Anaesthetic management of drainage of brain abscess in a child with untreated TOF physiology: A case report

 

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Introduction: Cyanotic congenital heart disease accounts for 12.8 to 69.4% of all brain abscess with increased incidence in children. Right to left shunt along with hypoxia & hyperviscosityincreases the propensity of seeding of microorganism in low perfusion area in brain. Case Summary: Presenting a case of 8 year old female child planned for emergancy drainage of brain abscess. The child was a case of TOF physiology diagnosed preoperatively. She presented with episode of seizure and altered sensorium since 15 days. Preoperatively, the patient was e4v5m6 with altered sensorium, Cyanosed. Baseline vitals were blood pressure of 106/78 mm of Hg, HR 82/min, spo2 86% on room air. A pansystolic murmur was present in precordial area with loud s2. Patient had left fronto parietal space occupying lesion? brain abscess on CT scan. On 2D ECHO, L- TGA with VSD with PS with PDA was diagnosed. Patient was planned for general anesthesia. After confirming NPO, all standard ASA monitors were attached with base line saturation 86% on room air. Child was preoxgenated for 3 mins. IV line 22 G was secured in right upper limb & preinduction 22 G canula inserted in left radial artery for invasive BP monitoring. Child was induced with inj fentanyl 40 mcg, thiopentone 100 mg and vecuronium 2 mg & airway secured with cuffed endotracheal tube size 5.5. Anesthesia was maintained with o2 + air + isoflurane. SpO2 was maintained to 95% intraoperatively and phenylephrine bolus was used to maintain systemic vascular resistance & minimize shunting. Intraoperative ABG showed 7.403/81.6/31.5/19.2/- 4.4/96.2/146.3/3.53/43%. Patient was reversed & extubated. Postoperatively patient was E4V5M6 with vital HR 96/mint, BP 112/65 mm of hg, spo2 88% on room air & shifted to ward. Patient was sent home after 1 weakwithout any neurological deficit & asked to follow up in cadiac OPD for heart disease. Conclusion: Children with undiagnosed heart disease may present directly to emergency for surgery & High suspicion of heart disease should be kept in mind in patients presenting with brain abscess specially in children. Understanding pathophysiology of disease is very important for anesthetic management of such patient for neurosurgery.