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PRESENTER :- BIKASH RAY MODERATOR :- DR.VIMI REWARI

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Presentation on theme: "PRESENTER :- BIKASH RAY MODERATOR :- DR.VIMI REWARI"— Presentation transcript:

1 PRESENTER :- BIKASH RAY MODERATOR :- DR.VIMI REWARI

2  Shubu 7 yr, male D.O.A – Res. - Karnal, Haryana History by - mother

3 C/O  Swelling noted by the parents in Lt groin since last 1 yr

4 H/o present illness  Swelling in lt groin,observed by parents -1yr not associated with pain,or tenderness H/o recurrent respiratory infection since 1 st yr of life, last episode x 4 months –  cough  Respiratory distress.  Rapid respiration.  Rise in temperature (mild).  Duration of symptom – few days to a week.  Relieved by medication.  No h/o bluish discoloration during crying.

5  No h/o  Swelling of body & face.  ↓ urine output.  Yellowish discolouration.  Abd. distension.  No h/o decreased /absent movement of extremities.

6 H/o past illness  Patient had h/o recurrent RTI in past frequency gradually decreasing  No history of any other significant medical or surgical illness  No h/o failure to thrive

7 Family history not significant Birth & developmental history  Antenatal – no maternal illness no drug/alcohol intake  Natal – Full Term, vaginal delivery neonatal period uneventful  Development – normal motor and personal social development

8  Immunization history Adequately immunised for age  Feeding & dietary history Vegetarian Normal solid and liquid intake  Treatment history Patient not taking any medication

9 General examination  Wt = 20 kg  Ht = 96 cm  A febrile  Conscious, active, cooperative  No pallor,cyanosis,jaundice,edema, clubbing  No lymphadenopathy  Neck veins- not engorged

10  Pulse – 98/min, regular,good volume, no radio-radial or radio-femoral delay  All peripheral pulse palpable  BP = 100/58 mmHg ( lt arm, supine position )  Peripheral venous access = adequate

11 Systemic examination  Cardiovascular system :-  Inspection – Precordium normal on inspection No visible apical impulse No visible pulsation No scar mark visible

12 Cont.  Palpation :- Apex Palpable at (L) 5 th ICS, at mid-clavicular line No thrill palpable Parasternal heave not palpable  Auscultation :- S1 & S2 audible Pan-systolic murmur at apex & LLSB

13 Cont. Respiratory system : -  No chest wall deformity on inspection  Respiratory rate 20/min, regular, accessory muscles not working  Auscultation: B/L air entry equal No added sounds

14 Cont. Central nervous system  Higher functions – normal  Cranial nerves, cerebellum, motor and sensory examination – within normal limits  Abdomen :-  no distension or venous engorgement  swelling in Lt groin, soft, non-tender, cough impulse positive  no organomegaly

15 Cont. Airway assessment  Mouth opening > 4 cm  Neck movement adequate  MMP class I  No facial deformity noted  Teeth –intact Spine examination  No abnormality detected

16 Provisional diagnosis  Acyanotic congenital heart disease with L-R shunt, probably ventricular septal defect, not in failure, with Lt inguinal hernia

17 Differential diagnosis  ASD – age (older) PAH ( absent) murmur (ejection systolic)  PDA – murmur (cont. machinary)

18 Investigations  Hb – 10.3  Tlc  Plt – 3.56  Bu -24  Na / k = 133 / 4.3  CXR- normal heart size  ECG – WNL  ECHO – - small 3 mm VSD - L-R shunt - no ASD,PDA,COA - normal ventricular function

19 Diagnosis  Small asymptomatic VSD for herniotomy (Lt ) not in failure

20 PAC orders  Adequate NPO  Inform written consent of parents  Ampicilin 50 mg / kg,iv,30 minutes before surgery

21 Anesthetic plan  General anesthesia with neuraxial block  Induction :- pre o2 -- propofol + fentanyl laryngeal mask airway  Maintenance : O2+ N2O+ ISOFLURANE Controlled ventilation  Post induction :- Lt lateral position caudal epidural with PAP

22 INTRA-OPERATIVE CONCERNS  Air embolism  Shunt reversal  Pulmonary hypertension  Volume overload - LVF

23 BUBBLE AVOIDANCE  Remove all bubbles from IV tubing.  Connect IV tubing to venous cannula while there is free flow of IVF and blood.  Eject small amount of solution from syringe to clear air from hub to needle before injection.  Aspirate injection port of 3-way before injection  Hold syringe upright - bubbles at plunger end.  Do not inject last ml from the syringe.  Do not leave central line open to air.

24 To prevent worsening of shunt  SVR to be kept below normal  PVR to be kept normal or above - Minimal FiO2 - Adequate tidal volume - Low RR, PEEP - PaCO mmHg - Temperature - Epidural

25 FACTORS AFFECTING PVR  ↑ PVR  Sympathetic stimulation– pain, light anesthesia  ↓pH, ↑PaCO2, ↓ PaO2  Hypothermia  ↑ intrathoracic pressure-- Controlled vent, PEEP,atelectasis  ↓PVR  Anesthesia  ↑ pH, ↓PaCO2, ↑ PaO2  ↓intrathoracic pressure--- SV, normal lung volumes  Drugs PDE inhibitors Isoproterenol PGE1,PGI2,NO

26 Indications of IE prophylaxis

27 Post-op  Sedation  Analgesia  Decongestive treatment  Pulmonary vasodilators  monitoring

28

29 Prevalence Congenital Incidence of CHD :8 / 1000 live birth  Cyanotic: 22%  Acyanotic: 68% VSD25% ASD6% PDA6% PS5% AS5%

30 VSD

31  Most common CHD  2.6 to 5.7 /1000 live birth  10 % of adult CHD  TYPES :- 1. Subpulmonary (5-7 % )- with AV insufficiency 2. Perimembranous (80 %)-with tricuspid valve abnormality 3. A-V canal (5-8%) 4. Muscular (5 -20 % )- multiple defect  Restrictive, non- restrictive  Small, medium, large (in relation to aortic root )

32 ANATOMY

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34 Severity of VSD :– - loud P2, parasternal lift/heave - duration of murmur - diastolic murmur at mitral area - features of CCF

35 Syndrome associated with VSD  Extra cardiac malformation in % - Trisomy 21,18,13 - CHARGE syndrome - Fetal hydantion syndrome - Fetal alcohol syndrome - Fetal valproate syndrome - Apert syndrome

36 Features of VSD based on size ShuntGradient ↑ ↑ PVR RVPRVHLVHMurmur SmallL – RHigh--NNoYesPSM MediumL-R20mm Hg± ↑ Mild ↑MildYesPSM LargeL-R R-L None+↑Yes Decreased Large with PVR R-LNone+YesNoNone

37 Severity of VSD :– - loud P2, parasternal lift/heave - duration of murmur - diastolic murmur at mitral area - features of CCF

38 NATURAL HISTORY  Spontaneous closure of defects less than 5mm before 5 yrs of age (40-50%).  Natural course depends on – size, change in PVR, age  Large defects – CHF in infancy (2-6 wks), when PVR falls  Tachypnea, Distress, Sweating while feeding, Failure to thrive  CHF- apathetic, no movement, weak cry, diaphoretic, hepatomegaly  Indications for surgical closure- >6.5 mm, Qp:Qs ratio >2

39 Severity of VSD :– - loud P2, parasternal lift/heave - duration of murmur - diastolic murmur at mitral area - features of CCF

40 LARGE L- R SHUNT ↑ PVR ↑ LA SIZE ↑ LA PRESSURE INTERSTITIAL AND ALVEOLAR EDEMA ↑ PA FLOW ↑ PA PRESSURE ENLARGEMENT OF VESSELS BRONCHIAL HYPERTROPHY AIRWAY OBSTRUCTION ↑ AIRWAY RESISTANCE ↓ PULMONARY COMPLIANCE INCREASED WORK OF BREATHING GAS TRAPPING, ATELECTASIS, INFECTION

41 Severity of VSD :– - loud P2, parasternal lift/heave - duration of murmur - diastolic murmur at mitral area - features of CCF

42 Cardiac Grid Preload HR HRContractilityPVRSVR VSD (L → R) unrepaired ↑NN↑↓ VSD (L → R) repaired ↑NNNN VSD (R → L) ↑NN↓↑

43 Severity of VSD :– - loud P2, parasternal lift/heave - duration of murmur - diastolic murmur at mitral area - features of CCF

44

45  Sobha  23 yr, female, primigravida  D.o.A  Haryna

46 Presented with  36 week of pregnancy with h/o cardiac disease for elective LSCS

47 Past history  h/o "heart disease " diagnosed at birth but not on any follow- up  H/o recurrent LRTI during childhood  h/0 progressive exertional dyspnea since the first trimester of her pregnancy.  Evaluated in 2 nd trimester for dyspnea- diagnosed as a case of VSD  No h/O any other significant medical or surgical illness

48  Treatment history Patient not on any medication  General examination wt = 68 kg,ht = 154 cm Afebrile Consious, oriented No pallor,cyanosis,jaundice,edema, clubbing No lymphadenopathy Neck veins- not engorged

49  Pulse – 9o/min, regular,good volume, no radio-radial or radio-femoral delay  All peripheral pulse palpable  BP = 130/88 mmHg ( lt arm, supine position )  Peripheral venous access = adequate

50 Systemic examination  Cardiovascular system :-  Inspection – Precordium normal on inspection No visible apical impulse No visible pulsation No scar mark visible  Palpation :- Apex Palpable at (L) 5 th ICS, at mid-clavicular line No thrill palpable Parasternal heave not palpable  Auscultation :- S1 & S2 audible Pan-systolic murmur at apex & LLSB

51 Respiratory system : -  RR = 14/min  Auscultation: B/L air entry equal No added sounds Central nervous system  Higher functions – normal  Cranial nerves, motor and sensory examination – within normal limits Abdomen :-  WNL for 34 week pregnancy

52 Investigations  Hb : g/dl  Plt lakh  Tlc – 6400  Bu -28  Sr. creatinine – 1  Na / K = 148/ 4.5  T. bil = 0.7  CXR –  ECG – LVH  ECHO - small VSD (5mm )

53 Anesthetic concern 1. Avoid accidental iv infusion of air bubble 2. Use loss of resistance to saline that air to identify epidural space 3. Early administration of epidural anesthesia is desirable. 4. Slow onset of epidural anesthesia is preferred 5. Patient should receive supplemental o2 & oxygen saturation should be monitored

54 EISENMENGER SYNDROME Pathophysiology of the Eisenmenger syndrome.

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56 Natural History: Course and Prognosis  8% of patients with CHD & 11% of those with L-R intracardiac shunting develop the Eisenmenger  syndrome [CHD that may result in the Eisenmenger syndrome include VSD,AV defect, PDA, ASD, D-TGA, and surgically created aortopulmonary connections  VSD :- 3% of patients who have a small or moderate-sized defect ( 1.5 cm) and about 50% who have a large defect (>1.5 cm ) develop the Eisenmenger  80% survival rate at 10 yr, 77% at 15 yr, and 42% at 25 yr

57  Wood's Units unit of measure for PVR. One Wood's Unit = PVR of an average healthy person. That is: MPAP = 13 mmHg LAP = 8 mmHg CO = 5 liters per minute so average healthy PVR = (13 minus 8) divided by 5, which equals one Wood's Unit

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