1. بسم الله الرحمن الرحيم

2. Anesthesia In Children With Congenital Heart Disease For Non-cardiac Surgery

3. Regarding investigations of CHD patients for non-cardiac surgery: A- Chest X – Ray has no rule B- Cardiac Catheterization is the first choice for diagnosis of CHD C- Echocardiography non invasive method for diagnosis of CHD D- MRI has no rule IM Premedication for CHD patients presenting for non-cardiac suergery: A- Cooperative child who able to take orally B- Ketamine 1mg/kg C- Midazolam 5 mg/kg D -Glycopyrrolate or Atropine 0.02 mg/kg Procedural antibiotic prophylaxis is required in patients with A- Aortic valve replacement B- Mitral valve prolapse with regurge C- Previous history of infective endocarditis D- Ostium secundum ASD

4. AHA guideline for antibiotic prophylaxis for genitourinary procedures: A- High risk adult patient: Ampicillin 1 g & gentamicin 1.5mg/kg i.m or i.v B- High risk Child patient: Ampicillin 5 mg/kg &gentamicin 1.5 mg/kg i.m or i.v C- Moderate risk child allergic to penicillin: Vancomycin 20 mg/kg i.v bolus D- High risk Adults allergic to penicillin: Vancomycin 1g/kg i.v over 1-2 hr Regarding using Succinylcholine in pediatric patients with CHD: A- Succinylcholine in pediatric is routine B- If used should be with atropine, to avoid tachycardia or sinus arrest C- If used with potent narcotic atropine should be used to avoid sever bradycardia in childern with Decreased cardiac reserve
Postoperative Anesthetic Management of CHD patients: A- No need for supplemental O2 and maintain patent airway B- Pain decrease catech. which can affect VR and shunt direction C- Pain  infundibular spasm in TOF  RVOT obstruction cyanosis, hypoxia, syncope, seizures, acidosis and death D- No conduction disturbances in septal defects

5. INTRODUCTION

6. Due to advances in diagnosis, medical, critical and surgical care for CHD
Therefore, it is common for patients with CHD to present for non-cardiac surgery, and even in patient with corrected CHD significant residual problems (arrhythmias, ventricular dysfunction, shunts, valvular stenosis, and PH) may be exist.

7. CLASSIFICATION OF CHD I- Acyanotic congenital heart disease: ASD VSD PDA II- Cyanotic congenital heart disease: Tetralogy of Fallot, with severe right ventricular outflow obstruction TGA Pulmonary atresia or severe stenosis Tricuspid atresia with pulmonary stenosis Truncus Arteriosus

8. ANESTHETIC MANAGEMENT

9. Perioperative management requires a team approach
CHD is polymorphic and may clinically manifest across a broad clinical spectrum
The plane of Anesthetic Management includes the following:
A - Preoperative Management
B - Intraoperative Management
C - Postoperative Management

10. Preoperative Anesthetic Management: A- History B- physical examination C- Investigations D- Premedications E- Fasting Guidelines

11. HISTORY & PHYSICAL EXAMINATION
Vital signs
Airway abnormality
Associated extracardiac congenital anomalies
Tachypnea, dyspnea, cyanosis
Squatting
Clubbing of digits
Heart murmur (s)
CHF:
- Jugular venous distention.
- Hepatomegally
- Ascitis
- Peripheral edema
Assess functional status
- daily activities
- exercise tolerance
↓ cardiac reserve
- cyanosis
- respiratory distress during feeding
Cyanosis
Dyspnea
Fainting attack
Fatigue
Palpitations
chest pain
Syncope
Abdominal fullness
Leg swelling
Medications

12. Cardiac Catheterization
MRI
Laboratory Evaluation
12 Lead ECG
INVESTIGATIONS
chest X – Ray
Echocardiography
Cardiac Catheterization

13. Premedication Fasting Guidelines Oral Premedication:
- Midazolam mg/kg
- Ketamine mg/kg
- Atropine 0.02 mg/kg
IV Premedication:
- Midazolam mg/kg titrated in small increments
- Ketamine 1-2 mg/kg
IM Premedication:
- Uncooperative or unable to take orally
- Ketamine 5 – 10 mg/kg
- Midazolam 0.2 mg/kg
- Glycopyrrolate or Atropine 0.02 mg/kg
Fasting Guidelines

14. AHA guidelines for bacterial endocarditis Prophylaxis in patients with cardiac conditions
Endocarditis prophylaxis not recommended
Endocarditis prophylaxis recommended
Negligible-risk category
- Physiologic, or functional heart murmurs
- Surgical repair without residua beyond
6 months : ASD, PDA,VSD
- Cardiac pacemaker or
- implanted defibrillator
- Isolated secundum atrial septal defect
- Mitral valve prolapse without reg.
- Previous coronary artery bypass surgery
- Previous rheumatic heart disease without valvular dysfunction
High-risk category
- Complex cyanotic congenital heart disease :
Transposition of the great vessels
Tetralogy of Fallot
- Surgically created systemic-to-pulmonary shuntsor conduits
- Prosthetic, Bioprosthetic, Homograft valves
- Previous bacterial endocarditis
Moderate-risk category
- Other congenital cardiac anomalies
- Acquired valvular dysfunction
- Hypertrophic cardiomyopathies
Regurg-- Mitral valve prolapse with valvar

15. AHA guidelines for antibiotic prophylaxis: dental, oral, Respiratory tract and esophageal procedures
Amoxicillin 1 h before procedure
-Children: 50 mg/kg p.o.
Adults: 2.0 g p.o.-
Standard prophylaxis
Ampicillin within 30 min before procedure
- Children: 50 mg/ kg i.m. or i.v.
Adults: 2.0 g i.m. or i.v. -
Unable to take oral medications
Clindamycin 1 h before procedure
Children: 20 mg/kg p.o.
Adults: 600 mg p.o.
OR Azithromycin or clarithromycin 1 h before procedure
-Children: 15 mg/kg p.o.
Adults: 500 mg p.o.-
Allergic to penicillin
Clindamycin within 30 min before procedur
-Children: 20 mg/ kg i.v
-Adult: 600 mg i.v..-
AND allergic to penicillin

16. AHA guidelines for antibiotic prophylaxis: genitourinary and gastrointestinal procedures
- within 30 min before procedure
- Children: Ampicillin 50 mg/ kg .and gentaicin 1.5 mg/kg i.m or i.v
- Adults: Ampicillin 2.0 g and gentamicin 1.5 mg/kg i.m or i.v
High risk patients
- Complete infusion 30 min before procedure
- Children: Vancomycin 20 mg/kg i.v over 1-2 hr
gentamicin 1.5 mg/kg i.m or i.v
-Adults: Vancomycin 1g/kg i.v over 1-2 hr
High risk patients Allergic to penicillin
Ampicillin within 30 min before procedure-
- Children: 50 mg/ kg i.m. or .iv
- Adults: 2.0 g i.m or i.v
Moderate risk patients
Complete infusion 30 min before procedure-
Moderate risk patients AND allergic to penicillin

17. Preoperative Anesthetic Considerations
1- Complete history and physical examin.
2- Review all investigations
3- Hydration should be maintained
4- All cardiac medication except possibly digitalis should
be continued until surgery
5- Premedication should be give particularly to patients
at risk for right to left shunt
6- Antibiotic prophylaxis against endocarditis must be
given

18. Anesthetic Management
A - Preoperative Management
B - Intraoperative Management :
1- Monitoring
2- Choice of anesthetic agent
3- Maintenance of anesthesia
4- Emergence from anesthesia

19. Monitoring Non-invasive Invasive - Clinical observation
- ECG
- NIBP
- Pulse oximetry on two different limbs
- Precordial stethoscope
- Continuous airway manometry
- Multiple site temperatur measurement
- Volumetric urine collection
- Art. catheterization
- CVP
- PAC
- TEE

20. Choice of anesthetic Regimen
● Development of anesthetic regimen is based on various factors such as presence and direction of shunts , HF, arrhythmia , pulmonary circulation, and lowering or maintenance of PVR

21. Choice of Anesthetic Agent
Intravenous anesthetics
Volatile anesthetics
Muscle relaxants
Barbiturates : Not recommended in patients with severe cardiac reserve
Ketamine : No change in PVR in children when airway maintained & ventilation supported
Sympathomimetic effects help maintain HR, SVR, MAP and contractility
Greater hemodynamic stability in hypovolemic patients
Copious secretions (laryngospasm)
Etomidate : Induction dose of 0.3mg/kg  no change in mean pulmonary artery pressure and PVR
Propofol : decrease in SBP and SVR, and increase in SBF in all patients,
whereas HR ,PAP, PBF remained unchanged
OPIOD: Excellent induction agents in very sick children
No cardiodepressant effects if bradycardia avoided
Fentanyl µg/kg IV , Sufentanil 5-20 µg/kg IV
- Halothane   PBF not affecting PVR, Depresses myocardial function, alters sinus node function,
sensitizes myocardium to catecholamines , MAP ,  HR , CI ,  EF
Desflurane  Pungent , PAP and  PVR, Less myocardial depression than Halothane  HR , SVR
Isoflurane  Pungent,  PAP not affecting PVR, Less myocardial depression than Halothane, Vasodilatation leads to  SVR →  MAP ,  HR which can lead to  CI
Sevoflurane  Less myocardial depression than Halothane, more  in PAP compared with isoflurane, No  HR, Mild  SVR, Can produce diastolic dysfunction
Nitrous oxide  At 50% concentration does not affect PVR and PAP in children
Avoid in children with limited pulmonary blood flow, PHT or  myocardial function

22. Neuromuscular Blocking Drugs
Nondepolarizing
Depolarizing
- Succinylcholine in pediatric is controversial
- If used should be with atropine, to avoid associated brady cardia or sinus arrest
- also if used with potent narcotic atropine should be used to avoid sever bradycardia in children with  CR
- Atracuruim and vecronium: have few cardiovascular side effects in children when given in recommended doses.
- Pancuronuim if given slowly doesn't produce HR or BP changes. if given as bolus doses it can produce tachycardia , ↑BP (through sympathomimetic effect )
-Cisatracuruim and Rocuroinuim: safe

23. REGIONAL ANESTHESIA &ANALGESIA
Considerations :
- Coarctation of aorta considerations
- Childern with chronic cyanosis  risk of
coagulation abnormality
- VD : which can:
1- be hazardous in patients with significant
AS or left-sided obstructive lesions
2- Cause  oxyhemoglobin saturation in R-L shunts

24. Anesthetic Management
A - Preoperative Management
B - Intraoperative Management
C - Postoperative Management

25. Postoperative Anesthetic Management
Supplemental O2 and maintain patent airway.
In patients with single ventricle titrate SaO2 to 85%. Higher oxygen sat. can  PVR  PBF   SBF
 Pain  catech. which can affect VR and shunt direction
 Pain  infundibular spasm in TOF  RVOT obstruction  cyanosis, hypoxia, syncope, seizures, acidosis and death
 Anticipate conduction disturbances in septal defects

26. SUMMARY
Familiarity with the CHD pathophysiology, adequate preoperative preparation, choice of monitors, induction, maintenance , emergence from anesthesia, and plans for the postoperative period to avoid major problems in anesthetic management
A wide variety of anesthetic regimens is used for patients with congenital heart disease (CHD) undergoing cardiac or non-cardiac surgery, or other diagnostic or therapeutic procures. The goal of all of these regimens is to produce anesthesia or adequate sedation, while preserving systemic cardiac output and oxygen delivery

27. Regarding investigations of CHD patients for non-cardiac surgery: A- Chest X – Ray has no rule B- Cardiac Catheterization is the first choice for diagnosis of CHD C- Echocardiography non invasive method for diagnosis of CHD D- MRI cannot give us idea about pulmonary veins IM Premedication for CHD patients presenting for non-cardiac suergery: A- Cooperative or unable to take orally B- Ketamine 1mg/kg C- Midazolam 5 mg/kg D -Glycopyrrolate or Atropine 0.02 mg/kg Procedural antibiotic prophylaxis is required in patients with A- Aortic valve replacement B- Mitral valve prolapse with regurge C- Previous history of infective endocarditis D- Ostium secundum ASD

28. AHA guideline for antibiotic prophylaxis for genitourinary procedures: A- High risk adult patient: Ampicillin 1 g & gentamicin 1.5mg/kg i.m or i.v B- High risk Child patient: Ampicillin 5 mg/kg &gentamicin 1.5 mg/kg i.m or i.v C- Moderate risk child allergic to penicillin: Vancomycin 20 mg/kg i.v bolus D- High risk Adults allergic to penicillin: Vancomycin 1g/kg i.v over 1-2 hr Regarding using Succinylcholine in pediatric patients with CHD: A- Succinylcholine in pediatric is routine B- If used should be with atropine, to avoid tachycardia or sinus arrest C- If used with potent narcotic atropine should be used to avoid sever Decreased cardiac reserve bradycardia in children with
Postoperative Anesthetic Management of CHD patients: A- No need for supplemental O2 and maintain patent airway B- Pain decrease catech. which can affect VR and shunt direction C- Pain  infundibular spasm in TOF  RVOT obstruction cyanosis, hypoxia, syncope, seizures, acidosis and death D- No conduction disturbances in septal defects

29. Thank You