GAP-111
Pediatric Cardiac Regional Anesthesia – the new sub-sub specialty!
1Babb A, 2Navaratnam M, 2McFayden G, 2Ramamurthi R, 3Motonaga K
1University of New Mexico, Albuquerque, New mexico, USA; 2Stanford University, Stanford, CA, USA; 3stanford University, Palo Alto, CA, USA
We present a case of a patient with failing Fontan physiology and severe heart failure who required pacemaker generator change to treat refractory atrial arrhythmias and describe the use of regional anesthesia in this high–risk population.
This is a 26 year old 73 kg, female with heterotaxy syndrome, double inlet left ventricle (DILV), transposition of great arteries (TGA) and interrupted aortic arch (IAA) who underwent a staged palliation with arch reconstruction, ultimately resulting in Fontan circulation with a lateral tunnel approach. Her history had been complicated by sick sinus syndrome requiring epicardial dual chamber pacemaker placement and heart failure resulting in severely depressed ventricular function and portal hypertension/cirrhosis leading to listing for heart/liver transplant. She was followed closely for refractory atrial flutter, and had been cardioverted and medically managed with procainamide and amiodarone. Her pacemaker was in AAIR mode with 100% atrial pacing. Her atrial lead threshold was very high at 7.5 V @ 0.52 ms and battery longevity predicted to be less than one month. A collaborative decision was made to attempt placement of a transvenous pacing system to avoid a high-risk sternotomy otherwise needed to replace the epicardial system prior to transplant. The patient was also motivated to avoid general anesthesia, so a pectoralis block with minor sedation for anxiolysis was chosen.
The patient was positioned supine with standard ASA monitors and nasal cannula. Using the ultrasound, a 13-6 Hz linear transducer was used to obtain the appropriate images for a pec 1 and pec 2 block. The transducer was placed at the level of the 3rd rib, with a superiomedial to inferolateral orientation. Using a 22g Stimuplex needle with an in-plane technique from medial to lateral, ropivacaine 0.5% 10 ml was injected between pectoralis major and pectoralis minor, followed by 20 ml injected between pectoralis minor and serratius anterior. The patient tolerated the block well. A small amount of lidocaine was used for incision, but otherwise no other local anesthetic was needed. She received versed and ketamine for the procedure and postoperatively had no discomfort or pain.
Patients with Fontan circulation face life-long morbidity from elevated systemic venous pressures and often develop expected complications such as arrhythmias, thrombosis, hepatic dysfunction and heart failure. Palliation with a classical Fontan (atria-pulmonary connection) or a lateral tunnel approach, (incorporating the right atrium with the inferior vena cava to the pulmonary artery), increases the risk of developing atrial arrhythmias and has lead to an increasing number of these complex patients requiring procedural management of their arrhythmias. This case demonstrates the feasibility of a pectoralis block as the primary anesthetic for high-risk patients with complex congenital heart disease, where general anesthesia is ideally avoided.
Jolley M, Colan S, Rhodes J, DiNardo J. Fontan Physiology Revisited. Anesthesia & Analgesia 2015; 121(1): 172-182.
Fujiwara et al. Pectoral Nerves (PECS) and intercostal nerve block for cardiac resynchronization therapy device implantation. SpringerPlus 2014; 3:409.
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