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S5 - Principles III - Test 4 > Congenital Hearts > Flashcards

Congenital Hearts Flashcards

1
Q

which CHDs increase pulmonary flow?

which direction is their shunt?

A
  • ASD
  • VSD
  • PDA

left → right

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2
Q

which CHDs decrease pulmonary flow?

what direction is their flow?

A

Tetrology of Fallot

right → left

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3
Q

which CHDs have mixing of the blood and cyanosis?

A
  • transposition of the great arteries
  • HLHS
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4
Q

which CHDs are obstructive?

A
  • aortic stenosis
  • coarctaction of the aorta
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5
Q

what a common example of an ASD?

A

PFO

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6
Q

what is the treatment of PFOs?

A

usually none since they typically close soon after birth

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7
Q

how many adults have an asymptomatic PFO?

A

30%

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8
Q

what precautions need to be taken with an ASD?

why?

A

bubble precautions

if left-sided pressure drops and is lower than right-sided pressure, a bubble can shunt to the left side (then systemically)

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9
Q

what is the most common CHD in children?

A

VSD

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10
Q

what is the most common type of VSD?

A

perimembranous

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11
Q

compare restrictive vs nonrestrictive VSD

A

restrictive - low flow, less problematic, LV pressure > RV pressure

nonrestrictive - high flow, more problematic, LV pressure = RV pressure

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12
Q

what determines the severity of a VSD?

A
  • defect size
  • degree of shunting
  • pulmonary vascular resistance
  • systemic vascular resistance
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13
Q

what determines the management of a VSD?

A
  • defect size
  • degree of shunting
  • pulmonary vascular resistance
  • systemic vascular resistance
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14
Q

describe the sequence of events that can cause systemic hypotension/pulmonary steal with a VSD

A

decreased PVR →

increased L to R flow →

increased pulm blood flow (pulm steal) →

systemic hypotension

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15
Q

T/F: after 1 year old, most VSDs are still present and causing problems

A

false - 75% close by one year

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16
Q

what are the 4 types of VSDs?

A
  • supracristal-subaortic/subulmonic/outlet
  • membranosus/perimembranosus-inferior to subracristal, and often under septal TV leaflet
  • inlet-AV septal defect
  • muscular

no chance im looking at this card again

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17
Q

what is a PDA?

A

remnant of fetal circulation (ductus arteriosus remains patent)

connects pulmonary artery to descending aorta

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18
Q

describe fetal circulation from the RV forward

A

RV → pulmonary artery → descending aorta via ductus arteriosus

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19
Q

describe neonatal circulation from the RV forward

A

RV → pulmonary artery → lungs (due to low PVR)

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20
Q

what must be done for a large PDA that remains open?

A

needs surgical closure - ligation via left thoracotomy

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21
Q

what is the only place that pre-ductal sats can be monitored?

A

right hand

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22
Q

what does a preductal sat measure?

*specifically

A

the level O2 in the blood AFTER it leaves the heart

but BEFORE it reaches the ductus arteriosus of the aorta where it gets sent to the upper extremities (such as the brain, etc.)

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23
Q

what does a postductal sat measure?

*specifically

A

the level of arterial oxygen in the blood AFTER it leaves the heart

and AFTER it has passed through the ductus arteriosus

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24
Q

what does each of the following measure - pre or post ductal?

  • R hand
  • L hand
  • R leg
  • L leg
A
  • R hand - preductal
  • L hand - postductal
  • R leg - postductal
  • L leg - postductal
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25
Q

what is seen when measuring pre/post ductal sats in a patient with a R to L shunt?

A

pre-ductal sat at least 3% above post-ductal sat

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26
Q

what is the most common cyanotic defect?

A

ToF

(tetrology of fallot)

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27
Q

what are the 4 features of ToF?

A
  • RV outflow tract obstruction
  • RV hypertrophy
  • overriding aorta
  • VSD
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28
Q

what causes a tet spell?

A

spasmodic narrowing just below the pulmonary valve (infundibulum) causing hypercyanotic spells

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29
Q

what anatomic changes are seen from chronic hypoxia?

A

clubbing of fingers and toes

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30
Q

anesthetic implications of ToF

A
  • optimize RV filling
  • ↓ PVR
  • ↑ preload
  • normal SVR
  • avoid tachycardia
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31
Q

what determines the degree of cyanosis with tet spells?

A

RV outflow tract obstruction and SVR

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32
Q

what are some of the known triggers for tet spells? (7)

A
  • crying
  • feeding
  • acidosis
  • hypercarbia
  • catecholamines
  • laryngoscopy
  • surgical stimulation
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33
Q

what emergent interventions should be done for a tet spell to decrease the cyanotic shunting?

A
  • increase SVR
  • increase LV pressure will decrease R to L shunt
  • phenylephrine 1 mcg/kg - repeat until BP up and sats improved
  • beta-blocker to relax infundibular spasm

(knees to chest, squatting if bebe is awake)

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34
Q

if your patient is having a tet spell and you place them on 100% O2 and do nothing else, will their sats improve?

A

nuh uh hunni

give em some phenylephrine

35
Q

anatomy of transposition of great arteries

A
  • aorta rises from the R ventricle
  • pulmonary artery arises from the L ventricle
36
Q

what is needed for TGA babies to remain oxygenated before their repair?

what happens without it

A
  • need a large PDA or VSD
  • without it they’ll have no systemic oxygenation - blood flow in parallel
37
Q

in a TGA bby, if there is no PDA, what is done to ensure the baby stays oxygenated until repair?

A

prostaglandin infusion and/or surgical balloon septostomy at birth

38
Q

definitive repair for TGA

A
  • arterial “switch” procedure (2 arterial trunks transected and re-anastamosed to correct position)
  • coronary arteries must also be transected/reconnected
39
Q

T/F: after TGA repair, the patient will still need CV precautions forever

A

false - should be normal after

40
Q

5 features of HLHS

A
  • hypoplastic L ventricle
  • mitral stenosis/atresia
  • aortic stenosis/atresia
  • hypoplastic aortic arch
  • ductal-dependent circulation
41
Q

what is necessary to keep a HLHS baby oxygenated until repair?

A

prostaglandin infusion (to keep ductus arteriosus open)

42
Q

what is the surgical goal of HLHS patients?

A
  • RV becomes systemic pump
  • passive pulmonary flow from SVC and IVC
43
Q

three stages of HLHS repair

A
  • Norwood I
  • Norwood II (hemi-Fontan)
  • Norwood III (Fontan)
44
Q

when is transplant the only next option for HLHS?

A

when RV begins to fail

45
Q

cardiac output anesthetic implications for HLHS patients

A
  • maintain CO with hydration and inotropes
  • ketamine good choice due CV stability
46
Q

respiratory/ventilatory anesthetic implications for HLHS

A

keep SaO2 near baseline (75-85%)

normal to low TVs and low PEEP to maintain venous return

47
Q

primary pathophysiology of aortic stenosis

A
  • imbalance of O2 supply/demand
  • decreased coronary blood flow with increased LV workload
  • LVH/failure
48
Q

what surgical intervention is done for severe aortic stenosis in neonates?

A

emergent valvuloplasty

49
Q

major anesthetic implication for aortic stenosis

A
  • maintain normal HR to maintain supply and demand balance
  • avoid tachycardia!!! ~~~ or they go to heaven 🥺
50
Q

why does coronary ischemia occur in aortic stenosis?

A

bc the coronaries come off the aorta “quick”

****lol what does this even mean

51
Q

immediate intervention necessary for a preductal coarc

A

prostaglandins (keep PDA open)

52
Q

what VS can indicate a coarc?

A

large BP gradient between pre-stenosis (R arm) and post stenosis (L-leg —- or anywhere after the coarc?)

53
Q

difference in LV function and systemic perfusion for neonates with coarc vs patients > 1 year old

A
  • neonates - poor LV function, less perfusion due to few/no collaterals
  • >1 yr - better LV function, good collaterals
54
Q

what is often seen after coarc repair?

A

HTN

55
Q

problem with CPB in kids?

A

there’s no pediatric pump - have hemodilution and dilutional coagulopathies

56
Q

what type of volume are CPB patients responsive to?

A

colliods

57
Q

fluids to avoid in kids on CPB?

why?

A
  • lactate and dextrose
  • to minimize metabolic acidosis
58
Q

what leads to better outcomes with CPB?

A

shorter bypass times

increasing age

59
Q

what history is needed for pre-op eval in CHD kiddos?

A
  • identify CHD and comorbidities
  • prior repair/anesthesia/hospitalization history
  • last CV visit, ECHO, EKG, CXR, MRI - get interpretations on chart
  • discuss CV symptoms, feeding (often failure to thrive), exercise tolerance
60
Q

oxygen saturation goal for heart bebes who have had palliative repairs

definitive repairs?

A

pallitive: 75-85%
definitive: >95%

61
Q

specific pre-op eval for aortic arch abnormalities?

A

check upper and lower BPs

62
Q

what assessments should be part of a pre-op eval for CHD patients?

A
  • edema
  • clubbing
  • cap refill
  • murmurs
  • labs depending on disease - CBC, fluid balance profile, coags
63
Q

do all CHD bebes need prophylactic antibiotics?

A

nope, only

  1. prosthetic valves
  2. history of endocarditis
  3. unrepaired cyanotic CHD (including palliative repairs)
  4. prosthetic devices/materials placed in <6 months
  5. transplant pts with valve abnormalities
64
Q

drug of choice for prophylactic antibiotics in CHD babes?

what else can be used instead?

A
  • choice: penicillin
  • can use cephalosporin or clindamycin if allergic
65
Q

peri-op considerations in CHD if hypotensive

A

must consider CHD and identify the cause

66
Q

peri-op considerations in CHD if polycythemic

why would they maybe be polycythemic?

A
  • hct may be high to compensate for chronic hypoxemia
  • increased viscosity/sludging leads to decreased organ perfusion and increased risk of thrombotic events
  • hydrate well, de-bubble all lines (consider filters)
67
Q

typical causes of heart failure in infants with CHD

A

usually due to ventricular overload, regurgitation, or obstructive lesions

68
Q

peri-op considerations in CHD re: myocardial ischemia

A
  • chronic hypoxemia
  • shunting
  • decreased coronary perfusion
  • decreased blood viscosity
69
Q

peri-op considerations in CHD re: paradoxical air embolus

A
  • mainly occur with R to Lshunts and increased R side pressure
  • use bubble precautions!!!
70
Q

peri-op considerations in CHD re: dysrhythmias

A
  • any agent or technique can cause dysrhythmias!
  • must know CHD pathology to avoid biggest risk - ex: tachycardia lethal in aortic stenosis
71
Q

peri-op considerations in CHD re: pacemakers

A
  • always consult cardiologist
  • have magnet in room to enable asynchronous pacing
  • have back-up pacing and chronotropes
  • evaluate and re-program pacer post-op
72
Q

what is Eisenmenger Syndrome?

A
  • irreversible pulmonary vascular disease causing shunt reversal with severe hypoxemia
  • uncommon now due to surgical repairs early in life
73
Q

life expectancy and common cause of death in Eisenmenger Syndrome

A
  • poor life expectancy and prognosis
  • common to die from sudden ventricular dysrhythmias
74
Q

med considerations for post-heart transplant pts

A
  • delayed compensatory response
  • better to give direct-acting meds - poor response to indirect meds
75
Q

normal HR in post-heart transplant patients

why?

A

usually increased due to loss of parasympathetic tone

76
Q

what kind of effects can immunosuppressants post-transplant cause?

A
  • drug interactions
  • renal, hepatic, hemodynamic problems
  • USE STRICT ASEPTIC TECHNIQUE PLS
77
Q

general management of pts on anticoagulants for atrial arrhythmias

A

stop 1-2 weeks preop

78
Q

preop management of pts on anticoagulants for prosthetic valves

A
  • high risk for thrombus if stopped
  • admit for pre-op heparin gtt or substitute with ASA therapy
  • restart 1-3 days postop
79
Q

when is pulmonary HTN common?

A

unrepaired CHD

80
Q

what is a pulmonary HTN crisis?

what triggers should be avoided?

A
  • severe R-L shunting that can cause arrest
  • triggers: acidosis, hypercarbia, hypothermia, hypoxemia, light anesthesia, pain
81
Q

pre-op considerations for a pt with known pHTN

A

in-depth risk v. benefit analysis is essential - even if the kid is well-appearing

82
Q

are tet spells typically seen in the periop period?

A
  • common during induction (stress)
  • uncommon with non-cardiac procedures during GA
83
Q

peri-op anesthetic implications for pts with tetralogy of fallot to prevent a tet-spell

A
  • maintain SVR
  • avoid hypotension, hypovolemia, vasodilation
84
Q

when should you consider normovolemic hemodilution

A

Hct > 65%

S5 - Principles III - Test 4 (7 decks)

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