TY  - CHAP
M1  - Book, Section
TI  - Chapter 53. Anesthesia for Surgical Treatment of Congenital Heart Disease: A Problem-Oriented Approach
A1  - Harrington, James S.
A1  - Shukla, Avinash C.
A1  - Hickey, Paul R.
A2  - Longnecker, David E.
A2  - Brown, David L.
A2  - Newman, Mark F.
A2  - Zapol, Warren M.
Y1  - 2012
N1  - 
T2  - Anesthesiology, 2e
AB  - Congenital  heart  diseases  that  decrease  cardiopulmonary  reserve  include  intracardiac  shunting,  hypoxemia  from  inadequate  pulmonary  blood  flow  or  intracardiac  shunting,  congestive  failure  from  volume  or  pressure  overload,  vascular  obstructive  disease  from  excessive  pulmonary  blood  flow,  various  kinds  of  stenoses,  and  occasional  coronary  ischemia.Many  of  the  determinants  of  shunting  (its  magnitude  and  direction)  may  change  considerably  during  anesthesia  and  operative  manipulations.There  are  simple  shunts,  bidirectional  shunts,  and  occasionally  complex  shunts.  The  key  for  anesthesia  providers  is  to  understand  the  effects  of  vasodilators,  cardiac  depressants,  and  surgical  manipulation  on  these  various  shunts."Bubble  discipline"  is  an  important  concept  for  patients  with  congenital  heart  disease.Chronic  hypoxia  leads  to  polycythemia,  which  in  turn  leads  to  dramatic  increases  in  blood  viscosity.The  anesthesia  provider  should  understand  the  hemodynamic  consequences  of  pulmonary  vascular  hypertrophy,  the  end  stage  of  which  is  the  Eisenmenger  syndrome.Even  though  a  child  with  congenital  heart  disease  may  not  have  frank  failure,  cardiac  reserves  may  be  dramatically  decreased,  especially  if  episodes  of  prolonged  congestive  failure  have  been  a  part  of  the  patient's  history  and  have  resulted  in  cardiomegaly  or  ventricular  hypertrophy."Transitional  circulation"  keeps  neonates  with  severe  life-threatening  congenital  heart  disease  alive.  In  this  context,  therapy  with  prostaglandin  E1  infusion  should  be  understood,  especially  the  possibility  of  side  effects  such  as  apnea  and  major  vasodilatation.The  functional  capacities  of  the  immature  heart  should  be  of  particular  interest  to  anesthesia  providers.  The  immature  noncompliant  ventricle  is  extraordinarily  sensitive  to  increases  in  volume  and  is  considerably  restricted  in  its  ability  to  respond  to  the  same  by  increasing  stroke  volume.  The  Starling  curve  plateau  in  neonates  is  reached  at  left  ventricular  end-diastolic  pressures  of  4  mm  Hg.  Therefore,  cardiac  compliance  values  in  neonates  do  not  correspond  to  values  for  adult  patients.Adult  arterial  pressures,  especially  during  bypass,  do  not  apply  to  neonates  and  infants.The  procedures  for  weaning  from  bypass  and  using  deep  hypothermic  circulatory  arrest  or  low-flow  hypothermic  bypass  are  important  and  should  be  reviewed  in  detail.The  anesthesia  provider  should  fully  understand  the  hemodynamic  consequences  and  purpose  of  various  pulmonary  artery  banding  procedures  and  various  kinds  of  transcatheter  management  of  congenital  lesions.  Transcatheter  procedures  require  anesthetic  care  in  the  interventional  cardiac  catheterization  laboratory.Halothane  has  been  a  successful  induction  anesthetic  in  children  with  various  kinds  of  transcatheter  treatment  of  congenital  lesions.Intravenous  anesthetics,  including  high-dose  opioids  and  ketamine,  may  provide  increased  margins  of  safety  in  some  infants  with  congenital  heart  disease.Intramuscular  ketamine  3  to  5  mg/kg  is  reasonably  well  tolerated,  even  in  sick  children  with  cyanotic  congenital  heart  disease.Inhaled  nitric  oxide  is  a  clinically  useful  and  efficacious  selective  pulmonary  vasodilator  for  many,  but  not  all,  patients  with  congenital  heart  disease.  
SN  - 
PB  - The McGraw-Hill Companies
CY  - New York, NY
Y2  - 2024/04/19
UR  - accessanesthesiology.mhmedical.com/content.aspx?aid=56642008
ER  -