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ACHD anaesthesia PowerPoint presentation.pptx
- 1. Anaesthesia for Adult CongenitalHeart Disease Davina Wong
- 2. Summary - aims •You won’t be an expert in ACHD • You will have an idea of the population • You will have a framework to manage acute presentations • You will be aware of some specific problems which cause most problems • You will know where to go to ask for help
- 3. Why is ityour problem? • Commonest congenital lesion • Predicted to rise by 10% in next 10 years • 90% survive to adulthood and beyond • Wherever you end up working, you will see increasing numbers of ACHD patients presenting as emergencies
- 7. First principles • DON’TPANIC! • Initial treatment just the same as any other unwell patient • Assess ABC • Treat arrhythmias as arrhythmias • Treat heart failure as heart failure • Treat chest pain as chest pain
- 8. Second Principles • ‘Repaired’does not mean normal – either structurally or physiologically • You won’t know what all the different operations are and what their importance is • Common sense and caution is key • The patient is likely to know muuch more than you about their condition – so be prepared to listen
- 9. Simple ACHD • Unrepaired •Isolated aortic valve disease (13/1000 births) • Isolated mitral valve disease (exc parachute valve/mitral cleft) • Isolated small PFO/small ASD/VSD • Mild PS • Operated • Previously ligated/occluded PDA • Repaired sinus venosus/secundum ASD with no residual defect • Repaired VSD with no residual defect
- 10. Moderate complexity ACHD • Aortato LV fistula • Partial or total anomalous pulmonary venous drainage • AV canal defects – partial or complete • Coarctation aorta • Ebsteins anomaly • Significant infundibular RVOT obstruction • Ostium primum or sinus venosus ASD • Unrepaired PDA • Moderate to severe PS/PR • Sinus of valsalve fisula/aneurysm • Subvalvar/supravalvar AS • Tetralogy of fallot • VSD with associated anomaly – AR/absent valve/subAS, MV disease, straddling AV valve
- 11. Severe complexity ACHD •Conduits – valved/non valved • All types of cyanotic heart disease • Eisenmenger syndrome • Fontan procedure or TCPC • Mitral/tricuspid/pulmonary atresia • Pulmonary hypertension • Single ventricle (double inlet/outlet/common) • Transposition great vessels • Truncus arteriosus • V rare complex anomalies eg) criss cross heart ventricular inversion, heterotaxy syndromes
- 12. Distribution of GUCHpatients
- 15. Pre-operative assessment- history • Originalpathology • Previous surgery (shunts, residual lesion) - current anatomy • Secondary effects - embolism risk/thrombosis/ischaemia/ventricular dysfunction/changes to pulmonary vasculature/ECG abnormalities • Additional co-morbid disease - e.g. atherosclerosis, diabetes • Anticoagulation • Non cardiac - anxiety/depression, renal abnormalities
- 16. Red flags • Cardiacmuscle • Valves • Coronary circulation • ECG abnormalities • Pulmonary vasculature
- 17. Examination • Airway • Breathing •Circulation
- 18. Investigations • Bloods • CXR •ECG • ECHO • Angiography • CPEX
- 19. Pre-operative preparation • ivfluids • Relative anaemia
- 20. Operative • Anaesthetic drugchoice • Line positions • TOE • Inhalational vs intravenous induction • Control of CO2 vs IPPV • Regional vs general anaesthetic • Fastidious care of intravenous lines – air emboli
- 21. Post-operative • Location • Resumingregular medications • Thromboprophylaxis
- 22. Pregnancy and Contraception • OCPnot recommended for patients with cyanosis, severe PAH or Fontan • Early ambulation/compression stockings with all patients with intracardiac right-to-left shunt • Subcut/LMWH for prolonged bed rest. Full anticoagulation for high risk patient
- 23. • Pre-pregnancy consultationwith ACHD expert for labour management/postpartum period management • Care plan should be made available to all providers • Those receiving chronic anticoagulation with warfarin should receive prepregnancy counselling to enable them to make an informed decision about maternal and foetal risk
- 24. Highest risk • Higheroverall risk of maternal cardiac death, neonatal death/spontaneous abortion, preterm birth fetal growth restriction and longer hospital stay • NHYA III or IV • High BMI • Prior medication use • Severe dilation aorta • Pulmonary hypertension
- 25.
- 26. Summary • ACHD patientsvery heterogeneous • Some anaesthetic considerations • Special considerations
Editor's Notes
- #2 10% learning difficulties
- #3 7/1000 at birth, 90% survival into adulthood. Estimated 2 million in USA in 2010. (3 x number of paediatric patients) Mild/moderate/severe
- #6 3:1 adults to kids Rising by 5% per year
- #7 Many lost to follow up Perceived lack of cardiac symptoms Ignorance regarding need for long-term surveillance Lack of access due to travel and insurance barriers Misconception that cardiac disease has been ‘cured’ by surgery 1:5 deaths
- #10 Can be cared for in the periphery, need to be seen once at ACHD centre to assess need to follow up.
- #11 Should be seen periodically at ACHD centre
- #17 Cyanotic congenital heart disease NYHA III or IV Severe systemic ventricular dysfunction (EF<35%) Severe Left sided heart obstructive lesions PH can be primary or secondary - severe Complex – residual heart failure, valve disease, need for anticoagulation, malignant arrhythmias
- #18 Previous intubations – subglottic stenosis, previous trachys Restrictive lung disease secondary to thoracotomy Pulses present?
- #19 Bloods – FBC, u and es, clotting