Background: Congenital obstructive anomalies of the trachea represent a unique perioperative challenge.
Extracorporeal membrane oxygenation (ECMO) provides adequate respiratory support during tracheoplasty surgery and the use of total intravenous anesthesia provides hemodynamic stability. There are a few studies that recommend the use of bispectral index monitoring in pediatric patients by showing a correlation of BIS with end-tidal sevoflurane concentrations.
We aimed to describe the use of TIVA in a patient diagnosed with a non-inherited genetic disorder who undergone tracheoplasty surgery under ECMO.
Case Report: A 13-month-old male infant weighing 6.7 kg, diagnosed with a non-inherited genetic disorder, congenital heart disease (intra-atrial communication type Ostium Secundum and interventricular defect) and systemic pulmonary hypertension, tracheostomized and hospitalized in Pediatric Intensive Care Unit with
respiratory failure due to recurrent tracheal granulomas, was scheduled for tracheoplasty surgery. A total intravenous technique was performed through TCI system (correlation with pediatric Paedfusor model through computerized software) and bispectral monitoring was used setting a BIS target of 45-55, dose
titration. Anaesthetic induction was made with Fentanyl 5 mcg, propofol TCI 2mcg/ml, remifentanil and vecuronium 2mg. Anaesthesia was maintained with TIVA using propofol (TCI 2mcg/ml), midazolam and remifentanil. During ECMO we noticed an increase in propofol requirements to 2.5-2.8 mcg/ml. Resection
and end-to-end anastomosis was performed. Extracorporeal membrane oxygenation support (veno-venous) was sufficient for gas exchange during surgery and the patient was successfully weaned off intraoperatively (213 minutes). No ECMO-related complications occurred. The patient showed hemodynamic stability
throughout the surgery, inotropic support was not necessary.
Discussion: TIVA allowed a safe handling of hypnosis and anesthetic depth during tracheoplasty surgery.
We noticed an increase in propofol requirements to obtain BIS values of 45-55 when the patient was supported through ECMO. There was no need of inotropic drugs and the anesthetic technique showed hemodynamic stability.

References: - Hoetzenecker K, et al. Extracorporeal support in airway surgery. Journal of Thoracic Disease. 2017;9(7). - Nirali N, et al. Correlation of BIS index with sevoflurane concentration in paediatric anaesthesia. National Journal of Medical Research. 2014;4(2).

11 / TIVA (total intravenous anaesthesia) for tracheoplasty surgery under ECMO (extracorporeal membrane oxygenation) in a 1 year old patient with congenital heart disease