Anaesthetic concerns in cyanotic congenital heart disease incidental surgery
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Dr. S. Parthasarathy MD., DA., DNB, MD ( Acu ), Dip. Diab . DCA, Dip. Software statistics Ph d( physio ) Mahatma gandhi medical college and research institute, puducherry , India . Anaesthetic concerns in cyanotic congenital heart disease – incidental surgery . Why to know??.

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Anaesthetic concerns in cyanotic congenital heart disease incidental surgery

Dr. S. Parthasarathy

MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics Ph d( physio)

Mahatma gandhi medical college and research institute, puducherry, India

Anaesthetic concerns in cyanotic congenital heart disease – incidental surgery


Why to know

Why to know??

  • Number of children reaching adulthood with CHD has increased over the last 5 decades

  • advances in diagnosis, medical, critical and surgical care,

  • not uncommon for adult patients with CHD to present for non-cardiac surgery


Incidence

Incidence

  • 7 to 10 per 1000 live births

  • Commonest cong. Disease

  • 15 % have associated anomalies

  • 15% survive to adulthood without treatment


What happens after birth

What happens after birth ??

There are 4 shunts in fetal circulation: placenta, ductusvenosus, foramen ovale, and ductusarteriosus

In adult, gas exchange occurs in lungs. In fetus, the placenta provides the exchange of gases and nutrients


Ductus venosus

Ductusvenosus

  • Removal of placenta results in following:

  • ↑ SVR(because the placenta has lowest vascular resistance in the fetus)

  • Cessation of blood flow in the umbilical vein resulting in closure of the ductusvenosus


Foramen ovale

Foramen ovale

  • Lung expansion → reduction of the pulmonary vascular resistance (PVR), an increase in pulmonary blood flow, & a fall in PA pressure

    • Functional closure of the foramen ovaleas a result ↑ LAP in excess RAP

      LAP increase ? RAP decrease ?

      DA closure D/T ↑ arterial oxygen saturation

      So all shunts close !!


Classification of chd

Classification of CHD

  • Acyanotic

  • Cyanotic


Incidental surgery concerns

Incidental surgery – concerns

  • Spectrum

  • Corrected fallots adult for I & D

  • to

  • Also uncorrected fallots for intestinal gangrene


Preop assessment

Preop assessment

  • Patients cardiac disease

  • Age

  • Present illness ,others


Patients cardiac disease

Patients cardiac disease

  • Cyanosis

  • Cyanotic spells

  • Cong. Cardiac failure

    Pulm. Vs Sys. Shunt > 2:1

    Exercise tolerance – siblings

    Adequate weight ?

    Sweating, dyspnoea during feeds??


Anaesthetic concerns in cyanotic congenital heart disease incidental surgery

AGE

  • Heart rate

  • LV pressure less

  • Educating the child ,family

  • Age related airway and IV access problems


Present illness others

Present illness ,others

  • Gangrene gut

  • Sepsis , dehydration

  • Pregnancy for LSCS

  • Orthopedics


Present illness others1

Present illness ,others

  • Evidence of downs syndrome

  • Macroglossia, hypoplastic mandible, protuberant teeth

  • Blood pressure in all limbs


Investigations

Investigations

  • Hb%

  • Cyanosis Hb % may be upto 20 gm/dl.

  • Hb level ??

    Hct decrease PBF increase

  • Polycythemia – increased viscosity sludging of blood flow –

  • So cold OR ??

  • Proper hydration is a must


Coagulation

Coagulation

  • Polycythemia – increased viscosity sludging of blood flow leads to IV thrombosis

  • Fibrinolysis and consumptive coagulopathy

  • Think of tonsillectomy

  • Remove 20 ml/ kg RBC

  • fill it with FFP.


Other investigations

Other investigations

  • Electrolytes

  • Digoxin, diuretics

  • Hypoglycemia , hypocalcemia

  • ABG

  • PaO2 30- 40 mmHg – SaO2 <70 % = risk

  • Cardiology consultation


Preop uri

Preop URI

  • Desaturation ,

  • Laryngospam

  • Bronchospasm

  • Post ext. stridor common

  • 4-6 weeks – gap ideal

  • Can we get such patients without URI ??


Anaesthesia

Anaesthesia

  • Cardiac grid

  • Five factors

  • 1. preload

  • 2. SVR

  • 3. PVR

  • 4. HR

  • 5.contractility


Preload

Preload

  • increase

  • Volume load

  • Capacitance vessel constriction

  • Decrease

  • Phlebotomy

  • Less volume replacement


Anaesthetic concerns in cyanotic congenital heart disease incidental surgery

SVR

  • increase

  • Arteriolar constriction

  • Anaesthetics – ketamine

  • Decrease

  • Anesthetics (volatile & IV)

  • Histamine releasing drugs


Anaesthetic concerns in cyanotic congenital heart disease incidental surgery

PVR

  • increase

    Hypoxia,

    hypercarbia

    peep

    high Hct

  • Decrease

    Pulm. dilators

    And others


Heart rate

Heart rate

  • Increase

    Atropine

    Pancuronium

    Isoflurane

  • Decrease

    Beta blockers

    Fent

    Digoxin


Contractility

Contractility

  • increase

    Inotropes

    Digoxin

    Calcium

  • Decrease

    All inh. Agents

    Ca. channel blockers


Cardiac grid five factors

Cardiac grid -- Five factors

  • 1. preload

  • 2. SVR

  • 3. PVR

  • 4. HR

  • 5.contractility


Premedication

Premedication

  • Avoid IM

  • Child may cry , precipitate cyanotic spell

  • Fasting 2 hours clear fluids for kids

  • Withhold

  • diuretic(one day)

  • anticoagulants to normalize coagulation profile


Premedicants described

Premedicants described

  • Oral / nasal midazolam

  • IV fentanyl + atropine

  • Morphine + atropine + midazolam

  • Nasal ketamine


For infective endocarditis

For Infective endocarditis

  • IV Ampi 2 gm + Genta 80 mg ½ hour before and 6 hours later

  • 50 mg /kg and 2mg/kg

  • Allergic to penicillin

  • Vancomycin 20 mg/kg + genta 2mg/kg


Venous access

Venous access

  • No ambulatory surgery

  • Always IV access even minor procedures

  • No air

  • Rigorous debubbling techniques to follow


Some do s

Some do”s


Debubbling techniques

Debubbling techniques

  • De bubble all IV tubing

  • Free flow before connection

  • Aspirate or eject air before Injection

  • Don’t use till last drop

  • IV air traps if possible

  • Inject vertical

  • Don’t open catheter to atmosphere

  • Avoid N2O if suspicion


Monitor

Monitor

  • SaO2

  • ETCO2 , TEE if air embolism possible

  • Other monitoring as usual

  • ECG – arrhythmias common

  • USG guided central line and

  • post Catheter X ray to ascertain position


Anaesthesia1

Anaesthesia

  • Ketamine ok

  • Pancuronium if necessary

  • High FiO2

  • Opioids

  • Inh. Agents

  • Maintain cardiac grid


Anaesthesia2

Anaesthesia

  • Maintain temperature

  • Adequate hydration

  • IV induction ??

  • Inh. Induction ??


Regional anaesthesia

Regional anaesthesia

  • No pain related side effects

  • No coagulopathy

  • Intrathecal narcotics

  • Fibro adenoma breast with Fallots ??


Post op

Post op

  • Care of pain

    Blocks , IV para , opioids

  • No hypoxemia or hypercarbia

  • Supplemental oxygen


Fallot s tetralogy

Fallot s tetralogy


Individual diseases cardiac grid fallots

Individual diseases Cardiac grid -Fallots


Special for tof

Special for TOF

  • Prevent cyanotic spell

    β blockers

    alpha agonist ready

    Preserve SVR


Treatment of hypercyanotic spells

Treatment of Hypercyanotic Spells

  • High FiO2 → pulmonary vasodilator → ↓ PVR

  • Hydration (fluid bolus) → opens RVOT

  • Morphine (0.1mg/kg/dose) → sedation,↓ PVR

  • Ketamine→ ↑ SVR, sedation, analgesia → ↑ PBF

  • Phenylephrine (1mcg/kg/dose) →↑ SVR

  • β-blockers (Esmolol 100-200mcg/kg/min)

    →↓HR,-veinotropy→ improves flow across obstructed valve &↓infundibular spasm


Truncus arteriosus

Truncusarteriosus


Cardiac grid

Cardiac grid

  • Preload -- N

  • Adjust SVR/PVR = 1

  • HR = N

  • Contractility = N


Ebsteins anomaly

Ebsteins anomaly


Cardiac grid ebsteins

Cardiac grid –ebsteins

  • Preload = increase

  • SVR = N

  • PVR = decrease

  • HR = N

  • Contractility = N


Tricuspid atresia

Tricuspid atresia


Tricuspid atresia1

Tricuspid atresia

  • Preload = N

  • SVR = decrease

  • PVR = increase

  • HR = N

  • Contractility = N


Transposition of great vessels

Transposition of great vessels


Transposition of great vessels1

Transposition of great vessels

  • Preload = N

  • SVR = N

  • PVR =

  • HR =

  • Contractility = N

  • Adequate mixing if we balance PVR and SVR


General principles

GENERAL PRINCIPLES

RINCIPLESQ= P/R

Q = Blood flow (CO)

P = Pressure within a chamber or vessel

R = Vascular resistance of pulmonary or systemic vasculature

Inf. endocarditis prophylaxis , debubbling techniques, present illness, hydration, induction ,coagulopathy


Topic is ocean but

Topic is ocean but


Adjust pre and alter preload inotropy pvr svr heart rate to get the ideal balance

Adjust pre and alter preload, inotropy,PVR, SVR,heart rate to get the ideal balance

  • Thank you


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