Skip to Main Content




A 3-year-old, 13-kg male with a history of an atrial septal defect (ASD) presents for surgical repair with cardiopulmonary bypass (CPB). The patient is asymptomatic and is otherwise healthy.


Physical exam: II/VI systolic murmur, fixed split second heart sound


ECG: Right axis deviation, prolonged PR interval


Echocardiogram: Large ostium secundum ASD




An ASD is a common congenital cardiac lesion that requires surgical repair with CPB if it is large. CPB is managed differently in children from the way it is managed in adults because of their different physiology, and it can have different physiologic consequences. The patient’s age and the specific lesion, as well as the planned surgical repair, dictate many of the principles of CPB management in children. Some notable differences include:


  1. Priming solution: Whole blood or packed red blood cells (PRBCs), fresh frozen plasma, and heparin for neonates and infants; PRBCs, crystalloid, albumin, and heparin for children 10-15 kg; crystalloid and heparin for children >15 kg.

  2. Priming volume: May exceed the blood volume of neonates and infants by 100-200%; more marked effects of hemodilution (eg, decreased hematocrit, reduction in drug levels, coagulopathy).

  3. Pump flow rates: Wide variation in pediatric patients, from 100-200 mL/kg/min (higher metabolic rate and oxygen demand) to 25-50 mL/kg/min (deep hypothermia).

  4. Perfusion pressure: 20-50 mm Hg in infants and young children versus 50-80 mm Hg in adults.

  5. Temperature: Frequent use of deep hypothermic circulatory arrest in pediatric patients (15-20 degrees).

  6. Glucose: Can have hyperglycemia on CPB from addition of blood products to priming solution, and/or from pre-CPB IV steroid administration; hypoglycemia may also be seen in neonates and infants.

  7. Cannulation: Increased likelihood of venous obstruction from venous cannula insertion; aortic cannulation complicated by frequent presence of aortopulmonary collaterals, patent ductus arteriosus, and aortic arch abnormalities.


Although surgical repair of an uncomplicated ASD tends to be uneventful and amenable to extubation in the operating room (OR), preoperative discussion with the parents should include the possibility of invasive line placement (and associated complications), postoperative intubation, transfusion of exogenous blood products, neurologic injury, dysrhythmias, need for postoperative pressors and/or pacing, and even death. Premedication with oral midazolam is warranted in anxious children. Lines can be placed after inhalational induction of general anesthesia (GA).




  • Oral midazolam premedication as needed for anxiety, with or without parental presence in the OR. GA usually is induced via inhalation induction.

  • Tailor anesthetic for possible extubation in the OR.

  • Arterial line for assessment of blood pressure (BP) on CPB (nonpulsatile flow) and for measurement of activated clotting time (ACT), arterial blood gases (ABGs), hematocrit, and electrolytes. The arterial line generally is placed after induction of GA.

  • Either a central venous pressure (CVP) line placed percutaneously (internal jugular [IJ], subclavian, or femoral), or ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.


About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.