The Challenging Pediatric Cardiac

Patient

Edmund Jooste

“A 5 -year old female with hypoplastic left heart

syndrome s/p the Fontan procedure presents

for laparoscopic appendectomy for acute

appendicitis”.

Practical approach

• Picture the plumbing

• Understand the PHYSIOLOGY

• Implication of the Non cardiac disease

• Plan the anesthetic and anticipate the potential

complications

Plumbing

Major Single Left Ventricle Anomalies

Hypoplastic Left Heart syndrome

Mitral valve Atresia

Double Outlet RV

Unbalanced complete AV canal

Heterotaxy syndrome

Hypoplastic Left Heart Syndrome

Stage 1

Norwood and BT Shunt Sano Shunt

Bidirectional Glenn

Fontan

Extracardiac Fontan Lateral Tunnel Fontan with fenestration

Question 1

• What should the oxygenation saturation be in a Fontan?

– A- 75%

– B- 95%

– C- 100%

Understand Physiology

• Don’t get lost in the details

• Single Right ventricle

• Circulations are in Series= cardiac output is completely

dependent on pulmonary blood flow.

• Pulmonary blood flow is passive

– Kinetic energy from systolic ventricle output

– Transpulmonary gradient (Difference between the CVP or MAP

and the mean Left atrial pressure

– Negative intra-thoracic pressure with inspiration

Understand Physiology cont.

• Volume dependent circulation

• Mean pulmonary artery pressure = CVP

• Qp:QS = 1

• O2 Saturation = +/- 95%

– Why not 100%?

• Rely on Sinus rhythm

Long term Consequences of Fontan

• Arrythmias

• Increased Thrombotic risks

• Elevated systemic venous pressures

– Liver congestion

– Protein losing enteropathy

– Plastic Bronchitus

• Low Cardiac output state.

Implications of the non cardiac disease

• Appendicitis

- Vomiting

- Dehydrated

- Septicemic

- Febrile

- Rapid sequence

induction

Negative effects on Fontan Physiology

Implications of the procedure

• Antibiotic prophylaxis ?

Antibiotic prophylaxis

• Prosthetic cardiac valve

• Previous endocarditis even in the absence of underlying heart disease.

• Congenital Heart Disease (CHD), with one of the following conditions:

– Unrepaired or incompletely repaired cyanotic (blue) heart disease including shunts and conduits

– Completely repaired CHD with prosthetic material or device during the first 6 months after procedure.

– Repaired CHD with residual defects at the site or adjacent to prosthetic patch or device

• Cardiac transplant recipients who develop cardiac valvulopathy

Antibiotic prophylaxis

• Dental procedures likely to involve manipulation of the gingival tissue or the peri-apical region of teeth or perforation of the oral mucosa.

• Respiratory procedures involving incision or biopsy of the respiratory mucosa such as tonsillectomy, adenoidectomy.

• Infected tissue such as incision and drainage of infected tissue.

Antibiotic prophylaxis

• Single dose 30-60 minutes before procedure

• Standard dose Route Child

– Ampicillin IV or IM 50 mg/kg

– Cefazolin/ceftriaxone IV or IM 50 mg/kg

• Penicillin allergy Route Child dose

– Cefazolin/ceftriaxone IV or IM 50mg/kg

– Clindamycin IV or IM 20 mg/kg

• If the dosage of antibiotic is inadvertently not administered before the procedure, the dosage may be administered up to 2 hours after the procedure.

Implications of the procedure

• Antibiotic prophylaxis ?- no according to guidelines

• Monitors

– NIRS?

– Aline?

– Central line?

• Laparoscopic pneumoperitonuem

Implications of the procedure

• Laparoscopic Pneumoperitoneum (10mmHg)

– 65%aortic blood flow and stroke volume, 150%

SVR, Preload

SVR, LV end diastolic pressure- Transpulmonary

gradient. Pulmonary blood flow

Abdominal pressure--- Preload-- TPG--Cardiac

filling

Abdominal pressure--- FRC–V/Q mismatch

– Elevated carbon dioxide tension

Anesthetic Management

• Preop:

– Sedative premedication

– CBC – HCT?

– Assess cardiac functional status

– Echocardiograph Study

– Emergency drugs/ infusions- Epi, Milrinone

– Aggressively Re-Hydrate

• Induction:

– Fluid bolus prior to induction- 10ml/kg

– RSI (it is not what meds you use but how you use them)

Anesthetic Management

Intraoperative

• Cardiovascular

– Adequate volume status- Critical

– Maintain good preload

– Avoid RV dysfunction by minimizing volatile anesthetic

– Maintain sinus rhythm

Anesthetic Management

• Respiratory

– Spontaneous ventilation unlikely. Keep paralyzed.

– Ventilate- Low rates, low PIP, Short Insp time, Normal/low peep

– Encourage Low PVR- FiO2, PCO2

Question 2

• If you had to choose which one monitor would you use

– A- NIRS

– B- Arterial Line

– C- CVP

Anesthetic Management

• General

• NIRS

• Arterial line- Fluid status and ABG monitoring

• Correct any acidosis

– Maintain Hct above 30

– Regional technique- ?

Anesthetic Management

• Laparoscopy

– Keep inflation pressures below 12 (preferably <10)

– How are vitals with abdomen inflated?

– Should you convert to an open procedure

Anesthetic Management

• Post operative: – Extubation is preferable

– Anti-emetic

– Pain management-

• Balance between comfort and over-sedation and fears of PVR due to PCO2 and hypoxia

• IV tylenol, fentanyl and Dexmedetomidine

• Disposition:

– ICU vs PACU

Conclusion

– Draw the anatomy

– Understand the Physiology

– Volume responsive

– Maintain preload, sinus rhythm and function

– Anticipate the physiological effects of the laparoscopic procedure

References

• 1. Bailey, P.D., Jr. and D.R. Jobes, The Fontan patient. Anesthesiology clinics,

2009. 27(2): p. 285-300.

• 2. Wilson, W., et al., Prevention of infective endocarditis: guidelines from the

American Heart Association: a guideline from the American Heart Association

Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on

Cardiovascular Disease in the Young, and the Council on Clinical Cardiology,

Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and

Outcomes Research Interdisciplinary Working Group. Circulation, 2007. 116(15):

p. 1736-54.

• 3. Yuki, K., A. Casta, and S. Uezono, Anesthetic management of noncardiac

surgery for patients with single ventricle physiology. Journal of anesthesia, 2011.

25(2): p. 247-56.

• 4. Taylor, K.L., H. Holtby, and B. Macpherson, Laparoscopic surgery in the

pediatric patient post Fontan procedure. Paediatric anaesthesia, 2006. 16(5): p.

591-5.

• 5. McClain, C.D., F.X. McGowan, and P.G. Kovatsis, Laparoscopic surgery in a

patient with Fontan physiology. Anesthesia and analgesia, 2006. 103(4): p.

856-8.