Anesthesia In Children With

Congenital Heart Disease For

Non-cardiac Surgery

Regarding investigations of CHD patients for non-Regarding investigations of CHD patients for non-cardiac surgery:cardiac surgery: A- Chest X – Ray has no rule A- Chest X – Ray has no rule B- Cardiac Catheterization is the first choice for diagnosis of B- Cardiac Catheterization is the first choice for diagnosis of CHD CHD C- Echocardiography non invasive method for diagnosis of C- Echocardiography non invasive method for diagnosis of CHD CHD D- MRI has no rule D- MRI has no rule

IM Premedication for CHD patients presenting for non-IM Premedication for CHD patients presenting for non-cardiac suergery:cardiac suergery: A- Cooperative child who able to take orally A- Cooperative child who able to take orally B- Ketamine 1mg/kg B- Ketamine 1mg/kg C- Midazolam 5 mg/kg C- Midazolam 5 mg/kg D -Glycopyrrolate or Atropine 0.02 mg/kg D -Glycopyrrolate or Atropine 0.02 mg/kg

Procedural antibiotic prophylaxis is required in patients Procedural antibiotic prophylaxis is required in patients withwith A- Aortic valve replacement A- Aortic valve replacement B- Mitral valve prolapse with regurge B- Mitral valve prolapse with regurge C- Previous history of infective endocarditis C- Previous history of infective endocarditis D- Ostium secundum ASD D- Ostium secundum ASD

AHA guideline for antibiotic prophylaxis for genitourinary AHA guideline for antibiotic prophylaxis for genitourinary procedures:procedures:A- High risk adult patient: Ampicillin 1 g & gentamicin 1.5mg/kg i.m or A- High risk adult patient: Ampicillin 1 g & gentamicin 1.5mg/kg i.m or i.v i.v B- High risk Child patient: Ampicillin 5 mg/kg &gentamicin 1.5 mg/kg B- High risk Child patient: Ampicillin 5 mg/kg &gentamicin 1.5 mg/kg i.m or i.v i.m or i.v C- Moderate risk child allergic to penicillin: Vancomycin 20 mg/kg i.v C- Moderate risk child allergic to penicillin: Vancomycin 20 mg/kg i.v bolusbolusD- High risk Adults allergic to penicillin: Vancomycin 1g/kg i.v over 1-D- High risk Adults allergic to penicillin: Vancomycin 1g/kg i.v over 1-2 hr2 hr

Regarding using Succinylcholine in pediatric patients with Regarding using Succinylcholine in pediatric patients with CHD:CHD:A- Succinylcholine in pediatric is routine A- Succinylcholine in pediatric is routine B- If used should be with atropine, to avoid tachycardia or sinus B- If used should be with atropine, to avoid tachycardia or sinus arrest arrest C- If used with potent narcotic atropine should be used to avoid sever C- If used with potent narcotic atropine should be used to avoid sever

bradycardia in childern with Decreased cardiac reservebradycardia in childern with Decreased cardiac reserve

Postoperative Anesthetic Management of CHD patients:Postoperative Anesthetic Management of CHD patients:A- No need for supplemental O2 and maintain patent airwayA- No need for supplemental O2 and maintain patent airwayB- Pain decrease catech. which can affect VR and shunt direction B- Pain decrease catech. which can affect VR and shunt direction C- Pain C- Pain infundibular spasm in TOF infundibular spasm in TOF RVOT obstruction RVOT obstruction cyanosis, cyanosis, hypoxia, syncope, seizures, acidosis and death hypoxia, syncope, seizures, acidosis and death D- No conduction disturbances in septal defectsD- No conduction disturbances in septal defects

INTRODUCTIONINTRODUCTION

Due to advances in diagnosis, medical, Due to advances in diagnosis, medical, critical and surgical care for CHDcritical and surgical care for CHD

Therefore, it is common for patients with Therefore, it is common for patients with CHD to present for non-cardiac surgery, CHD to present for non-cardiac surgery, and even in patient with corrected CHD and even in patient with corrected CHD significant residual problems significant residual problems (arrhythmias, ventricular dysfunction, (arrhythmias, ventricular dysfunction, shunts, valvular stenosis, and PH) may be shunts, valvular stenosis, and PH) may be exist.exist.

CLASSIFICATION OF CHDCLASSIFICATION OF CHDI- Acyanotic congenital heart disease:I- Acyanotic congenital heart disease: 1- ASD 1- ASD 2- VSD 2- VSD 3- PDA 3- PDA

II- Cyanotic congenital heart disease:II- Cyanotic congenital heart disease: 1- Tetralogy of Fallot, with severe right 1- Tetralogy of Fallot, with severe right ventricular outflow obstruction ventricular outflow obstruction 2- TGA 2- TGA 3- Pulmonary atresia or severe stenosis 3- Pulmonary atresia or severe stenosis 4- Tricuspid atresia with pulmonary stenosis 4- Tricuspid atresia with pulmonary stenosis 5- Truncus Arteriosus 5- Truncus Arteriosus

ANESTHETIC ANESTHETIC MANAGEMENTMANAGEMENT

Perioperative management requires a Perioperative management requires a team approachteam approach

CHD is polymorphic and may clinically CHD is polymorphic and may clinically manifest across a broad clinical spectrummanifest across a broad clinical spectrum

The plane of Anesthetic Management The plane of Anesthetic Management includes the following:includes the following:

A - Preoperative ManagementA - Preoperative Management B - Intraoperative ManagementB - Intraoperative Management C - Postoperative ManagementC - Postoperative Management

Preoperative Anesthetic Management:Preoperative Anesthetic Management:

A- History A- History B- physical examinationB- physical examinationC- InvestigationsC- InvestigationsD- PremedicationsD- PremedicationsE- Fasting Guidelines E- Fasting Guidelines

HISTORY & PHYSICAL HISTORY & PHYSICAL EXAMINATIONEXAMINATION

Assess functional Assess functional statusstatus

- daily activities- daily activities - exercise tolerance- exercise tolerance

↓↓ cardiac reservecardiac reserve - cyanosis- cyanosis - respiratory distress during - respiratory distress during

feedingfeeding

CyanosisCyanosis DyspneaDyspnea Fainting attackFainting attack FatigueFatigue PalpitationsPalpitations chest painchest pain Syncope Syncope Abdominal fullnessAbdominal fullness Leg swellingLeg swelling MedicationsMedications

Vital signsVital signs Airway abnormalityAirway abnormality Associated extracardiac Associated extracardiac

congenital anomaliescongenital anomalies Tachypnea, dyspnea, cyanosisTachypnea, dyspnea, cyanosis Squatting Squatting Clubbing of digitsClubbing of digits Heart murmur (s)Heart murmur (s) CHF:CHF:

- Jugular venous distention.- Jugular venous distention.

- Hepatomegally- Hepatomegally

- Ascitis- Ascitis

- Peripheral edema- Peripheral edema

INVESTIGATIONINVESTIGATIONSS

MRI

Laboratory Evaluation

Cardiac Catheterization

12 Lead ECG

Echocardiography

chest X – Ray

PremedicationPremedication Oral Premedication:Oral Premedication: - Midazolam 0.25 -1.0 mg/kg - Midazolam 0.25 -1.0 mg/kg

- - Ketamine 2 - 4 mg/kgKetamine 2 - 4 mg/kg - - Atropine 0.02 mg/kgAtropine 0.02 mg/kg

IV Premedication:IV Premedication: - Midazolam 0.02 - 0.05 mg/kg titrated in small increments- Midazolam 0.02 - 0.05 mg/kg titrated in small increments - Ketamine 1-2 mg/kg- Ketamine 1-2 mg/kg IM PremedicationIM Premedication:: - Uncooperative or unable to take orally- Uncooperative or unable to take orally

- - Ketamine 5 – 10 mg/kgKetamine 5 – 10 mg/kg - - Midazolam 0.2 mg/kgMidazolam 0.2 mg/kg

- - Glycopyrrolate or Atropine 0.02 mg/kgGlycopyrrolate or Atropine 0.02 mg/kg

Fasting GuidelinesFasting Guidelines

AHA guidelines for bacterial endocarditis Prophylaxis in AHA guidelines for bacterial endocarditis Prophylaxis in

patients with cardiac conditionspatients with cardiac conditions Endocarditis prophylaxis recommendedEndocarditis prophylaxis recommendedEndocarditis prophylaxis not recommendedEndocarditis prophylaxis not recommended

High-risk categoryHigh-risk category

- -Complex cyanotic congenital heart diseaseComplex cyanotic congenital heart disease: :

Transposition of the great vesselsTransposition of the great vessels

Tetralogy of FallotTetralogy of Fallot

- -Surgically created systemic-to-pulmonary Surgically created systemic-to-pulmonary shuntsor conduits shuntsor conduits

- -Prosthetic, Bioprosthetic, Homograft valvesProsthetic, Bioprosthetic, Homograft valves

- -Previous bacterial endocarditisPrevious bacterial endocarditis

Moderate-risk categoryModerate-risk category

- -Other congenital cardiac anomaliesOther congenital cardiac anomalies

- -Acquired valvular dysfunctionAcquired valvular dysfunction

- -Hypertrophic cardiomyopathiesHypertrophic cardiomyopathies

RegurgRegurg--- Mitral valve prolapse with valvar- Mitral valve prolapse with valvar

Negligible-risk categoryNegligible-risk category

- -Physiologic, or functional heart murmursPhysiologic, or functional heart murmurs

- -Surgical repair without residua beyondSurgical repair without residua beyond

66 months : ASD, PDA,VSDmonths : ASD, PDA,VSD

- -Cardiac pacemaker orCardiac pacemaker or

- -implanted defibrillatorimplanted defibrillator

- -Isolated secundum atrial septal defectIsolated secundum atrial septal defect

- -Mitral valve prolapse without regMitral valve prolapse without reg . .

- -Previous coronary artery bypass surgeryPrevious coronary artery bypass surgery

- -Previous rheumatic heart disease Previous rheumatic heart disease without valvular dysfunctionwithout valvular dysfunction

AHA guidelines for antibiotic prophylaxis: dental, oral, AHA guidelines for antibiotic prophylaxis: dental, oral, Respiratory tract and esophageal proceduresRespiratory tract and esophageal procedures

Standard prophylaxisStandard prophylaxis Amoxicillin 1 h before procedureAmoxicillin 1 h before procedure

--Children: 50 mg/kg p.oChildren: 50 mg/kg p.o . .

Adults: 2.0 g p.oAdults: 2.0 g p.o-.-.

Unable to take oral Unable to take oral medicationsmedications

Ampicillin within 30 min before Ampicillin within 30 min before procedureprocedure

- - Children: 50 mg/ kg i.m. or i.vChildren: 50 mg/ kg i.m. or i.v..

Adults: 2.0 g i.m. or i.vAdults: 2.0 g i.m. or i.v..- -

Allergic to penicillinAllergic to penicillin Clindamycin 1 h before procedureClindamycin 1 h before procedure

Children: 20 mg/kg p.oChildren: 20 mg/kg p.o..

Adults: 600 mg p.oAdults: 600 mg p.o..

OROR Azithromycin or clarithromycin 1 Azithromycin or clarithromycin 1 h before procedureh before procedure

--Children: 15 mg/kg p.oChildren: 15 mg/kg p.o..

Adults: 500 mg p.oAdults: 500 mg p.o.. - -

Unable to take oral Unable to take oral medicationsmedications

AND allergic to penicillinAND allergic to penicillin

Clindamycin within 30 min before Clindamycin within 30 min before procedurprocedur

--Children: 20 mg/ kg i.vChildren: 20 mg/ kg i.v

--Adult: 600 mg i.vAdult: 600 mg i.v.... - -

AHA guidelines for antibiotic prophylaxis: genitourinary AHA guidelines for antibiotic prophylaxis: genitourinary and gastrointestinal proceduresand gastrointestinal procedures

High risk patientsHigh risk patients - -within 30 min before procedurewithin 30 min before procedure

- - Children: Ampicillin 50 mg/ kg .and Children: Ampicillin 50 mg/ kg .and gentaicin 1.5 gentaicin 1.5 mg/kg i.m or i.vmg/kg i.m or i.v

- -Adults: Ampicillin 2.0 g and gentamicin 1.5 Adults: Ampicillin 2.0 g and gentamicin 1.5 mg/kg i.m or i.vmg/kg i.m or i.v

High risk patients High risk patients Allergic to penicillinAllergic to penicillin

- -Complete infusion 30 min before procedureComplete infusion 30 min before procedure

- -Children: Vancomycin 20 mg/kg i.v over 1-Children: Vancomycin 20 mg/kg i.v over 1-2 hr2 hr

gentamicin 1.5 mg/kg i.m or i.vgentamicin 1.5 mg/kg i.m or i.v

--Adults: Vancomycin 1g/kg i.v over 1-2 hrAdults: Vancomycin 1g/kg i.v over 1-2 hr

gentamicin 1.5 mg/kg i.m or i.vgentamicin 1.5 mg/kg i.m or i.v

Moderate risk patientsModerate risk patients Ampicillin within 30 min before procedureAmpicillin within 30 min before procedure--

- - Children: 50 mg/ kg i.m. or .ivChildren: 50 mg/ kg i.m. or .iv

- -Adults: 2.0 g i.m or i.vAdults: 2.0 g i.m or i.v

Moderate risk patients Moderate risk patients AND allergic to AND allergic to penicillinpenicillin

Complete infusion 30 min before procedureComplete infusion 30 min before procedure--

- -Children: Vancomycin 20 mg/kg i.v over 1-Children: Vancomycin 20 mg/kg i.v over 1-2 hr2 hr

--Adults: Vancomycin 1g/kg i.v over 1-2 hrAdults: Vancomycin 1g/kg i.v over 1-2 hr

Preoperative Anesthetic ConsiderationsPreoperative Anesthetic Considerations

1- Complete history and physical examin.1- Complete history and physical examin.

2- Review all investigations2- Review all investigations

3- Hydration should be maintained 3- Hydration should be maintained

4- All cardiac medication except possibly digitalis 4- All cardiac medication except possibly digitalis shouldshould

be continued until surgery be continued until surgery

5- Premedication should be give particularly to 5- Premedication should be give particularly to patients patients

at risk for right to left shunt at risk for right to left shunt

6- Antibiotic prophylaxis against endocarditis must be 6- Antibiotic prophylaxis against endocarditis must be

given given

Anesthetic Anesthetic ManagementManagement

A - Preoperative Management A - Preoperative Management

B - Intraoperative Management :B - Intraoperative Management :

1- Monitoring1- Monitoring

2- Choice of anesthetic agent2- Choice of anesthetic agent

3- Maintenance of anesthesia3- Maintenance of anesthesia

4- Emergence from anesthesia4- Emergence from anesthesia

MonitoringMonitoring

Non-invasive Invasive

-Clinical observation -ECG -NIBP

-Pulse oximetry on two different limbs

-Precordial stethoscope

-Continuous airway manometry

-Multiple site temperatur

measurement

-Volumetric urine collection

-Art. catheterization - CVP - PAC - TEE

Choice of anesthetic Choice of anesthetic RegimenRegimen

● ● Development of anesthetic Development of anesthetic regimen is based on various regimen is based on various factors such as presence and factors such as presence and direction of shunts , HF,direction of shunts , HF, arrhythmia , pulmonary arrhythmia , pulmonary circulation, and lowering or circulation, and lowering or maintenance of PVR maintenance of PVR

Choice of Anesthetic AgentChoice of Anesthetic Agent

Intravenous

anesthetics

Volatile anesthetic

s

Muscle relaxants

• Barbiturates : Not recommended in patients with severe cardiac reserve

• Ketamine : No change in PVR in children when airway maintained & ventilation supported

Sympathomimetic effects help maintain HR, SVR, MAP and contractility Greater hemodynamic stability in hypovolemic patients

Copious secretions (laryngospasm) • Etomidate : Induction dose of 0.3mg/kg no change in mean pulmonary artery pressure

and PVR

• Propofol : decrease in SBP and SVR, and increase in SBF in all patients, whereas HR ,PAP, PBF remained unchanged

• OPIOD: Excellent induction agents in very sick childrenNo cardiodepressant effects if bradycardia avoided Fentanyl 15-25 µg/kg IV , Sufentanil 5-20 µg/kg IV

-Halothane PBF not affecting PVR, Depresses myocardial function, alters sinus node

function, sensitizes myocardium to catecholamines , MAP , HR , CI , EF

• Desflurane Pungent , PAP and PVR, Less myocardial depression than Halothane HR , SVR •Isoflurane Pungent, PAP not affecting PVR, Less myocardial depression than Halothane, Vasodilatation leads to SVR → MAP , HR which can lead to CI

• Sevoflurane Less myocardial depression than Halothane, more in PAP compared with isoflurane, No HR, Mild SVR, Can produce diastolic dysfunction

• Nitrous oxide At 50% concentration does not affect PVR and PAP in childrenAvoid in children with limited pulmonary blood flow, PHT or myocardial function

Neuromuscular Blocking Neuromuscular Blocking DrugsDrugs

Depolarizing

Nondepolarizing

- Succinylcholine in pediatric is controversial

-If used should be with atropine, to avoid associated brady-

cardia or sinus arrest

-also if used with potent narcotic atropine should be used to avoid sever bradycardia in

children with CR

-Atracuruim and vecronium: have few cardiovascular side effects in children when given in recommended doses.

-Pancuronuim if given slowly doesn't produce HR or BP changes. if given as bolus doses it can produce tachycardia , ↑BP (through sympathomimetic effect )

-Cisatracuruim and Rocuroinuim: safe

REGIONALREGIONAL ANESTHESIA ANESTHESIA &ANALGESIA&ANALGESIA

• Considerations :

- Coarctation of aorta considerations

-Childern with chronic cyanosis risk of coagulation abnormality

-VD : which can : 1 -be hazardous in patients with significant

AS or left-sided obstructive lesions 2 -Cause oxyhemoglobin saturation in

R-L shunts

Anesthetic Anesthetic ManagementManagement

A - Preoperative Management A - Preoperative Management

B - Intraoperative Management B - Intraoperative Management

C - C - Postoperative ManagementPostoperative Management

Postoperative Anesthetic Postoperative Anesthetic ManagementManagement Supplemental OSupplemental O22 and maintain patent airway. and maintain patent airway. In patients with single ventricle titrate SaOIn patients with single ventricle titrate SaO22 to to

85%. Higher oxygen sat. can 85%. Higher oxygen sat. can PVR PVR PBF PBF SBFSBF

Pain Pain catech. which can affect VR and shunt catech. which can affect VR and shunt direction direction

Pain Pain infundibular spasm in TOF infundibular spasm in TOF RVOT RVOT obstructionobstruction cyanosis, hypoxia, syncope, cyanosis, hypoxia, syncope, seizures, acidosisseizures, acidosis and deathand death

Anticipate conduction disturbances in septal Anticipate conduction disturbances in septal defectsdefects

Familiarity with the CHD pathophysiology, Familiarity with the CHD pathophysiology, adequate preoperative preparation, choice of adequate preoperative preparation, choice of monitors, induction, maintenance , emergence monitors, induction, maintenance , emergence from anesthesia, and plans for the from anesthesia, and plans for the postoperative period to avoid major problems in postoperative period to avoid major problems in anesthetic managementanesthetic management

A wide variety of anesthetic regimens is used A wide variety of anesthetic regimens is used for patients with congenital heart disease (CHD) for patients with congenital heart disease (CHD) undergoing cardiac or non-cardiac surgery, or undergoing cardiac or non-cardiac surgery, or other diagnostic or therapeutic procures. The other diagnostic or therapeutic procures. The goal of all of these regimens is to produce goal of all of these regimens is to produce anesthesia or adequate sedation, while anesthesia or adequate sedation, while preserving systemic cardiac output and oxygen preserving systemic cardiac output and oxygen delivery delivery

SUMMARYSUMMARY

Regarding investigations of CHD patients for non-Regarding investigations of CHD patients for non-cardiac surgery:cardiac surgery: A- Chest X – Ray has no rule A- Chest X – Ray has no rule B- Cardiac Catheterization is the first choice for diagnosis of B- Cardiac Catheterization is the first choice for diagnosis of CHD CHD C- Echocardiography non invasive method for diagnosis of C- Echocardiography non invasive method for diagnosis of CHD CHD D- MRI cannot give us idea about pulmonary veins D- MRI cannot give us idea about pulmonary veins

IM Premedication for CHD patients presenting for non-IM Premedication for CHD patients presenting for non-cardiac suergery:cardiac suergery: A- Cooperative or unable to take orally A- Cooperative or unable to take orally B- Ketamine 1mg/kg B- Ketamine 1mg/kg C- Midazolam 5 mg/kg C- Midazolam 5 mg/kg D -Glycopyrrolate or Atropine 0.02 mg/kg D -Glycopyrrolate or Atropine 0.02 mg/kg

Procedural antibiotic prophylaxis is required in patients Procedural antibiotic prophylaxis is required in patients withwith A- Aortic valve replacement A- Aortic valve replacement B- Mitral valve prolapse with regurge B- Mitral valve prolapse with regurge C- Previous history of infective endocarditis C- Previous history of infective endocarditis D- Ostium secundum ASD D- Ostium secundum ASD

AHA guideline for antibiotic prophylaxis for genitourinary AHA guideline for antibiotic prophylaxis for genitourinary procedures:procedures:A- High risk adult patient: Ampicillin 1 g & gentamicin 1.5mg/kg i.m or A- High risk adult patient: Ampicillin 1 g & gentamicin 1.5mg/kg i.m or i.v i.v B- High risk Child patient: Ampicillin 5 mg/kg &gentamicin 1.5 mg/kg B- High risk Child patient: Ampicillin 5 mg/kg &gentamicin 1.5 mg/kg i.m or i.v i.m or i.v C- Moderate risk child allergic to penicillin: Vancomycin 20 mg/kg i.v C- Moderate risk child allergic to penicillin: Vancomycin 20 mg/kg i.v bolusbolusD- High risk Adults allergic to penicillin: Vancomycin 1g/kg i.v over 1-D- High risk Adults allergic to penicillin: Vancomycin 1g/kg i.v over 1-2 hr2 hr

Regarding using Succinylcholine in pediatric patients with Regarding using Succinylcholine in pediatric patients with CHD:CHD:A- Succinylcholine in pediatric is routine A- Succinylcholine in pediatric is routine B- If used should be with atropine, to avoid tachycardia or sinus B- If used should be with atropine, to avoid tachycardia or sinus arrest arrest C- If used with potent narcotic atropine should be used to avoid sever C- If used with potent narcotic atropine should be used to avoid sever

Decreased cardiac reserveDecreased cardiac reserve bradycardia in children withbradycardia in children with

Postoperative Anesthetic Management of CHD patients:Postoperative Anesthetic Management of CHD patients:A- No need for supplemental O2 and maintain patent airwayA- No need for supplemental O2 and maintain patent airwayB- Pain decrease catech. which can affect VR and shunt direction B- Pain decrease catech. which can affect VR and shunt direction C- Pain C- Pain infundibular spasm in TOF infundibular spasm in TOF RVOT obstruction RVOT obstruction cyanosis, cyanosis, hypoxia, syncope, seizures, acidosis and death hypoxia, syncope, seizures, acidosis and death D- No conduction disturbances in septal defectsD- No conduction disturbances in septal defects