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Duct Dependant Congenital Heart Disease –
Anaesthetic Principles
Communication is key – ensure Consultant Paediatrician, Anaesthetist and
PICU all involved.
Background
These babies depend on maintaining a patent ductus arteriosus to sustain
adequate systemic perfusion. They present at or shortly after birth as the duct
starts to close. Keys to management depend on supportive treatment, maintaining
duct patency and close early liaison with PICU/Cardiology. Some of the babies
with low oxygenation and/or persistent severe shock may need emergency atrial
septostomy and hence transfer to cardiovascular surgical centre is time critical.
Suspect if:
 Clinical presentation first few days of life
 May have been suggested on ante-natal US scanning
 Difficulty feeding secondary to breathlessness
 Cyanosis unresponsive to supplemental oxygen
 Weak or absent femoral pulses
 Hepatomegaly
 A murmur (but absence does not exclude diagnosis)
Airway & Breathing
May require intubation if
 Recurrent apnoeas
 Shock
 Respiratory failure
N.B. All induction agents will drop cardiac output to some extent therefore ensure
adequate IV acess and fluid boluses ready to give.
Post intubation ensure
Paralysed and ETT strapped securely
Aim to ventilate in air. (Oxygen acts to close the duct). Supplemental oxygen may be
required to keep SpO2 75-80%
CXR (Check ETT position and evidence of cardiac failure e.g. cardiomegaly
Monitor pre-ductal (right hand) and post-ductal (either foot) oxygen saturations.
Ver. 1. Nov 2014
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Circulation
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Ensure 2 x IV access (umbilical vein cannulation may be an option paediatricians may be able to help)
Treat hypotension with 10ml/kg of isotonic solution and evaluate response to
further fluid boluses.
If hypotension persists after 20 mls/kg of fluid bolus, start dopamine infusion
initially (can go peripherally) or adrenaline as 2nd line (ideally centrally or IO)
Commence dinoprostone infusion (PGE2) at 5-10ng/kg/min (see Cardiff drug
calculator) to maintain duct patency. Side effects include:
o Apnoeas (likely to require intubation)
o Hypotension
o Fever
N.B. Do not use Prostacyclin, Epoprostenol or Flolan – these are all pulmonary
vasodilators and DO NOT maintain ductal patency
Other
Check blood glucose regularly (due to risk of hypoglycaemia)
Ensure 12 lead ECG is performed
Start empirical antibiotics (Cefotaxime and Amoxicillin) after blood culture, as one of the
differential diagnosis for cyanosis and shock in newborns is sepsis with Persistent
Pulmonary Hypertension.
Ver. 1. Nov 2014