The Challenging Pediatric Cardiac Patient -...
Transcript of The Challenging Pediatric Cardiac Patient -...
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.