Abstract PR036

Abstract

Case Report: A 27 year old woman with Down’s syndrome and a cardiac history significant for a large ventricular septum defect, patent ductus arteriosus and Eisenmenger syndrome was scheduled for pleurodesis via left Video Assisted Thorascopic Surgery (VATS). She had persistent left pneumothorax with bullae that has failed conservative treatment. In view of difficult venous access and lack of patient cooperation for intravenous cannula placement, an inhalational induction was performed with Sevoflurane 4% and oxygen/air mixture with FiO2 of 0.6. Intravenous access was obtained after induction. Fentanyl 25mcg, Ketamine 40mg and Atracurium 40mg were given in preparation for double lumen tube insertion. Arterial line and central venous catheter were placed post intubation. Anaesthesia was maintained with Sevoflurane with end tidal concentrations ranging between 1.3 to 1.8. Systemic vascular resistance was maintained with Noradrenaline, with doses ranging from 0.05 to 0.14mcg/kg/min. To control pulmonary artery pressure, ventilation was performed with oxygen 60% and inhaled nitric oxide 20 ppm. An intercostal nerve block was performed by the surgeons at the end of the operation. Patient was successfully extubated at the end of the operation and weaned from Noradrenaline and inhaled nitric oxide. Her post operative recovery remained uneventful and was discharged home on post op day 7. Conclusion: A careful balance between the systemic vascular resistance and pulmonary vascular resistance is essential for the management of patients with Eisenmenger syndrome. In view of this patient having Down’s syndrome, previously described interventions for a patient with Eisenmenger syndrome needing one lung ventilation such as intravenous induction and placement of epidural catheter1 was challenging. Thus, we have described successful management of a patient with both Down syndrome and Eisenmenger syndrome with inhalational induction and maintenance; and intercostal nerve block for analgesia.