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HYPERCYANOTIC SPELLS
Pathophysiology
In TOF, The level of cyanosis and onset
of cyanotic spell is determined the SVR & level
of PS component. In case of mild PS, the RV
pressures are usually less than the left ventricle
and hence the shunt is usually left to right. If
Figure 1. Mechanism of Hypoxic Spell
Severe PS then the RV after load becomes high
and hence the RV pressures become high. If the Five mechanisms are involved in the
SVR is low (TOF with cyanotic spells) then the pathogenesis of fallot spells 1) An acceleration
shunt flow becomes right to left. This results in in heart rate 2) An increase in cardiac output and
*M.D., (Fellow) **M.D.,D.M, Head and Consultant venous return 3) An increase in right to left shunt
***M.D., D.M,(Consultant),****M.D., FNB,(Consultant) 4) Vulnerable respiratory control centers and 5)
Address For Correspondence : Dr. Amar Taksande, Infundibular contraction. Manual compression
Innova Children Heart Hospital And Research
Centre, White House, Tarnaka, Hyderabad, A.P. 500017 of abdominal aorta can abort spell by decreasing
E mail : amar_bharti2000@yahoo.co.uk cardiac output and decreasing cardiac output(3-4).
Figure 2. Various postures assumed for relief of dyspnea in TOF 1) squatting, 2) sitting with legs drawn underneath
(squatting equivalent), 3) legs crossed while standing, 4) infant held with legs flexed on its abdomen, and 5) lying down.
There is very limited benefit to administer induce hypotension. Correct anemia and con-
oxygen, since the problem is reduced pulmonary sider operation9.
blood flow, not the ability to deliver oxygen to
the lungs. Administer morphine sulfate 0.1 mg/ References
kg IV or IM. It depresses respiratory center and 1. Perloff JK. The Clinical Recognition of
congenital heart disease. 5th edn., Saunder,
lead to decreases in systemic venous return.
Philadelphia; 2003:356-360.
Correct acidosis : Obtain pH, give Inj. Soda 2. Weng YM, Chang YC, Chiu TF, Weng CS. Tet
bicarbonate(1-2 meq/kg IV). It reduces the spell in an adult. Am J Emerg Med. 2009 Jan; 27(1):
130.e3-5.
respiratory stimulation by metabolic acidosis,
and may diminish the increase in pulmonary 3. Neches W, Park S, Ettedgui J. Tetralogy Of Fallot
and Tetralogy of Fallot with Pulmonary Atresia.
vascular resistance caused by hypoxia and acidosis.
In: Garson A., Bricker J., Fisher D., and Neish
Propranolol, 0.1 mg/kg slow IV push. May be S.(Eds). The Science and Practice of Pediatric
repeated in 15 minutes. By decreasing cardiac Cardiology, edn. 2nd Williams and Wilkins.1999.
contractility, propranolol may decrease 4. Ghai OP. In: Essential Pediatrics. Ed.Ghai OP,
infundibular obstruction of right ventricular Gupta P, Paul VK. 6th Edn CBS Publisher, Delhi,
outflow. Given orally at 2-4 mg/kg/day PO to 2005, 409-10.
prevent spells. When used chronically, have the 5. Wood P. Attack of Deeper cyanosis and loss of
beneficial effect of stabilizing peripheral vascular consciousness (syncope) in Fallot's Tetralogy.
Br Heart Journal 1958;20:282
reactivity. or Inj Esmolol(0.5mg/kg over 1 min
6. Guntheroth WG, Morgan BC, Mullins GL,
then 50mcg/kg/min over 4 min. or Inj
Physiologic studies of Paroxysmal hyperpnea
Metoprolol- 0.1mg/kg over 5 min, repeat every 5 in cyanotic congenital heart disease. Circulation
min to max 3 doses , then start infusion 1-5 mcg/ 1965;31: 70.
kg/min. Phenylephrine 5-20 mcg/kg IV every 7. Kothari S.S., Mechanism of cyanotic spells in
10-15 minutes. Increases the SVR, forcing more tetralogy of Fallot--the missing link?, Int Journal
blood flow to the lungs. Continuous phenylephrine of Cardio 1992;37(1):1-5.
infusion to maintain adequate pulmonary 8. Park MK. Pediatric cardiology for Practitioners.
blood flow to keep oxygen saturations in the 90. 4th end. Mosey, St. Louis 2004: 123
A phenylephrine drip may be run at 0.1-0.5 mcg/ 9. Ponce FE, Luther CW, Hazel MW, Donald AR,
kg/min, titrated to desired effect. It is a potent Arno RH. Propranolol palliation ot tetralogy
of fallot: Experience with long term drug
vasoconstrictor that will result in reduced renal
treatment in pediatric patients. Pediatrics 1973 ;
and mesenteric perfusion as well. Ketamine- 0.25 52(1):100-108.
- 1.0 mg/kg. IV or IM? has dual benefit causes
10. van Roekens CN, Zuckerberg AL. Emergency
sedation and increase SVR. Methoxamine - 0.10mg/ Management of Hypercyanotic Crisis in
kg IV over 5-10 min.--> Leads to increase SVR. Tetralogy of Fallot. Annals of Emergency Medicine
1995;25:256-258.
Intravenous fluids - preferably initially as bolus
11. Nussbaum J, Zane EA, Thys DM. Esmolol for
of 10-20cc/kg à 60cc/kg. Crystalloid or colloid
the treatment of hypercyanotic spells in infants
fluid bolus: This maximises preload and should
with tetralogy of Fallot. J Cardiothorac Vasc Anesth
be given prior to the following drugs which may 1989;3:200-202.