Transcript Practical Peds Cardi..

Practical Pediatric Cardiac
Anesthesia
Michael S. Mazurek, MD
Overview
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Preoperative Workup
Pathophysiology
Induction
Pre-pump considerations
On-pump considerations
Post-pump considerations
?Extubation
Preoperative Workup
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Heart Center 4th floor
Medicines
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Previous surgeries
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Heart failure, arrythmias
Sternotomy, BT shunt
Recent echocardiogram
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Pathophysiology, ventricular function
Preoperative Workup
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Labs
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CXR
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Cardiomegaly, pulmonary congestion
Physical exam
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Electrolytes, CBC, Coags
Failing to thrive, tachypneic, pulses, perfusion,
rales, hepatomegaly
Consent
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Caudal morphine
Intubated, sedated in ICU
Preoperative Workup Orders
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NPO same as usual
Preop versed same as usual
Inotrope drip sheet order
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Dopamine, dobutamine, epinephrine,
nitroglycerine usually (discuss with staff)
Send to pharmacy night before
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Give to nurses in heart center
Fax it to the pharmacy yourself
Pathophysiology
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Understand the patient’s lesion (recent echo
most helpful)
Cyanotic or acyanotic lesion (RA sats)
Ventricular function good or poor
Obstructive lesion?
Are there oxygenation and ventilation issues?
Are there line placement issues?
Postop pulmonary hypertension?
Room Setup
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Normal setup plus:
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Phenyephrine 100mics/cc
Epinephrine 10mics/cc
Have inotrope drips in the room
2 or 3 IVs and A-line
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Add several stopcocks to D5LR line
Hot line
Need blood available
Bair hugger (for post-pump use)
Cerebral oximeter
Induction
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IV induction or inhalation induction
Again, know the pathophysiology
If ventricular function poor or LVOT
obstructive lesion (critical AS), lean
towards gentle IV induction (ketamine,
narcotic, etomidate)
If ventricular function good, inhalation
induction most likely well tolerated
Induction
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Again consider oxygenation/ventilation
issues
Again consider line placement issues
Caudal morphine 70-100mics/kg if plan
on early extubation
Cefuroxime 25mg/kg if not allergic
Anesthesia Maintenance
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Narcotic based
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Remifentanil infusion
Fentanyl bolus
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< 10mic/kg if plan on extubation
50 – 100mic/kg as sole anesthetic for many neonatal
pumps
Volatile anesthetic titration
Ketamine
Muscle relaxant (usually cisatra infusion)
Intermittent midazolam
Pre-Pump Considerations
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Aprotinin? (Surgeon’s decision)
Dr. Brown
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Dr. Turrentine
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2.5 + 2.5 + 2.5cc/kg
Heparin 400Units/kg given in RA
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3.5cc/kg IV shortly before cannulation (wait until
pursestring sutures in)
3.5cc/kg in pump per perfusionist
ACT 2mins after
Midazolam dose pre-cannulation
Pre-Pump Considerations
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Cannulation
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Aortic line first (trendelenburg position)
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Look for bubbles
IVC and SVC cannulation
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Valsalva 10-20 cm/H20 until pursestrings
cinched
Potential for blood loss – watch field and ABP
and have perfusionist give volume through
aortic line if necessary
On-Pump Considerations
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IVFs to keep open
Turn off humidifier
Monitor mean ABP
Monitor urine output
Get inotropes ready for post-pump
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Dopamine, nitroglycerine
On-Pump Considerations
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Nitroglycerine 0.25mcg/kg/min
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Dr. Turrentine for whole case
Helps with rewarming
Dopamine 5mcg/kg/min ready to go
Call for echo and blood products 20
minutes before coming off pump
Repeat midazolam with rewarming
Set up RA, LA, PA lines
On-Pump Considerations
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Start ventilating when patient starts
ejecting
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One of venous canulas out
Decompression line out
Re-expand lungs with large breath and
hold
Off-Pump Considerations
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Weaning off pump
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Full ventilation 100% O2
Bair hugger full warm
Hypotension?
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What does echo show – volume and function
Hct, calcium
Consider small dose epi or phenylephrine
Consider inotropes
Modified Ultrafiltration (MUF)
Off-Pump Considerations
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Protamine after MUF
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Half dose at a time
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Hypotension and pulmonary hypertension side
effects
ACT and ABG 5 minutes after protamine
Start blood products if coagulopathy
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Platelets first, then cryo
Rarely need FFP
Off-Pump Considerations
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Coagulopathy Risk
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< 8 kg
Cyanotic lesions
Long pump run
Redo sternotomy
Residual hypothermia
Keep calcium > 1.0 (20mg/kg/dose CaGluc)
NaHCO3 for metabolic acidosis: mEq dose=
base deficit x wt. x 0.3
Extubation
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Extubation criteria (case by case basis)
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Non-neonate
Stable hemodynamics
Stable coagulopathy
Caudal helpful, not mandatory
Reasonable PaO2 on 40-50% O2
Transport to ICU
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Emergency supplies (laryngoscope, ETT,
drugs, etc.)
Oxygen (Jackson-Rees circuit or Ambu)
Discuss case with ICU resident and
nurses
Return monitor and oxygen to
workroom
Case Example
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5 year old boy who is otherwise healthy
for repair of a secundum ASD.
5 year old ASD
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Preoperative workup
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What’s important
Pathophysiology
Induction
Anesthesia maintenance
Aprotinin?
Coagulopathy?
Extubation?
Case Example
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3 day old with hypoplastic left heart
syndrome for Norwood procedure.
3 day old Norwood
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Preoperative workup
Pathophysiology
Induction
Anesthesia maintenance
Aprotinin?
Coagulopathy?
Extubation?