This patient is especially susceptible to infection because of baseline depressed cellular immunity. As with every patient, strict attention must be paid to maintaining a sterile technique during the central line placement. The anesthesiologist must wear a sterile gown and gloves to protect the neonate. Sterility of the disposable circle system, mask, endotracheal tube, and airway equipment should be ensured. Routine monitors for all surgery on infants include pulse oximetry, electrocardiogram, blood pressure, capnograph, spirometer, and temperature probe. Multiple pulse oximeters should be available to offer flexibility in the event of monitor dysfunction. In this neonate, the IAA precludes saturation data from the lower body and left arm. End-tidal expired gas concentrations should be recorded for anesthetic gases, nitrogen, and oxygen. Accurate capnography in small infants can be hampered by sidearm gas sampling resulting from the relatively high gas flows relative to the expired gas flow from the infant.

In this procedure, an arterial line should be inserted in the right upper extremity because the IAA will not allow accurate blood pressure determination on the left side. Because there is potential for significant blood loss, a central line should be placed under ultrasound guidance at the best available site (ie, internal jugular, subclavian, or femoral). Obtaining central access in such a small patient with distorted anatomy can be very difficult. If an internal jugular or subclavian central line is placed, a chest radiograph should be obtained after placement and reviewed for correct positioning and to rule out pneumothorax before proceeding with this complicated case. Catheter length must be taken into consideration during placement to avoid inadvertently inserting the central line inside the right atrium or across the tricuspid valve, leading to arrhythmias and misleading right ventricular pressures. The arterial line and central venous pressure (CVP) transducers should be placed at the approximate level of the right atrium and adjusted accordingly as the table height is changed. Cerebral and somatic oximetry is useful in providing early recognition of intraoperative hypoperfusion to the brain and body.

References

• Burbano-Vera N, Zaleski KL, Latham GJ, et al. Perioperative and anesthetic considerations of interrupted aortic arch. Semin Cardiothorac Vasc Anesth. 2018;22:270-277.
• Modestini M, Hoffmann L, Niezen C, Armocida B, Vos JJ, Scheeren TWL. Cerebral oxygenation during pediatric congenital cardiac surgery and its association with outcome: a retrospective observational study. Can J Anaesth. 2020;67:1170-1181.