the derangements caused by infection, and the space-occupying lesion in the brain. Transposition of great arteries (TGA) and tricuspid atresia (TA) (prevalence of 0.295 and 0.117 per 1000 live births, respectively) are rare causes of cCHD.[1] We present the cases of two pediatric patients, diagnosed cases of dextro-TGA (dTGA), and TA, respectively, presenting with brain abscess, for which burr-hole and drainage were done under general anesthesia. To the best of our knowledge, this is the first case report of untreated TA undergoing surgery for brain abscess.
| Case Description | | |
Case 1
A 7-year-old male child presented to the pediatric emergency with a history of fever, headache, and vomiting in the last three days. The child had been diagnosed with dTGA at the age of one and a half years when he was admitted to the hospital with pneumonia and congestive cardiac failure (CCF). Echocardiography done previously showed atrioventricular concordance with ventriculoarterial discordance, suggestive of dTGA, with a large subaortic ventricular septal defect and severe pulmonary arterial hypertension. The child was not receiving any cardiac medications. On examination, the child weighed 20 kg, he was alert, oriented, had a pulse rate of 96/min, and oxygen saturation of 70% on room air. Central cyanosis and clubbing of digits were also noted. CT of the brain showed a right frontal lobe ring-enhancing lesion of 3.9 cm x 3.8 cm x 4.4 cm with mild perilesional edema suggestive of brain abscess [Figure 1]. Mass effect was seen in the form of compression of the frontal horn of the ipsilateral lateral ventricle with a midline shift of 7 mm. After taking a sample for blood culture, intravenous antibiotics were started. A burr-hole evacuation of the brain abscess was planned.
Preoperative investigations showed Hemoglobin 20.7 g/dL, total leucocyte count 11,900/ mm3, and platelet count 136,000 /mm3. Coagulogram and other investigations were within normal limits. The patient was preloaded with 10 mL/kg of isotonic saline and premedicated with intravenous midazolam 20 microgram/kg and fentanyl 2 microgram/kg. A combination of ketamine (1 mg/kg) and propofol (1 mg/kg) was used for induction. Atracurium (0.5 mg/kg) was used for endotracheal intubation. Invasive blood pressure monitoring was started. Anesthesia was maintained with 100% oxygen, with sevoflurane (1.2 MAC). An intraoperative ABG showed a PaO2 of 52.2 mm Hg and SaO2 of 84.6%. No hypotensive or hypercyanotic episodes occurred intra-operatively. Intravenous paracetamol (15 mg/kg) was administered for post-operative analgesia. The procedure lasted for an hour, trachea was extubated and the patient was shifted to the post-anesthesia care unit.
Case 2
A 5-year-old male child presented to the pediatric emergency with a history of fever, headache, and weakness for the past four days. There was no history of vomiting or seizures. On examination, the child weighed 11 kg, was conscious and oriented. The vitals were stable, and SpO2 in room air was 87%. Central cyanosis and clubbing were noted. There was a right-sided hemiparesis, with a power of 3/5 in the upper and lower limbs. Right-sided sixth and seventh cranial nerve palsy was also noted. The child had been diagnosed with CHD at the age of three years. An echocardiogram revealed TA with a large ASD (8 mm), with right to left shunting, and a subaortic restrictive VSD (5 mm) with left to right shunting.
CT of the brain showed a contrast-enhancing large, multiloculated, cystic space-occupying lesion in the left frontoparietal region, causing a midline shift [Figure 2]. Investigations revealed Hemoglobin 14gm/dL, total leukocyte count 13,800/mm3, and platelet count 532,000/mm3. Coagulogram and other investigations were within normal limits. Antibiotics were started similar to Case 1. Burr-hole evacuation of the abscess was done under general anesthesia, following the same protocol as for Case 1. The surgery was uneventful, no intra-operative complications were seen, intraoperative SpO2 was maintained at around 92%. | Figure 2: CT showing multiloculated abscess in left frontoparietal region
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In Case 1, antibiotics as per the culture report were continued for 2 weeks and he recovered without any neurological deficit, whereas Case 2 received antibiotics for 4 weeks. However, he had residual right-sided hemiparesis at the time of discharge.
| Discussion | | |
Brain abscess is one of the most dreaded complications in patients with cCHD. Lower oxygen saturation, lower oxygen content, and higher base excess of arterial blood have been identified as risk factors for the development of brain abscess in these patients.[2] Tetralogy of Fallot is the commonest cCHD and therefore is the commonest reported condition presenting with brain abscess.[1],[2] dTGA is the second most common cCHD, whereas TA is relatively rare.[3],[4] Hence, brain abscess in association with TA is quite rare, and to the best of our knowledge, this is the first reported case.
Intermittent bacteremia and focal encephalomalacia have been suggested as mechanisms for the development of brain abscess in these patients.[2] A right to left shunt results in the bypassing of blood from the phagocytic filtering action of the pulmonary capillary bed. Severe hypoxia and increased viscosity result in decreased cerebral blood flow and make these patients susceptible to microinfarcts. Subsequent seeding of microinfarcts with blood-borne bacteria is thought to be the mechanism for the formation of brain abscess.
Brain abscesses may be multiple, as reported recently by Kudo-Kubo et al.[5] The abscess may be multiloculated, as was the case in our second patient. Early identification, early institution of a combination of antibiotics, and early surgical drainage have been identified as essential to improve outcomes. Burr-hole drainage of the abscess, combined with antibiotics has been shown to be associated with lower morbidity compared to craniotomy and excision.[6] We, therefore, proceeded with burr-hole and drainage, after optimization, and followed the principles listed in [Table 1].
Preoperative optimization includes correction of dehydration, which may be present due to fever, and reduced oral intake. Dehydration increases blood viscosity and predisposes to cyanotic spells. Anesthetic goals in cCHD include maintaining systemic vascular resistance (SVR) and avoiding increases in pulmonary vascular resistance, thereby preventing cyanotic spells. In addition, in these cases, the anesthesiologist should avoid increases in intracranial pressure (ICP), and maintain the cerebral perfusion pressure.
General anesthesia has been used with a safe anesthetic outcome in children with cCHD, as reported by Raha et al.[7] Ketamine maintains the SVR and is the agent of choice for induction in cCHD; however, it causes a rise in ICP. On the other hand, propofol causes a reduction in SVR and can result in a worsening of the right to left shunt but has a good ICP reducing effect. Therefore, we used a combination of ketamine and propofol (ketofol) in 50% of the dose of each drug as they would counteract undesirable effects of each other. Ketofol has been used successfully in these two cases because it provides hemodynamic stability.[8] Intravenous induction would be rapid in patients with a right to left shunt and hence, ketofol was administered slowly. Sevoflurane was used for maintenance as it has minimal effect on the shunt fraction and on cerebral blood flow.
Close postoperative monitoring is essential in these patients because cyanotic spells could be triggered by pain, anxiety, or inadequate hydration. Seizures, intracranial hemorrhage, and re-formation of abscess are other complications in the postoperative period.[9]
Financial support and sponsorship
Not applicable.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 2. | Takeshita M, Kagawa M, Yonetani H, Izawa M, Yato S, Nakanishi T, et al. Risk factors for brain abscess in patients with congenital cyanotic heart disease. Neurol Med Chir (Tokyo) 1992;32:667-70. |
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[Figure 1], [Figure 2]
[Table 1]
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