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LETTER TO THE EDITOR

Surviving Sepsis in an Adult Patient with Tetralogy of Fallot

Department of Anesthesia, Alexandra Hospital, Singapore, uma_shridhar{at}rediffmail.com

To the Editor:

Tetralogy of Fallot (TOF) is a congenital heart disease with a poor chance of survival into adulthood without surgery. A 60-yr-old man with uncorrected TOF was admitted with hepatobiliary sepsis secondary to cholecystitis. His medical history also included secondary polycythemia, hypertension, peptic ulcer diseases, and gout. Cardiac catheterization at 45 yr of age revealed classic TOF physiology and pulmonary collaterals via right internal mammary and right intercostal arteries. There was a gradient of 100 mm Hg across the pulmonary valve due to a right ventricular outlet obstruction.

Failed percutaneous cholecystostomy led to a emergency cholecystectomy. Preoperatively, his SaO₂ on room air was 84%. After placement of arterial and central venous catheters, anesthesia was induced and maintained with ketamine. Intraoperative SaO₂ ranged from 75% to 89% despite ventilation with 100% oxygen. Postoperatively, the patient was maintained on intermittent positive pressure ventilation with 100% oxygen. Despite this, his arterial Pao₂ decreased to as low as 33 mm Hg. Continuous efforts to improve his oxygenation included central venous pressure-guided fluid administration and norepinephrine infusion at 0.1–0.2 µg · kg^–1 · min^–1 to increase his systemic arterial blood pressure and reduce right to left shunt. Esmolol was administered to maintain his heart rate <100 bpm and correct any reversible infundibular spasm (1). After muscle paralysis was treated, his airway pressures increased to 55 mm Hg. Inhaled nitric oxide was unavailable, and so, the patient was treated with oral sildenafil (Viagra), 25 mg via the nasogastric tube (2).

The patient developed intraabdominal bleeding requiring two additional surgeries and multiple transfusions to correct his coagulopathy and maintain hemoglobin at more than 10 g/dL. He continued to be hemodynamically unstable. Despite continuous ventilation with 100% oxygen, the Spo₂ was seldom higher than 80%, with occasional episodes of severe desaturation and cyanosis. His recovery was slow. However, a month later, he was discharged from the hospital.

Patients with cyanotic heart disease have adapted to low oxygenation and appear capable of tolerating sustained moderate hypoxemia. Thorough understanding of the physiology of TOF and patience led to a favorable outcome in this patient despite three major surgeries complicated by sepsis and postoperative hemorrhage.

REFERENCES

1. Dhir AK, Dhir S. Esmolol in infundibular spasm. Anaesthesia 1991;46:998.[Web of Science][Medline]
2. Ng J, Finney SJ, Shulman R, et al. Treatment of pulmonary hypertension in the general adult intensive care unit: a role for oral sildenafil? Br J Anaesth 2005;94:774–7.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Iyer, U. S. Articles by Fah, K. K. Search for Related Content PubMed PubMed Citation Articles by Iyer, U. S. Articles by Fah, K. K.