Transcript Anesthesia for patients with pulmonary hypertension

Anesthesia
In Children With
Congenital Heart Disease For
Non-cardiac Surgery
Regarding investigations of CHD patients for non-cardiac
surgery:
A- Chest X – Ray has no rule
B- Cardiac Catheterization is the first choice for diagnosis of CHD
C- Echocardiography non invasive method for diagnosis of CHD
D- MRI has no rule
IM Premedication for CHD patients presenting for non-cardiac
suergery:
A- Cooperative child who able to take orally
B- Ketamine 1mg/kg
C- Midazolam 5 mg/kg
D -Glycopyrrolate or Atropine 0.02 mg/kg
Procedural antibiotic prophylaxis is required in patients with
A- Aortic valve replacement
B- Mitral valve prolapse with regurge
C- Previous history of infective endocarditis
D- Ostium secundum ASD
AHA guideline for antibiotic prophylaxis for genitourinary procedures:
A- High risk adult patient: Ampicillin 1 g & gentamicin 1.5mg/kg i.m or i.v
B- High risk Child patient: Ampicillin 5 mg/kg &gentamicin 1.5 mg/kg i.m or i.v
C- Moderate risk child allergic to penicillin: Vancomycin 20 mg/kg i.v bolus
D- High risk Adults allergic to penicillin: Vancomycin 1g/kg i.v over 1-2 hr
Regarding using Succinylcholine in pediatric patients with CHD:
A- Succinylcholine in pediatric is routine
B- If used should be with atropine, to avoid tachycardia or sinus arrest
C- If used with potent narcotic atropine should be used to avoid sever
bradycardia in childern with Decreased cardiac reserve
Postoperative Anesthetic Management of CHD patients:
A- No need for supplemental O2 and maintain patent airway
B- Pain decrease catech. which can affect VR and shunt direction
C- Pain  infundibular spasm in TOF  RVOT obstruction cyanosis,
hypoxia, syncope, seizures, acidosis and death
D- No conduction disturbances in septal defects
INTRODUCTION
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Due to advances in diagnosis, medical, critical
and surgical care for CHD
Therefore, it is common for patients with CHD
to present for non-cardiac surgery, and even in
patient with corrected CHD significant residual
problems (arrhythmias, ventricular dysfunction,
shunts, valvular stenosis, and PH) may be exist.
CLASSIFICATION OF CHD
I- Acyanotic congenital heart disease:
1- ASD
2- VSD
3- PDA
II- Cyanotic congenital heart disease:
1- Tetralogy of Fallot, with severe right
ventricular outflow obstruction
2- TGA
3- Pulmonary atresia or severe stenosis
4- Tricuspid atresia with pulmonary stenosis
5- Truncus Arteriosus
ANESTHETIC MANAGEMENT
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Perioperative management requires a team
approach
CHD is polymorphic and may clinically
manifest across a broad clinical spectrum
The plane of Anesthetic Management includes
the following:
A - Preoperative Management
B - Intraoperative Management
C - Postoperative Management
Preoperative Anesthetic Management:
A- History
B- physical examination
C- Investigations
D- Premedications
E- Fasting Guidelines
HISTORY & PHYSICAL EXAMINATION
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Assess functional status
- daily activities
- exercise tolerance
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↓ cardiac reserve
- cyanosis
- respiratory distress during feeding
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Cyanosis
Dyspnea
Fainting attack
Fatigue
Palpitations
chest pain
Syncope
Abdominal fullness
Leg swelling
Medications
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Vital signs
Airway abnormality
Associated extracardiac congenital
anomalies
Tachypnea, dyspnea, cyanosis
Squatting
Clubbing of digits
Heart murmur (s)
CHF:
- Jugular venous distention.
- Hepatomegally
- Ascitis
- Peripheral edema
MRI
Laboratory
Evaluation
12 Lead ECG
INVESTIGATIONS
chest X – Ray
Echocardiography
Cardiac Catheterization
Premedication
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Oral Premedication:
- Midazolam 0.25 -1.0 mg/kg
- Ketamine 2 - 4 mg/kg
- Atropine 0.02 mg/kg
IV Premedication:
- Midazolam 0.02 - 0.05 mg/kg titrated in small increments
- Ketamine 1-2 mg/kg
IM Premedication:
- Uncooperative or unable to take orally
- Ketamine 5 – 10 mg/kg
- Midazolam 0.2 mg/kg
- Glycopyrrolate or Atropine 0.02 mg/kg
Fasting Guidelines
AHA guidelines for bacterial endocarditis Prophylaxis in
patients with cardiac conditions
Endocarditis prophylaxis recommended
Endocarditis prophylaxis not recommended
High-risk category
- Complex cyanotic congenital heart disease :
Transposition of the great vessels
Tetralogy of Fallot
- Surgically created systemic-to-pulmonary
shuntsor conduits
- Prosthetic, Bioprosthetic, Homograft valves
- Previous bacterial endocarditis
Negligible-risk category
- Physiologic, or functional heart murmurs
Moderate-risk category
- Other congenital cardiac anomalies
- Acquired valvular dysfunction
- Hypertrophic cardiomyopathies
- Mitral valve prolapse with valvar- Regurg
- Surgical repair without residua beyond
6 months : ASD, PDA,VSD
- Cardiac pacemaker or
- implanted defibrillator
- Isolated secundum atrial septal defect
- Mitral valve prolapse without reg.
- Previous coronary artery bypass surgery
- Previous rheumatic heart disease
without valvular dysfunction
AHA guidelines for antibiotic prophylaxis: dental, oral,
Respiratory tract and esophageal procedures
Standard prophylaxis
Amoxicillin 1 h before procedure
-Children: 50 mg/kg p.o.
-.Adults: 2.0 g p.o
Unable to take oral
medications
Ampicillin within 30 min before procedure
- Children: 50 mg/ kg i.m. or i.v.
-.Adults: 2.0 g i.m. or i.v
Allergic to penicillin
Clindamycin 1 h before procedure
Children: 20 mg/kg p.o.
Adults: 600 mg p.o.
OR Azithromycin or clarithromycin 1 h
before procedure
-Children: 15 mg/kg p.o.
- .Adults: 500 mg p.o
Unable to take oral
medications
AND allergic to penicillin
Clindamycin within 30 min before procedur
-Children: 20 mg/ kg i.v
- .-Adult: 600 mg i.v.
AHA guidelines for antibiotic prophylaxis: genitourinary
and gastrointestinal procedures
High risk patients
- within 30 min before procedure
- Children: Ampicillin 50 mg/ kg .and gentaicin 1.5
mg/kg i.m or i.v
- Adults: Ampicillin 2.0 g and gentamicin 1.5
mg/kg i.m or i.v
High risk patients Allergic
to penicillin
- Complete infusion 30 min before procedure
- Children: Vancomycin 20 mg/kg i.v over 1-2 hr
gentamicin 1.5 mg/kg i.m or i.v
-Adults: Vancomycin 1g/kg i.v over 1-2 hr
gentamicin 1.5 mg/kg i.m or i.v
Moderate risk patients
- Ampicillin within 30 min before procedure
- Children: 50 mg/ kg i.m. or .iv
- Adults: 2.0 g i.m or i.v
Moderate risk patients
AND allergic to penicillin
- Complete infusion 30 min before procedure
- Children: Vancomycin 20 mg/kg i.v over 1-2 hr
-Adults: Vancomycin 1g/kg i.v over 1-2 hr
Preoperative Anesthetic Considerations
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Complete history and physical examin.
Review all investigations
Hydration should be maintained
All cardiac medication except possibly digitalis should
be continued until surgery
5- Premedication should be give particularly to patients
at risk for right to left shunt
6- Antibiotic prophylaxis against endocarditis must be
given
Anesthetic Management
A - Preoperative Management
B - Intraoperative Management :
1- Monitoring
2- Choice of anesthetic agent
3- Maintenance of anesthesia
4- Emergence from anesthesia
Monitoring
Non-invasive
- Clinical observation
- ECG
- NIBP
- Pulse oximetry on two
different limbs
- Precordial stethoscope
- Continuous airway
manometry
- Multiple site
temperatur
measurement
Invasive
- Volumetric urine
collection
- Art. catheterization
- CVP
- PAC
- TEE
Choice of anesthetic Regimen
Development of anesthetic regimen
is based on various factors such as
presence and direction of shunts ,
arrhythmia , pulmonary HF,
circulation,
and lowering or
maintenance of PVR
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Choice of Anesthetic Agent
Intravenous
anesthetics
Volatile
anesthetics
Muscle
relaxants
Barbiturates : Not recommended in patients with severe cardiac reserve
: No
in PVR
in children
when airway
maintained
& ventilation
supported
-Ketamine
Halothane
change
 PBF not
affecting
PVR, Depresses
myocardial
function,
alters sinus
node function,
Sympathomimetic
effects help
HR, SVR,,MAP
contractility
sensitizes myocardium
tomaintain
catecholamines
MAPand
,  HR
, CI ,  EF
Greater hemodynamic stability in hypovolemic patients
Copious
secretions
(laryngospasm)
• Desflurane
 Pungent
, PAP
and  PVR, Less myocardial depression than Halothane  HR , SVR
Etomidate : 
Induction
of 0.3mg/kg
 no
change
mean pulmonary
artery
pressure and PVR
•Isoflurane
Pungentdose
,  PAP
not affecting
PVR,
Less in
myocardial
depression
than
Halothane,
Vasodilatation leads to  SVR →  MAP ,  HR which can lead to 
Propofol
:
decrease
in
SBP
and
SVR,
and increase in SBF in all patients,
CI
whereas HR ,PAP, PBF remained unchanged
• Sevoflurane  Less myocardial depression than Halothane, more  in PAP compared
OPIOD: Excellent induction agents in very sick children
with
isoflurane,
No  HR,avoided
Mild  SVR, Can produce diastolic dysfunction
No cardiodepressant effects
if bradycardia
Fentanyl 15-25 µg/kg IV , Sufentanil 5-20 µg/kg IV
• Nitrous oxide  At 50% concentration does not affect PVR and PAP in children
Neuromuscular Blocking Drugs
Depolarizing
- Succinylcholine in pediatric
controversial is
- If used should be with atropine,
to avoid associated bradycardia or sinus arrest
- also if used with potent narcotic
atropine should be used
avoid sever to
bradycardia in children with 
Nondepolarizing
- Atracuruim and vecronium: have few
cardiovascular side effects in children
when given in recommended doses.
- Pancuronuim if given slowly doesn't
produce HR or BP changes. if given as
bolus doses it can produce tachycardia ,
↑BP (through sympathomimetic effect )
-Cisatracuruim and Rocuroinuim: safe
REGIONAL ANESTHESIA &ANALGESIA
• Considerations :
- Coarctation of aorta considerations
- Childern with chronic cyanosis  risk of
coagulation abnormality
- VD : which can:
1- be hazardous in patients with significant
AS or left-sided obstructive lesions
2- Cause  oxyhemoglobin saturation in R-L
shunts
Anesthetic Management
A - Preoperative Management
B - Intraoperative Management
C - Postoperative Management
Postoperative Anesthetic Management
Supplemental O2 and maintain patent airway.
 In patients with single ventricle titrate SaO2 to 85%.
Higher oxygen sat. can  PVR  PBF   SBF
 Pain  catech. which can affect VR and shunt
direction
 Pain  infundibular spasm in TOF  RVOT
obstruction  cyanosis, hypoxia, syncope, seizures,
acidosis and death
 Anticipate conduction disturbances in septal defects
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SUMMARY
 Familiarity with the CHD pathophysiology, adequate
preoperative preparation, choice of monitors,
induction, maintenance , emergence from anesthesia,
and plans for the postoperative period to avoid major
problems in anesthetic management
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A wide variety of anesthetic regimens is used for
patients with congenital heart disease (CHD)
undergoing cardiac or non-cardiac surgery, or other
diagnostic or therapeutic procures. The goal of all of
these regimens is to produce anesthesia or adequate
sedation, while preserving systemic cardiac output and
oxygen delivery
Regarding investigations of CHD patients for non-cardiac
surgery:
A- Chest X – Ray has no rule
B- Cardiac Catheterization is the first choice for diagnosis of CHD
C- Echocardiography non invasive method for diagnosis of CHD
D- MRI cannot give us idea about pulmonary veins
IM Premedication for CHD patients presenting for non-cardiac
suergery:
A- Cooperative or unable to take orally
B- Ketamine 1mg/kg
C- Midazolam 5 mg/kg
D -Glycopyrrolate or Atropine 0.02 mg/kg
Procedural antibiotic prophylaxis is required in patients with
A- Aortic valve replacement
B- Mitral valve prolapse with regurge
C- Previous history of infective endocarditis
D- Ostium secundum ASD
AHA guideline for antibiotic prophylaxis for genitourinary procedures:
A- High risk adult patient: Ampicillin 1 g & gentamicin 1.5mg/kg i.m or i.v
B- High risk Child patient: Ampicillin 5 mg/kg &gentamicin 1.5 mg/kg i.m or i.v
C- Moderate risk child allergic to penicillin: Vancomycin 20 mg/kg i.v bolus
D- High risk Adults allergic to penicillin: Vancomycin 1g/kg i.v over 1-2 hr
Regarding using Succinylcholine in pediatric patients with CHD:
A- Succinylcholine in pediatric is routine
B- If used should be with atropine, to avoid tachycardia or sinus arrest
C- If used with potent narcotic atropine should be used to avoid sever
bradycardia in children with Decreased cardiac reserve
Postoperative Anesthetic Management of CHD patients:
A- No need for supplemental O2 and maintain patent airway
B- Pain decrease catech. which can affect VR and shunt direction
C- Pain  infundibular spasm in TOF  RVOT obstruction cyanosis,
hypoxia, syncope, seizures, acidosis and death
D- No conduction disturbances in septal defects