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Anesthesia For Pediatric CARDIAC CATHETERIZATION Hala El-Mohamady, professor of Anaesthesia, Ain Shams University Introduction Cardiac catheterisation in man was first introduced as a diagnostic procedure in 1941. Since then, there has been a tremendous development in the field of cardiac catheterisation and interventional techniques. Techniques of anaesthesia have also changed with the changing requirements of the cardiologist as well as the interest in better patient care and safety. Role of the Anaesthesiologist Presence of anaesthesiologist may be necessary during the conduct of several catheterisation procedures for monitored anaesthetic care, sedation, analgesia, general anaesthesia and also for the resuscitation of patients if complications arise during the procedure Interventional procedures A. Angioplasty of the: 1. coarctation of the aorta 2. pulmonary vasculature B. Valvuloplasty: 1. Aortic valve 2. Pulmonic valve C. Coil embolization: 1. PDA 2. Aorto-pulmonary collaterals D. Balloon atrial septostomy and stents: E. Device closures: 1. ASD closure 2. VSD closure 3. PDA device closure F. Electrophysiologic procedures: Diagnostic and interventional procedures for patients with Hx of PSVT, SVT, atrial flutter, and WPW for mapping and ablation of the foci of arrhythmia. G. Biventricular pacer placements : General Anesthesia In Cath Lab ???? patients require GA include - uncooperative children - high risk patients such as hypoxaemic infants, infants with CHF and obstructed valvular lesion, and infants with cyanotic heart disease - Due to increasing invasive nature of the procedures, complications can arise in the cath. Lab., therefore anaesthesiologist’s presence may be desired as a stand-by in high risk patients Difficulties In Cath. Lab The anaesthesiologist who is more comfortable in the operation theatre often describes the environment of the cath. Lab. as “unknown”. Access to the patient is difficult due to fluoroscopy equipment all around the patient with dimmed light and movable tables. Anaesthesiologist must be assured easy access to the patient and in particular to the patient’s airway. The priorities of the anaesthesiologist, such as the need to maintain the airway and oxygenation as well as the equipments necessary to do so are not fully appreciated by the cardiologist. so interaction between the cardiologist and anaethesiologist is necessary. PREOPERATIVE EVALUATION 1-Complete diagnosis: all details of pt’s cardiac anatomy and physiology and the last ECHO report is mandatory 2. List of the procedures pt has undergone in the past (surgical and interventional) 3. Pt’s level of activity (weight gain, feeding tolerance, SOB, exercise tolerance, developmental delay) 4. Review with cardiologist anatomy of the case and review the ECHO films 5- Ask the cardiologist about reason for the catheterization and what he is planning to do? 5. Rule out recent URI After a recent URI patients are more likely to have reactive airway and develop peri-GA laryngospasm, bronchospasm, desaturate and increase their PVR during the procedure. 6. Medication list: last time medication was taken. (Lasix, Captopril and Digoxin is a common combination for pts in CHF.) When you speak to the patient or family the night before the procedure, please instruct them to take all antihypertensives and antiarrhythmics with sips of water but to hold all other medications the morning of the exam. Ask about allergies 7-Physical examination should emphasise on the airway, heart, and lung problems Patients should be examined for the signs of CHF such as pedal edema, jugular venous distention, enlarged liver and rales and for signs of respiratory distress such as increased respiratory rate, diaphoresis, chest retraction, nasal flaring, and use of accessory muscles of respiration Also Inquire regarding loose teeth 8- Special attention to the presence of other congenital lesions, as nearly 25% of patients with (CHD) may have other associated congenital abnormality including musculoskeletal abnormality neurological defects genitourinary irregularities One congenital lesion that needs particular attention is the atlanto-occipital subluxation that occurs in 20% of patients with Down’s syndrome. Patient with cyanotic CHD having a haemoglobin (Hb) level > 20 gm/dL or haematocrit >65% may have hyperviscosity, RBC sludging, and reduced oxygen delivery to tissues which may further exaggerate in dehydrated patients and after hypothermia during the procedure. Patients with polycythemia and cyanosis may also have thrombocytopenia, hypofibrinogenemia, and low levels of vitamin K dependent clotting factors. Therefore, coagulation tests such as prothrombin time (PT), partial thromboplastin time (PTT), partial thromboplastin time with kaolin (PTTK) should also be done. Serum electrolytes should be determined in patients receiving digoxin or diuretics. ECHO REPORT 1. How many chambers 2. Ventricular function 3. Presence of the flow obstruction (degree of obstruction or pressure gradient) and level of obstruction 4. Pressure gradient across the valves and intracardiac communications. 5. Coronary artery anatomy, if delineated 6. Presence and direction of the shunt 7. Rule out suprasystemic pressures in the chambers of the heart Monitoring - Standard monitoring includes ECG, noninvasive blood pressure, pulse oximetry, and temperature. - Arterial, atrial, and pulmonary pressures can be obtained during the procedure by the cardiologist. Endtidal carbon dioxide (EtCO2) for the patients decided to be mechanically ventilated. Anaesthetic technique There is no ideal anaesthetic technique that can be universally applied for all patients undergoing interventional and diagnostic procedures Sedation and analgesia to GA Considerations 1. Pt’s age and clinical condition 2. Access by cardiologist: neck vs. groin. 3. Length of the procedure. 4. Pts disease. (Such as hypoplastic heart or single ventricle.) 5. If procedure is diagnostic or interventional. 6. Remember that pt’s cardiopulmonary physiology has to be as close to the baseline (awake state) as possible in order to obtain real data from the procedure. 7. Note Qp/Qs ratio if available. You will not be successful in mask induction of GA for pts with with decreased pulmonary blood flow. 8. Evaluate pt’s cardiac function and remember that all inhalation anesthetics are myocardial depressants. During diagnostic procedure an ideal technique would be to maintain normal respiration on room air steady haemodynamics, normal blood gas values, immobility and to provide adequate analgesia and amnesia PROCEDURE CONCERNS 1. Vascular access by cardiologist: If neck approach is planned you will have better control of the airway using LMA or ETT. 2. FiO2 concerns: during procedure cardiologist will measure O2 saturations in the different chambers of the heart to evaluate degree of the shunt and calculate Qp/Qs ratio. If pt is sedated keep them on room air if tolerated, if not, inform cardiologist that you have to administer supplemental O2 and they will stop the measurements. Return the pt to room air as soon as tolerated, and inform cardiologist. If pt is intubated or has LMA in place keep FiO2 @ 25 % or below. 3. Specifics of the procedure: diagnostic vs. invasive. if invasive, there is always possibility of vessel rupture and uncontrolled bleeding. So have volume expanders available and blood typed, screened and crossmatched 4. If a neck approach is used: there is possibility of hemo and pneumothorax. If suspected these can be easily diagnosed via chest fluoroscopy 5. Ectopy: always possible with wires and catheters in the heart chambers. Development of the heart block is also a possibility. 6. Coil embolization of the PDA: more distal embolization of the pulmonary arteries is always a possibility 7. Balloon dilatation: rupture of the balloon is always a possibility. 8. Coronary angiogram: thrombosis or dissection of coronary arteries is always a possibility. Conclusion In CHOOSING YOUR ANESTHESTIC TECHNIQUE 1. Premedication highly recommended. 2. Routes of premedication include oral, rectal, IM, IV. Oral Versed 0.5 mg/Kg to 1 mg/Kg is a good choice. 3. Pt may be very sensitive to premedication and your presence @ pt’s bedside after premedication as well as pulse oxymeter monitoring is mandatory. 4. Consider adding Ketamine to your premedication to improve level of sedation w/o increased respiratory depression. 5. When considering inhalation induction, keep in mind that it requires adequate pulmonary blood flow. 6. Etomidate, Ketamine, Versed and Fentanyl are good choices for IV induction. 7. When administering narcotics for the induction and maintenance of the anesthesia remember that the majority of these cyanotic patients are going home in 6 hours after end of procedure. 8. Remember that Ketamine maintains cardiac function and spontaneous respiration and also is a good analgesic.