Indian Journal of Anaesthesia

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

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

Nupur Dua, Anju R Bhalotra 
 Department of Anesthesia and Critical Care, Maulana Azad Medical College, Lok Nayak Hospital, New Delhi, India

Correspondence Address:
Dr. Nupur Dua
94, Satya Niketan, Moti Bagh, New Delhi - 110 021

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

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Dua N, Bhalotra AR. Induction of anaesthesia in cyanotic heart diseases: 'Ketomidate' to the rescue!. Indian J Anaesth [serial online] 2018 [cited 2021 Jan 25 ];62:237-237
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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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