Cyanotic congenital heart disease is characterized by a right-to-left shunt and decreased pulmonary blood flow, causing hypoxemia and cyanosis. Tetralogy of Fallot is a common cyanotic heart defect where there is a ventricular septal defect, right ventricular outflow tract obstruction, overriding aorta, and right ventricular hypertrophy. Without surgical intervention, most patients would not survive beyond childhood. Complete repair aims to relieve obstruction and close defects, but may require multiple staged procedures. Preoperative evaluation focuses on assessing cyanosis, growth, polycythemia, and identifying other anomalies to optimize timing of repair.
TAPVC defines the anomaly in which the pulmonary veins have no connection with the left atrium. Rather, the pulmonary veins connect directly to one of the systemic veins (TAPVC) or drain in to right atrium.
A PFO or ASD is present essentially in those who survive after birth
When pulmonary veins drain anomalously into the right atrium either because of complete absence of the interatrial septum or malattachment of the septum primum , then it is known as total anomalous pulmonary venous drainage.
When some or all of the pulmonary veins drain anomalously in to RA or its tributaries without being abnormally connected, the terms partially anomalous pulmonary venous drainage (PAPVD) or totally anomalous pulmonary venous drainage (TAPVD) with normal pulmonary venous connections are used.
TAPVC defines the anomaly in which the pulmonary veins have no connection with the left atrium. Rather, the pulmonary veins connect directly to one of the systemic veins (TAPVC) or drain in to right atrium.
A PFO or ASD is present essentially in those who survive after birth
When pulmonary veins drain anomalously into the right atrium either because of complete absence of the interatrial septum or malattachment of the septum primum , then it is known as total anomalous pulmonary venous drainage.
When some or all of the pulmonary veins drain anomalously in to RA or its tributaries without being abnormally connected, the terms partially anomalous pulmonary venous drainage (PAPVD) or totally anomalous pulmonary venous drainage (TAPVD) with normal pulmonary venous connections are used.
presentation regarding investigations and treatment of heart failure in pediatrics, including the management of an emergency , and includes brief description about even drugs used
most common congenital cyanotic heart disease.one of the conotruncal family of heart lesions.. It accounts for 7 to 10% of all congenital heart abnormalities.
congenital health problems in children is very serios problem in children ,it is major cause of mortality in children .it can prevented by proper care of mothers during pregnancy .
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
2. • Tracheoesophageal fistula
• Cleft lip and palate
• Anorectal anomalies
• Skeletal anomalies
Congenital heart disease: Scope of theCongenital heart disease: Scope of the
problemproblem
Commonest birth defect
1 in 125 live births
30% of children have extra
cardiac anomalies
3.
4.
5. foramen ovaleforamen ovale
Blood is shunted fromBlood is shunted from
right atrium to leftright atrium to left
atrium, skipping theatrium, skipping the
lungs.lungs.
More than one-third ofMore than one-third of
blood takes this route.blood takes this route.
Is a valve with twoIs a valve with two
flaps that preventflaps that prevent
back-flow.back-flow.
6. ductus arterioususductus arteriousus
The blood pumpedThe blood pumped
from the rightfrom the right
ventricle enters theventricle enters the
pulmonary trunk.pulmonary trunk.
Most of this blood isMost of this blood is
shunted into the aorticshunted into the aortic
arch through thearch through the
ductus arteriousus.ductus arteriousus.
7. Foramen ovaleForamen ovale Closes shortly after birth,Closes shortly after birth,
fuses completely in firstfuses completely in first
year.year.
Ductus arterioususDuctus arteriousus Closes soon after birth,Closes soon after birth,
becomes ligamentumbecomes ligamentum
arteriousum in about 3arteriousum in about 3
months.months.
Ductus venosusDuctus venosus Ligamentum venosumLigamentum venosum
Umbilical arteriesUmbilical arteries Medial umbilical ligamentsMedial umbilical ligaments
Umbilical veinUmbilical vein Ligamentum teresLigamentum teres
11. Cyanotic heart diseaseCyanotic heart disease
Decreased
pulmonary
blood flow
Mixing of systemic
venous and
pulmonary venous
blood
12. CYANOTIC CONGENITAL HEARTCYANOTIC CONGENITAL HEART
DISEASESDISEASES
Characterized byCharacterized by
a right-to-left intracardiac shunt with associateda right-to-left intracardiac shunt with associated
decrease in pulmonary blood flow and thedecrease in pulmonary blood flow and the
development of arterial hypoxemia.development of arterial hypoxemia.
Chronic hypoxemia results in erythrocytosis andChronic hypoxemia results in erythrocytosis and
thromboembolism.thromboembolism.
Secondary erythrocytosis may cause coagulationSecondary erythrocytosis may cause coagulation
defect.defect.
Risk of CVA and brain abscess.Risk of CVA and brain abscess.
Without surgical treatment patient can not survive toWithout surgical treatment patient can not survive to
adulthood.adulthood.
13. Cyanotic with increased PBFCyanotic with increased PBF
TruncusTruncus
arteriosusarteriosus
TGATGA
TAPVRTAPVR
HLHSHLHS
Complex shunts
14. Cyanotic with decreasedCyanotic with decreased
PBFPBF
TOFTOF
Ebstein’sEbstein’s
anomalyanomaly
Tricuspid atresiaTricuspid atresia
PulmonaryPulmonary
atresiaatresia
Simple right to
left shunts
15. The Five Ts of Cyanotic CongenitalThe Five Ts of Cyanotic Congenital
Heart DiseaseHeart Disease
Tetralogy of FallotTetralogy of Fallot
Transposition of the great arteriesTransposition of the great arteries
Truncus arteriosusTruncus arteriosus
Total Anomalous PulmonaryTotal Anomalous Pulmonary
Venous ReturnVenous Return
Tricuspid AtresiaTricuspid Atresia
First and last have decreased
pulmonary blood flow
17. DefinitionDefinition
10% of all congenital10% of all congenital
heart defectheart defect
Four characteristicsFour characteristics
Large VSDLarge VSD
RVOT obstructionRVOT obstruction
Overriding aortaOverriding aorta
RVHRVH
Spectrum of TOFSpectrum of TOF
TOF with PATOF with PA
TOF with PS ( the classicTOF with PS ( the classic
form)form)
TOF with InfundibularTOF with Infundibular
19. Cyanotic with decreased PBFCyanotic with decreased PBF
Right to left
shunting of blood
due to
obstruction to
pulmonary blood
flow
Hypoxemia
and
Cyanosis
Polycythemia
Altered
hemostasis
Microvascular
thrombosis
Growth
retardation
Myocardial
dysfunction
Poor tissue
perfusion
Renal and
cerebral
thrombosis
Acidosis
20. R – L shunt: Balance between SVR and PVRR – L shunt: Balance between SVR and PVR
Pulmonar
yvascular
resistance
Systemic
vascular
resistance
Pulmonary
vascular
resistance
Systemic
vascular
resistance
Low
Hig
h
Right to left shunt
increases
21. R – L shuntR – L shunt
Avoid increase in PVRAvoid increase in PVR Avoid decrease in SVRAvoid decrease in SVR
HypoxiaHypoxia
HypercapniaHypercapnia
AcidosisAcidosis
High airway pressuresHigh airway pressures
PEEPPEEP
High hematocritHigh hematocrit
Inadequate anesthesiaInadequate anesthesia
HypothermiaHypothermia
Anesthetic agents whichAnesthetic agents which
cause hypotensioncause hypotension
HypovolemiaHypovolemia
Avoid increase in
systemic oxygen demand
22. Clinical manifestationClinical manifestation
Pink tetPink tet
TOF with adequate PBFTOF with adequate PBF
Minimal RVOTO with a net LMinimal RVOTO with a net L R shuntR shunt
Acyanotic TOFAcyanotic TOF
TOF with pulmonary atresia/ severe stenosisTOF with pulmonary atresia/ severe stenosis
with PATENT DUCTUS ARTERIOSUSwith PATENT DUCTUS ARTERIOSUS
Normal saturationNormal saturation
even show signs of CHFeven show signs of CHF
Medical MX- diuretics, digoxin,ACE inhibitorsMedical MX- diuretics, digoxin,ACE inhibitors
23. Hypercyanotic or tet spellsHypercyanotic or tet spells
Paroxysmal episodes of acutely worsensParoxysmal episodes of acutely worsens
cyanosiscyanosis
Usually in response to crying, feeding,Usually in response to crying, feeding,
defecating, agitation or frightdefecating, agitation or fright
↑↑R to L shuntingR to L shunting
↑↑PVRPVR
Hyperventilation with 100% O2
Bicarbonate administration
24. Hypercyanotic or tet spellsHypercyanotic or tet spells
Paroxysmal episodes of acutely worsensParoxysmal episodes of acutely worsens
cyanosiscyanosis
Usually in response to crying, feeding,Usually in response to crying, feeding,
defecating, agitation or frightdefecating, agitation or fright
↑↑R to L shuntingR to L shunting
↑↑PVRPVR
↓↓SVRSVR
During induction of anesthesiaDuring induction of anesthesia
Squatting position
Flexing the legs or
compressing abdominal aorta
Volume administration
α-adrengeric agonist
25. Hypercyanotic or tet spellsHypercyanotic or tet spells
Paroxysmal episodes of acutely worsensParoxysmal episodes of acutely worsens
cyanosiscyanosis
Usually in response to crying, feeding,Usually in response to crying, feeding,
defecating, agitation or frightdefecating, agitation or fright
↑↑R to L shuntingR to L shunting
↑↑PVRPVR
↓↓SVRSVR
Dynamic outflow obstructionDynamic outflow obstruction
(infundibular spasm )(infundibular spasm )
Tachycardia, hypovolemia and increasedTachycardia, hypovolemia and increased
myocardial contractilitymyocardial contractility
volume expansion
β-blockers
Deepening anesthesia
Morphine
26. Natural historyNatural history
Without surgeryWithout surgery
25~35% die in the first year of life25~35% die in the first year of life
40~50% die by the age of 440~50% die by the age of 4
70% by 10 years70% by 10 years
95% by 40 years95% by 40 years
Chronic hypoxemia lead to polycythemiaChronic hypoxemia lead to polycythemia
With complete repairWith complete repair
>> 85% survive to adulthood85% survive to adulthood
27. Surgical ApproachSurgical Approach
Palliative proceduresPalliative procedures
Principle is to increase PBF by creating aPrinciple is to increase PBF by creating a
shunt B/W systemic & pulmonary circulationshunt B/W systemic & pulmonary circulation
Balloon dilatationBalloon dilatation
systemic-pulmonary arterial shuntssystemic-pulmonary arterial shunts
Classic Blalock-Taussig shuntClassic Blalock-Taussig shunt
Pott’s procedurePott’s procedure
Waterston shuntWaterston shunt
Modified Blalock-Taussig shunt (MBTS)Modified Blalock-Taussig shunt (MBTS)
28.
29. Thomas-Blalock-Taussig Shunt
Vivien Thomas, Partners of the Heart, 1998 and
Something the Lord Made - Best Made-for-TV Movie, 2004
Helen Taussig
Alfred Blalock
Vivien Thomas
31. Surgical ApproachSurgical Approach
Complete repairComplete repair
GoalsGoals
Maximal relief of RVOTOMaximal relief of RVOTO
Closure of VSDClosure of VSD
Preservation of RV functionPreservation of RV function
Full correction between age ofFull correction between age of 2 to 10 months2 to 10 months
Primary total repairPrimary total repair
Staged surgeryStaged surgery
Presence of coronary abnormalitiesPresence of coronary abnormalities
Multiple VSDsMultiple VSDs
Inadequate pulmonary artery anatomyInadequate pulmonary artery anatomy
The RV pressure at least half of SBP followingThe RV pressure at least half of SBP following
correctioncorrection
33. Preoperative informationPreoperative information
Presence of hypercyanotic spellsPresence of hypercyanotic spells
Weight loss, growth, developmentWeight loss, growth, development
and level of activityand level of activity
Prevent problems associated withPrevent problems associated with
polycythemiapolycythemia
Identify other congenital anomaliesIdentify other congenital anomalies
38. Airway examinationAirway examination
Airway abnormalities commonAirway abnormalities common
Examine child from front and sideExamine child from front and side
Pierre Robin, Treacher Collins, Down’sPierre Robin, Treacher Collins, Down’s
Tracheal stenosisTracheal stenosis
Previous prolonged intubation afterPrevious prolonged intubation after
cardiac surgerycardiac surgery
Vascular ringsVascular rings
Compression by enlarged CVSCompression by enlarged CVS
structures as well as artificial conduitsstructures as well as artificial conduits
44. NPO guidelines andNPO guidelines and
PremedicationPremedication
NPO guidelinesNPO guidelines
Solid food and particulate fluid: 6 hrsSolid food and particulate fluid: 6 hrs
Clear fluid: 2 hrsClear fluid: 2 hrs
PremedicationPremedication
Recommend for patients withRecommend for patients with
hypercyanotic spellshypercyanotic spells
Propranolol should be continued up toPropranolol should be continued up to
and including the day of surgeryand including the day of surgery
45. Infective endocarditis prophylaxisInfective endocarditis prophylaxis
Unrepaired cyanotic CHDUnrepaired cyanotic CHD, including, including
palliative shunts and conduitspalliative shunts and conduits
Completely repairedCompletely repaired congenital heartcongenital heart
defect with prosthetic material or device,defect with prosthetic material or device,
whether placed by surgery or by catheterwhether placed by surgery or by catheter
intervention, during theintervention, during the first 6 monthsfirst 6 months afterafter
the procedurethe procedure
Repaired CHD with residual defectsRepaired CHD with residual defects at theat the
site or adjacent to the site of a prostheticsite or adjacent to the site of a prosthetic
patch or prosthetic device (which inhibitpatch or prosthetic device (which inhibit
endothelialization)endothelialization)
46. IE prophylaxisIE prophylaxis
IndicatedIndicated Not indicatedNot indicated
Dental procedures withDental procedures with
bleeding or manipulationbleeding or manipulation
of gingival tissueof gingival tissue
Incision or biopsy of theIncision or biopsy of the
respiratory mucosarespiratory mucosa
TonsillectomyTonsillectomy
Rigid bronchoscopyRigid bronchoscopy
Procedures on infectedProcedures on infected
skin, skin structures orskin, skin structures or
musculoskeletal tissuemusculoskeletal tissue
Dental proceduresDental procedures
without bleedingwithout bleeding
Endotracheal intubationEndotracheal intubation
Flexible bronchoscopyFlexible bronchoscopy
Diagnostic GI scopyDiagnostic GI scopy
47. Situation Agent Regimen: Single
dose 30 – 60 min
before procedure
Oral Amoxicillin 50 mg/kg
Unable to take oral
medication
Ampicillin
OR
Cefazolin or Ceftriaxone
50 mg/kg IM or IV
50 mg/kg IM or IV
Allergic to
penicillins or
ampicillin (oral)
Cephalexin
OR
Clindamycin
OR
Azithromycin or
Clarithromycin
50 mg/kg
20 mg/kg
15 mg/kg
Allergic to
penicillins or
ampicillin and
unable to take oral
medication
Cefazolin or Ceftriaxone
OR
Clindamycin
50 mg/kg IM or IV
20 mg/kg IM or IV
49. Standard monitoringStandard monitoring
ECGECG
Pulse oximetryPulse oximetry
Oppose to the side of proposed shuntOppose to the side of proposed shunt
BPBP
Site of arterial cannulationSite of arterial cannulation
ETCO2ETCO2
Rectal and esophageal temperatureRectal and esophageal temperature
Urine outputUrine output
Meticuloous care to make sure syringes &Meticuloous care to make sure syringes &
tubings are free from air bubblestubings are free from air bubbles
51. Avoid dehydration,
especially if polycythemic
Maintain adequate tissue oxygenation
1.Avoid increasing O2 demand
2.Maintain SVR, systemic BP
3.Minimize PVR
Oral premed/induction
midazolam + ketamine
52. Free written board answer:
Speed of induction:
R->L shunt
• Inhalational: slower
• IV: faster
L->R shunt
• Inhalational: maybe faster
• IV: slower
But probably not clinically important
Tanner et al. Anesth Analg 64:101, 1985
53. TETRALOGY OFTETRALOGY OF
FALLOTFALLOT
Induction of AnesthesiaInduction of Anesthesia
Induce with Ketamine 1-2 mg/kg i/v.Induce with Ketamine 1-2 mg/kg i/v.
Decrease rate of muscle rexalant dose.Decrease rate of muscle rexalant dose.
Induction with volatile anesthetics is slow.Induction with volatile anesthetics is slow.
Sevoflurane and Halothane can be used but with cautionSevoflurane and Halothane can be used but with caution
and careful monitoring of oxygenation.and careful monitoring of oxygenation.
Hypercyanotic attacks may occur.Hypercyanotic attacks may occur.
55. Maintenance ofMaintenance of
anesthesiaanesthesia
Can be achieved by Ketamine.Can be achieved by Ketamine.
Nitrous oxide but not more than 50% can be used but disadvantageNitrous oxide but not more than 50% can be used but disadvantage
is mild increase in PVR and decrease in FIOis mild increase in PVR and decrease in FIO2.2.
Opiods and benzodiazepine can be used in low dose to avoidOpiods and benzodiazepine can be used in low dose to avoid
decrease in SVR and BP.decrease in SVR and BP.
Muscle relaxation by pancuronium to maintain SVR and BP.Muscle relaxation by pancuronium to maintain SVR and BP.
IPPV – avoid increase in airway pressure and peep.IPPV – avoid increase in airway pressure and peep.
Maintain intravascular volume.Maintain intravascular volume.
Avoid infusion of air.Avoid infusion of air.
PhenylephrinePhenylephrine must be available to treat decrease in BP due tomust be available to treat decrease in BP due to
decrease in SVR.decrease in SVR.
57. Cardiopulmonary bypassCardiopulmonary bypass
ThoracotomyThoracotomy v.sv.s. median sternectomy. median sternectomy
Sudden decompensation duringSudden decompensation during
anesthesiaanesthesia
FluidFluid
VasopressorsVasopressors
Ventilation adjustmentsVentilation adjustments
Once open the shuntOnce open the shunt
Saturation improves immediatelySaturation improves immediately
BP may drop significantlyBP may drop significantly
Diastolic hypotension may cause MIDiastolic hypotension may cause MI
58. Assessment of the shunt flowAssessment of the shunt flow
O2 saturation≒80%O2 saturation≒80%
balanced pulmonary and systemic bloodbalanced pulmonary and systemic blood
flowflow
Higher saturationHigher saturation
Pulmonary over-circulationPulmonary over-circulation
Unilateral pulmonary edema or hemorrhageUnilateral pulmonary edema or hemorrhage
shunt size may be reducedshunt size may be reduced
Low saturationLow saturation
Inadequate PBFInadequate PBF
59. For shunt patencyFor shunt patency
Low dose heparin infusion (8~10Low dose heparin infusion (8~10
U/kg/hr)U/kg/hr)
Shift to Aspirin after enteral intakeShift to Aspirin after enteral intake
Avoid platelet transfusionsAvoid platelet transfusions
61. Arrhythmia and heart blockArrhythmia and heart block
Common after VSD repairsCommon after VSD repairs
Heart blockHeart block
Epicardial pacingEpicardial pacing
Permanent pacing if not resolved after 7~10Permanent pacing if not resolved after 7~10
daysdays
Junctional ectopic tachycardiaJunctional ectopic tachycardia
AmiodaroneAmiodarone
ProcainamineProcainamine
Post-CPB bleedingPost-CPB bleeding
62. ExtubationExtubation
Elective shunt procedureElective shunt procedure
In the OR or soon after arrival ICUIn the OR or soon after arrival ICU
Usually within 4 hrsUsually within 4 hrs
Emergency shunt placementEmergency shunt placement
After resolution of hemodynamic,After resolution of hemodynamic,
metabolic and pulmonary problemsmetabolic and pulmonary problems
Complete repairComplete repair
same as elective shunt proceduresame as elective shunt procedure
63. Uncorrected patient forUncorrected patient for
noncardiac surgerynoncardiac surgery
Prevention of hypercyanotic spellsPrevention of hypercyanotic spells
Maintain SVR and improve PBFMaintain SVR and improve PBF
MonitoringMonitoring
The location of shunts and arterial linesThe location of shunts and arterial lines
65. 22NDND
COMMON CYANOTICCOMMON CYANOTIC
HEART DISEASEHEART DISEASE
Results fromResults from failure of Truncus arteriosus tofailure of Truncus arteriosus to
spiralspiral
Aorta arises from anterior portion of right ventricleAorta arises from anterior portion of right ventricle
& pulmonary artery from left ventricle& pulmonary artery from left ventricle
Complete seperation of systemic & pulmonaryComplete seperation of systemic & pulmonary
circulationcirculation
Survival is possible only if there is communicationSurvival is possible only if there is communication
B/W two circulationsB/W two circulations
VSD PDA ASDVSD PDA ASD
69. TreatmentTreatment
Immediate MxImmediate Mx
Creating intracardiac mixing or increasing theCreating intracardiac mixing or increasing the
degree of mixing bydegree of mixing by
infusions ofprostaglandin E to maintaininfusions ofprostaglandin E to maintain
patency of the ductus arteriosuspatency of the ductus arteriosus
and/or balloon atrial septostomy (Rashkindand/or balloon atrial septostomy (Rashkind
procedure)procedure)
Administration of oxygen may decrease pulmonaryAdministration of oxygen may decrease pulmonary
vascular resistance and increase pulmonary bloodvascular resistance and increase pulmonary blood
flow.flow.
Diuretics and digoxin are administered to treatDiuretics and digoxin are administered to treat
congestive heart failurecongestive heart failure
70. Surgical correction –Surgical correction –
ARTERIAL SWITCHARTERIAL SWITCH
the pulmonary artery and ascending aorta arethe pulmonary artery and ascending aorta are
transected above the semilunar valvestransected above the semilunar valves
and re anastomosed with the right and leftand re anastomosed with the right and left
ventricles, and coronary arteries are thenventricles, and coronary arteries are then
reimplanted,reimplanted,
so the aorta is connected to the left ventricle andso the aorta is connected to the left ventricle and
the pulmonary artery is connected to the rightthe pulmonary artery is connected to the right
ventricleventricle..
71. ANAESTHETICANAESTHETIC
MANAGEMENTMANAGEMENT
doses and rates of injection of intravenouslydoses and rates of injection of intravenously
administered drugs may have to be decreased.administered drugs may have to be decreased.
the onset of anesthesia produced by inhaled drugsthe onset of anesthesia produced by inhaled drugs
is delayedis delayed
induction and maintenance of anesthesia-induction and maintenance of anesthesia-
ketamine combined with muscle relaxants toketamine combined with muscle relaxants to
facilitate tracheal intubationfacilitate tracheal intubation
Ketamine + benzodiazepines/opiodsKetamine + benzodiazepines/opiods
Dehydration must be avoided during theDehydration must be avoided during the
perioperative periodperioperative period
73. Tricuspid Atresia
3rd most common cyanotic CHD
Characterised byCharacterised by
Arterial hypoxemiaArterial hypoxemia
Small rt ventricleSmall rt ventricle
Large lt ventricleLarge lt ventricle
Marked decrease in pulmonary blood flowMarked decrease in pulmonary blood flow
Poorly oxygenated blood from rt atrium-Poorly oxygenated blood from rt atrium-
through ASD – Lt atrium- mixes with oxygenatedthrough ASD – Lt atrium- mixes with oxygenated
blood- Lt ventricle- systemic circualtionblood- Lt ventricle- systemic circualtion
PBF is via a VSD , PDA or BronchialPBF is via a VSD , PDA or Bronchial
vesselsvessels
75. Management of AnaesthesiaManagement of Anaesthesia
Opiods / volatile anaaestheticsOpiods / volatile anaaesthetics
In early post op Maintain increasedIn early post op Maintain increased
RT atrial pressure (16-20mm hg) toRT atrial pressure (16-20mm hg) to
facilitate PBFfacilitate PBF
Early extubation is desirableEarly extubation is desirable
Dopamine with or without vasodilatorsDopamine with or without vasodilators
are required to maintain CO & loware required to maintain CO & low
PVRPVR
77. Abnormality of the tricuspid valveAbnormality of the tricuspid valve
The valve leaflets are malformed or displacedThe valve leaflets are malformed or displaced
downward into the right ventricledownward into the right ventricle..
Usually regurgitant but may be stenotic alsoUsually regurgitant but may be stenotic also
Most pts will hv a interatrial communication (ASD ,Most pts will hv a interatrial communication (ASD ,
PFO) through which RT to LT shunting occursPFO) through which RT to LT shunting occurs
78. Signs & symptomsSigns & symptoms
severity of the hemodynamic derangements in patientsseverity of the hemodynamic derangements in patients
depends ondepends on
the degree of displacementthe degree of displacement
the functional status of the tricuspid valve leafletsthe functional status of the tricuspid valve leaflets
Neonates - cyanosis and congestive heart failureNeonates - cyanosis and congestive heart failure
older children incidental murmur(systolic murmur of TRolder children incidental murmur(systolic murmur of TR
in the LT sternal border)in the LT sternal border)
Adults presents as supraventricular dysrhythmias thatAdults presents as supraventricular dysrhythmias that
lead to congestive heart failure, worsening cyanosis,lead to congestive heart failure, worsening cyanosis,
and occasionally syncopeand occasionally syncope..
79. HEPATOMEGALY due to increased RT atrialHEPATOMEGALY due to increased RT atrial
pressurepressure
ECG-tall & broad P wave(RBBB)ECG-tall & broad P wave(RBBB)
AV blockAV block
PSVT & ventricular dysarrythmiasPSVT & ventricular dysarrythmias
Ventricular preexcitation(WPW)Ventricular preexcitation(WPW)
ECHO- to assess RT atrial dilatation & distortion ofECHO- to assess RT atrial dilatation & distortion of
tricuspid leafletstricuspid leaflets
To assess severity of tricuspid regurgitation /To assess severity of tricuspid regurgitation /
stenosisstenosis
80. Hazards of pregnancy in ptsHazards of pregnancy in pts
with EBSTEIN’S ANOMALYwith EBSTEIN’S ANOMALY
Deterioration in RT ventricular Fn due toDeterioration in RT ventricular Fn due to
increased blood volume & COincreased blood volume & CO
Increased RT to LT shunt & arterialIncreased RT to LT shunt & arterial
hypoxemia if ASD is presenthypoxemia if ASD is present
Cardiac dysrythmiasCardiac dysrythmias
PIH may cause Congestive Heart FailurePIH may cause Congestive Heart Failure
81. TreatmentTreatment
Arterial shunt from systemic to pulmonaryArterial shunt from systemic to pulmonary
circulationcirculation
Glen shunt & Fontan procedure to createGlen shunt & Fontan procedure to create
Univentricular heartUniventricular heart
Repair /replacement of tricuspid valve along withRepair /replacement of tricuspid valve along with
closure of interatrial communicationclosure of interatrial communication
Diuretics / Digoxin for Mx of Congestive heartDiuretics / Digoxin for Mx of Congestive heart
failurefailure
IE prophylaxisIE prophylaxis
82. Anaesthetic managemnetAnaesthetic managemnet
Hazards during anaesthesiaHazards during anaesthesia
Accentuation of arterial hypoxemia due to increasedAccentuation of arterial hypoxemia due to increased
RT to LT shuntRT to LT shunt
Development of supraventricular tachydysrhythmiasDevelopment of supraventricular tachydysrhythmias
Increased RT atrial pressure indicates RT ventricularIncreased RT atrial pressure indicates RT ventricular
failurefailure
Unexplained hypoxemia or air embolism during intraopUnexplained hypoxemia or air embolism during intraop
may be due to shunting thr previously closed foramenmay be due to shunting thr previously closed foramen
ovaleovale
Delayed onset of iv drugs due to pooling & dilution inDelayed onset of iv drugs due to pooling & dilution in
RT atriumRT atrium
Epidural analgesia has been used safe for labor &Epidural analgesia has been used safe for labor &
deliverydelivery