ANAESTHETIC MANAGEMENT OF A CHILD WITH AN EPICARDIAL PACEMAKER FOR LEFT EXTENDED HEPATECTOMY:
A CASE REPORT
Shreyas A Chawathey MBBS, Junior Resident III
&
Madhavi Desai MD, Consultant
Dept of Anaesthesiology, Critical Care and Pain,
Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
PRESENTATION
2-year-old/10 kg male child, known case of CCAVB with an epicardial pacemaker (VVI mode, set HR 120) inserted 3 weeks prior
Having a chemoport in Right Internal Jugular Vein in situ
s/p 6# Superplado (Sorafenib + Doxorubicin + Cisplatin)
Diagnosed with Hepatoblastoma (PRETEXT stage III)
Posted for left extended hepatectomy
Fluoroscopy image showing guidewire of IV Pacing sheath transmigration before start of surgery; IV Pacing sheath insertion abandoned
INTRAOPERATIVE MANAGEMENT
Standard monitors: 5 Lead ECG, NIBP, SpO2 probe
Induction of anaesthesia using 8% Sevoflurane + 100% FiO2
Intubation: IV access and continued induction with Fentanyl 20 mcg IV + Propofol 60 mg IV + Atracurium 5 mg IV —> Direct laryngoscopy with MAC 2 blade—> CLI —> ML ETT 4.0 ID inserted and fixed at 13 cm mark at upper incisors—> maintained with O2 + Air + IPPV + Isoflurane + closed circle system with passive Carbon dioxide absorber
Pacemaker reprogramming to asynchronous mode with set heart rate (HR) 135/min
Pacemaker sheath insertion attempted (6 Fr) in Left IJV —> Guidewire migration; abandoned
Transcutaneous pacing electrodes applied to the anterior and posterior chest wall
Arterial cannula (22G) inserted in Left Radial artery and transduced
Epidural catheter (18G) inserted in T7-8 intervertebral space and kept on 2ml/h of 0.0625% Levobupivacaine + Fentanyl 1 mcg/ml
Preparedness for massive blood transfusion: Blood bank informed, shoot system checked
Minimisation of EMI using CUSA and bipolar cautery
Significant risk of lead fracture/pacemaker malfunction
Blood loss: 1400 mL (Estimated Blood vol 700 mL) replaced with 500 mL PRBCs, 400 mL of FFPs, 500 mL Gelaspan (4%) and 2L RL.
Noradrenaline (3/50) required intermittently —> tapered off at the end of surgery
Pacemaker reprogrammed to VVI mode with HR 130/min after surgery
Extubated in the OT
No pacemaker-related events occurred throughout the perioperative period
POSTOPERATIVE CARE
No significant post-operative events except fever on postoperative day 1 and 2
Patient shifted with Transcutaneous pacing electrodes to the recovery and later to the ward
Cardiology consult for optimisation of Pacemaker status with new HR set to 100/min on VVI mode
Patient discharged on POD 5 after completion of post-operative course of antibiotics and cardiology opinion; transcutaneous pacing electrodes removed.
DISPOSITION
Patient received Adjuvant chemotherapy as an outpatient (Carboplatin + Doxorubicin #7 given in Jan 2023) for residual disease. Patient is being followed up at another cancer centre affiliated to our centre now in Varanasi, Uttar Pradesh, India.