This document provides information on anesthesia for congenital heart disease. It discusses the incidence and classification of congenital heart defects. Left-to-right shunts like atrial septal defects and ventricular septal defects are more common than right-to-left shunts like tetralogy of Fallot. Preoperative evaluation includes labs, EKG, chest x-ray, echocardiogram and possibly cardiac catheterization. Anesthetic management aims to manipulate pulmonary and systemic vascular resistances depending on the type of shunt. Inhalational agents, opioids, ketamine and etomide are used. Careful induction and maintenance are needed depending on the severity and complexity of the defect.
Educative power-point presentation for students in paediatrics, paediatric critical care, neonatology, And trainees or fellows in paediatric critical care
A presentation by Ulf Thilén at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
Educative power-point presentation for students in paediatrics, paediatric critical care, neonatology, And trainees or fellows in paediatric critical care
A presentation by Ulf Thilén at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
Struggling with intense fears that disrupt your life? At Renew Life Hypnosis, we offer specialized hypnosis to overcome fear. Phobias are exaggerated fears, often stemming from past traumas or learned behaviors. Hypnotherapy addresses these deep-seated fears by accessing the subconscious mind, helping you change your reactions to phobic triggers. Our expert therapists guide you into a state of deep relaxation, allowing you to transform your responses and reduce anxiety. Experience increased confidence and freedom from phobias with our personalized approach. Ready to live a fear-free life? Visit us at Renew Life Hypnosis..
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
QA Paediatric dentistry department, Hospital Melaka 2020Azreen Aj
QA study - To improve the 6th monthly recall rate post-comprehensive dental treatment under general anaesthesia in paediatric dentistry department, Hospital Melaka
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
2. INCIDENCE
• 7 to 10 per 1000 live births
• Premature infants 2-3X higher incidence
• Most common form of congenital disease
• Accounts for 30% of total incidence of all
congenital diseases
• 10% -15% have associated congenital
anomalies of skeletal, RT, GUT or GIT
• Only 15% survive to adulthood without
treatment
4. CLASSIFICATION OF CHD
• L - R SHUNTS INCLUDE :
– ASD →7.5% of CHD
– VSD → COMMONEST CHD – 25%
– PDA → 7.5% of CHD
• Common in premature infants
– ENDOCARDIAL CUSHION DEFECT - 3%
• Often seen with trisomy 21
– AORTOPULMONARY WINDOW
5. CLASSIFICATION OF CHD
• R – L SHUNTS
– Defect between R and L heart
– Resistance to pulmonary blood flow → ↓ PBF →
hypoxemia and cyanosis
• INCLUDE :
– TOF – 10% of CHD, commonest R-L shunt
– PULMONARY ATRESIA
– TRICUSPID ATRESIA
– EBSTEIN’S ANOMALY
6. R – L SHUNTS
• GOAL → ↑ PBF to improve oxygenation
– Neonatal PGE1 (0.03 – 0.10mcg/kg/min)
maintains PDA → ↑ PBF
– PGE1 complications → vasodilatation,
hypotension, bradycardia, arrhythmias, apnea or
hypoventilation, seizures, hyperthermia
– Palliative shunts → ↑ PBF, improve hypoxemia
and stimulate growth in PA → aids technical
feasibility of future repair
7. Almost any anesthetic technic
may be used in any CHD patient
if
the anesthesiologist understands
•the pathophysiology of the lesion and
•the pharmacology of the drugs employed.
8. ANESTHETIC MANAGEMENT
• Perioperative management requires a team
approach
• Most important consideration is necessity for
individualized care
• CHD is polymorphic and may clinically
manifest across a broad clinical spectrum
9. ANESTHETIC MANAGEMENT
• 50% Dx by 1st
week of life; rest by 5 years
• Child’s diagnosis & current medical condition
will determine preoperative evaluation
• Understand the anatomic and hemodynamic
function of child’s heart
• Discuss case with pediatrician and cardiologist
• Review diagnostic & therapeutic interventions
• Above will estimate disease severity and help
formulate anesthetic plan
14. LABORATORY EVALUATION
• CHEST X - RAY
– Heart size and shape
– Prominence of pulmonary vascularity
– Lateral film if previous cardiac surgery for
position of major vessels in relation to sternum
15. LABORATORY EVALUATION
• ECHOCARDIOGRAPHY
– Anatomic defects/shunts
– Ventricular function
– Valve function
– Doppler & color flow imaging → direction of
flow through defect/valves, velocities and
pressure gradients
16. LABORATORY EVALUATION
• CARDIAC CATHERIZATION
– Size & location of defects
– Degree of stenosis & shunt
– Pressure gradients & O2 saturation in each
chamber and great vessel
– Mixed venous O2saturation obtained in SVC or
proximal to area where shunt occurs
– Low saturations in LA and LV = R – L shunt
– High saturations in RA & RV = L – R shunt
17. LABORATORY EVALUATION
• CARDIAC CATHERIZATION
– Determine shunt direction: ratio of pulmonary to
systemic blood flow : Qp / Qs
– Qp / Qs ratio < 1= R – L shunt
– Qp / Qs ratio > 1= L – R shunt
18. Congenital Cardiac Surgery
• Preoperative medication
– D/C diuretics and digoxin unless heart failure is
poorly controlled or digoxin is being used
primarily for rhythm
– Continue inotropes
– Continue prostaglandin infusions
19. MONITORING
• Routine CAS monitoring
• Precordial or esophageal stethoscope
• Continuous airway manometry
• Multiple - site temperature measurement
• Volumetric urine collection
• Pulse oximetry on two different limbs
• TEE
20. MONITORING
• PDA
– Pulse oximetry right hand to measure pre-ductal
oxygenation
– 2nd
probe on toe to measure post-ductal
oxygenation
• COARCTATION OF AORTA
– Pulse oximeter on right upper limb
– Pre and post - coarctation blood pressure cuffs
should be placed
21. ANESTHETIC MANAGEMENT
• GENERAL PRINCIPLES
Where:
Q = Blood flow (CO)
P = Pressure within a chamber or vessel
R = Vascular resistance of pulmonary or
systemic vasculature
Ability to alter above relationship is the basic tenet of
anesthetic management in children with CHD
R
P
Q =
22. ANESTHETIC MANAGEMENT
P → manipulate with positive or negative
inotropic agents
Q → hydration + ↑preload and inotropes
However, the anesthesiologist’s principal focus
is an attempt to manipulate resistance, by
dilators and constrictors
23. ANESTHETIC MANAGEMENT
• GENERAL CONSIDERATIONS
– De-air intravenous lines air bubble in a R-L shunt
can cross into systemic circulation and cause a
stroke
– L-R shunt air bubbles pass into lungs and are
absorbed
– Endocarditis prophylaxis
– Tracheal narrowing d/t subglottic stenosis or
associated vascular malformations
24. ANESTHETIC MANAGEMENT
– Tracheal shortening or stenosis esp. in children
with trisomy 21
– Strokes from embolic phenomena in R-L shunts
and polycythemia
– Chronic hypoxemia compensated by polycythemia
→ ↑ O2 carrying capacity
– HCT ≥ 65% → ↑ blood viscosity → tissue hypoxia
& ↑ SVR & PVR → venous thrombosis → strokes
& cardiac ischemia
25. ANESTHETIC MANAGEMENT
– Normal or low HCT D/T iron deficiency → less
deformable RBCs → ↑ blood viscosity
– Therefore adequate hydration & decrease RBC
mass if HCT > 65%
– Diuretics → hypochloremic, hypokalemic
metabolic alkalosis
26. Air Bubble precautions
• To prevent paradoxical air embolism
• Remove all bubbles from iv tubing
• Connect the iv tubing to the venous cannula while there is free flowing
in fluid .
• Eject small amount of solution from syringe to clear air from the needle
hub before iv injection
• Aspirate injection port before injection to clear any air
• Hold the syringe upright to keep bubbles at the plunger end
• Do not leave a central line open to air
• Use air filters
• ? No N2O.
27. PREMEDICATION
a) Omit for infants < six months of age
b) Administer under direct supervision of
Anesthesiologist in preoperative facility
c) Oxygen, ventilation bag, mask and pulse
oximetry immediately available
d) Oral Premedication
• Midazolam 0.25 -1.0 mg/kg
• Ketamine 2 - 4 mg/kg
• Atropine 0.02 mg/kg
28. PREMEDICATION
e) IV Premedication
• Midazolam 0.02 - 0.05 mg/kg titrated in small
increments
e) IM Premedication
• Uncooperative or unable to take orally
• Ketamine 1-2 mg/kg
• Midazolam 0.2 mg/kg
• Glycopyrrolate or Atropine 0.02 mg/kg
29. ANESTHETIC AGENTS
• INHALATIONAL AGENTS
– Safe in children with minor cardiac defects
– Most common agents used are halothane and
sevoflurane in oxygen
– Monitor EKG for changes in P wave → retrograde
P wave or junctional rhythm may indicate too deep
anesthesia
30. INHALATIONAL ANESTHETICS
• HALOTHANE
– Depresses myocardial function, alters sinus
node function, sensitizes myocardium to
catecholamines
↓ MAP + ↓ HR
↓ CI + ↓ EF
• Relax infundibular spasm in TOF
• Agent of choice for HOCM
31. INHALATIONAL ANESTHETICS
SEVOFLURANE
• No ↓ HR
• Less myocardial depression than Halothane
• Mild ↓ SVR → improves systemic flow in L-
R shunts
• Can produce diastolic dysfunction
32. INHALATIONAL ANESTHETICS
ISOFLURANE
• Pungent → not good for induction
• Incidence of laryngospasm > 20%
• Less myocardial depression than Halothane
• Vasodilatation leads to ↓ SVR → ↓ MAP
∀↑ HR which can lead to ↑ CI
33. INHALATIONAL ANESTHETICS
DESFLURANE
• Pungent → not good for induction; highest
incidence of laryngospasm
• SNS activation → ↓ with fentanyl
∀↑ HR + ↓ SVR
• Less myocardial depression than Halothane
34. INHALATIONAL ANESTHETICS
NITROUS OXIDE
• Enlarge intravascular air emboli
• May cause microbubbles and macrobubbles to
expand → ↑ obstruction to blood flow in
arteries and capillaries
• In shunts, potential for bubbles to be shunted
into systemic circulation
35. INHALATIONAL ANESTHETICS
NITROUS OXIDE
• At 50% concentration does not affect PVR and
PAP in children
• Mildly ↓ CO at 50% concentration
• Avoid in children with limited pulmonary
blood flow, PHT or ↓ myocardial function
36. IM & IV ANESTHETICS
KETAMINE
• No change in PVR in children when airway
maintained & ventilation supported
• Sympathomimetic effects help maintain HR,
SVR, MAP and contractility
• Greater hemodynamic stability in
hypovolemic patients
• Copious secretions → laryngospasm →
atropine or glycopyrrolate
37. IM & IV ANESTHETICS
KETAMINE
• Relative contraindications may be coronary
insufficiency caused by:
– anomalous coronary artery
– severe critical AS
– hypoplastic left heart syndrome with aortic atresia
– hypoplasia of the ascending aorta
• Above patients prone to VF d/t coronary
insufficiency d/t catecholamine release from
ketamine
38. IM & IV ANESTHETICS
IM Induction with Ketamine:
• Ketamine 5 mg/kg
• Succinylcholine 5 mg/kg or Rocuronium 1.5 – 2.0
mg/kg
• Atropine or Glycopyrrolate 0.02 mg/kg
IV Induction with Ketamine:
• Ketamine 1-2 mg/kg
• Succinylcholine 1-2 mg/kg or Rocuronium 0.6-1.2
mg/kg
• Atropine or Glycopyrrolate 0.01 mg/kg
39. IM & IV ANESTHETICS
OPIOIDS
• Excellent induction agents in very sick children
• No cardiodepressant effects if bradycardia avoided
• If used with N2O - negative inotropic effects of
N2O may appear
• Fentanyl 25-100 µg/kg IV
• Sufentanil 5-20 µg/kg IV
• Pancuronium 0.05 - 0.1 mg/kg IV → offset
vagotonic effects of high dose opioids
40. IM & IV ANESTHETICS
ETOMIDATE
• CV stability
• 0.3 mg/kg IV
THIOPENTAL & PROPOFOL
• Not recommended in patients with severe cardiac
defects
• In moderate cardiac defects:
– Thiopental 1-2 mg/kg IV or Propofol 1-1.5 mg/kg IV
– Patient euvolemic
41. ANESTHETIC MANAGEMENT
ANESTHESIA INDUCTION
• Myocardial function preserved → IV or
inhalational techniques suitable
• Severe cardiac defects → IV induction
• Modify dosages in patients with severe
failure
43. ANESTHETIC MANAGEMENT
• L - R SHUNTS :
• Continuous dilution in pulmonary
circulation may ↑ onset time of IV
agents
• Speed of induction with inhalation
agents not affected unless CO is
significantly reduced
• Degree of RV overload and/or failure
underappreciated – careful induction
47. ANESTHETIC MANAGEMENT
• R –L SHUNTS :
– Continue PE1 infusions
– Adequate hydration esp. if HCT > 50%
– Inhalation induction prolonged by limited
pulmonary blood flow
– IV induction times are more rapid d/t bypassing
pulmonary circulation dilution
– PEEP and PPV increase PVR
48. ANESTHETIC MANAGEMENT
• COMPLEX SHUNTS :
• Manipulating PVR or SVR to ↑ PBF will:
• Not improve oxygenation
• Worsen biventricular failure
• Steal circulation from aorta and cause
coronary ischemia
• Maintain “status” quo with high dose opioids
that do not significantly affect heart rate,
contractibility, or resistance is recommended
49. ANESTHETIC MANAGEMENT
• COMPLEX SHUNTS :
– Short procedures slow gradual induction with low
dose Halothane least effect on +ve chronotropy &
SVR
– Nitrous Oxide limits FiO2 & helps prevent
coronary steal & ↓ Halothane requirements
51. Congenital Cardiac Surgery
• Cardiopulmonary Bypass
– Differences from adult
• Lower temperatures (15-20 degrees C)
• Lower perfusion pressure (20-30mmHg)
• Very significant hemodilution (3-15 times greater)
• Pump flows range from 200ml/kg/min to zero!
• Different blood pH management (alpha-stat vs pH
stat)
• Tendency to hypoglycemia
• Cannula placement is much more critical
53. Current clinical protocol
• Heparin – 300 units/kg i.v.
• Draw arterial sample for ACT in 3-5 min.
• Give additional heparin to achieve
ACT >300 (normothermic CPB)
ACT > 400 (hypothermic CPB)
• Prime extracorporial circuit with heparin 3
units/ml
•
54. • Monitor ACT every 30 min. during CPB
• If ACT decreases below desired minimum
value – supplemental dose of 50-100 units/kg
55. Haemostasis
At conclusion of CPB
• Protamine – mainstay of heparin neutralization
• Dosage – 1.3 mg to neutralise 100units of heparin
• ACT after administration
if more then baseline – additional bolus (25 -50mg)
of protamine
56. protamine reaction
• Increase in PAP & CVP
• Decrease in LAP & SAP
Precaution
• via peripheral line
• Administer slowly < 5mg/min.
• Test bolus dose 25-50 mg – look for
haemodynamics
• Careful with pt. having food allergy
57. Treatment
• Stop protamine
• Administration of fluids and epinephrine
• Steroids
• Pulmonary vasodialators - NTG, SNP
58. Congenital Cardiac Surgery
• Deep hypothermic circulatory arrest (DHCA)
– Neonates and small infant usually < 10 kg
– Oxygen consumption falls 2-2.5 times per 10
degree fall in temperature
– Allows more controlled complex surgery in a
bloodless field
– Often total CPB time is actually shortened by this
technique
59. Congenital Cardiac Surgery
• Weaning from CPB
– Heart assessed by direct visualization and right or
left atrial filling pressure, central cannula or TEE
– Pulse oximetry is also very helpful
– Problems weaning are due to:
• Inadequate repair,
• pulmonary hypertension
• And/or left or right ventricular dysfunction
60. Congenital Cardiac Surgery
• Weaning from CPB
– Problems weaning diagnosed by
• Intraoperative cardiac catheterization
• Echo-doppler
– Leaving the operating room before correcting the
problem leads to a significant INCREASE in
morbidity
61. Postoperative care
• Observation on a monitored bed in ICU/HDU for 24 hours or overnight
atleast because of their predisposition to develop ventricular/
supraventricular tachycardia, bradyarrhythmia and myocardial ischemia
• Meticulous attention to fluid balance to prevent hypovolumia
• Monitoring of blood pressure preferably invasive, Oxygen saturation and
CVP
• Position slowly- risk of postoperative postural hypotension with secondary
increase in right to left shunting
• Prevention of venous stasis by early ambulation and by applying effective
elastic stocking or periodic pneumatic compression.
• Adequate pain management – adverse hemodynamics and possibly
hypercoagulable state
62. Post op pain management
• Opioid analgesia
• Regional analgesia
• Alternative and supplementary analgesia
63. Congenital Cardiac Surgery
• Selected Specific Conditions/Procedures:
– Tetralogy of Fallot
– Patent Ductus Arteriosus(PDA)
– ASD
– VSD
65. TETRALOGY OF FALLOT
• 10% of all CHD
• Most common R – L shunt
• 4 anomalies:
– RVOT obstruction ( infundibular, pulmonic or
supravalvular stenosis )
– Subaortic VSD
– Overriding aorta
– RVH
66. CXR IN TOF
• Normal heart size
• Pulmonary oligemia
• Upturned cardiac apex
• Rt aortic arch
68. Congenital Cardiac Surgery
• Laboratory data
– Cyanosis leads to polycythemia
• May consider phlebotomy esp if no CPB
• Leads to coagulation problems
– Anemia may be “relative” and need transfusion
– Newborn infant has immature systems including
renal/hepatic/coagulation
– Hypoglycemia is much more common
74. Congenital Cardiac Surgery
• Tetralogy of Fallot
– Preoperative Preparation
• Heavy premedication
– Consider IM ketamine or inhalation induction but
get rapid control of airway.
– Keep SVR up and PVR down, maintain heart rate
– Intraoperative TEE
75. Congenital Cardiac Surgery
• Tetralogy of Fallot
– Weaning from CPB, ratio RV:LV pressure should
be < 0.8
– May need to keep PVR low with NTG, milrinone,
dobutamine phentolamine, PGE1
– May need RV inotrope post op
– May need temporary pacing wire
76. Congenital Cardiac Surgery
• Tetralogy of Fallot
– Perioperative concerns
• Increase in PVR or decrease in SVR leading to Right to
Left shunt
• Tet Spells pre induction (crying/anxiety)
• Polycythemia and bleeding
• Air embolus
• RV failure
77. PALLIATIVE SHUNTS IN
TOF
• Blalock-Taussig shunt [anastomosis of
subclavian artery and pulmonary artery]
• Modified B-T shunt [Goretex graft used]
• Pott’s shunt [descending aorta left
pulmonary artery]
• Waterston’s shunt [ascending aorta right
pulmonary artery]
78. Patent Ductus Arteriosus
• Ductus Arteriosus connects the
descending aorta to the main
pulmonary trunk near the
origin of the left subclavian
• Normal postnatal closure
results in fibrosis- which
becomes the ligamentum
arteriosum.
• Small PDA does not increase
risk for heart failure- but does
carry a risk for bacterial
endocarditis.
79. Congenital Cardiac Surgery
• PATENT DUCTUS ARTERIOSUS
– 1/8000 live births, associated with prematurity
and female predominance of approx 3:1
– Left to right shunt causes pulmonary edema
– Occasionally right to left cause lower body
cyanosis
– SpO2 probe on Right hand and lower limb
• Confirms correct vessel ligated
– Vagal reflex is pronounced by lung traction
– Antibiotics required to prevent endocarditis
80. • Confirmation of crossmatched blood in OT.
• Radial arterial line preferably on opposite side
of aortic arch.
• At the time of PDA ligation SBP reduced to
80-90 mm of hg with Halothane/SNP
• Watch for haemorrhage due to rupture.