Anesthesia For
Congenital
Cardiothoracic surgery
without cardio
pulmonary bypass
By Mohamed Abd el Moneim Fouly
Resident of Anesthesiology
Ain Shams university Hospitals
Under supervision of
Prof. Dr. Samia Sharaf
Professor of Anesthesiology &
intensive care
Ain Shams University
What are the surgical procedures ?
Systemic pulmonary Arterial shunts.
Systemic pulmonary venous shunts.
Coarctation of the aorta.
PDA ligation
General principles in Anesthetic
management.
Preoperative Assessment : Should be
complete with special attention to history
taking & the developmental milestones of
the patients , both motor & cognitive
status, With a full lab work up, CXR & and
echocardiography.
N.B. Coronary angiography is not
mandatory but may be needed in some
cases
Intra operative management
Monitoring : basic for all cases with some
modifications in some cases.
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Pulse Oximetry.
12 Lead ECG ( we use only 5)
Invasive arterial blood pressure monitoring ,
also used for frequent ABGs Sampling.
Trans esophageal echo is also used as a
monitor to cardiac functions.
Swan Ganz catheter may be used.
Induction of Anesthesia
In halational induction with Sevoflurane has
always been the best choice , others as
Halothane are less favored due to dramatic
effect on the haemodynamics.
I.V. induction in cases with available venous
access is also good with less effect on
haemodynamics using either ketamine & or
Fentanyl in critically ill patients with little effect
on haemodynamics so it is suitable for preterm
infants & those with heart failure.
Induction of Anesthesia
I.M. Induction with ketamine 5 mg/kg is of
choice but may precipitate a cyanotic spell
in infants with Fallot tetralogy.
Systemic pulmonary Arterial shunts
Indications: Palliative surgery for TOF.
Aim: Increasing pulmonary blood flow.
Types:
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Central shunt: artificial tube graft between the aorta &
the pulmonary artery.
Blalock Tausssig shunt: anastmosis of the right or left
subclavian arteries to the ipsilateral PA.
MBT shunt: artificial tube graft between the right or
the left PA & their adjacent Subclavian artery.
MBT SHUNT
Most of the patients are critically ill due to
decreased pulmonary blood flow.
Anesthetic management:
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Preoperative: Mechanical ventilation to improve
oxygenation & PGE2 infusion to prevent closure of
the DA may be of help.
Monitoring : basic with care for radial artery
cannulation in the side opposite to that of shunt
placement as this might lead to steal pressure giving
false low readings.
MBT SHUNT
Central venous cannulation.
Femoral artery cannulation with care for
lower limb ischemia.
Induction:
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I.V. Ketamine 1mg/kg+ Fentanyl + MR .
Inhalational with SEVO is the best.
I.M. ketamine 5mg/kg for unstable patients is
the last choice.
MBT SHUNT
Intra operative management
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The myocardial depressant effect of the
volatile agents is also useful in limiting the
infundibular spasm.
Care to maintain SVR in order to limit Right to
left shunt through the VSD so SEVO is the
best
Low SVR is treated with phenyl ephrine or nor
epinephrine & preload augmentation with fluid
boluses.
MBT SHUNT
Intra operative management
All inotropes will worsen the infundibular
spasm by increasing HR & contractility.
Classically it is placed through
thoracotomy
Median sternotomy is done if:
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Patient can't tolerate lung retraction or side
clamping of the pulmonary artery.
Possibility of CPB or central shunts.
MBT SHUNT
Intra operative management
Low dose heparin 100 IU/Kg prior to shunt
placement.
Lung retraction may severely impair
oxygenation & ventilation so intermittent
reinflation may be required.
Also side clamping of the PA may lead to
the same which is managed by fluid ,
vasopressors & ventilation adjustment.
MBT SHUNT
Intra operative management
Attempting to normalize PCO2 during one
lung ventilation may lead to over inflation
of the dependant lung & thus increasing
PVR & impairing venous return.
For central shunts partial clamping of the
ascending aorta may be required but it
may be poorly tolerated in this case
inotropic support with dopamine may be
helpful.
MBT SHUNT
Intra operative management
Once the shunt is opened O2 saturation
markedly improves however blood
pressure may drop which may be treated
with vasopressors & volume infusion.
Decrease in Diastolic BP may lead to
decrease in coronary blood flow which in
turn may lead to ischemic ECG changes.
MBT SHUNT
Intra operative management
Ventilation & inspired O2 is adjusted to mimic
spontaneous non anesthetized patients for
accurate assessment of shunt flow.
O2 saturation of 80% is optimum indicating
balanced pulmonary & systemic blood flow.
High O2 saturation indicates pulmonary over
circulation & the shunt size may have to be
reduced & Vice versa.
MBT SHUNT
Intra operative management
In cases of persistence of hypoxemia after
apparently uneventful shunt placement it is
important to rule out endobronchial
intubation because failure to do so may
lead to unnecessary shunt revision or
even sternotomy.
MBT SHUNT
Post operative management
Ventilation for 12 – 24 hours.
Checking the patency of the shunt by
auscultating a continuous murmur on the
endotracheal tube.
Low dose heparin at 8 – 10 U/Kg/min to
maintain patency of the shunt after
diminishing the risk of postoperative
bleeding.
MBT SHUNT
Complications
Increased PBF may lead to pulmonary
edema & hemorrhage.
Injury to phrenic or recurrent Laryngeal
nerve.
Injury of sympathetic chain.
Chylothorax or shunt thrombosis.
Systemic pulmonary Venous
shunts
Glenn shunt
Indications: TO bypass the right side of the
heart as in pulmonary or tricuspid atresia.
Aim: Increasing pulmonary blood flow.
Procedure: surgical anastmosis between
SVC & Right pulmonary artery.
It may be a 1st stage of a 2 stage
management ( the second is called Fontan
operation).
Glenn Shunt
It may be of two types either (side to end)
or ( side to side) the later is called a
bidirectional Glenn.
GLENN SHUNT
Intra operative management
Monitoring : as usual
Induction : inhalational induction in these
patients is less convenient due to
decreased pulmonary blood flow.
Vascular access:
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A single lumen IJV central venous catheter
which is not used for infusions.
GLENN SHUNT
Intra operative management
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All wide bore I.V. access should be placed in
the lower half of the body.
Central venous catheter is inserted in the
femoral vein which is used for transfusion &
infusion of drugs.
Arterial cannulation either radial or femoral.
GLENN SHUNT
Intra operative management
Inotropic support might be needed ;
adrenaline, dobutamine, or phenylephrine
Also vasodilators might be needed as
nitroglycerine or nitroprusside.
GLENN SHUNT
Intra operative management
Immediately after the shunt is opened use the
IJV catheter to measure the Pulmonary blood
pressure.
In some cases excessive shunting may lead to
pulmonary edema.
In other cases symptoms & signs of systemic
venous congestion e.g. edema & puffiness of the
face & the eye lids & edema of the upper ½ of
the body.
GLENN SHUNT
Intra operative management
In case of the need to infuse large volume
use the wide bore I.V access in the lower
½ of the body as any infusion in the upper
½ will be a direct infusion in the pulmonary
circulation & may lead to pulmonary
edema.
GLENN SHUNT
Post operative management
Post operative ventilation for 24 – 48
hours for fear of pulmonary edema.
Pulmonary vasodilator is mandatory oral ,
sublingual or I.V sildenafil is a very potent
pulmonary vasodilator.
Coarctation of the aorta
Characterized by narrowing of the aortic
lumen opposite to the ductus arteriosus &
just distal tot the opening of the left
subclavian artery.
8 % of all cardiac patients may have
associated coarctation.
Incidence Male : Female = 3:1
Coarctation of the aorta
If not treated early collaterals will develop.
Types of surgical interventions:
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Subclavian flap aortoplasty
Resection anastmosis either end to end or
end to side.
Tube graft interpositioning.
Coarctation of the aorta
Preoperative management
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Inotropic support & diuretics
If the age is less than 1 month I.V
prostaglandins to prevent closure of the
ductus arteriosus..
Elective intubation & ventilation to decrease
work of breathing & decrease left ventricular
demand.
Coarctation of the aorta
Preoperative management
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Correction of metabolic acidosis to improve
left ventricular function.
Right sided arterial cannulation in to a
preductal artery is mandatory.
Intraoperative management:
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Intra arterial catheter to ensure monitoring of
the blood pressure during phases of the
operation when the left subclavian artery or
the aorta is clamped or compressed.
Coarctation of the aorta
Intraoperative management
Cool the child to 35 C to avoid spinal cord
ischemia.
I.V. or inhalational induction.
Avoid hypertension due to exaggerated
response to inotropes.
Application of cross clamp may lead to
upper body hypertension.
Coarctation of the aorta
Intraoperative management
Blood flow to the lower ½ of the body & the
spinal cord is highly dependant on collaterals
that can vary depending on the systolic pressure
generated by the myocardium.
It is possible that the failing ventricle may be
unable to mount appropriate arterial blood
pressure in which case dopamine or other
inotropic agent is administered.
Coarctation of the aorta
Postoperative management
Early post operative complication is
hypertension for 2 weeks which is
explained by secondary stimulation of the
sympathetic system distal to anastmotic
site, if it was untreated it may lead to
mesenteric arteritis. So it must be treated
with vasodilators , calcium channel
blockers & or B- blockers.
Patent Ductus Arteriosus
Standard monitoring with pulse oximetry of
the four limbs to detect incidental ligation
of the descending aorta.
Large venous access.
Forced air warming devices.
High spinal & epidural has always been
safe
Patent Ductus Arteriosus
In neonates I.V. anesthetics are better &
more stable on the hemodynamics, than
inhalational anesthetics e.g. fentanyl &
benzodiazepines with muscle relaxants.
Lung isolation may improve surgical
exposure but may require ventilation with
100 % O2 to maintain adequate
oxygenation.
Patent Ductus Arteriosus
Prior to lung isolation , efforts should be
made to limit left to right shunt by
maintaining or improving pulmonary
vascular tone : minimize FiO2 & maintain
PaCO2 between 40 – 50 mmHg.
Avoid air bubbles in the I.V. lines to
decrease the risk of paradoxical air
embolism.
Patent Ductus Arteriosus
Critically ill patients may require high
doses of narcotics to minimize stress
response to surgery.
Lung isolation is needed for VAS to allow
adequate exposure.
Thank
You