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Anesthesia for Adult Patient with Congenital Heart Disease

Anesthesia for Adult Patient with Congenital Heart Disease. Mohamed Saleh, MD Department of Anesthesia and Intensive Care, Ain-Shams University. Case Scenario.

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Anesthesia for Adult Patient with Congenital Heart Disease

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  1. Anesthesia for Adult Patient with Congenital Heart Disease Mohamed Saleh, MD Department of Anesthesia and Intensive Care, Ain-Shams University

  2. Case Scenario • A 17 years-old patient, was presented for emergency appendectomy. He had a history of repaired TOF at the age of 2 years. 12 years later, he started to complain of palpitations, exertional dyspnea, and was diagnosed as pulmonary regurgitation and right ventricular dysfunction. • How to manage this patient in the peri-operative period?

  3. Introduction

  4. Journal of Cardiothoracic and Vascular Anesthesia, Vol 20, No 3 (June), 2006: pp 414-437

  5. Arrhythmias

  6. Pulmonary hypertension

  7. Ventricular dysfunction • Volume Overload • Pressure Overload

  8. Hematologic dysfunction • Erythrocytosis • Hyper-viscosity • Iron deficiency anemia

  9. Hemostatic Dysfunction • Thrombocytopenia • Platelet function abnormalities • Disseminated intravascular coagulation • Decreased production of coagulation factors • Impaired liver function • Vitamin K deficiency • Primary fibrinolysis

  10. Renal dysfunction • Hypercellular glomeruli • Basement membrane thickening • Focal interstitial fibrosis • Tubular atrophy • Hyalinization of afferent and efferent arterioles.

  11. Neurologic disease Cerebral emboli / thrombosis Cerebral abscess

  12. Common congenital heart diseases

  13. Atrial Septal Defect

  14. Ventricular Septal Defect

  15. Coarctation of the aorta

  16. Aortic Stenosis

  17. Tetralogy of Fallot

  18. Transposition of Great Arteries

  19. Univentricular Heart

  20. Strategy for management of ACHD patient through non-cardiac surgery

  21. Adult Congenital Heart Center

  22. Classification of ACHD according to complexity

  23. 1- Define the Condition • Primary lesion • Previous palliative and corrective surgeries • Residual and sequelae

  24. 2- Assess the Surgical Risk • Predictors and risks of the proposed surgical procedure itself • Specific ACHD risk factors • Other co-morbid conditions

  25. 3- Develop a Management Plan • Understanding of anatomy and physiology • Hemodynamic goals • Perioperative management

  26. HISTORY & PHYSICAL EXAMINATION • Assess functional status • Symptoms, signs of right sided failure • Symptoms, signsof left sided failure • Symptoms of low cardiac output • Arrhythmias • Cyanosis & its sequelae

  27. De-airing • All intravenous lines must be meticulously de-aired. • Patent foramen ovaleis present in approximately 25% of adults

  28. Indications for Prophylaxis against IEC in CHD* • Unrepaired cyanotic CHD, including palliative shunts and conduits • Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure** • Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization) • Previous IE • *Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD. • **Prophylaxis is reasonable because endothelialization of prosthetic material occurs within 6 months after the procedure.

  29. Premedication Patients often anxious Cognitive impairments Psychosocial issues Premedication with anxiolytics and hypnotics must be undertaken very cautiously.

  30. Monitoring Non-invasive Invasive • ECG • NIBP • Pulse oximetry • End tidal capnogram - Art. catheterization - CVP - PAC - TEE

  31. Choice of anesthetics • There are no evidence-based recommendations to guide the anesthetic management of patients with CHD undergoing non-cardiac surgery.

  32. Intravenous anesthetics

  33. Inhalational anesthetics

  34. Regional anesthesia

  35. Fluid management • Minimizing the NPO interval • Preoperative hydration • Maintenance of adequate intravascular volume • Adjustment of the transfusion threshold.

  36. Positioning

  37. Positive Pressure Ventilation • Control pulmonary vascular resistance • Reduces systemic venous return, in patients with single ventricle physiology

  38. Postoperative Management PACU vs. ICU Major risk factors during the postoperative period: • Bleeding. • Dysrhythmias. • Thromboembolic events.

  39. Postoperative Management • Post-operative analgesia • Fluid Management

  40. Thank you

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