Anesthesia For

Pediatric CARDIAC CATHETERIZATION

Hala El-Mohamady, professor of Anaesthesia, Ain Shams University

IntroductionIntroduction

Cardiac catheterisation in man was first introduced as a diagnostic procedure in 1941.

Since then, there has been a tremendous development in the field of cardiac catheterisation and interventional techniques.

Techniques of anaesthesia have also changed with the changing requirements of the cardiologist as well as the interest in better patient care and safety.

Role of the Role of the AnaesthesiologistAnaesthesiologist

Presence of anaesthesiologist Presence of anaesthesiologist may be necessary during the may be necessary during the conduct of several conduct of several catheterisation procedures for catheterisation procedures for monitored anaesthetic care, monitored anaesthetic care, sedation,sedation, analgesiaanalgesia, , generalgeneral anaesthesiaanaesthesia and also for the and also for the resuscitation resuscitation of patients if of patients if complications arise during the complications arise during the procedureprocedure

Interventional procedures

A. Angioplasty of theA. Angioplasty of the:: 11 . .coarctation of the aortacoarctation of the aorta 22 . .pulmonary vasculaturepulmonary vasculature

B. ValvuloplastyB. Valvuloplasty:: 11 . .Aortic valveAortic valve

22 . .Pulmonic valvePulmonic valve

C.C. Coil embolizationCoil embolization:: 11 . .PDAPDA

22 . .Aorto-pulmonary collateralsAorto-pulmonary collaterals

D.D. Balloon atrial septostomy and Balloon atrial septostomy and stentsstents::

E. Device closuresE. Device closures:: 11 . .ASD closureASD closure

22 . .VSD closureVSD closure 33 . .PDA device closurePDA device closure

FF. . Electrophysiologic proceduresElectrophysiologic procedures:: Diagnostic and interventional procedures Diagnostic and interventional procedures for patients with Hx of PSVT, SVT, atrial for patients with Hx of PSVT, SVT, atrial flutter, and WPW for mapping and flutter, and WPW for mapping and ablation of the foci of arrhythmiaablation of the foci of arrhythmia . .

G. Biventricular pacer G. Biventricular pacer placementsplacements ::

General Anesthesia

In

Cath Lab????

patients require GA includepatients require GA include

- -uncooperative childrenuncooperative children

- -high risk patients such as hypoxaemic high risk patients such as hypoxaemic infants, infants with CHF and obstructed infants, infants with CHF and obstructed valvular lesion, and infants with cyanotic valvular lesion, and infants with cyanotic heart diseaseheart disease

- -Due to increasing invasive nature of the Due to increasing invasive nature of the procedures, complications can arise in procedures, complications can arise in the cath. Lab., therefore the cath. Lab., therefore anaesthesiologist’s presence may be anaesthesiologist’s presence may be desired as a stand-by in high risk patientsdesired as a stand-by in high risk patients

Difficulties In Cath. LabDifficulties In Cath. LabThe anaesthesiologist who is more comfortable in the The anaesthesiologist who is more comfortable in the operation theatre often describes the environment of operation theatre often describes the environment of

the cath. Lab. as the cath. Lab. as “unknown“unknown””..

Access to the patient is difficult due to fluoroscopy Access to the patient is difficult due to fluoroscopy equipment all around the patient with dimmed light and equipment all around the patient with dimmed light and

movable tablesmovable tables . .

Anaesthesiologist must be assured easy access to the Anaesthesiologist must be assured easy access to the patient and in particular to the patient’s airwaypatient and in particular to the patient’s airway..

The priorities of the anaesthesiologist, such as the need The priorities of the anaesthesiologist, such as the need to maintain the airway and oxygenation as well as the to maintain the airway and oxygenation as well as the equipments necessary to do so are not fully equipments necessary to do so are not fully appreciated by the cardiologist. so interaction between appreciated by the cardiologist. so interaction between the cardiologist and anaethesiologist is necessarythe cardiologist and anaethesiologist is necessary..

PREOPERATIVE EVALUATION

11--Complete diagnosis:Complete diagnosis: all details of pt’s cardiac all details of pt’s cardiac anatomy and physiology and the last ECHO anatomy and physiology and the last ECHO report is mandatoryreport is mandatory

22 . .List of the proceduresList of the procedures pt has undergone in pt has undergone in the past (surgical and interventional)the past (surgical and interventional)

33 . .Pt’s level of activityPt’s level of activity (weight gain, feeding (weight gain, feeding tolerance, SOB, exercise tolerance, tolerance, SOB, exercise tolerance, developmental delay)developmental delay)

44 . .ReviewReview with cardiologist with cardiologist anatomy anatomy of the of the case and review the case and review the ECHO filmsECHO films

55 - -Ask the cardiologist about Ask the cardiologist about reason for the reason for the catheterizationcatheterization and what he is and what he is planning planning to to

dodo ? ?

55 . .Rule out recent URIRule out recent URI After a recent URI patients are more likely to have After a recent URI patients are more likely to have reactive airway and develop peri-GA reactive airway and develop peri-GA laryngospasm, bronchospasm, desaturate and laryngospasm, bronchospasm, desaturate and

increase their PVR during the procedureincrease their PVR during the procedure . .

66 . .Medication list:Medication list: last time medication was taken. last time medication was taken. (Lasix, Captopril and Digoxin is a common (Lasix, Captopril and Digoxin is a common combination for pts in CHF.) When you speak to combination for pts in CHF.) When you speak to the patient or family the night before the the patient or family the night before the procedure, please instruct them to take all procedure, please instruct them to take all antihypertensives and antiarrhythmics with sips antihypertensives and antiarrhythmics with sips of water but to hold all other medications the of water but to hold all other medications the morning of the exam. Ask about allergiesmorning of the exam. Ask about allergies

77--Physical examinationPhysical examinationshould emphasise on the should emphasise on the airway, heart, and airway, heart, and lunglung problems problems

Patients should be examined for the signs of Patients should be examined for the signs of CHFCHF such as pedal edema, jugular venous distention, such as pedal edema, jugular venous distention, enlarged liver and rales and for signs of enlarged liver and rales and for signs of respiratory distress such as increased respiratory distress such as increased respiratory rate, diaphoresis, chest retraction, respiratory rate, diaphoresis, chest retraction, nasal flaring, and use of accessory muscles of nasal flaring, and use of accessory muscles of respirationrespiration

Also Inquire regarding loose teethAlso Inquire regarding loose teeth

88 - -Special attention to the presence of Special attention to the presence of otherother congenital lesionscongenital lesions, as nearly 25% of , as nearly 25% of patients with (CHD) may have other patients with (CHD) may have other associated congenital abnormality associated congenital abnormality including including musculoskeletal abnormalitymusculoskeletal abnormality neurological defectsneurological defects

genitourinary irregularitiesgenitourinary irregularities

One congenital lesion that needs particular One congenital lesion that needs particular attention is the attention is the atlanto-occipital atlanto-occipital subluxationsubluxation that occurs in 20% of patients that occurs in 20% of patients

with Down’s syndromewith Down’s syndrome . .

Patient with Patient with cyanotic CHDcyanotic CHD having a having a haemoglobin (Hb) level > 20 gm/dL or haemoglobin (Hb) level > 20 gm/dL or haematocrit >65% may have haematocrit >65% may have hyperviscosity, RBC sludging, and hyperviscosity, RBC sludging, and reduced oxygen delivery to tissues which reduced oxygen delivery to tissues which may further exaggerate in dehydrated may further exaggerate in dehydrated patients and after hypothermia during the patients and after hypothermia during the

procedureprocedure . .

Patients with polycythemia and cyanosis Patients with polycythemia and cyanosis may also have thrombocytopenia, may also have thrombocytopenia, hypofibrinogenemia, and low levels of hypofibrinogenemia, and low levels of

vitamin K dependent clotting factorsvitamin K dependent clotting factors . .

Therefore, Therefore, coagulation testscoagulation tests such such as prothrombin time (PT), partial as prothrombin time (PT), partial thromboplastin time (PTT), partial thromboplastin time (PTT), partial thromboplastin time with kaolin thromboplastin time with kaolin

(PTTK) should also be done(PTTK) should also be done . .

Serum electrolytesSerum electrolytes should be should be determined in patients receiving determined in patients receiving digoxin or diureticsdigoxin or diuretics..

ECHO REPORTECHO REPORT11 . .How many chambersHow many chambers

22 . .Ventricular functionVentricular function

33 . .Presence of the flow obstruction Presence of the flow obstruction (degree of obstruction or pressure (degree of obstruction or pressure gradient) and level of obstructiongradient) and level of obstruction

44 . .Pressure gradient across the valves Pressure gradient across the valves and intracardiac communicationsand intracardiac communications . .

55 . .Coronary artery anatomy, if delineatedCoronary artery anatomy, if delineated 66 . .Presence and direction of the shuntPresence and direction of the shunt

77 . .Rule out suprasystemic pressures in the Rule out suprasystemic pressures in the chambers of the heartchambers of the heart

MonitoringMonitoring - -Standard monitoring includes ECG, Standard monitoring includes ECG,

noninvasive blood pressure, pulse noninvasive blood pressure, pulse oximetry, and temperatureoximetry, and temperature . .

- -Arterial, atrial, and pulmonary Arterial, atrial, and pulmonary pressures can be obtained during the pressures can be obtained during the procedure by the cardiologist. End-procedure by the cardiologist. End-tidal carbon dioxide (EtCO2) for the tidal carbon dioxide (EtCO2) for the patients decided to be mechanically patients decided to be mechanically ventilatedventilated..

Anaesthetic technique

There is no ideal anaesthetic There is no ideal anaesthetic technique that can be technique that can be

universally applieduniversally applied

forfor

all patients undergoing all patients undergoing interventional and interventional and

diagnostic proceduresdiagnostic procedures

Sedation and analgesia to GASedation and analgesia to GAConsiderationsConsiderations

11 . .Pt’s age and clinical conditionPt’s age and clinical condition

22 . .Access by cardiologist: neck vs. groinAccess by cardiologist: neck vs. groin . .

33 . .Length of the procedureLength of the procedure . .

44 . .Pts disease. (Such as hypoplastic heart or Pts disease. (Such as hypoplastic heart or single ventricle.)single ventricle.)

55 . .If procedure is diagnostic or If procedure is diagnostic or interventionalinterventional . .

66.. Remember that pt’s cardiopulmonary Remember that pt’s cardiopulmonary physiology has to be as close to the physiology has to be as close to the baseline (awake state) as possible in baseline (awake state) as possible in order to obtain real data from the order to obtain real data from the

procedureprocedure . .

77.. Note Qp/Qs ratio if available. You will Note Qp/Qs ratio if available. You will not be successful in mask induction not be successful in mask induction of GA for pts with with decreased of GA for pts with with decreased pulmonary blood flowpulmonary blood flow..

88.. Evaluate pt’s cardiac function and Evaluate pt’s cardiac function and remember that remember that all inhalation anesthetics all inhalation anesthetics

are myocardial depressantsare myocardial depressants . .

During diagnostic procedureDuring diagnostic procedure

an ideal technique would be to an ideal technique would be to maintainmaintain

normal respiration on room air normal respiration on room air steady haemodynamics, normal steady haemodynamics, normal

blood gas values, immobility blood gas values, immobility

and toand to

provide adequateprovide adequate

analgesia and amnesiaanalgesia and amnesia

PROCEDURE CONCERNS

11 . .Vascular access by cardiologist:Vascular access by cardiologist: If neck If neck approach is planned you will have better control of approach is planned you will have better control of

the airway using LMA or ETTthe airway using LMA or ETT . .

22 . .FiO2 concerns:FiO2 concerns: during procedure cardiologist during procedure cardiologist will measure O2 saturations in the different will measure O2 saturations in the different chambers of the heart to evaluate degree of the chambers of the heart to evaluate degree of the shunt and calculate Qp/Qs ratio. If pt is sedated keep shunt and calculate Qp/Qs ratio. If pt is sedated keep them on room air if tolerated, if not, inform them on room air if tolerated, if not, inform cardiologist that you have to administer cardiologist that you have to administer supplemental O2 and they will stop the supplemental O2 and they will stop the measurements. Return the pt to room air as soon as measurements. Return the pt to room air as soon as tolerated, and inform cardiologist. If pt is intubated tolerated, and inform cardiologist. If pt is intubated

or has LMA in place keep FiO2 @ 25 % or belowor has LMA in place keep FiO2 @ 25 % or below . .

33 . .Specifics of the procedure:Specifics of the procedure: diagnostic vs. diagnostic vs. invasive. if invasive, there is always possibility invasive. if invasive, there is always possibility of vessel rupture and uncontrolled bleeding. So of vessel rupture and uncontrolled bleeding. So have volume expanders available and blood have volume expanders available and blood typed, screened and crossmatchedtyped, screened and crossmatched

44 . .If a neck approach isIf a neck approach is used:used: there is there is possibility of hemo and pneumothorax. If possibility of hemo and pneumothorax. If suspected these can be easily diagnosed via suspected these can be easily diagnosed via chest fluoroscopychest fluoroscopy

55 . .Ectopy:Ectopy: always possible with wires and always possible with wires and catheters in the heart chambers. Development catheters in the heart chambers. Development

of the heart block is also a possibilityof the heart block is also a possibility . .

66 . .Coil embolization of the PDA: Coil embolization of the PDA: more more distal embolization of the pulmonary distal embolization of the pulmonary arteries is always a possibilityarteries is always a possibility

77 . .Balloon dilatation:Balloon dilatation: rupture of the balloon rupture of the balloon is always a possibilityis always a possibility . .

88 . .Coronary angiogram:Coronary angiogram: thrombosis or thrombosis or dissection of coronary arteries is always dissection of coronary arteries is always

a possibilitya possibility . .

ConclusionIn

CHOOSING YOUR ANESTHESTIC TECHNIQUE

11 . .Premedication highly recommendedPremedication highly recommended..

22 . .Routes of premedication include oral, rectal, IM, IV. Oral Routes of premedication include oral, rectal, IM, IV. Oral Versed 0.5 mg/Kg to 1 mg/Kg is a good choiceVersed 0.5 mg/Kg to 1 mg/Kg is a good choice..

33 . .Pt may be very sensitive to premedication and your Pt may be very sensitive to premedication and your presence @ pt’s bedside after premedication as well as presence @ pt’s bedside after premedication as well as pulse oxymeter monitoring is mandatorypulse oxymeter monitoring is mandatory..

44 . .Consider adding Ketamine to your premedication to Consider adding Ketamine to your premedication to improve level of sedation w/o increased respiratory improve level of sedation w/o increased respiratory depressiondepression..

55 . .When considering inhalation induction, keep in When considering inhalation induction, keep in mind that it requires adequate pulmonary blood mind that it requires adequate pulmonary blood

flowflow . .

66 . .Etomidate, Ketamine, Versed and Fentanyl are Etomidate, Ketamine, Versed and Fentanyl are good choices for IV inductiongood choices for IV induction . .

77 . .When administering narcotics for the induction When administering narcotics for the induction and maintenance of the anesthesia remember and maintenance of the anesthesia remember that the majority of these cyanotic patients are that the majority of these cyanotic patients are

going home in 6 hours after end of proceduregoing home in 6 hours after end of procedure . .

88 . .Remember that Ketamine maintains cardiac Remember that Ketamine maintains cardiac function and spontaneous respiration and also function and spontaneous respiration and also

is a good analgesicis a good analgesic . .