Anesthesia for noncardiac surgery in children with congenital heart disease

Sheila Espina-Bertoso MD, DPBA University of the Philippines-PGH

Introduction
Decades of advancement in diagnostic and interventional cardiology, surgical techniques, cardiopulmonary bypass, anesthetic management, and critical care have dramatically altered the natural history of congenital heart disease (CHD). This resulted to a decrease in morbidity and mortality in affected children and improved quality of life.

Introduction
Anesthesiologists will encounter children with CHD for elective non-cardiac surgery at one of three stages: Unpalliated Partially palliated Completely palliated ASD and PDA only congenital lesions that can be truly corrected

Introduction
Increase in life expectancy leads to increased survival rates In some cases, children may require noncardiac surgery before undergoing procedures to repair their cardiovascular pathology.

Objective

Review general principles of anesthetic practice with a focus on preoperative assessment, intraoperative management, and postoperative care for children with CHD having noncardiac surgery.

Pre-operative Assessment
50% Dx by 1st week of life; rest by 5 years Childs diagnosis & current medical condition will determine preoperative evaluation Understand the anatomic and hemodynamic function of childs heart Discuss case with pediatrician and cardiologist Review diagnostic & therapeutic interventions Above will estimate disease severity and help formulate anesthetic plan

Preoperative Assessment
Gather information regarding the nature of the cardiovascular disease and prior therapeutic interventions. Determine functional status. The history and physical examination, in addition to the laboratory data and ancillary tests provide complementary information.

Preoperative Assessment
Based on this clinical assessment and consideration of the major pathophysiologic consequences, a systematic, detailed, organized plan should be formulated for anesthetic and perioperative management.

History and Physical Examination

History should focus on the status of the cardiovascular system. Relevant information includes the type of CVD and comorbid conditions medications allergies prior hospitalizations, surgeries, anesthetic experiences, and complications elective cases.

History and Physical Examination

Symptomatology tachypnea, dyspnea, tachycardia, dysrhythmias, and fatigue should be sought. feeding difficulties and diaphoresis may represent significant symptoms in infants decreased activity level or exercise intolerance may be of concern in older children palpitations, chest pain, and syncope should be characterized.

History and Physical Examination

Should include an assessment of growth and development
History of recent illnesses such as respiratory infections or pulmonary disease

Physical Examination
Physical Examination weight and height vital signs: HR, RR, O2 sat, BP.
ex1: In general, children who have undergone definitive procedures should be expected to have normal to near-normal SpO2 (95%). After palliative interventions, SpO2 values typically range between 75% and 85%.

ex2: For those aortic arch obstruction or has had any systemic-topulmonary shunt, upper and lower extremity as well as right and left upper extremity blood pressure and palpation of the quality of pulses should be documented.

Physical Examination
Airway General appearance - child's level of activity - breathing pattern - level of distress and presence of cyanosis Respiratory evaluation - quality of the breath sounds - the presence or absence of labored breathing, - intercostal retractions, wheezing, rales, or rhonchi..

Physical Examination
Cardiac Examination assessment of heart sounds, pathologic murmurs, and gallop rhythms presence of a thrill, representing a palpable murmur, should be noted GI Examination - Hepatosplenomegaly

Physical Examination
Extremities should include examination of pulses, overall perfusion, capillary refill, cyanosis, clubbing, and edema. Noncardiac anomalies or pathology that may affect anesthetic care (e.g., a specific syndrome complex, a potentially difficult airway, gastroesophageal reflux) should be noted.

Ancillary Studies and Laboratory Data

In cyanotic children, CBC provides the determination of polycythemia, microcytic anemia, and thrombocytopenia. Prothrombin time, partial thromboplastin times, and international normalized ratio (INR) provide an indication of clotting ability In those receiving diuretic therapy, digoxin, or angiotensinconverting enzyme inhibitors, the determination of serum electrolytes may be useful.

Ancillary Studies and Laboratory Data

Blood typing and crossmatching A recent ECG should be reviewed for changes from prior studies. Exercise tolerance test or treadmill study

Ancillary Studies and Laboratory Data

Review of a recent chest Xray, including a lateral view, provides information regarding cardiac size, chamber enlargement, and pulmonary vascularity.
Recent echocardiogram, cardiac catheterizations, electrophysiologic procedures, and magnetic resonance imaging should be reviewed.

Goal of Pre-operative Evaluation

The goals of the preoperative evaluation is to obtain the most diagnostic information with the fewest tests and the least risk, discomfort, and expense to the child.

Intraoperative Management
Premedication Should be routine. This facilitates parental separation, entry into the operating room, placement of monitors, and induction of anesthesia. Commonly used premedications include oral or intravenous benzodiazepines, opioids, and small amounts of hypnotic agents.

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

Premedication
e) IV Premedication Midazolam 0.02 - 0.05 mg/kg titrated in small increments f) 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

Intravenous Access

To secure a good intravenous access is mandatory for administration of fluids and medications during anesthetic care.

Intravenous Access
Regarding: Size of the intravenous catheter Central venous access Air in the intravenous infusion tubing.

Emergency Drugs
In view of the potential for hemodynamic instability in some children with CHD that may occur at any time, drugs for emergency situations should be prepared or immediately available to the anesthesiologist.

Monitoring
Basic monitoring involves observation of the child, including skin color, capillary refill, respiration, pulse palpation, events on the surgical field, and color of shed blood. Standard noninvasive monitors
blood pressure electrocardiography (5-lead) pulse oximetry capnography temperature monitoring

Monitoring
Electrocardiography An ECG is used to monitor heart rate, cardiac rhythm, and ST-segment analysis. Usually one or multiple leads are displayed. Most systems use two leads: standard lead II and lead V5.

Monitoring
Pulse Oximetry Placement is often well tolerated One of the earliest monitors applied during anesthetic induction. Indicate the adequacy of peripheral perfusion and cardiac output.[

Monitoring
Capnography To confirm proper placement of the ETT To assess adequacy of ventilation To recognize certain pathologic conditions such as bronchospasm, airway obstruction, and malignant hyperthermia.

Monitoring
Temperature Monitoring Watch out for hypothermia This may influence oxygen delivery (increased oxygen consumption) and emergence from anesthesia, cause detrimental changes in hemodynamics, and affect hemostasis.

Monitoring
Urinary Output Measurements Useful index of the adequacy of renal perfusion and cardiac output esp during cases involving major fluid shifts or blood loss, or long surgical procedures.

Monitoring
Precordial stethoscope can be extremely helpful to monitor for changes in heart tones that may suggest early hemodynamic compromise. Invasive monitoring (A-line) may be needed depending on the level of monitoring required is influenced by the child's cardiovascular pathology, clinical condition and functional status, and the complexity and duration of the surgery or procedure being performed.

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

Anesthetic Technique
No specific formula or recipe. The anesthetic techniques and agents used for a particular situation should be selected in consideration of the procedure to be performed the child's disease process and functional status factors such as age, physical characteristics, and preferences of the anesthesiologist must be taken into consideration.

Anesthetic Technique
The primary goals of anesthetic management with respect to the cardiovascular system are
to optimize systemic oxygen delivery maintain ventricular function within expected parameters for the individual patient ensure the adequacy of cardiac output. always keep in mind a potential decreased cardiovascular reserve and reduced tolerance for perioperative stress. to do a carefully titrated anesthetic, regardless of the specific agents.

Anesthetic technique
General Anesthesia Advantage widely accepted ease of application certainty of effect the appropriate choice for most children undergoing noncardiac surgery

General Anesthesia
DISADVANTAGES - a greater potential for wide fluctuations in the hemodynamics - prolonged recovery period.

Regional Anesthesia
Demonstrated to be safe and effective in children with CHD ADVANTAGES effect is limited to the surgical site decreased number of systemic medications potentially shorter overall recovery period a more pleasant experience for the child. may be used for post-op pain mangement

Regional Anesthesia
DISADVANTAGE Its use is limited in small children and may not always be effective. There is also the potential for hemodynamic compromise, particularly in hypovolemic children or those with a fixed cardiac output, and is contraindicated in those with coagulation defects.

Inhalational Agents
Halothane was considered for many decades the primary agent for inhalation induction in children in combination with oxygen and nitrous oxide. However, with the introduction of sevoflurane in the mid 1990s, it has replaced halothane for induction of anesthesia in many centers.

Inhalational Agents
The safety and efficacy of halothane vs sevoflurane in infants and children with CHD during cardiac surgery. Sevoflurane provides better hemodynamic stability minimal impact on myocardial performance advocated as the preferred anesthetic for children with heart disease.

Inhalational Agents
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

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 Increases SVR, not recommended for L-R shunt CHD Copious secretions laryngospasm atropine or glycopyrrolate

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

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

IM & IV ANESTHETICS
OPIOIDS & BENZODIAZEPINE Excellent induction agents in very sick children Blunt the stress response in the pulmonary circulation elicited by airway manipulations and at the same time provide sedation and amnesia. No cardiodepressant effects if bradycardia avoided Fentanyl 25-100 g/kg IV Midazolam 0.05-0.1 mg/kg

IM & IV ANESTHETICS
ETOMIDATE CV stability 0.3 mg/kg IV Pain on injection & myoclonic movements 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

Induction of Anesthesia
Techniques: 1. Intravenous: preferred technique because of greater margin of safety 2. Inhalational: should be carefully titrated, but generally safe even with patients with moderate hemodynamic issues 3. IM: Ketamine: uncooperative, devt delayed px 4. Intranasal, Rectal and Subcutaneous: less common

Anesthetic Management
ANESTHESIA INDUCTION Myocardial function preserved IV or inhalational techniques suitable Severe cardiac defects IV induction Modify dosages in patients with severe failure

Maintenance of Anesthesia
Inhalation or intravenous technique. A combination of inhalational and intravenous anesthetics (opioid and muscle relaxant) is frequently used. The same inhalational agent administered for induction may be continued or a different anesthetic or technique may be selected for maintenance.

Emergence
Most children undergoing noncardiac surgical interventions are expected to awaken immediately at the completion of the procedure . This usually involves reducing and then discontinuing intravenous or inhalational anesthetics, antagonizing neuromuscular blockade, and removing the endotracheal tube, if present.

Classification of CHD
A. B. C. D. L-R shunt R-L Shunt Complex Shunts Obstructive Lesions

A. L-R Shunts
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

L-R Shunts
L R SHUNTS Defects connecting arterial & venous circulation SVR > PVR PBF pulmonary blood flow pulmonary congestion CHF Long standing L-R shunts PHT PVR > SVR R-L shunt Eisenmengers syndrome

SVR?
Systemic Vascular Resistance
Systemic vascular resistance (SVR) refers to the resistance to blood flow offered by all of the systemic vasculature, excluding the pulmonary vasculature. SVR = (MAP - CVP) CO

VENTRICULAR SEPTAL DEFECT

Anesthetic Considerations:
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

Anesthetic Considerations
L-R SHUNTS :
GOAL = SVR and PVR L-R shunt
PPV & PEEP increases PVR Ketamine increases SVR Inhalation agents decrease SVR

B. R-L Shunts

Defect between R and L heart PVR> SVR Resistance to pulmonary blood flow PBF hypoxemia and cyanosis Goal: Increase SVR

Anesthetic Considerations
R-L SHUNTS :
GOAL : PBF by SVR and PVR

PVR & SVR PBF

Hypoxemia/atelectasis/PEEP Acidosis/hypercapnia HCT Sympathetic stimulation & surgical stimulation Vasodilators & inhalation agents SVR

B. R-L Shunt
TOF 10% of CHD, commonest R-L shunt PULMONARY ATRESIA TRICUSPID ATRESIA EBSTEINS ANOMALY

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

Tetralogy of Fallot

Tetralogy of Fallot
The main perioperative issues in unoperated children is the potential for hypercyanotic episodes. In awake patient manifests as acute cyanosis & hyperventilation May occur with feeding, crying, defecation or stress What are tet spells?

Tet Spells (hypercyanotic episodes)

Result from decreased pulmonary blood flow in children with significant dynamic right ventricular outflow tract obstruction. Relatively rare during noncardiac surgery, probably because GA attenuates the triggers. Factors that decrease systemic blood pressure and systemic vascular resistance such as hypovolemia and extreme vasodilation should be avoided.

Tet Spells
MANAGEMENT 1. Increasing blood volume 2. Increase inspired oxygen concentrations 3. Increase systemic vascular resistance, often with phenylephrine 4. Lower inspiratory ventilatory pressures may also lead to clinical improvement. 5. Increase the level of sedation or anesthetic depth and adrenergic blockade.

Tetralogy of Fallot
Treatment of Hypercyanotic Spells High FiO2 pulmonary vasodilator PVR Hydration (fluid bolus) opens RVOT Morphine (0.1mg/kg/dose) sedation, PVR Ketamine SVR, sedation, analgesia PBF Phenylephrine (1mcg/kg/dose) SVR -blockers (Esmolol 100-200mcg/kg/min) HR,-ve inotropy improves flow across obstructed valve & infundibular spasm

Anesthetic Considerations
PVR & SVR PBF Hyperoxia/Normal FRC Alkalosis/hypocapnia Low HCT Low mean airway pressure Blunted stress response Nitric oxide/ pulmonary vasodilators

Anesthetic Considerations
R L SHUNTS : 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 Avoid PEEP and PPV increase PVR

C. Complex Shunts
COMPLEX SHUNTS (MIXING LESIONS) Continuous mixing of venous and arterial blood blood saturation 70% - 80% May or may not be obstruction to flow Produce both cyanosis and CHF Overzealous improvement in PBF steals circulation from aorta systemic hypotension coronary ischemia

Complex Shunts
COMPLEX SHUNTS INCLUDE :
TRUNCUS ARTERIOSUS TRANSPOSITION OF GREAT VESSELS 5%

Arterial switch procedure > 95% survival

TOTAL ANOMALOUS PV RETURN DOUBLE OUTLET RIGHT VENTRICLE HYPOPLASTIC LEFT HEART SYNDROME

Most common CHD presenting 1st week of life Most common cause of death in 1st month of life

Total Anomalous Pulmonary Venous Return

Total Anomalous Pulmonary Venous Return

Hupoplastic Left Heart Syndrome

Transposition of Great Vessels

Truncus Arteriosus

Double Outlet Right Ventricle

Fontan Procedure

Norwood Procedure

Jantene Procedure

Anesthetic Considerations
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

Anesthetic Considerations
COMPLEX SHUNTS : Short procedures :slow gradual induction with low dose Sevoflurane has least effect on +ve chronotropy & SVR Nitrous Oxide limits FiO2 & helps prevent coronary steal & sevoflurane requirements

D. Obstuctive Lesions
OBSTRUCTIVE LESIONS Either valvular stenosis or vascular bands perfusion & pressure overload of corresponding ventricle CHF common Right sided obstructions PBF hypoxemia and cyanosis Left sided obstructions systemic blood flow tissue hypoperfusion, metabolic acidosis and shock

Classification of CHD
OBSTRUCTIVE LESIONS INCLUDE : AORTIC STENOSIS MITRAL STENOSIS PULMONIC STENOSIS COARCTATION OF AORTA 8% of CHD 80% have bicuspid aortic valve COR TRIATRIATUM INTERRUPTED AORTIC ARCH

Coarctation of Aorta

Interuption of Aortic Arch

Cor Triatiatium

Anesthetic Considerations
OBSTRUCTIVE LESIONS Lesions with > 50 mmHg pressure gradient + CHF opioid technique Optimize preload improves flow beyond lesion Avoid tachycardia myocardial demand & flow beyond obstruction Inhalation agents -ve inotropy & decrease SVR worsens gradient & flow past obstruction

Classification of CHD

Classification of CHD

Postoperative Management
Children with CHD are very susceptible to: i. Deleterious effects of hypoventilation ii. Mild decreases in oxyhemoglobin saturation Therefore, give supplemental O2 and maintain patent airway In patients with single ventricle titrate SaO2 to 85%. Higher oxygen saturations can PVR PBF systemic blood flow

Postoperative Management
Avoid significant hypoventilation during this time because this may negatively affect pulmonary vascular tone and overall hemodynamics in vulnerable children. Analgesia is very important postoperatively Pain catecholamines which can affect vascular resistance and shunt direction Pain infundibular spasm in TOF RVOT obstruction cyanosis, hypoxia, syncope, seizures, acidosis and death Anticipate conduction disturbances in septal defects

Thank You!