Anaesthetic management in a neonate with congenital complete heart block

Feasibility of Laryngeal Mask Airway Device Placement in Neonates

BACKGROUND

The laryngeal mask airway (LMA) has been used in adult and pediatric populations for decades. While the familiarity of its use in the neonatal population is increasing, there are few data investigating this.

OBJECTIVE

The objective of this study was to determine the feasibility of LMA placement in neonates by investigating the time and number of attempts required for successful placement and physiologic stability during the placement of the device.

METHODS

This study is one component of a national, multicenter, randomized controlled trial investigating surfactant administration through an LMA in neonates. Videotape of LMA placement was reviewed to determine the total procedure time and the number of attempts required to successfully place the device. Heart rate and oxygen saturation (SaO2) were analyzed as change from baseline, in order to examine physiologic stability during device placement.

RESULTS

Videotape and physiologic data were analyzed for 36 infants. Gestational age ranged from 293/7 to 354/7 weeks (mean 33 ± 1.7) with the birth weight ranging from 1,290 to 3,180 g (mean 2,006 ± 482). Average total procedure time was 88 s (±136) with 64% of the procedures successfully completed in <35 s. Successful placement was achieved on the first attempt in 69% of the cases. Compared to baseline, heart rate increased by an average of 1 bpm (±4.5) and SaO2 decreased an average of 6% (±7).

CONCLUSIONS

Successful placement was achieved in the majority of patients in <35 s and required only one attempt. Physiologic parameters were maintained close to baseline, measured by minimal fluctuation in heart rate and SaO2 during the procedure. Placement of the LMA is feasible in neonates.

Anaesthetic management of a premature low-birth-weight neonate with congenital complete heart block for implantation of temporary epicardial pacing wires

The optimal anaesthetic management of neonates with complete congenital heart block (CCHB) is unknown, as there is a low incidence of such cases. Neonates with CCHB often require surgery for the initiation of electronic pacing. In addition to the challenges of anaesthetising a neonate, this procedure is risky due to the potential for hypotension, arrhythmias and cardiac arrest. We herein present the case of a premature low-birth-weight neonate with antibody-related CCHB and normal heart structure who underwent anaesthesia and surgery for epicardial pacing wire insertion on Day 1 of life. We also compare our patient's anaesthetic conduct and outcome with similar previously reported cases.

Anesthetic management of the neonate with congenital complete heart block: a 16-year review

BACKGROUND

Anesthesia for patients with complete heart block can be associated with significant hemodynamic instability. The aim of this study is to review our anesthetic experience of neonates with congenital complete heart block (CCHB) who underwent placement of either a temporary epicardial pacing system or a permanent epicardial pacemaker.

METHODS

The anesthetic management of neonates with CCHB who underwent pacemaker placement at a single institution over a 16-year period was reviewed.

RESULTS

Twenty-four neonates were identified, 17 with a structurally normal heart (NL) and seven with associated congenital heart defects (CHD). Median (range) gestational age was 36.9 (26-41) weeks, birth weight 2.9 (1.0-4.1) kg, and baseline heart rate 47 (38-80) b.min(-1). A temporary epicardial pacing system was placed in six patients (four CHD, two NL; P = 0.003) following institution of mechanical ventilation and inotropic support for a low cardiac output state, and a permanent epicardial pacemaker was placed in 18 patients. Atropine 0.02 mg.kg(-1) IV prior to induction (n = 5) increased heart rate less than 20%. Intraoperative hypotension was documented in nine neonates, five of seven with CHD and four of 17 with NL (P = 0.02). In four patients (44%) hypotension occurred despite concurrent inotropic support. Intraoperative cardiac arrest occurred in one neonate, necessitating institution of extracorporeal membrane oxygenation. Two patients (8.3%) died in hospital from complex CHD and complications of prematurity.

CONCLUSIONS

Early institution of mechanical ventilation, inotropic support and pacing are necessary in the neonate with CCHB and poor hemodynamic function, particularly with coexisting CHD or prematurity.

Congenital cardiac emergencies

Cardiac emergencies are rare in children in comparison to adults. The pathophysiology differs; ischaemic heart disease is virtually unknown, whereas most congenital cardiac emergencies occur secondary to structural heart disease. Of the myriad lesions many decompensate in the perinatal period, usually in association with arterial duct closure. Subsequent rapid haemodynamic deterioration may lead to a moribund infant in extremis at presentation and with more home deliveries and early discharges such infants may present not only to paediatricians, but to accident and emergency departments, GPs and community midwives.