1) Cavopulmonary connections like the Glenn shunt divert systemic venous return directly to the pulmonary circulation, improving oxygen saturation for patients with single ventricle physiology.
2) The Glenn shunt involves anastomosis of the superior vena cava to the right pulmonary artery, reducing the volume load on the single ventricle.
3) Immediate postoperative issues include managing ventilation, elevated cavopulmonary pressures, hypertension/bradycardia, low cardiac output, and cyanosis which may result from pulmonary or systemic venous desaturation or decreased pulmonary blood flow.
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
Single ventricle presentation for pediatricianLaxmi Ghimire
As the number of children who survive single ventricle physiology, it is very important for the pediatrician to understand about them to give them the best care.
Various coronary physiological measurements can be made in the cardiac catheterization laboratory using sensor-tipped guidewires; they include the measurement of poststenotic absolute coronary flow reserve, the relative coronary flow reserve, and the pressure-derived fractional flow reserve of the myocardium. Ambiguity regarding abnormal microcirculation has been reduced or eliminated with measurements of relative coronary flow reserve and fractional flow reserve. The role of microvascular flow impairment can be separately determined with coronary flow velocity reserve measurements. In addition to lesion assessment before and after intervention, emerging applications of coronary physiology include the determination of physiological responses to new pharmacological agents, such as glycoprotein IIb/IIIa blockers, in patients with acute myocardial infarction. Measurements of coronary physiology in the catheterization laboratory provide objective data that complement angiography for clinical decision-making
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
a cardiac surgery presentation about Atrioventricular septal defect,Definition, Prevalence,Anatomy,Classification,presentation ,diagnosis and management
A lecture on the echocardiographic evaluation of hypertrophic cardiomyopathy. Starts with an overview of the topic then a systematic approach to diagnosis and then a differential diagnosis followed by take-home messages and conclusion.
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.
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
Single ventricle presentation for pediatricianLaxmi Ghimire
As the number of children who survive single ventricle physiology, it is very important for the pediatrician to understand about them to give them the best care.
Various coronary physiological measurements can be made in the cardiac catheterization laboratory using sensor-tipped guidewires; they include the measurement of poststenotic absolute coronary flow reserve, the relative coronary flow reserve, and the pressure-derived fractional flow reserve of the myocardium. Ambiguity regarding abnormal microcirculation has been reduced or eliminated with measurements of relative coronary flow reserve and fractional flow reserve. The role of microvascular flow impairment can be separately determined with coronary flow velocity reserve measurements. In addition to lesion assessment before and after intervention, emerging applications of coronary physiology include the determination of physiological responses to new pharmacological agents, such as glycoprotein IIb/IIIa blockers, in patients with acute myocardial infarction. Measurements of coronary physiology in the catheterization laboratory provide objective data that complement angiography for clinical decision-making
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
a cardiac surgery presentation about Atrioventricular septal defect,Definition, Prevalence,Anatomy,Classification,presentation ,diagnosis and management
A lecture on the echocardiographic evaluation of hypertrophic cardiomyopathy. Starts with an overview of the topic then a systematic approach to diagnosis and then a differential diagnosis followed by take-home messages and conclusion.
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.
central venous pressure and intra-arterial blood pressure monitoring. invasiv...prateek gupta
central venous pressure and intra-arterial blood pressure monitoring. various sites for cvp and Ibp insertion. working principle for cvp and ibp. indication and complication. various waveform of cvp and ibp
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
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.
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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
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
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.
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
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
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
Glen shunt (BDG)
1.
2. GENERAL PRINCIPLES OF SUPERIOR AND TOTAL
CAVOPULMONARY CONNECTIONS
Goal =separate the systemic and pulmonary circuits, resulting in
normal or near normal oxygen saturation.
Cavopulmonary connections -divert systemic venous return
directly into the pulmonary vascular bed, providing more
“effective” pulmonary blood flow and reducing the volume load
on the single ventricle.
GLENN SHUNT-A REVIEW
3. After these procedures, the single ventricle ejects blood only to the
systemic circuit, with pulmonary blood flow derived by “passive
flow” into the pulmonary vascular bed at the expense of higher
central venous pressure.
improve cyanosis and minimize ventricular work
elevated PVR in the neonate precludes their use until
approximately 3 months of age
GLENN SHUNT-A REVIEW
4. The cavopulmonary connections -stage to the modified Fontan
1)BDG
2)Hemi-Fontan.
Staging - high incidence of pleural effusions and low-output
myocardial failure when taken directly for fontan procedure..
GLENN SHUNT-A REVIEW
5. Single left ventricle physiologies
Tricuspid atresia with normally related great arteries
Double-inlet left ventricle with normally related great arteries
Transposition of the great arteries with PS
Malaligned atrioventricular canal with hypoplastic right ventricle
Pulmonary atresia with intact ventricular septum
GLENN SHUNT-A REVIEW
9. GOALS OF STAGE 1 PALLIATION
Unobstructed systemic blood flow
Limited PBF
Undistorted PA
Unobstructed PVreturn
Minimal AV valve regurgitation
GLENN SHUNT-A REVIEW
10. allows the neonate to survive into infancy
not a stable anatomic or physiologic long-term solution.
ultimately undergo some variation of the Fontan operation as their
final surgical palliation
GLENN SHUNT-A REVIEW
11. Selecting Patients with Tricuspid Atresia for the
Fontan Procedure: The “Ten Commandments”
1. Minimum age, 4 years
2. Sinus rhythm
3. Normal caval drainage
4. Right atrium of normal volume
5. Mean pulmonary artery pressure ≤ 15 mm Hg
6. Pulmonary arterial resistance < 4 U/m2
7. Pulmonary-artery-to-aorta-diameter ratio ≥ 0.75
8. Normal ventricular functions (ejection fraction > 0.6)
9. Competent left atrioventricular valve
10. No impairing effects of previous shunts
GLENN SHUNT-A REVIEW
12. Glenn.
unidirectional (classic) and bidirectional superior cavopulmonary
anastomoses and inferior cavopulmonary anastomosis (inferior
vena cava [IVC]-to-PA connection).
Interim palliation with a BDG shunt - standard of care in infancy (4
to 9 months of age).
GLENN SHUNT-A REVIEW
13. Timing of shunt
decrease in PVR= superior cavopulmonary anastomoses by 3 to 6
months of age.
Mahle - early ventricular unloading after neonatal single-
ventricle palliation improved aerobic exercise performance in
preadolescents with the Fontan palliation.
early -opportunity to address distorted pulmonary arteries from
previous bands or shunts and to create a better distribution of
PA blood flow and growth of the pulmonary vascular bed.
GLENN SHUNT-A REVIEW
14. Indications for early shunt procedure
Cyanosis secondary to inadequate pulmonary blood flow after
neonatal palliation
CHF from an excessive volume load caused by severe
atrioventricular valve regurgitation or by an elevated Qp:Qs.
GLENN SHUNT-A REVIEW
15. early - weighed against the risks of elevated SVC pressure and
cyanosis.
Bradley - younger than 3 months was associated with lower oxygen
saturation in the early postoperative period and a risk of PA
thrombosis.
Some infants with severe ventricular dysfunction or
atrioventricular valve regurgitation - not be suitable for further
staged palliation and may require heart transplantation
GLENN SHUNT-A REVIEW
16. Prerequisites before the procedure
Echo
cath
For anatomic and hemodynamic assessment of the
PA
Aortic arch
Ventricular and AV valve function
Caval anatomy-Presence of decompressing veins that may
result in cyanosis after superior cavopulmonary
anastomosis.
GLENN SHUNT-A REVIEW
17. CLASSIC GLENN SHUNT
Dr. Glenn
anastomosis between the transected distal end of the right
pulmonary artery and the side of the SVC, which is ligated
distal to the anastomosis.
azygous vein is ligated to prevent its decompressing flow
from the SVC.
GLENN SHUNT-A REVIEW
18. BIDIRECTIONAL GLENN SHUNT
GLENN SHUNT-A REVIEW
median sternotomy
CPB
shunt is ligated with a vascular clip or ligature.
Preservation of the proper spatial orientation of the
SVC relative to the PA is essential
azygos vein is ligated but not divided
SVC is then divided, and the cardiac end is oversewn.
cephalic end is anastomosed end to side to the
ipsilateral PA.
19. bi-directional - far less likely to engender Pulmonary vascular obstructive
disease compared with systemic-pulmonary shunts
minimal Distortion of the pulmonary artery architecture.
GLENN SHUNT-A REVIEW
20. Shunt between the Superior Vena Cava and Right Pulmonary Artery — Technic of Anastomosis.
Glenn WW. N Engl J Med 1958;259:117-120.
21. Angiogram Taken Two Months after Operation.
Glenn WW. N Engl J Med 1958;259:117-120.
22. Arterial Oxygen Studies before and after the Shunt.*
Glenn WW. N Engl J Med 1958;259:117-120.
23. Technique Without Cardiopulmonary Bypass
BDG
Patients with sources of pulmonary blood flow that do not need
interruption as part of the cavopulmonary anastomosis
(antegrade flow through a stenotic pulmonary valve or banded
PA) and have no specific intracardiac pathology requiring
revision are candidates for cavopulmonary anastomosis without
CPB.
HLHS -not candidates -pulmonary blood flow is shunt
dependent/ may require PA reconstruction and other
intracardiac procedures at the time of their superior
cavopulmonary anastomosis
GLENN SHUNT-A REVIEW
28. Postoperative Physiology
circulation to the lungs is from the upper body systemic venous
return.
pulmonary blood flow results from upper body blood flow, all SVC
return must pass through the lungs to reach the heart in the
absence of decompressing venous collaterals.
GLENN SHUNT-A REVIEW
29. early age - reduction of the volume work of the single ventricle and
a predictable Qp:Qs of a 0.6 to 0.7.
This ratio is higher in young infants because of the relative size of
the head and the upper extremities in young infants as opposed to
those in older children, but in general, systemic arterial oxygen
saturations (SaO2) are 75% to 85%.
GLENN SHUNT-A REVIEW
30. immediate reduction in the volume load of the single ventricle by
removing the aortopulmonary shunt decreases the work of the
single ventricle and may improve long-term AV valve and
myocardial function.
AV valve regurgitation resulting from physiologic rather than
structural abnormalities may decrease as the ventricular geometry
normalizes
GLENN SHUNT-A REVIEW
31. oxygen is delivered more efficiently to the body because only
deoxygenated blood from the SVC rather than admixed blood from
the ventricle is presented to the lungs for oxygen uptake.
reduction in cardiac output needed to achieve a given tissue O2
delivery
GLENN SHUNT-A REVIEW
33. ventricular filling is not absolutely dependent on pulmonary
venous return, because IVC flow is still diverted directly to the
single ventricle and maintains preload.
acute volume reduction noted after superior cavopulmonary
anastomosis is better tolerated than in the case of transitioning a
child from a neonatal palliation directly to the Fontan completion
without an intervening superior cavopulmonary anastomosis
GLENN SHUNT-A REVIEW
34. SaO2 - lower in very young younger than 3 months patients.
as young as 4 weeks have had satisfactory BDG shunt creation
patients younger than 3 months -early cyanosis, PA thrombosis, and
vascular congestion.
delay of the procedure until the child is older than 3 months
By age 6 months-mortality risk approaches 0
GLENN SHUNT-A REVIEW
36. Mechanical Ventilation
Positive pressure ventilation with increased mean airway pressures
adversely affects PVR and ventricular filling
Early institution of spontaneous ventilation improves
hemodynamics
Spontaneous breathing also increases pco2, which will promote
increased cerebral blood flow and, thereby, increase pulmonary
blood flow.
GLENN SHUNT-A REVIEW
37. “Physiologic” (3 to 5 cm H2O) PEEP-well tolerated, does not
significantly affect PVR or CO, and may improve oxygenation by
reducing areas of microatelectasis, reestablishing functional
residual capacity, and improving ventilation/–perfusion matching.
GLENN SHUNT-A REVIEW
38. Elevated Cavopulmonary Pressures
minimize the transpulmonary gradient (PA mean pressure – common
atrium mean pressure) to allow passive PBFthrough the lungs and
back to the single ventricle.
elevated transpulmonary gradient - pulmonary venous obstruction,
elevated PVR, or pleural effusion, hemothorax, or pneumothorax.
Extubating - reduce the common atrial pressure and promote flow
through the lungs by creating a greater transthoracic gradient from
the extrathoracic space to the intrathoracic space.
Diminished cavopulmonary blood flow will reduce systemic SaO2
GLENN SHUNT-A REVIEW
39. Elevation of PVR from the inflammatory effects of CPB may be
minimized with pulmonary vasodilators -nitric oxide at 5 to 20
parts per million in inspired gas.
Mild facial edema after superior cavopulmonary anastomosis
may persist for up to 72 hours.
Majority of pleural effusions - diminish over time with judicious
diuretic use and fluid restriction.
GLENN SHUNT-A REVIEW
40. aspirin (5 mg/kg/day) - reduce the risk of thrombosis of the
superior cavopulmonary circuit
GLENN SHUNT-A REVIEW
41. significantly elevated SVC pressure ,upper extremity plethora and
edema - obstruction at the cavopulmonary anastomosis, distal PA
distortion, or marked elevations in PVR.
Significant elevations of pressure in the SVC may limit cerebral
blood flow.
If the SVC pressure is more than 18 mm Hg- early catheterization
GLENN SHUNT-A REVIEW
42. Hypertension and Bradycardia
Transient postoperative hypertension and bradycardia -first 24
to 72 hours
Hypertension - pain, catecholamine secretion, intracranial
hypertension
acute elevation of the central venous pressure -reflex similar to
that seen in head trauma, such that systemic hypertension is
necessary to preserve adequate cerebral perfusion.
aggressive lowering of the blood pressure may adversely affect
the cerebral perfusion pressure
vasodilators =cautiously.
GLENN SHUNT-A REVIEW
43. Transient bradycardia =acute reduction of the volume load of the
single ventricle, or may be due to injury to the sinus node or its
arterial supply.
GLENN SHUNT-A REVIEW
44. Low Cardiac Output
preexisting ventricular dysfunction or severe atrio-ventricular valve
regurgitation- volume-loaded ventricles, which need high filling
pressures to generate adequate output, volume reduction and the
effects from CPB may significantly reduce cardiac output and
oxygen delivery to the tissues.
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47. Systemic venous desaturation/Decreased
oxygen delivery
Anemia
Low cardiac output
Decreased ventricular function
Severe AV valve regurgitation
Pericardial tamponade
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48. Increased oxygen consumption
Sepsis
Venovenous collateral from superior cavopulmonary circuit via the
systemic venous circuit to the systemic ventricle
Baffle leak
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50. Decreased pulmonary blood flow - decompressing venovenous
collaterals, an undiagnosed contralateral LSVC
decompressing venous collaterals – MC IN bilateral superior vena
cava, a higher early postoperative transpulmonary gradient, and
elevated pressure in the SVC.
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51. A left SVC to coronary sinus- may re-canalize, resulting in
significant desaturation after superior cavopulmonary
anastomosis.
Successful transcatheter coil embolization
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52. PULMONARY AV MALFORMATIONS
particularly in patients with heterotaxy syndrome.
Diversion of normal hepatic venous flow from the pulmonary
circulation
regress after incorporation of hepatic venous flow into the lungs.
young age
polysplenia (interrupted IVC with azygos continuation to the
SVC).
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53. gradual hypoxemia months to years
pulsatile second source of pulmonary blood flow may minimize
the development
malformations diminish or disappear completely after fontan
completion
theoretic advantages exist to an ivc-pa cavopulmonary
anastomosis relative to the formation of pulmonary
arteriovenous malformations, the elevation in hepatic venous
pressure and the detrimental effects on liver function may be
prohibitive
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54. long-term aspirin (a cyclooxygenase inhibitor) = prevented the
development of cyanosis by preventing pulmonary AV fistula
formation.
Transcatheter embolisation when feeding artery greater than 3mm.
Surgery-Fistulectomy/Lobectomy
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