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Year : 2021  |  Volume : 5  |  Issue : 4  |  Page : 279-281

Emergency management of cyanotic spell in a COVID-19 suspect tetralogy of Fallot child

Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India

Date of Submission12-Apr-2021
Date of Decision29-May-2021
Date of Acceptance03-Jun-2021
Date of Web Publication24-Nov-2021

Correspondence Address:
Dr. Iti Shri
Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi - 110 001.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bjoa.BJOA_44_21

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The novel coronavirus (SARS-CoV-2) is suggested to increase the risk of morbidity and mortality in patients with underlying cardiac and pulmonary disorders. Reports of COVID-19-related multisystem inflammatory syndrome in children, past experiences with influenza virus and the respiratory syncytial virus, and British Congenital Cardiac Association recommendation on congenital heart disease warrant caution even in children. We present a case of a 2-year-old child with tetralogy of Fallot, who got admitted in the emergency with cyanotic spell and fever (suspected to be due to COVID-19), potentially compounding the challenge of managing cyanotic spell emergency.

Keywords: COVID-19, ketamine, oxygen therapy, tetralogy of Fallot

How to cite this article:
Magoon R, Shri I, Kohli JK, Kashav RC. Emergency management of cyanotic spell in a COVID-19 suspect tetralogy of Fallot child. Bali J Anaesthesiol 2021;5:279-81

How to cite this URL:
Magoon R, Shri I, Kohli JK, Kashav RC. Emergency management of cyanotic spell in a COVID-19 suspect tetralogy of Fallot child. Bali J Anaesthesiol [serial online] 2021 [cited 2021 Nov 28];5:279-81. Available from: https://www.bjoaonline.com/text.asp?2021/5/4/279/330948

  Introduction Top

The COVID-19 pandemic has posed a major health hazard with a high incidence of morbidity and mortality. It impacted people across all ages, but those with comorbidities were the worst hit. Analysis of the data across different age groups indicated toward disparity in angiotensin-converting enzyme-2 receptor, innate immunity, and inflammatory responses responsible for the different spectrum and severity of disease in children in comparison to adults.[1]

Up to the writing of this manuscript, only 9% of all the cases of COVID-19 reported to the Centre for Disease Control and Prevention were children. However, this number and rate are steadily increasing in the United States of America (USA), and a cross-sectional study across pediatric intensive care units in the USA confirms acute illness in children, especially those with severe comorbidity. Children, particularly, those with congenital heart disease (CHD) may develop serious COVID-19-related complications and are more likely to require intensive care and artificial support (especially with cyanotic defects) owing to a propensity to hypoxemia and compromised tissue perfusion.[2]

It is not only the complexity of the underlying disease but also any syndromic associations and compromised functional status which makes the matters worse.[3],[4] Hence, we present a case report of a 2-year-old child admitted in the emergency ward for cyanotic spell, who was an initial suspect for COVID-19. Our case report highlights the dilemma, various management challenges as well as the precautions a physician needs to take while treating patients with peculiar underlying conditions in this pandemic.

  Case Report Top

A 2-year-old child, a known case of tetralogy of Fallot (TOF), got admitted to the Severe Acute Respiratory Infection (SARI) emergency ward that is equipped with two high-efficiency particulate air filter and exhaust fans filtering air to the outdoors. On presentation, his temperature was 102°F, had tachycardia (146 beats/min), and oxygen saturation was at 80%. The child was crying, restless, and displayed clinical evidence of cyanosis. Considering the child to be a COVID-19 suspect, full aerosol-generating procedure personal equipment consisting of a fluid-resistant gown with hood, and a plastic apron underneath, N-95 mask and full-face visor, and double gloves and boot covers was donned. We tried putting him in a knee–chest position and started on a low-flow nasal cannula at 2.0 L/min (the child was restless on putting oxygen rebreathing mask and cried even more intractably).

An intravenous (IV) line was secured and injection ketamine 20 mg was administered along with 0.1 mg injection of glycopyrrolate for sedation and injection esmolol 5 mg to relieve infundibular spasm. Injection paracetamol 150 mg was given, and cold sponging was done to bring down the fever. IV fluids with soda-bicarbonate were administered to decrease right to left shunt. Considering the precarious condition of the child, we simultaneously prepared for resuscitation as per the American Heart Association Emergency Cardiovascular Care Committee Interim COVID Guidance by keeping the T piece, laryngoscope, proper cuffed endotracheal tubes, and defibrillator readily available at hand. We collected the swabs for COVID-19 testing and sent samples for routine investigations.

Continuing with cold sponging, injection ketamine 20 mg was repeated along with injection midazolam 0.05 mg this time. This calmed down the child and after approximately 2 h of admission, the fever had come down to 98.4–99°F, and his SpO2 was 92%–94% on the nasal cannula. After initial management in the SARI ward and a negative COVID-19 report (obtained 24 h after admission), he was shifted to pediatric cardiology ward for further evaluation and treatment. He was evaluated for fever, for which no conclusive cause was found, managed symptomatically, and discharged 3 days later with proper instructions for care and admission for surgical management later on.

  Discussion Top

Our case highlights the unique management challenges one faces during these unprecedented times. The situation demanded meticulous management of the precarious underlying condition, which could have been made worse due to an associated COVID-19 infection, along with the anticipation and prevention of any unforeseen conundrum. This case was uniquely challenging because cyanotic spell is a life-threatening condition and the concomitant fever, tachycardia, and crying only added to the predisposition to spells owing to a resultant decrease in systemic vascular resistance and an increase in pulmonary vascular resistance, thereby potentially exacerbating right to left shunt in TOF.[5] These cyanotic spells are further exacerbated by inflammation and infection that increase metabolic demands, thereby again aggravating right to left shunt; also any amount of pulmonary involvement can potentially result in pulmonary venous desaturation contributing further to the spell. Acute history of fever, desaturation, underlying CHD, and suspicion of COVID-19 only aggravated the severity of the situation.

The intractable crying not only aggravated the spell but also in the current scenario of COVID-19, increased the generation of aerosols that fails the containment of the infection. COVID-19 and TOF, both, share a prothrombotic milieu, thereby adding to the risk of stroke and cerebral abscess. Hence, the appropriate treatment approach was not only in tailoring the pharmacological and nonpharmacological management of cyanotic spell in the pandemic but also following proper precautions so as not to become an instrument in the transmission of the virus while simultaneously recognizing the patient at risk of deterioration and preparedness for a safe resuscitation. The commonly employed drug, ketamine, in the management of a cyanotic spell is well known to increase the risk of bronchorrhea and hypersalivation (counterproductive in a pandemic).[6] Oxygen supplementation, a ubiquitous therapy, also presents a challenge in such a scenario considering that high-flow nasal cannula, continuous positive airway pressure, bag-mask ventilation, and tracheal intubation are all associated with increased aerosol generation.[7]

The risk of respiratory tract infection and pulmonary hypertension is higher in this subset of patients and may require an aggressive airway support. In the COVID-19 pandemic, therefore it becomes indispensable to have overarching goals of minimizing aerosol generation using anxiolytic medications, IV induction, tracheal intubation using video laryngoscopes and using cuffed tracheal tubes, and in line suction catheters along with proper barrier precautions and a limited number of physicians coming in contact with the patient. It is postulated since the adult patients with cardiac disease are at increased risk of severe COVID-19 disease so are the children with CHD as well. Cardiomyocyte injury seems to be a consequence of the cytokine storm with severe inflammation, direct viral invasion as well as ischemia from hypoxia due to acute lung injury.[8]

The British Congenital Cardiac Association has identified a subset of CHD patients presenting an increased risk of severe disease following COVID-19 infection[9] that includes single ventricle patients after palliative Fontan procedure, presence of cyanosis, impaired ventricular function, severe pulmonary hypertension, immunocompromised patients, infants with unrepaired significant CHD, and adults with CHD with associated comorbidities. Hence, several trials are underway to evaluate the impact of COVID-19 in patients with CHD, their response to therapy, and the efficacy of postexposure prophylaxis. COVID-19-related evaluation and perioperative protocols for CHD patients, case-based prioritization and new institutional care strategies, crisis management guidelines, proper surveillance, and plans for unintended consequences of delayed access to hospital care[10] should be formed on an a priori basis to provide the best clinical care to the CHD patients in these challenging times.

  Conclusion Top

This case nevertheless describes the caveats emanating in the mitigation of emergency in sick CHD patients during the unprecedented times of the COVID-19 pandemic. It emphasizes more rigorous and cautious management as well as surveillance toward this subset of patients who supposedly are at a greater risk of severe infection with COVID-19 considering a propensity of these patients to depressed myocardial contractility, pulmonary hypertension, worsening hypoxemia, and compromised tissue perfusion as it is aptly said: to be forewarned is to be forearmed and half the battle won.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Zimmermann P, Curtis N. Why is COVID-19 less severe in children? A review of the proposed mechanisms underlying the age-related difference in severity of SARS-CoV-2 infections. Arch Dis Child 2020;106:429-39.  Back to cited text no. 1
Zareef RO, Younis NK, Bitar F, Eid AH, Arabi M. COVID-19 in pediatric patients: A focus on CHD patients. Front Cardiovasc Med 2020;7:612460.  Back to cited text no. 2
Alsaied T, Saidi A. COVID-19 in Congenital Heart Disease: Ten Points to Remember. American College of Cardiology. Available from: https://www.acc.org/latest-in-cardiology/articles/2020/06/04/10/53/covid-19-in-congenitalheart-disease#. [Last accessed on 2020 Aug 10].  Back to cited text no. 3
Magoon R. COVID-19 and congenital heart disease: Cardiopulmonary interactions for the worse! Paediatr Anaesth 2020;30:1160-1.  Back to cited text no. 4
Tandale SR, Kelkar KV, Ghude AA, Kambale PV. Anesthesia considerations in neonate with tetralogy of fallot posted for laparotomy. Ann Card Anaesth 2018;21:465-6.  Back to cited text no. 5
[PUBMED]  [Full text]  
Suri A, Sindwani G. Ketamine use in the COVID-19 era: Be cautious! Korean J Anesthesiol 2020;73:568-9.  Back to cited text no. 6
Cheung JC, Ho LT, Cheng JV, Cham EY, Lam KN. Staff safety during emergency airway management for COVID-19 in Hong Kong. Lancet Respir Med 2020;8:e19.  Back to cited text no. 7
Babapoor-Farrokhran S, Gill D, Walker J, Rasekhi RT, Bozorgnia B, Amanullah A. Myocardial injury and COVID-19: Possible mechanisms. Life Sci 2020;253:117723.  Back to cited text no. 8
Alsaied T, Aboulhosn JA, Cotts TB, Daniels CJ, Etheridge SP, Feltes TF, et al. Coronavirus disease 2019 (COVID-19) pandemic implications in pediatric and adult congenital heart disease. J Am Heart Assoc 2020;9:e017224.  Back to cited text no. 9
Stephens EH, Dearani JA, Guleserian KJ, Overman DM, Tweddell JS, Backer CL, et al. COVID-19: Crisis management in congenital heart surgery. Ann Thorac Surg 2020;110:701-6.  Back to cited text no. 10


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