The Successful Resuscitation in a Neonate with Down Syndrome after 45 minutes: A Case Report

Introduction: Patients with Down syndrome (DS due to relative macroglossia and dynamic airway collapse) are vulnerable to significant upper airway complications. Obstructive sleep apnea (OSA) is a common condition and noted in about 79% of these children . Children with OSA, with or without DS, are sensitive to respiratory depression by drugs such as sedatives, opioids and hypnotics. Abnormalities of the cardiovascular system are also common in Down syndrome. Case Report: A nine_ day old male preterm newborn with DS (e.g. gestational age of 35 weeks) was brought to operation room (OR) for insertion of central venous line and surgery of duodenal atresia. During transportation to NICU, in OR he arrested and then after 45 minutes resuscitation, he returned to life. Conclusion: The placement of CVL could precipitate triggers of cardiac arrest, particularly in preterm newborn.


INTRODUCTION
Down syndrome(DS) is one of most prevalent congenital abnormalities (1).It is most obviously that outcome is poor in resuscitation cases due to cardiac or cardiorespiratory arrest, and is associated with 87% to 89% mortality rate or sever morbidity (2). Children with heart disease in comparison with patients without heart disease may be sicker in the time of occurrence of anesthesia -related cardiac events and they experience higher mortality rate. These types of arrests are frequently reported from general operation room and it has probably originated from cardiovascular reasons (3). In one study, mortality was particularly as high as 56% in duodenal stenosis DS patients. Associated congenital heart disease especially endocardia cushion defects and high prevalence of pneumonia are contributor factors in this remarkable mortality rate (4).Obstruction of upper airway in children with Down syndrome is frequently a complex course with various causes and symptoms of residual airway obstruction are common in postoperative period (5). Although, due to medical improvements in multidisciplinary cares, the median survival rate of patients with DS has evolved (1) there is no comprehensive reports about incidence of all important unpleasant events such as bradycardia during induction of anesthesia, obstruction of natural airway and croup in post-intubation or-instrumentation period, even in children with DS (no cardiac case), it seems to be high in comparison with remain of children (2,6).

Case Presentation
We present a nine-day old the preterm and premature male. DS with gestational age of 35 weeks, who was brought to operation room for insertion of central venous line and surgery due to duodenal atresia. His weight was 2400 grams. He was icteric, and has symptoms of atrial septum defect (ASD) in echocardiography. The surgery was performed within an hour without any problem and the vital signs were stable during operation 55 minutes after finishing the surgery while was waiting for NICU staff in to transportation .During transferring the neonate to NICU, suddenly some changes appeared in electrocardiogram (ECG) such as tall T waves and bradycardia (HR=87 beat/min) and then converted to ventricular tachycardia (VT).Immediately, the patient was return to OR and we began to CPR .Up to 35 min, the CPR was not successful. Synchronized cardioversion was applied for 4 times (5-15 j).One dose of intracardiac epinephrine(1/10000,2ml) was injected and central vein catheter was pulled out about 1cm.The CPR was continued all the time without interruption (with chest compression and epinephrine injection).After 45 min attempt , the CPR was successful, the rhythm became normal( HR=163 beat/ min, BP=71/49mmHg and Sao2 = 96%)and then he was 14-year-male this study postulated that in DS patients asystole was triggered by a dysfunction in the autonomic cardiac regulation and sympathetic activation, due to the use of high concentrations of sevoflurane. In future cases of pediatric patients with Down syndrome, with or without heart disease, the concentration of sevoflurane should be increased gradually, and intravenous catheter should be promptly inserted to administer anticholinergic drugs as quickly as possible in order to prevent transient arrhythmia and cardiac arrest. After short instruction based on a brief video and hands-on session DS young people with mild or moderate intellectual disability and without physical disability were able to deliver CC but could not achieve good CC quality. transferred to NICU. The patient was intubated with endotracheal tube No 3 and he was not awake during transfer to NICU. He was stable in NICU and was extubated 2 days after the CPR and transferred to the neonatal ward.

CONCLUSION
The placement of central venous line may be the reason. Therefore, neonates with congenital anomalies specially ones with cardiac problems are vulnerable to even mild stimulations by internal device and inter-cardiac instrumental, for example, clv.

Financial Disclosures
The authors declared they had no financial disclosere. We obtain informed consent of parents. The authors declare that they have no conflicts of interests..

Learning Points
1 Please be patient during resuscitation of children, do not give up CPR early 2 INTRACARDIAC epinephrine may be last choice in CPR and rescue the child 3 Please check central venous catheter site as soon as possible in infants and children. 4 There are no population-level data on the incidence of acquired major cardiovascular ,cerebrovascular complications in children with DS, and no data examining how risk factors or cardiovascular comorbidities in DS might impact on cardiovascular event incidence. The data of this paper may be also valuable to inform health care planning for children with DS.