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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??.

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Anaesthetic concerns in cyanotic congenital heart disease – incidental surgery

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  1. 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

  2. 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

  3. Incidence • 7 to 10 per 1000 live births • Commonest cong. Disease • 15 % have associated anomalies • 15% survive to adulthood without treatment

  4. 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

  5. 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

  6. 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 !!

  7. Classification of CHD • Acyanotic • Cyanotic

  8. Incidental surgery – concerns • Spectrum • Corrected fallots adult for I & D • to • Also uncorrected fallots for intestinal gangrene

  9. Preop assessment • Patients cardiac disease • Age • Present illness ,others

  10. Patients cardiac disease • Cyanosis • Cyanotic spells • Cong. Cardiac failure Pulm. Vs Sys. Shunt > 2:1 Exercise tolerance – siblings Adequate weight ? Sweating, dyspnoea during feeds??

  11. AGE • Heart rate • LV pressure less • Educating the child ,family • Age related airway and IV access problems

  12. Present illness ,others • Gangrene gut • Sepsis , dehydration • Pregnancy for LSCS • Orthopedics

  13. Present illness ,others • Evidence of downs syndrome • Macroglossia, hypoplastic mandible, protuberant teeth • Blood pressure in all limbs

  14. 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

  15. 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.

  16. Other investigations • Electrolytes • Digoxin, diuretics • Hypoglycemia , hypocalcemia • ABG • PaO2 30- 40 mmHg – SaO2 <70 % = risk • Cardiology consultation

  17. Preop URI • Desaturation , • Laryngospam • Bronchospasm • Post ext. stridor common • 4-6 weeks – gap ideal • Can we get such patients without URI ??

  18. Anaesthesia • Cardiac grid • Five factors • 1. preload • 2. SVR • 3. PVR • 4. HR • 5.contractility

  19. Preload • increase • Volume load • Capacitance vessel constriction • Decrease • Phlebotomy • Less volume replacement

  20. SVR • increase • Arteriolar constriction • Anaesthetics – ketamine • Decrease • Anesthetics (volatile & IV) • Histamine releasing drugs

  21. PVR • increase Hypoxia, hypercarbia peep high Hct • Decrease Pulm. dilators And others

  22. Heart rate • Increase Atropine Pancuronium Isoflurane • Decrease Beta blockers Fent Digoxin

  23. Contractility • increase Inotropes Digoxin Calcium • Decrease All inh. Agents Ca. channel blockers

  24. Cardiac grid -- Five factors • 1. preload • 2. SVR • 3. PVR • 4. HR • 5.contractility

  25. 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

  26. Premedicants described • Oral / nasal midazolam • IV fentanyl + atropine • Morphine + atropine + midazolam • Nasal ketamine

  27. 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

  28. Venous access • No ambulatory surgery • Always IV access even minor procedures • No air • Rigorous debubbling techniques to follow

  29. Some do”s

  30. 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

  31. 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

  32. Anaesthesia • Ketamine ok • Pancuronium if necessary • High FiO2 • Opioids • Inh. Agents • Maintain cardiac grid

  33. Anaesthesia • Maintain temperature • Adequate hydration • IV induction ?? • Inh. Induction ??

  34. Regional anaesthesia • No pain related side effects • No coagulopathy • Intrathecal narcotics • Fibro adenoma breast with Fallots ??

  35. Post op • Care of pain Blocks , IV para , opioids • No hypoxemia or hypercarbia • Supplemental oxygen

  36. Fallot s tetralogy

  37. Individual diseases Cardiac grid -Fallots

  38. Special for TOF • Prevent cyanotic spell β blockers alpha agonist ready Preserve SVR

  39. 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

  40. Truncusarteriosus

  41. Cardiac grid • Preload -- N • Adjust SVR/PVR = 1 • HR = N • Contractility = N

  42. Ebsteins anomaly

  43. Cardiac grid –ebsteins • Preload = increase • SVR = N • PVR = decrease • HR = N • Contractility = N

  44. Tricuspid atresia

  45. Tricuspid atresia • Preload = N • SVR = decrease • PVR = increase • HR = N • Contractility = N

  46. Transposition of great vessels

  47. Transposition of great vessels • Preload = N • SVR = N • PVR = • HR = • Contractility = N • Adequate mixing if we balance PVR and SVR

  48. 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

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