بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم

2. Anesthesia In Children With Congenital Heart Disease For Non-cardiac Surgery

3. Regarding investigations of CHD patients for non-cardiac surgery: A- Chest X – Ray has no rule B- Cardiac Catheterization is the first choice for diagnosis of CHD C- Echocardiography non invasive method for diagnosis of CHD D- MRI has no ruleIM Premedication for CHD patients presenting for non-cardiac suergery: A- Cooperative child who able to take orally B- Ketamine 1mg/kg C- Midazolam 5 mg/kg D -Glycopyrrolate or Atropine 0.02 mg/kgProcedural antibiotic prophylaxis is required in patients with A- Aortic valve replacement B- Mitral valve prolapse with regurge C- Previous history of infective endocarditis D- Ostium secundum ASD

4. AHA guideline for antibiotic prophylaxis for genitourinary procedures:A- High risk adult patient: Ampicillin 1 g & gentamicin 1.5mg/kg i.m or i.v B- High risk Child patient: Ampicillin 5 mg/kg &gentamicin 1.5 mg/kg i.m or i.v C- Moderate risk child allergic to penicillin: Vancomycin 20 mg/kg i.v bolusD- High risk Adults allergic to penicillin: Vancomycin 1g/kg i.v over 1-2 hrRegarding using Succinylcholine in pediatric patients with CHD:A- Succinylcholine in pediatric is routine B- If used should be with atropine, to avoid tachycardia or sinus arrest C- If used with potent narcotic atropine should be used to avoid sever bradycardia in childern with Decreased cardiac reserve Postoperative Anesthetic Management of CHD patients:A- No need for supplemental O2 and maintain patent airwayB- Pain decrease catech. which can affect VR and shunt direction C- Pain  infundibular spasm in TOF  RVOT obstruction cyanosis, hypoxia, syncope, seizures, acidosis and death D- No conduction disturbances in septal defects

5. INTRODUCTION

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

7. CLASSIFICATION OF CHDI- Acyanotic congenital heart disease: 1- ASD 2- VSD 3- PDAII- Cyanotic congenital heart disease: 1- Tetralogy of Fallot, with severe right ventricular outflow obstruction 2- TGA 3- Pulmonary atresia or severe stenosis 4- Tricuspid atresia with pulmonary stenosis 5- Truncus Arteriosus

8. ANESTHETIC MANAGEMENT

9. Perioperative management requires a team approach • CHD is polymorphic and may clinically manifest across a broad clinical spectrum • The plane of Anesthetic Management includes the following: A - Preoperative Management B - Intraoperative Management C - Postoperative Management

10. Preoperative Anesthetic Management:A- History B- physical examinationC- InvestigationsD- PremedicationsE- Fasting Guidelines

11. HISTORY & PHYSICAL EXAMINATION • Vital signs • Airway abnormality • Associated extracardiac congenital anomalies • Tachypnea, dyspnea, cyanosis • Squatting • Clubbing of digits • Heart murmur (s) • CHF: - Jugular venous distention. - Hepatomegally - Ascitis - Peripheral edema • Assess functional status - daily activities - exercise tolerance • ↓ cardiac reserve - cyanosis - respiratory distress during feeding • Cyanosis • Dyspnea • Fainting attack • Fatigue • Palpitations • chest pain • Syncope • Abdominal fullness • Leg swelling • Medications

12. MRI Laboratory Evaluation 12 Lead ECG INVESTIGATIONS chest X – Ray Echocardiography Cardiac Catheterization

13. Premedication • Oral Premedication: - Midazolam 0.25 -1.0 mg/kg - Ketamine 2 - 4 mg/kg - Atropine 0.02 mg/kg • IV Premedication: - Midazolam 0.02 - 0.05 mg/kg titrated in small increments - Ketamine 1-2 mg/kg • IM Premedication: - Uncooperative or unable to take orally - Ketamine 5 – 10 mg/kg - Midazolam 0.2 mg/kg - Glycopyrrolate or Atropine 0.02 mg/kg Fasting Guidelines

14. AHA guidelines for bacterial endocarditis Prophylaxis in patients with cardiac conditions

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

16. AHA guidelines for antibiotic prophylaxis: genitourinary and gastrointestinal procedures

17. Preoperative Anesthetic Considerations 1- Complete history and physical examin. 2- Review all investigations 3- Hydration should be maintained 4- All cardiac medication except possibly digitalis should be continued until surgery 5- Premedication should be give particularly to patients at risk for right to left shunt 6- Antibiotic prophylaxis against endocarditis must be given

18. Anesthetic Management A - Preoperative Management B - Intraoperative Management : 1- Monitoring 2- Choice of anesthetic agent 3- Maintenance of anesthesia 4- Emergence from anesthesia

19. Monitoring 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

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

21. Choice of Anesthetic Agent Intravenous anesthetics Volatile anesthetics 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 children • No 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 children • Avoid in children with limited pulmonary blood flow, PHT or  myocardial function

22. Neuromuscular Blocking Drugs Nondepolarizing Depolarizing -Succinylcholine in pediatric is controversial - If used should be with atropine, to avoid associated brady- cardia or sinusarrest - 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

23. REGIONALANESTHESIA &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

24. Anesthetic Management A - Preoperative Management B - Intraoperative Management C - Postoperative Management

25. Postoperative Anesthetic Management • Supplemental O2 and maintain patent airway. • In patients with single ventricle titrate SaO2 to 85%. Higher oxygen sat. can  PVR  PBF   SBF  Pain  catech. which can affect VR and shunt direction  Pain  infundibular spasm in TOF  RVOT obstruction cyanosis, hypoxia, syncope, seizures, acidosisand death  Anticipate conduction disturbances in septal defects

26. SUMMARY • Familiarity with the CHD pathophysiology, adequate preoperative preparation, choice of monitors, induction, maintenance , emergence from anesthesia, and plans for the postoperative period to avoid major problems in anesthetic management • A wide variety of anesthetic regimens is used for patients with congenital heart disease (CHD) undergoing cardiac or non-cardiac surgery, or other diagnostic or therapeutic procures. The goal of all of these regimens is to produce anesthesia or adequate sedation, while preserving systemic cardiac output and oxygen delivery

27. Regarding investigations of CHD patients for non-cardiac surgery: A- Chest X – Ray has no rule B- Cardiac Catheterization is the first choice for diagnosis of CHD C- Echocardiography non invasive method for diagnosis of CHD D- MRI cannot give us idea about pulmonary veinsIM Premedication for CHD patients presenting for non-cardiac suergery: A- Cooperative or unable to take orally B- Ketamine 1mg/kg C- Midazolam 5 mg/kg D -Glycopyrrolate or Atropine 0.02 mg/kgProcedural antibiotic prophylaxis is required in patients with A- Aortic valve replacement B- Mitral valve prolapse with regurge C- Previous history of infective endocarditis D- Ostium secundum ASD

28. AHA guideline for antibiotic prophylaxis for genitourinary procedures:A- High risk adult patient: Ampicillin 1 g & gentamicin 1.5mg/kg i.m or i.v B- High risk Child patient: Ampicillin 5 mg/kg &gentamicin 1.5 mg/kg i.m or i.v C- Moderate risk child allergic to penicillin: Vancomycin 20 mg/kg i.v bolusD- High risk Adults allergic to penicillin: Vancomycin 1g/kg i.v over 1-2 hrRegarding using Succinylcholine in pediatric patients with CHD:A- Succinylcholine in pediatric is routine B- If used should be with atropine, to avoid tachycardia or sinus arrest C- If used with potent narcotic atropine should be used to avoid sever Decreased cardiac reservebradycardia in children with Postoperative Anesthetic Management of CHD patients:A- No need for supplemental O2 and maintain patent airwayB- Pain decrease catech. which can affect VR and shunt direction C- Pain  infundibular spasm in TOF  RVOT obstruction cyanosis, hypoxia, syncope, seizures, acidosis and death D- No conduction disturbances in septal defects

29. Thank You