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Year : 2018  |  Volume : 62  |  Issue : 3  |  Page : 237  

Induction of anaesthesia in cyanotic heart diseases: 'Ketomidate' to the rescue!

Department of Anesthesia and Critical Care, Maulana Azad Medical College, Lok Nayak Hospital, New Delhi, India

Date of Web Publication14-Mar-2018

Correspondence Address:
Dr. Nupur Dua
94, Satya Niketan, Moti Bagh, New Delhi - 110 021
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ija.IJA_395_17

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How to cite this article:
Dua N, Bhalotra AR. Induction of anaesthesia in cyanotic heart diseases: 'Ketomidate' to the rescue!. Indian J Anaesth 2018;62:237

How to cite this URL:
Dua N, Bhalotra AR. Induction of anaesthesia in cyanotic heart diseases: 'Ketomidate' to the rescue!. Indian J Anaesth [serial online] 2018 [cited 2021 Jun 23];62:237. Available from: https://www.ijaweb.org/text.asp?2018/62/3/237/227342


Patients with cyanotic heart diseases undergoing non-cardiac surgery are at a great risk of increase in the magnitude of right to left intracardiac shunt and the associated decreases in pulmonary blood flow and PaO2 under anaesthesia. This requires a thorough understanding of the events and drugs that may alter the shunt.

Conventionally, ketamine has been considered the induction agent of choice in such patients owing to its effect of an increase in systemic vascular resistance and a decrease in the right to left intracardiac shunt.[1] However, the surge in catecholamines with ketamine and the associated infundibular spasm may aggravate the outflow tract obstruction. Furthermore, the increase in pulmonary vascular resistance by inhibition of endothelium-dependent pulmonary vasodilatation may further reduce the pulmonary blood flow.[2] Combination of ketamine with propofol and fentanyl has been studied to reduce these undesirable effects. However, the associated decreases in the peripheral vascular resistance with these drugs may be detrimental in such patients.

Utilising the haemodynamic stable effects of etomidate, we used a combination of the two drugs – etomidate and ketamine, in a patient with untreated pentology of Fallot undergoing non-cardiac surgery. The associated suppression of adrenocortical function with etomidate can be considered desirable from the standpoint of 'stress-free' anaesthesia and its structural similarity to α2 receptors helps in the maintenance of systemic vascular resistance.[3],[4] Using the two drugs in combination for induction of anaesthesia helped reduce the dose requirement of both the drugs and maintain an adequate depth of anaesthesia with desirable haemodynamics and oxygenation. There was no fall in blood pressure or oxygen saturation or an increase in the heart rate on induction.

Hence, we suggest the combination of these two drugs for induction as a suitable alternative to monotherapy in patients with cyanotic heart disease. Ketamine and etomidate are ideal agents to prevent a fall in the systemic vascular resistance while maintaining the pulmonary blood flow, thus helping in avoiding the much dreaded intraoperative complication of a hyper-cyanotic spell.[5]

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Conflicts of interest

There are no conflicts of interest.

   References Top

Andropoulos DB, Stayer SA, Mossad EB, Miller-Hance WC. Anesthesia for Congenital Heart Disease. 3nd ed. Wylie-Blackwell; 2015.  Back to cited text no. 1
Tavakollian AR, Allahyary E. The comparison of the effect of three anesthetic induction regimens on the arterial oxygen saturation in children with tetralogy of fallot undergoing cardiac surgery. Iran Red Crescent Med J 2011;13:702-6.  Back to cited text no. 2
Dhawan N, Chauhan S, Kothari SS, Kiran U, Das S, Makhija N, et al. Hemodynamic responses to etomidate in pediatric patients with congenital cardiac shunt lesions. J Cardiothorac Vasc Anesth 2010;24:802-7.  Back to cited text no. 3
Dönmez A, Kaya H, Haberal A, Kutsal A, Arslan G. The effect of etomidate induction on plasma cortisol levels in children undergoing cardiac surgery. J Cardiothorac Vasc Anesth 1998;12:182-5.  Back to cited text no. 4
Malik M, Malik V, Chauhan S, Dhawan N, Kiran U. Ketamine-etomidate for children undergoing cardiac catheterization. Asian Cardiovasc Thorac Ann 2011;19:143-8.  Back to cited text no. 5


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