Anaesthetic Management during Balloon Atrial Septostomy in Transposition of Great Arteries

Background: Transposition of the great arteries (TGA) is a congenital heart defect that can cause death in 30% of the first week of birth, 50% in the first month, 70% in 6 months, and 90% in the first year, thus requiring immediate corrective action in neonates with rapid early detection. The purpose of this case study is to highlight management considerations in TGA cases in the Balloon Atrial septostomy (BAS) procedure. Discussion: A 1-day-old newborn girl was brought to Dr. Moewardi General Hospital in February 2022. The patient had a history of cyanosis when she cried and was born with an APGAR score of 6.7.8. The lips were cyanotic on physical examination, with a SpO2 of 77% with a nasal O2 of 2 lpm. The echocardiography results obtained TGA, ASD II, PFO, and PDA. The patient then underwent a BAS procedure. Anesthesia management was performed using ketamine for induction, air bar, O2, and sevoflurane for maintenance of anesthesia. The operation was successful, and postoperative care was carried out. Anesthesia management aims to keep SVR and PVR to a minimum, with a PVR lower than SVR, to prevent desaturation in the patient. A decrease in PVR also can increase pulmonary blood flow, allowing more blood to be mixed and higher oxygen saturation in the blood for the patient. Conclusion: The principle of anesthesia management in TGA cases is to avoid a reduction in cardiac output and SVR and keep the PVR lower than the SVR.


INTRODUCTION
TGA (transposition of the great arteries) accounts for 7-8% of all congenital cardiac anomalies, with an incidence rate of 0.2 per 1000 live births.
TGA can be fatal to an infant without surgery, with a 30% mortality rate in the first week and a 90% mortality rate in the  It was concluded that TGA and ventricular septal defect (VSD) (Figure 1).Sevoflurane is safe, reliable, quick, and well tolerated by patients and is used to keep PVR lower than SVR 11,13 .

CONFLICT OF INTEREST
The Authors declare that they have no conflict of interest.
first year.Left-to-right shunting is the most dependable technique to boost systemic oxygen delivery in TGA babies.But, in the TGA babies with severe cyanosis, Balloon atrial septostomy (BAS) is immediately indicated 1 .Infants and newborns have immature respiratory control, ineffective respiratory muscles, altered airway and lung mechanics, and a more significant basal metabolic oxygen requirement.Then, greater Fetal Hemoglobin levels in babies at risk of perioperative hypoxia and anesthetic drugs may impede the ventilatory response to hypoxia and hypercarbia.In addition, neonates cannot endure increased pre-and post-load, myocardial depression, hypovolemia, or arrhythmia.Elevated pulmonary vascular resistance (PVR) can manifest as 'poor mixers' in TGA newborns.Because of these changes, young children are more susceptible to anesthesia-related critical events, such as cardiac arrest.Thus, the anesthesiologist needs appropriate anesthetic plans to administer anesthesia to avoid morbidity and mortality two.Therefore, we report an anesthetic management case of a 1-day-old newborn baby who underwent a BAS procedure for TGA.CASE ILLUSTRATION A 1-day-old baby was referred to Dr. Moewardi General Hospital for shortness of breath and blue lips when crying.While at the previous hospital, the patient had early CPAP installed but was still short of breath, so she was given CPAP with PEEP 7.0 FiO2 100%.She was treated in the previous hospital neonatal HCU with CPAP PEEP 7.0 FIO2 40% oxygenation.The patient could still cry intensely, move actively, and have a good tone.Then, the patient was referred to Dr. Moewardi General Hospital with a nasal cannula of 0.5 lpm.When the patient arrived, he looked at cyanosis and had a retraction of the respiratory muscles.The oxygen was increased to 1 lpm, the baby looked calm and comfortable, and the cyanosis disappeared with minimal retraction.

Figure 3 .
Figure 3. Transposition of Great Arteries.The right ventricle (RV) and left ventricle (LV) are connected in parallel to each other, creating independent circulations, with the aorta (Ao) arising from the RV and the pulmonary artery (PA) arising from the LV.Through an ASD (atrial septal defect), VSD (ventricular septal defect), or PDA (patent ductus arteriosus), blood must be mixed between the two circulations to survive.IVC, Inferior vena cava; LA, left atrium; PV, pulmonary vein; RA, right atrium; SVC, superior vena cava 7 .

Devina
Ravelia Tiffany Subroto, Ulya A'malia, Ardian Wibowo Anaesthetic Management during Balloon Atrial Septostomy in Transposition of Great Arteries Anesthesia was maintained with Oxygen: air bar = 2: 2 L/minute and Sevoflurane.Sevoflurane is less irritating to the airways, less hemodynamically impacted, and has lower odor acuity than desflurane and isoflurane 14 .Ketamine and fentanyl were administered to patients as multimodal analgesia since it helps to avoid opioid dependency as well as opioid-related side effects 15,16 .Neonatal patients usually get ketamine because of its ability to sustain hemodynamics by raising SVR and PVR.Moreover, ketamine can enhance fentanyl's antinociception without affecting the sedation index 5,13,14 .The neonatal vulnerability associated with hypothermia is related to several aspects, including less effective regulatory abilities compared to adults, a lesser weight-to-surface area (WSA) ratio, increased heat loss from the head, a limited amount of subcutaneous fat storage for thermal insulation, and the inability of the neonate to move to a warmer environment or wear warmer clothing.Moreover, newborns cannot increase their metabolic rate in the case of intraoperative hypothermia, just like adults cannot.Hence, an excellent perioperative warming strategy is required, including accurate core temperature assessment, maintenance of normothermia during transportation, active warming before anesthesia induction and throughout and surgery.When fluids must be administered to the patient, we need infusion warming.We can also control the efficacy of active warming therapy and prevent overheating children by measuring core temperature 10 .CONCLUSION Anesthesia management of TGA TGA cases is to avoid reducing cardiac output and SVR and keep the PVR lower than the SVR.The administration of an anesthetic regimen for newborns with TGA must consider circulatory and pulmonary physiology and the patient's clinical status.
physiology in children.Vol.63, Indian Journal of Anaesthesia.