Transcript Document

Anesthesia
For
Pediatric CARDIAC
CATHETERIZATION
Hala El-Mohamady, professor of Anaesthesia,
Ain Shams University
Introduction
Cardiac catheterisation in man was first
introduced as a diagnostic procedure in 1941.
Since then, there has been a tremendous
development in the field of cardiac catheterisation
and interventional techniques.
Techniques of anaesthesia have also changed
with the changing requirements of the
cardiologist as well as the interest in better
patient care and safety.
Role of the Anaesthesiologist
Presence of anaesthesiologist
may be necessary during the
conduct of several
catheterisation procedures for
monitored anaesthetic care,
sedation, analgesia, general
anaesthesia and also for the
resuscitation of patients if
complications arise during the
procedure
Interventional procedures
A. Angioplasty of the:
1. coarctation of the aorta
2. pulmonary vasculature
B. Valvuloplasty:
1. Aortic valve
2. Pulmonic valve
C. Coil embolization:
1. PDA
2. Aorto-pulmonary collaterals
D. Balloon atrial septostomy and
stents:
E. Device closures:
1. ASD closure
2. VSD closure
3. PDA device closure
F. Electrophysiologic procedures:
Diagnostic and interventional procedures for
patients with Hx of PSVT, SVT, atrial flutter,
and WPW for mapping and ablation of the
foci of arrhythmia.
G. Biventricular pacer placements :
General
Anesthesia
In
Cath Lab ????
patients require GA include
- uncooperative children
- high risk patients such as hypoxaemic
infants, infants with CHF and obstructed
valvular lesion, and infants with cyanotic
heart disease
- Due to increasing invasive nature of the
procedures, complications can arise in
the cath. Lab., therefore
anaesthesiologist’s presence may be
desired as a stand-by in high risk patients
Difficulties In Cath. Lab
The anaesthesiologist who is more comfortable in the
operation theatre often describes the environment of
the cath. Lab. as
“unknown”.
Access to the patient is difficult due to fluoroscopy
equipment all around the patient with dimmed light and
movable tables.
Anaesthesiologist must be assured easy access to the
patient and in particular to the patient’s airway.
The priorities of the anaesthesiologist, such as the need
to maintain the airway and oxygenation as well as the
equipments necessary to do so are not fully appreciated
by the cardiologist. so interaction between the
cardiologist and anaethesiologist is necessary.
PREOPERATIVE
EVALUATION
1-Complete diagnosis: all details of pt’s cardiac
anatomy and physiology and the last ECHO
report is mandatory
2. List of the procedures pt has undergone in
the past (surgical and interventional)
3. Pt’s level of activity (weight gain, feeding
tolerance, SOB, exercise tolerance,
developmental delay)
4. Review with cardiologist anatomy of the
case and review the ECHO films
5- Ask the cardiologist about reason for the
catheterization and what he is planning to
do?
5. Rule out recent URI
After a recent URI patients are more likely to have
reactive airway and develop peri-GA
laryngospasm, bronchospasm, desaturate and
increase their PVR during the procedure.
6. Medication list: last time medication was taken.
(Lasix, Captopril and Digoxin is a common
combination for pts in CHF.) When you speak to
the patient or family the night before the
procedure, please instruct them to take all
antihypertensives and antiarrhythmics with sips
of water but to hold all other medications the
morning of the exam. Ask about allergies
7-Physical examination
should emphasise on the airway, heart, and
lung problems
Patients should be examined for the signs of CHF
such as pedal edema, jugular venous distention,
enlarged liver and rales and for signs of
respiratory distress such as increased
respiratory rate, diaphoresis, chest retraction,
nasal flaring, and use of accessory muscles of
respiration
Also Inquire regarding loose teeth
8- Special attention to the presence of other
congenital lesions, as nearly 25% of
patients with (CHD) may have other
associated congenital abnormality
including musculoskeletal abnormality
neurological defects
genitourinary irregularities
One congenital lesion that needs particular
attention is the atlanto-occipital
subluxation that occurs in 20% of patients
with Down’s syndrome.
Patient with cyanotic CHD having a
haemoglobin (Hb) level > 20 gm/dL or
haematocrit >65% may have
hyperviscosity, RBC sludging, and
reduced oxygen delivery to tissues which
may further exaggerate in dehydrated
patients and after hypothermia during the
procedure.
Patients with polycythemia and cyanosis
may also have thrombocytopenia,
hypofibrinogenemia, and low levels of
vitamin K dependent clotting factors.
Therefore, coagulation tests such
as prothrombin time (PT), partial
thromboplastin time (PTT), partial
thromboplastin time with kaolin
(PTTK) should also be done.
Serum electrolytes should be
determined in patients receiving
digoxin or diuretics.
ECHO REPORT
1. How many chambers
2. Ventricular function
3. Presence of the flow obstruction
(degree of obstruction or pressure
gradient) and level of obstruction
4. Pressure gradient across the valves
and intracardiac communications.
5. Coronary artery anatomy, if delineated
6. Presence and direction of the shunt
7. Rule out suprasystemic pressures in the
chambers of the heart
Monitoring
- Standard monitoring includes ECG,
noninvasive blood pressure, pulse
oximetry, and temperature.
- Arterial, atrial, and pulmonary
pressures can be obtained during the
procedure by the cardiologist. Endtidal carbon dioxide (EtCO2) for the
patients decided to be mechanically
ventilated.
Anaesthetic
technique
There is no ideal anaesthetic
technique that can be
universally applied
for
all patients undergoing
interventional and
diagnostic procedures
Sedation and analgesia to GA
Considerations
1. Pt’s age and clinical condition
2. Access by cardiologist: neck vs. groin.
3. Length of the procedure.
4. Pts disease. (Such as hypoplastic heart or
single ventricle.)
5. If procedure is diagnostic or
interventional.
6. Remember that pt’s cardiopulmonary
physiology has to be as close to the
baseline (awake state) as possible in
order to obtain real data from the
procedure.
7. Note Qp/Qs ratio if available. You will
not be successful in mask induction
of GA for pts with with decreased
pulmonary blood flow.
8. Evaluate pt’s cardiac function and
remember that all inhalation anesthetics
are myocardial depressants.
During diagnostic procedure
an ideal technique would be to
maintain
normal respiration on room air
steady haemodynamics, normal
blood gas values, immobility
and to
provide adequate
analgesia and amnesia
PROCEDURE
CONCERNS
1. Vascular access by cardiologist: If neck
approach is planned you will have better control of
the airway using LMA or ETT.
2. FiO2 concerns: during procedure cardiologist
will measure O2 saturations in the different
chambers of the heart to evaluate degree of the
shunt and calculate Qp/Qs ratio. If pt is sedated keep
them on room air if tolerated, if not, inform
cardiologist that you have to administer
supplemental O2 and they will stop the
measurements. Return the pt to room air as soon as
tolerated, and inform cardiologist. If pt is intubated or
has LMA in place keep FiO2 @ 25 % or below.
3. Specifics of the procedure: diagnostic vs.
invasive. if invasive, there is always possibility
of vessel rupture and uncontrolled bleeding. So
have volume expanders available and blood
typed, screened and crossmatched
4. If a neck approach is used: there is
possibility of hemo and pneumothorax. If
suspected these can be easily diagnosed via
chest fluoroscopy
5. Ectopy: always possible with wires and
catheters in the heart chambers. Development
of the heart block is also a possibility.
6. Coil embolization of the PDA: more
distal embolization of the pulmonary
arteries is always a possibility
7. Balloon dilatation: rupture of the balloon
is always a possibility.
8. Coronary angiogram: thrombosis or
dissection of coronary arteries is always
a possibility.
Conclusion
In
CHOOSING YOUR
ANESTHESTIC
TECHNIQUE
1. Premedication highly recommended.
2. Routes of premedication include oral, rectal, IM, IV. Oral
Versed 0.5 mg/Kg to 1 mg/Kg is a good choice.
3. Pt may be very sensitive to premedication and your
presence @ pt’s bedside after premedication as well as
pulse oxymeter monitoring is mandatory.
4. Consider adding Ketamine to your premedication to
improve level of sedation w/o increased respiratory
depression.
5. When considering inhalation induction, keep in
mind that it requires adequate pulmonary blood
flow.
6. Etomidate, Ketamine, Versed and Fentanyl are
good choices for IV induction.
7. When administering narcotics for the induction
and maintenance of the anesthesia remember
that the majority of these cyanotic patients are
going home in 6 hours after end of procedure.
8. Remember that Ketamine maintains cardiac
function and spontaneous respiration and also
is a good analgesic.