Anesthetic Challenges in the
OR: How I do it
Panel Discussion
•Nitya
•Apollo Delhi
•Kanagrajan
•Madras Medical Mission
•Jeril George Kurien
•H.N. Reliance Foundation Hospital,
Mumbai
•Shridhar Joshi
•Narayana Hirudalya, Bengaluru
•Shankar Kadam
•Kokilaben Dhirubhai Ambani
Hospital, Mumbai
•Chandan Kumar Mandal
•NH RTIICS, Kolkata
Sick Obstructed TAPVC
What are the challenges for anesthetic
induction
• Hemodynamic stability
• Expeditious control of airway
• Securing the lines in aseptic way
• Consolidating the gains made during induction
What extra logistics you like to have before
you wheel in the patient
• Expert working hands
• Armamentarium of inotropes with option of
mechanical support
• Expert fellow pediatric cardiac surgeon
Does the challenge ends at induction or it
continues?
• Understand the physiology of lesion
• Increase the inotropy
• Might need both inodilator & vasopressor
• Restricted fluid therapy with an eye on the heart
Will you like to have ECMO as standby?
• Depends upon the site of lesion
• Varies from institution to institution
• Limited role of pre operative ECMO
Perfusion practice/goals
• Regular intermittent cardioplegia/long acting
cardioplegia
• Target Hct
• Ultrafilteration
Nuts & Bolts of safe completion
• Cautious use of suction/cautery
• Putting the chest tubes while the patient is still on partial
CPB
• Keeping PFO open
• Delayed sternal closure
When do we label a patient severely
polycythaemic
Is it only hematological manifestations or a
myraid
• Hypoxic myocardium leading to cardiomyopathy
• Bleeding diathesis
• Renal dysfunction
• Altered liver profile
Will you go for exchange transfusion ? If yes,
how & when
Is it the children or adults who bother you
more?
Does NIRS help? Does it work?
Is there role of point of care testing in the
management
Antifibrinolytics /yellow products ?
Do the inotropes differ than routine
tetralogy?
What are the conditions included in spectrum
of LVOTO with LV dysfuntion
Are they more sick or less sick than
obstructed TAPVC
How the inotropes are different
Perfusion strategy & Myocardial protection ?
Any additional monitoring ?
Is there a role of vein finder
• Do they really help ?
• Preferred cannula size & site
• Do you take femoral as primary vein in distressful
conditions
When do you anticipate difficult airway
• What are your extra precautions/readiness
• What are your plans
• Difficult mask ventilation
• Difficult intubation
• Can’t intubate Can’t ventilate