The Challenging Pediatric Cardiac Patient. Edmund Jooste

Transcription

1 The Challenging Pediatric Cardiac Patient Edmund Jooste

2 A 5 -year old female with hypoplastic left heart syndrome s/p the Fontan procedure presents for laparoscopic appendectomy for acute appendicitis.

3 Practical approach Picture the plumbing Understand the PHYSIOLOGY Implication of the Non cardiac disease Plan the anesthetic and anticipate the potential complications

4 Plumbing Major Single Left Ventricle Anomalies Hypoplastic Left Heart syndrome Mitral valve Atresia Double Outlet RV Unbalanced complete AV canal Heterotaxy syndrome

5 Hypoplastic Left Heart Syndrome

6 Norwood and BT Shunt Stage 1 Sano Shunt

7 Bidirectional Glenn

8 Fontan Extracardiac Fontan Lateral Tunnel Fontan with fenestration

9 Question 1 What should the oxygenation saturation be in a Fontan? A- 75% B- 95% C- 100%

10 Understand Physiology Don t get lost in the details Single Right ventricle Circulations are in Series= cardiac output is completely dependent on pulmonary blood flow. Pulmonary blood flow is passive Kinetic energy from systolic ventricle output Transpulmonary gradient (Difference between the CVP or MAP and the mean Left atrial pressure Negative intra-thoracic pressure with inspiration

11 Understand Physiology cont. Volume dependent circulation Mean pulmonary artery pressure = CVP Qp:QS = 1 O2 Saturation = +/- 95% Why not 100%? Rely on Sinus rhythm

12 Long term Consequences of Fontan Arrythmias Increased Thrombotic risks Elevated systemic venous pressures Liver congestion Protein losing enteropathy Plastic Bronchitus Low Cardiac output state.

13 Implications of the non cardiac disease Appendicitis - Vomiting - Dehydrated - Septicemic - Febrile Negative effects on Fontan Physiology - Rapid sequence induction

14 Implications of the procedure Antibiotic prophylaxis?

15 Antibiotic prophylaxis Prosthetic cardiac valve Previous endocarditis even in the absence of underlying heart disease. Congenital Heart Disease (CHD), with one of the following conditions: Unrepaired or incompletely repaired cyanotic (blue) heart disease including shunts and conduits Completely repaired CHD with prosthetic material or device during the first 6 months after procedure. Repaired CHD with residual defects at the site or adjacent to prosthetic patch or device Cardiac transplant recipients who develop cardiac valvulopathy

16 Antibiotic prophylaxis Dental procedures likely to involve manipulation of the gingival tissue or the peri-apical region of teeth or perforation of the oral mucosa. Respiratory procedures involving incision or biopsy of the respiratory mucosa such as tonsillectomy, adenoidectomy. Infected tissue such as incision and drainage of infected tissue.

17 Antibiotic prophylaxis Single dose minutes before procedure Standard dose Route Child Ampicillin IV or IM 50 mg/kg Cefazolin/ceftriaxone IV or IM 50 mg/kg Penicillin allergy Route Child dose Cefazolin/ceftriaxone IV or IM 50mg/kg Clindamycin IV or IM 20 mg/kg If the dosage of antibiotic is inadvertently not administered before the procedure, the dosage may be administered up to 2 hours after the procedure.

18 Implications of the procedure Antibiotic prophylaxis?- no according to guidelines Monitors NIRS? Aline? Central line? Laparoscopic pneumoperitonuem

19 Implications of the procedure Laparoscopic Pneumoperitoneum (10mmHg) 65% aortic blood flow and stroke volume, 150% SVR, Preload SVR, LV end diastolic pressure- Transpulmonary gradient. Pulmonary blood flow Abdominal pressure--- Preload-- TPG-- Cardiac filling Abdominal pressure--- FRC V/Q mismatch Elevated carbon dioxide tension

20 Anesthetic Management Preop: Sedative premedication CBC HCT? Assess cardiac functional status Echocardiograph Study Emergency drugs/ infusions- Epi, Milrinone Aggressively Re-Hydrate Induction: Fluid bolus prior to induction- 10ml/kg RSI (it is not what meds you use but how you use them)

21 Intraoperative Anesthetic Management Cardiovascular Adequate volume status- Critical Maintain good preload Avoid RV dysfunction by minimizing volatile anesthetic Maintain sinus rhythm

22 Anesthetic Management Respiratory Spontaneous ventilation unlikely. Keep paralyzed. Ventilate- Low rates, low PIP, Short Insp time, Normal/low peep Encourage Low PVR- FiO2, PCO2

23 Question 2 If you had to choose which one monitor would you use A- NIRS B- Arterial Line C- CVP

24 Anesthetic Management General NIRS Arterial line- Fluid status and ABG monitoring Correct any acidosis Maintain Hct above 30 Regional technique-?

25 Anesthetic Management Laparoscopy Keep inflation pressures below 12 (preferably <10) How are vitals with abdomen inflated? Should you convert to an open procedure

26 Anesthetic Management Post operative: Extubation is preferable Anti-emetic Pain management- Balance between comfort and over-sedation and fears of PVR due to PCO2 and hypoxia IV tylenol, fentanyl and Dexmedetomidine Disposition: ICU vs PACU

27 Conclusion Draw the anatomy Understand the Physiology Volume responsive Maintain preload, sinus rhythm and function Anticipate the physiological effects of the laparoscopic procedure

28 References 1. Bailey, P.D., Jr. and D.R. Jobes, The Fontan patient. Anesthesiology clinics, (2): p Wilson, W., et al., Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation, (15): p Yuki, K., A. Casta, and S. Uezono, Anesthetic management of noncardiac surgery for patients with single ventricle physiology. Journal of anesthesia, (2): p Taylor, K.L., H. Holtby, and B. Macpherson, Laparoscopic surgery in the pediatric patient post Fontan procedure. Paediatric anaesthesia, (5): p McClain, C.D., F.X. McGowan, and P.G. Kovatsis, Laparoscopic surgery in a patient with Fontan physiology. Anesthesia and analgesia, (4): p