The large and growing population of patients who are living with CHD requires anaesthesia for non-cardiac surgeries and other procedures. Knowledge of the pathophysiology of the common CHD lesions, as well as careful preoperative assessment and preparation, and communication with the patient’s cardiologist and surgeon, are essential to provide optimal care in the best setting for these patients.

1. ANESTHETIC CONSIDERATIONS
OF PEDIATRIC PATIENTS WITH
CARDIAC SHUNT FOR NON
CARDIAC SURGERY
DR BHAVNA GUPTA
DEPARTMENT OF ANAESTHESIA
AIIMS RISHIKESH

2. INTRODUCTION
■ A cardiac shunt - pattern of blood flow that deviates from the normal circuit of the circulatory
system
■ R-L, L-R or bidirectional.
Ramamoorthy C, Haberkern CM, Bhananker SM, Domino KB, Posner KL, Campos JS, et al. Anesthesia-related cardiac arrest in children with heart disease: Data from the Pediatric Perioperative Cardiac
Arrest (POCA) registry. Anesth Analg. 2010;110:1376–82.
Anaesthesia-related paediatric cardiac arrest, occurred in 75% of
patients under 2 years of age with CHD during non-cardiac
surgery.* Neonates and infants are a/w two fold increase in
mortality from non-cardiac surgery.

4. LEFT TO RIGHT SHUNT RIGHT TO LEFT SHUNT

5. SINGLE VENTRICULAR PHYSIOLOGY

6. ANAESTHETIC ROLE
■ The challenge for anaesthesiologists in handling patients with CHD for
extra-cardiac surgery relies on-
■ age,
■ complexity of the heart lesion,
■ capacity to compensate,
■ urgency of surgery and
■ co-existing diseases.

7. PRE-OPERATIVE CONSIDERATIONS
■ Underlying defect and type of circulation?
■ Non-cardiac anomalies?
■ LRTI?
■ Drug therapy:?
■ Assessment of ventricular function, PVR.
■ NPO

8. HIGH RISK OF PERIOPERATIVE MORBIDITY
■ < 2 years old
■ Complex lesions (single ventricle physiology, cardiomyopathy)
■ Major Sx
■ Emergency Sx
■ Presence of long-term sequelae (arrhythmia, CHF, PHTN)
Anaesthesia, Critical Care & Pain | Volume 12 Number 1 2012, Anaesthetic management of children with congenital heart disease for non-cardiac surgery

9. PRE OP ASSESSMENT AND INVESTIGATIONS
■ Hemogram
■ S. electrolytes
■ Coagulation profile
■ CXR
■ ABG
■ ECG, Echo
PAC
• HR
• BP
• RR
• SpO2 on room air

10. PRE-MEDICATION
■ Commonly used to –
 avoid distress,
 minimize O2 consumption, and
 reduce the amount of induction agent.
Cautious usage!!  Hypoventilation and hypercapnia 
deleterious increases in PVR, particularly, in PAH.
Cyanotic
patients
require vital
monitoring

11. INTRAOPERATIVE CONSIDERATIONS
■ Choice of anaesthesia:
■ Induction agent:
■ Hemodynamic goals: PVR, SVR, HR, contractility
■ Invasive monitoring: depend on the type of surgery & cardiac lesion
■ Ventilation & Oxygenation
Indian J Anaesth. 2012 Sep-Oct; 56(5): 491–495. Anaesthetic considerations in children with congenital heart disease undergoing non-cardiac surgery

12. INTRAOPERATIVE MONITORING
■ ROUTINE STANDARD MONITORING
AND
■ Specific monitoring

13. REGIONAL ANAESTHESIA
■ Optimize volume and coagulation status.
■ Slowly titrated epidural / rapid spinal block
■ RA or RA combined with GA has been used successfully in patients
with single ventricles, shunt physiology, left-sided obstructive lesions,
and pulmonary hypertension
J Obstet Anesth. 2016 Dec;28:83-91. doi: 10.1016/j.ijoa.2016.08.004. Epub 2016 Sep 7. Anaesthetic management of parturients with univentricular congenital heart disease and the Fontan operation.
Smith's Anesthesia for Infants and Children.Clinical management of specialized surgical problems

14. GENERAL ANAESTHESIA
• Major advantages–
■ avoidance of sympathectomy,
■ hemodynamic stability,
■ blunting stress responses and
■ airway management in events of crisis situation.
SVR PVR

15. INDUCTION MODE
Inhalation Mode
■ Acceptable in CHD patients with
uncomplicated cardiac lesion.
■ Poor cardiac function (myocardial
depression)
■ Slow induction in R-L shunting
Intravenous mode
■ Right-to left shunts : more rapid
intravenous induction
■ Prolong inductive time in low
cardiac output state ∴slow titration
& reduced dose
Left-to right shunting has little effect on either IV or inhalational inductions.
Rt.-to-Lt. shunt prolong inhalation induction and more rapid intravenous induction

16. PALLIATIVE SHUNTS
■ Adequate Preload,
■ Preserving PBF,
■ Afterload reduction,
■ Adequate ventricular contractility and
filling,
■ Avoidance of sympathetic response,
Gupta B, Gupta A, Agarwal M, Gupta L. Glenn shunt: Anaesthetic concerns for a non cardiac surgery. Northern Journal of ISA. 2017;2: 36-42

17. INTRAVENOUS INDUCTION AGENTS
■ Most agents depress myocardial contractility and decrease SVR.
■ ETOMIDATE
■ Propofol – cautious -veno- and vasodilation.
■ Ketamine- sedation and analgesia. PVR? L-R shunt

18. FACTORS AFFECTING PVR
AVOID:
■ hypoxia,
■ hypercarbia,
■ acidosis,
■ hyperinflation of lungs,
■ atelectasis,
WHAT ABOUT NITROUS OXIDE??
 Positive pressure ventilation
 Early institution of spontaneous ventilation
 “Physiologic” (3 to 5 cm H2O) (PEEP)
Avoid excessive PBF in Lt.-to-Rt. shunt lesions (pulmonary congestion)

20. OTHER CONCERNS
■ Adequate postoperative analgesia.
■ Intra-cardiac shunt, Concerns for IV
injections, paradoxical embolism
■ Positioning
■ Fluid administration
 “Fast-track extubation" to avoid
respiratory complications.
 Risk factors for reintubation in PACU
•Patient factors: age <1 y, COPD,
preop hypo-albuminaemia, and renal
insufficiency
•Surgical factors -emergency case,
head& neck, airway surgery, and OT
time >3 hr
•Anaesthetic factors: ASA PS III

21. CONCLUSION
■ The large and growing population of patients who are living with CHD requires
anaesthesia for non-cardiac surgeries and other procedures.
■ Knowledge of the pathophysiology of the common CHD lesions, as well as
careful preoperative assessment and preparation, and communication with
the patient’s cardiologist and surgeon, are essential to provide optimal care in
the best setting for these patients.

22. REFERENCES
1. Anesthetic considerations for video-assisted thoracoscopic surgery in a child with Glenn shunt for thoracic duct ligation and
pleurodesis. Saudi J Anaesth 2018;12:DOI: 10.4103/sja.SJA_395_17
2. Gupta B, Gupta A, Agarwal M, Gupta L. Glenn shunt: Anaesthetic concerns for a non cardiac surgery. Northern Journal of ISA.
2017;2: 36-42
3. Glenn WW. Circulatory bypass of the right side of the heart. IV. Shunt between superiorvena cava and distal right pulmonary
artery; report of clinical application. N Engl J Med. 1958; 259:117–20. crossref PMid:13566431
4. Azzolina G, Eufrate S, Pensa P. Tricuspid atresia, experience in surgical management with a modified cavopulmonary
anastomosis. Thorax. 1972; 27(1):111–5. crossref PMid:5017561 PMCid:PMC472475
5. Fontan F, Baudet E. Surgical repair of tricuspid atresia. Thorax. 1971; 26:240–8. crossref PMid:5089489 PMCid:PMC1019078
6. Senzaki H, Masutani S, Kobayashi J, Kobayashi T, Sasaki N, Asano H, Kyo S, Yokote Y, Ishizawa A. Ventricular after load and
ventricular work in fontan circulation: Comparison with normal two-ventricle circulation and single-ventricle circulation with
blalock-taussig shunts. Circulation. 2002; 105:2885–92. crossref PMid:12070118
7. Tanoue Y, Sese A, Imoto Y, Joh K. Ventricular mechanics in the bidirectional glenn procedure and total cavopulmonary
connection. Ann Thorac Surg. 2003; 76:562–6. crossref
8. Anaesthesia, Critical Care & Pain | Volume 12 Number 1 2012, Anaesthetic management of children with congenital heart
disease for non-cardiac surgery

23. THANK
YOU