Presentation on theme: "Postoperative Care in the Patient With Congenital Heart Disease UTHSCSA Pediatric Resident Curriculum for the PICU."— Presentation transcript:
Postoperative Care in the Patient With Congenital Heart Disease UTHSCSA Pediatric Resident Curriculum for the PICU
General Principles Patient homeostasis Early – declining trends do not correct themselves Early – declining trends do not correct themselves Late – time can be important diagnostic tool Late – time can be important diagnostic tool “The enemy of good is better”
Specific Approaches Cardiovascular principles Approach to respiratory management Pain control/sedation Metabolic/electrolytes Infection Effects of surgical interventions on these parameters NO PARAMETER EXISTS IN ISOLATION
Cardiovascular Principles Maximize O 2 delivery/ O 2 consumption ratio Oxygen delivery: Oxygen delivery: Cardiac Output Cardiac Output Ventilation/Oxygenation Ventilation/Oxygenation Hemoglobin Hemoglobin
Maximizing Oxygen Delivery Metabolic acidosis is the hallmark of poor oxygen delivery
O 2 Content = Saturation(O 2 Capacity)+(PaO 2 )0.003 Oxygen Capacity = Hgb (10) (1.34) So.. Hemoglobin and saturations are determinants of O 2 delivery Hemoglobin and saturations are determinants of O 2 delivery Maximizing Oxygen Delivery Cardiac Output
Gidding SS et al 1988 y=-0.26(x)+38R=0.77S.E.E.=1.6 Maximizing Oxygen Delivery Cardiac Output
Stroke Volume Contractility Contractility Diastolic Filling Diastolic Filling Afterload Afterload Heart rate Physiologic Response Non-physiologic Response Sinus vs. junctional vs. paced ventricular rhythmCardiacOutputStrokeVolume HeartRate = X
Pain Control/Sedation Opioids MSO4 – Gold standard: better sedative effects than synthetic opioids Cardioactive – histamine release and limits endogenous catecholamines Cardioactive – histamine release and limits endogenous catecholamines Fentanyl/sufentanyl Less histamine release Less histamine release More lipid soluble – better CNS penetration More lipid soluble – better CNS penetration
Pain Control/Sedation Sedatives Chloral hydrate Can be myocardial depressant Can be myocardial depressant Metabolites include trichloroethanol and trichloroacetic acid Metabolites include trichloroethanol and trichloroacetic acid Benzodiazepines Valium/Versed/Ativan Valium/Versed/Ativan
Circulatory Arrest Hypothermic protection of brain and other tissues Access to surgical repair not accessible by CPB alone Further activation of SIRS/ worsened capillary leak.
Fluid and Electrolyte Principles Crystalloid Total body fluid overload Total body fluid overload Maintenance fluid = 1500-1700 cc/m 2 /day Maintenance fluid = 1500-1700 cc/m 2 /day Fluid advancement: POD 0 : 50-75% of maintenance POD 0 : 50-75% of maintenance POD 1 : 75% of maintenance POD 1 : 75% of maintenance Increase by 10% each day thereafter Increase by 10% each day thereafter
Fluid and Electrolyte Principles Flushes and Cardiotonic Drips Remember: Flushes and Antibiotics = Volume Remember: Flushes and Antibiotics = Volume UTHSCSA protocol to minimize crystalloid: Standard Drip Concentration Mix in dextrose or saline containing fluid to optimize serum glucose & electrolytes Sedation: (Used currently as carrier for drips) MSO4 2cc/hr = 0.1 mg/kg/hr Fentanyl 2 cc/hr = 3 mcg(micrograms)/kg/hr Cardiotonic medications: Dopamine/Dobutamine50 mg/50 cc Epi/Norepinephrine0.5 mg/50 cc Milrinone5 mg/50 cc Nipride (Nitroprusside)0.5 mg/50 cc Nitroglycerin50 mg/50 cc PGEI500 mcg/50 cc
Fluid and Electrolyte Principles Intravascular volume expansion/ Fluid challenges Colloid – osmotically active Colloid – osmotically active FFP FFP 5% albumin/25% albumin 5% albumin/25% albumin PRBC’s PRBC’s HCT adequate: 5% albumin (HR, LAP, CVP) HCT adequate: 5% albumin (HR, LAP, CVP) HCT inadequate: 5-10 cc/kg PRBC HCT inadequate: 5-10 cc/kg PRBC Coagulopathic: FFP/ Cryoprecipitate Coagulopathic: FFP/ Cryoprecipitate Ongoing losses: CT and Peritoneal frequently = 5% albumin Ongoing losses: CT and Peritoneal frequently = 5% albumin
Metabolic Effects Glucose Neonates vs. children/adults Neonates vs. children/adults Hyperglycemia in the early post-op period Hyperglycemia in the early post-op period
Metabolic Effects Calcium Myocardial requirements Myocardial requirements Rhythm Rhythm Contractility Contractility Vascular resistance Vascular resistance NEVER UNDERESTIMATE THE POWER OF CALCIUM!
Calcium/inotropes Sarcoplasmic Reticulum cAMP-Dependent PK Ca Phosphodiesterase AdenylateCyclase Regulatory G Protein Na Alpha 1 Beta 1 DAG IP3 Na K SR
Effects of Surgical Interventions Cardiopulmonary Bypass vs. Non-Bypass Fluids and electrolytes Fluids and electrolytes Modified ultrafiltration Types of anatomic defects Overcirculated – increased blood volumes preoperatively Overcirculated – increased blood volumes preoperatively Undercirculated – reperfusion of area previously experiencing much reduced flow volumes. Undercirculated – reperfusion of area previously experiencing much reduced flow volumes.
Summary Optimize oxygen delivery by manipulation of cardiac output and hemoglobin Sedation and pain control can aid in the recovery Appreciate effects of cardiopulmonary bypass and circulatory arrest on fluid and electrolyte management Tight control of all parameters within the first 12 hours; after that time, patients may be better able to declare trends that can guide your interventions.