PEDIATRIC CARDIAC ANESTHESIA

INTRODUCTION (by Jamil Elmawieh)

Congenital heart dz divided into 4 categories:

shunts,
Lt to right shunt (3Ds) -> CHF, volume overload
Rt to Lt shunt -> cyanosis, pressure overload
mixing lesions (TGV,TAVR),
flow obstruction (CoA),
regurgitation valves (Ebstein)

Rt to Lt shunt
(TOF, TGV, TA..)

Lt to Rt shunt
(ASD, VSD, PDA)

IV induction
Increases rate of IV
induction (blood
bypasses lung and go
directly to brain)
Slows IV induction
(bcz IV agent is diluted)

Inhalational induction
Slows rate

It speeds inhalational
induction only if it
results in decreased
cardiac output

Increasing SVR:
Worsens Left to Right shunt
Ameliorates Right to Left sunt here OK for ketamine
In TOF: Ketamine is great.
Ductal patency is maintained by PGE1.

Clin Perinatol. 1988 Sep;15(3):681-97.

Closed heart surgery for congenital heart disease in infancy.

Closed heart surgery in congenital heart disease can be palliative or corrective. Palliative surgery
aims at improving the physiologic deficit rather than the anatomic defect of the heart. Palliative
procedures aim to increase pulmonary blood flow in cyanotic children with decreased pulmonary
blood flow (Blalock-Taussig shunt), decrease pulmonary blood flow when there is unrestricted flow
(pulmonary artery banding), or improve venous mixing in cyanotic children that require pulmonary
and systemic venous mixing for survival (atrial septectomy). The indications for palliation over
corrective surgery have changed over time. Now we reserve palliation for children that require low
pulmonary vascular resistance for correction, a conduit that will require replacement as the child
grows, or where the risk of the corrective procedure decreases rapidly with age.
For palliation with systemic to pulmonary artery shunts, we prefer to perform a Blalock-Taussig
subclavian to pulmonary artery shunt using a synthetic (PTFE) tube graft in infants. The operative
mortality is higher in infants under 1 month of age but is not affected by weight or diagnosis.
Palliative surgery to decrease pulmonary blood flow is restricted primarily to infants with large left-toright shunts where the risk of correction in infancy is high (multiple VSDs) or not feasible
(univentricular heart). The operative risk for pulmonary artery banding is affected mostly by the
complexity of the cardiac defect and the clinical state of the infant (severe congestive failure) at the
time of surgery. A trial septectomy to improve venous mixing is used mostly in infants with
univentricular heart in whom a balloon septostomy was ineffective.

Section 4: Subspecialty Management

Chapter 50: Anesthesia for Pediatric Cardiac Surgery
ANESTHESIA FOR CLOSED HEART OPERATIONS
Palliative - target:
To increase PBF shunt: Blalock Taussig (extracardiac)
To decrease PBF PA banding, PDA ligation
To increase mixing atrial septostomy
Early corrective repair in infancy has significantly reduced the number of
noncorrective, palliative closed heart operations.
Corrective closed heart procedures include PDA ligation and repair of coarctation
of the aorta.
Noncorrective closed heart operations include pulmonary artery banding
and extracardiac shunts such as the Blalock-Taussig shunt. These

procedures are performed without cardiopulmonary bypass. Therefore, venous

access and intra-arterial monitoring are important in evaluating and supporting
these patients. A pulse oximeter remains an invaluable monitor during
intraoperative management.
Ligation of PDA is typically performed through a left thoracotomy, although videoassisted thoracoscopic techniques are increasingly common. Physiologic
management is that of a left-to-right shunt producing volume overload. Patients
with a large PDA and low PVR generally present with excessive pulmonary blood
flow and congestive heart failure. Neonates and premature infants also run the
risk of having substantial diastolic runoff to the pulmonary artery, potentially
impairing coronary perfusion. Thus patients range from an asymptomatic healthy
young child to the sick ventilator-dependent premature infant on inotropic support.
The former patient allows for a wide variety of anesthetic techniques culminating
in extubation in the operating room. The latter patient requires a carefully
controlled anesthetic and fluid management plan. Generally a trial of medical
management with indomethacin and fluid restriction is attempted in the premature
infant prior to surgical correction. In the premature infant, transport to the
operating room can be especially difficult and potentially hazardous, requiring
great vigilance to avoid extubation, excessive patient cooling, or venous access
disruption. For these reasons, many centers are now performing ligation in the
neonatal ICU. Intraoperatively, retractors may interfere with cardiac filling and
ventilatory management so that hypotension, hypoxemia, and hypercarbia occur.
Complications include inadvertent ligation of the left pulmonary artery or
descending aorta, recurrent laryngeal nerve damage, and excessive bleeding due
to inadvertent PDA disruption. After ductal ligation in premature infants, worsening
pulmonary compliance can precipitate a need for increased ventilatory support,
and manifestations of an acute increase in LV afterload should be anticipated,
especially if LV dysfunction has developed preoperatively. More recently, PDA
ligation has been performed in infants and children using thoracoscopic surgical
techniques. This approach has the advantage of limited incisions at thoracoscopic
sites, promoting less postoperative pain and discharge from the hospital the same
day of surgery.
Coarctation of the aorta is a narrowing of the descending aorta near the insertion
of the ductus arteriosus. Obstruction to aortic flow is the result and this may range
from severe obstruction with compromised distal systemic perfusion to mild upper
extremity hypertension as the only manifestation. Associated anomalies of both
the mitral and aortic valves can occur. In the neonate with severe coarctation,
systemic perfusion is dependent on right-to-left shunting across the PDA. In these
circumstances, LV dysfunction is very common and prostaglandin E1 is necessary
to preserve sufficient systemic perfusion. Generally, a peripheral intravenous line
and an indwelling arterial catheter, preferably in the right arm, are recommended
for intraoperative and postoperative management. In patients with LV dysfunction,

a central venous catheter may be desirable for pressure monitoring and inotropic
support. The surgical approach is through a left thoracotomy, whereby the aorta is
cross-clamped and the coarctation repaired with an onlay prosthetic patch, a
subclavian artery flap, or resection of the coarctation with an end-to-end
anastomosis. During cross-clamp, we usually allow significant proximal
hypertension (2025% increase over baseline), based on evidence that
vasodilator therapy may jeopardize distal perfusion and promote spinal cord
ischemia. 253 Intravascular volume loading with 10 to 20 mL/kg of crystalloid is
given just before removal of the clamp. The anesthetic concentration is
decreased, and additional blood volume support is given until the blood pressure
rises. Post-repair rebound hypertension due to heightened baroreceptor reactivity
is common and often requires medical therapy. After cross-clamp, aortic wall
stress due to systemic hypertension is most effectively lowered by institution of
beta blockade with esmolol or alpha/beta-blockade with labetalol. 254 Propranolol
is useful in older patients but can cause severe bradycardia in infants and young
children. Although it actually increases calculated aortic wall stress in the absence
of beta blockade by accelerating dP/dT, the addition of sodium nitroprusside may
become necessary to control refractory hypertension. Captopril or an alternative
antihypertensive regimen is begun in the convalescent stage of recovery in those
patients with persistent hypertension.
The management of infants undergoing placement of extracardiac shunts without
cardiopulmonary bypass centers around goals similar to those of other shunt
lesions: balancing pulmonary and systemic blood flow by altering PaCO2, PaO2,
and ventilatory dynamics. Central shunts are usually performed through a median
sternotomy, while Blalock-Taussig shunts may be performed through a
thoracotomy or sternotomy. In patients in whom pulmonary blood flow is critically
low, partial cross-clamping of the pulmonary artery required for the distal
anastomosis causes further reduction of pulmonary blood flow and desaturation,
necessitating meticulous monitoring of pulse oximetry. Careful application of the
cross-clamp to avoid pulmonary artery distortion will help maintain pulmonary
blood flow. Under circumstances in which severe desaturation and bradycardia
occur with cross-clamping, CPB will be required for the procedure. Intraoperative
complications include bleeding and severe systemic oxygen desaturation during
chest closure, usually indicating a change in the relationship of the intrathoracic
contents that results in distortion of the pulmonary arteries or kink in the shunt.
Pulmonary edema may develop in the early postoperative period in response to
the acute volume overload that accompanies the creation of a large surgical
shunt. Measures directed at increasing PVR, such as lowering inspired O2 to
room air, allowing the PaCO2 to rise, and adding positive end-expiratory pressure
are helpful maneuvers to decrease pulmonary blood flow until the pulmonary
circulation can adjust. Decongestive therapy such as diuretics and digoxin may
alleviate the manifestations of congestive heart failure. Under such
circumstances, early extubation is inadvisable.

Pulmonary artery banding is used to restrict pulmonary blood flow in infants

whose defects are deemed uncorrectable for either anatomic or physiologic
reasons. These patients are generally in congestive heart failure with reduced
systemic perfusion and excessive pulmonary blood flow. The surgeon places a
restrictive band around the main pulmonary artery to reduce pulmonary blood
flow. Band placement is very imprecise and requires careful assistance from the
anesthesia team to accomplish successfully. Many approaches have been
suggested. We place the patient on 21 percent inspired oxygen concentration and
maintain the PaCO2 at 40 mm Hg, to simulate the postoperative state. Depending
on the malformation, a pulmonary artery band is tightened to achieve
hemodynamic (e.g., distal pulmonary artery pressure 5025% systemic pressure)
or physiologic (e.g., Qp:Qs approaching 1) goals. Should the attainment of these
objectives produce unacceptable hypoxemia, the band is loosened.
Blalock-Hanlon atrial septectomy is now an uncommon procedure for enlarging an
intra-atrial connection. This procedure is done by occluding caval flow and
creating an intra-atrial communication through the atrial septum. In patients with
hypoplastic left heart syndrome with an intact atrial septum, this procedure is lifesaving and must be performed within hours of birth. Balloon atrial septostomies
(Rashkind procedure) and blade septectomies performed in the cardiac
catheterization laboratory have replaced surgical intervention, except when left
atrial size is very small or the atrial septum is thickened. Improved safety of CPB
has led to the virtual elimination of such intracardiac procedures using inflow
occlusion. Surgical septectomies, because they are currently confined to the most
difficult subset, are rarely performed without benefit of CPB.

One more word: Blalock Taussig..

Blalock-Taussig Shunt (BTS)

Aris Sophocles,
Mark Twite

Risk

Indicated for infants with congenital heart lesions resulting in either severely reduced
pulm blood flow (PBF) (e.g., tetralogy of Fallot, pulm and tricuspid atresia) or as the
first stage of single ventricle palliation (e.g., hypoplastic left heart syndrome [HLHS])

Perioperative Risks

Fewer BT shunts are performed now compared to previous decades and operative
mortality has fallen despite a higher percentage of pts with single ventricle
physiology

Periop complications incl Horner's syndrome, chylothorax, phrenic nerve damage

and acute arm ischemia with classic BTS.

Worry About

BTS for decreased PBF keep PVR as low as possible (high FIO2, avoid hypercarbia
and acidosis)

BTS for single ventricle staged palliation essential to balance SVR and PVR (often
requires FIO2 0.17 - 0.21 and normocarbia)

Overview

One of multiple types of systemic to pulm shunts to increased PBF

Familiarity with underlying anatomy and physiology is essential to

Preoperative Preparation

Pts often already intubated, consider placing a nasal ETT for infants under 12 mo
(tube more stable and makes placement of TEE probe easier)

Arterial line: For cardiac lesions with PBF place A-line in contralateral radial artery
from BTS or in the femoral artery. For single ventricle lesions place an A-line in right
radial artery if low flow cerebral perfusion technique to be used for Stage 1 Norwood
and/or in the umbilical or femoral artery.

Central venous line: All cases for inotropes. Consider co-oximetry central venous
catheter.

Intraoperative Period

May use inhalation induction. Single ventricle pts often have IV access.

Infants with tetralogy of Fallot may have tet spells due to worsening RVOT
obstruction.

Lateral thoracotomy classic approach: Anticipate worsened hypoxia with PA

clamping, blood product transfusion usually not required

Sternotomy and CPB for complex and single