Anesthetic management of children with pulmonary arterial hypertension - Reply
Stanford University, Palo Alto, California, United StatesPediatric Anesthesia (Impact Factor: 1.85). 04/2008; 18(3):208-16. DOI: 10.1111/j.1460-9592.2008.02419.x
Pulmonary arterial hypertension (PAH) is associated with significant perioperative risk for major complications, including pulmonary hypertensive crisis and cardiac arrest. Several mechanisms of hemodynamic deterioration, including acute increases in pulmonary vascular resistance (PVR), alterations of ventricular contractility and function and coronary hypoperfusion can contribute to morbidity. Anesthetic drugs exert a variety of effects on PVR, some of which are beneficial and some undesirable. The goals of balanced and cautious anesthetic management are to provide adequate anesthesia and analgesia for the surgical procedure while minimizing increases in PVR and depression of myocardial function. The development of specific pulmonary vasodilators has led to significant advances in medical therapy of PAH that can be incorporated in anesthetic management. It is important that anesthesiologists caring for children with PAH be aware of the increased risk, understand the pathophysiology of PAH, form an appropriate anesthetic management plan and be prepared to treat a pulmonary hypertensive crisis.
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- "This situation may be associative with lactic acidosis and ischemic changes on ECG. Pulmonary circulation may be limited by ventilation maneuvers that rising mean airway pressure, such as positive end-expiratory pressure, reducing oxygen fraction and increase in PaCO2 (45-55 mmHg). The surgeon with temporary place vascular snare can partially occlude the lung arteries and restrict pulmonary blood flow. "
ABSTRACT: Now-a-days truncus arteriosus has been known as "common arterial trunk" (CAT) and is an uncommon congenital cardiac defect presenting in about 1-3% congenital heart disease. Environmental and genetic factors effects on incidence of CAT and other conotruncal anomalies. The majority patients with CAT and 22q11 deletion have other anomalies such as hypoplasia or aplasia of the thymus or parathyroid glands and immune deficits (T-cell deficiency), calcium metabolism disorder (hypocalcemia), palatal defects, learning and speech disorder, craniofacial anomalies, and neuropsychological abnormalities. CAT without surgical treatment frequently involves early severe pulmonary arterial hypertension (PAH) or early death from heart failure and associated conditions. Therefore, without corrective surgical repair, most CAT patients die in the initial years of life. In numerous centers early surgical repair associated with superior than 80% long-standing survival. Anesthesiologist must be performs comprehensive preoperative evaluation of infants or neonates with this disorder. In CAT patient exactly hemodynamic monitoring and suitable techniques to regulate pulmonary vascular resistance and systemic vascular resistance and cardiac function are more important than the select of a special anesthetic drug. Therefore, anesthetic drugs should be carefully administrated and titrate and under monitoring. Management of CAT after surgical repair depends on the adequacy of treatment, cardiac function, level of PAH, and degree of bleeding. Inotropic support is frequently necessary after the cardiac ischemia associated to the surgical repair. Pulmonary vasodilator drugs were used to PAH treatment.
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- "High pulmonary flow as occurs in unrestricted L–R shunt will lead to congestive heart failure (CHF) and pulmonary HTN. Initially pulmonary HTN is reactive and responds to hypothermia, stress, pain, acidosis, hypercarbia, hypoxia and elevated intrathoracic pressure, but later pulmonary HTN becomes fixed. The anaesthetic goals in managing such a patient are to prevent increase in PVR and depression of myocardial function. "
ABSTRACT: The objective of this article is to provide an updated and comprehensive review on current perioperative anaesthetic management of paediatric patients with congenital heart disease (CHD) coming for non-cardiac surgery. Search of terms such as "anaesthetic management," "congenital heart disease" and "non-cardiac surgery" was carried out in KKH eLibrary, PubMed, Medline and Google, focussing on significant current randomised control trials, case reports, review articles and editorials. Issues on how to tailor perioperative anaesthetic management on cases with left to right shunt, right to left shunt and complex heart disease are discussed in this article. Furthermore, the author also highlights special considerations such as pulmonary hypertension, neonates with CHD coming for extracardiac surgery and the role of regional anaesthesia in children with CHD undergoing non-cardiac operation.
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