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Neonate > CV In Pediatric Population > Flashcards

CV In Pediatric Population Flashcards

1
Q

What is the anesthetic implication of infant HR control maturing before B-adrenergic control?

A
  • Infants are more apt to become bradycardic

- May not respond to hypovolemia or light anesthesia with tachycardia (Immature SNS)

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2
Q

What is the anesthetic major anesthesia concern of succinylcholine administration of the neonate?

A
  • A vagotonic response that may lead to bradycardia and/or asystole
  • Immature SNS
  • Can also happen with opioids
  • OFFSET BY ATROPINE (OPPOSE PNS)
  • PEDS: EXAGGERATED RESPONSE TO SUCCINYLCHOLINE, ALWAYS DRAW ATROPINE!!!!
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3
Q

What is the organ of prenatal respiration?

A
  • The placenta
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4
Q

With fetal circulation bypassing the lungs, what are the three special shunts that allow perfusion to the heart and brain?

A
  • Ductus venosus
  • Foramen Ovale
  • Ductus arteriosus
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5
Q

Due to increased pulmonary vascular resistance (secondary to pulmonary hypoxia), and patency of the ductus arteriosus and foramen ovale. What percentage of blood flow actually crosses pulmonary circulation?

A
  • Only 10%

- 90% bypasses pulmonary circulation via the foramen ovale and ductus arteriosus

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6
Q

Describe the path of oxygenated blood from the placenta through fetal circulation

A
  • Umbilical vein
  • Ductus venosus
  • Inferior vena cava
  • Right atrium
  • Foramen ovale
  • Left atrium (cerebral circulation)
  • Remaining right ventricle output goes through ductus arteriosus (systemic circulation)
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7
Q

Where are the origin and role of the two umbilical arteries?

A
  • Internal iliac arteries

- Return UNOXYGENATED BLOOD to the placenta

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8
Q

What is the role of the umbilical vein? What is the typical Pa02 of blood in the umbilical vein?

A
  • Carry OXYGENATED blood from placenta to fetus

- 60-70%

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9
Q

How would you characterize vascular resistance in fetal circulation and why? Pulmonary vascular resistance and why?

A
  • Low SVR, secondary to low-resistance placenta

- High PVR, secondary to fluid-filled lung and hypoxic pulmonary vasoconstriction

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10
Q

What is the functional role of the ductus venosus and foramen ovale?

A
  • Circulate the most oxygenated blood from umbilical vein to the brain and heart
  • DV bypasses liver
  • FA bypasses RV
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11
Q

Where is pre-ductal Sp02 measured?

A
  • Right hand
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12
Q

Where is post-ductal Sp02 measured?

A
  • Feet
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13
Q

What is the result that high PVR has on the majority of RV output?

A
  • Forces RV output across the ductus arteriosus into the descending aorta
  • Allows deoxygenated blood to return to the placenta
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14
Q

What is maternal Pa02? Umbilical vein 02? Blood ejected from LV in the fetus?

A
  • 100
  • 30-35
  • 25-30
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15
Q

What three factors act to decrease PVR in transitional circulation?

A
  • Lungs expand to normal FRC when air enters lungs
  • Marked reduction in PaC02
  • Increase in Pa02
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16
Q

What factor results in functional closure of the foramen ovale?

A
  • LVED pressure surpasses RA pressure

- FUNCTIONAL closure occurs within minutes

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17
Q

What percentage of adults will remain with a patent foramen ovale?

A
  • 25-30%
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18
Q

When does anatomic closure of the foramen ovale occur?

A
  • Months
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19
Q

When does the FUNCTIONAL closure of the ductus arteriosus occur?

A
  • Day 4 of life in 98% of infants

- Initial constriction occurs with increase in arterial oxygen tension

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20
Q

When does ANATOMIC closure of the ductus arteriosus occur?

A
  • 2-3 weeks after birth
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21
Q

When does FUNCTIONAL closure of the ductus venosus occur?

A
  • Right away
  • Ligation of the umbilical vein drops portal pressure and triggers closure
  • Anatomic closure takes 1-2 weeks
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22
Q

What changes occur in the LV in the transitional circulation?

A
  • RV and LV are the same size at birth
  • LV takes over volume workload
  • LV hypertrophies and is twice as heavy as RV by 6 months
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23
Q

What occurs if PVR exceeds SVR? And what is the major concern with this development?

A
  • A right-to-left shunt can develop via the ductus arteriosus
  • Produces life-threatening hypoxemia
  • May require NO or ECMO to sustain life
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24
Q

What is the net result of persistent fetal circulation?

A
  • A right-to-left shunt
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25
Q

What are the major characteristics of the neonatal CV system in comparison to adults?

A
  • Contractile myocytes are 30% in the neonate, 60% in adults
  • More reliant on Ca+ influx to initiate and terminate contraction
  • CO is increased, high metabolic rate
  • Increased sensitivity to negative inotropic and chronotropic drugs
  • Immature SNS, and mature PNS predisposes neonate to exaggerated vagal responses
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26
Q

Describe pulmonary vascular development of the neonate?

A
  • Matures during the first few years of life
  • PVR decreases due to lung expansion and increased oxygenation
  • Certain pathophysiologic conditions lead to increased PVR, right-to-left shunt may develop via ductus arteriosus
  • Will lead to PATENT DUCTUS ARTERIOSUS
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27
Q

What four conditions can develop into PERSISTENT FETAL CIRCULATION?

A
  • Hypoxia
  • Hypercarbia
  • Acidosis
  • Shock
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28
Q

What are the anesthetic implications of administering midazolam to the neonate?

A
  • WELL TOLERATED IN CHILDREN WITH CARDIAC DISEASE

- CAN DECREASE CO WHEN COMBINED WITH MORPHINE

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29
Q

What are the anesthetic implications of administering inhaled anesthetics to the neonate?

A
  • ALL INHALED ANESTHETICS ARE MYOCARDIAL DEPRESSANTS
30
Q

What are the anesthetic implications of administering opioids to the neonate?

A
  • HIGH CV STABILITY, EVEN AT HIGH DOSES
  • MINIMAL EFFECT ON HR, CO, PVR, MAP, AND SVR
  • MAY BE USED AS THE SOLE AGENT
31
Q

What are the anesthetic implications of administering Propofol to the neonate?

A
  • Can decrease BP and HR
32
Q

What are the anesthetic implications of administering Ketamine to the neonate?

A
  • Sympathomimetic action preserves myocardial function

- Is actually a myocardial depressant and this effect manifests when catecholamines are depleted

33
Q

What are the anesthesia concerns with regional anesthesia of the neonate?

A
  • Spinal and epidurals have minimal hemodynamic effects compared with the vasodilation in adults
  • Fluid loading not required
  • Negligible hemodynamic effects
34
Q

What is the occurrence of congenital heart disease (CHD)

A
  • 7-10 in 1,000 live births
  • 30% of all congenital diseases
  • 2/3 of lesions are found in children trisomy-21
35
Q

What is the process by where venous return into one circulatory system is recirculated through the arterial outflow of the same circulatory system?

A
  • Shunting

- (Shunting is necessary w/ transposition of the great vessels)

36
Q

What occurs when there is complete mixing of pulmonary and systemic venous blood at the atrial or ventricular level?

A
  • Single ventricle
37
Q

What occurs in a single ventricle pathology when a patent ductus arteriosus is the sole source of systemic blood?

A
  • Ductal dependent circulation
38
Q

What are 3 congenital heart defects that occur with 2 well-formed anatomic ventricles and rely on ductal dependent circulation?

A
  • Tetralogy of fallot
  • Truncus arteriosus
  • Severe neonatal aortic stenosis
  • All require VSDs for circulation
39
Q

What is the unique situation that occurs in the transposition of the great vessels where two independent circulatory systems form and rely on a PDA and/or VSD?

A
  • Intercirculatory mixing
40
Q

What is the importance of a CBC in a cyanotic child?

A
  • Will determine:
  • Polycythemia
  • Microcytic anemia
  • Thrombocytopenia
41
Q

What commonly used sympathomimetics in adults is contraindicated in neonates?

A
  • Norepinephrine
  • Ephedrine
  • Phenylephrine
42
Q

What are the emergency drugs that need to be available in children with severe cardiac disease?

A
  • Atropine 0.01mg/kg-0.02mg/kg
  • Epinephrine 0.01mg/kg
  • CaCl- 5-20mg/kg
  • Lidocaine- 1mg/kg
  • Succinylcholine 2-3mg/kg
43
Q

What is the preferred anesthetic technique for the infant with severe CV disease and what is the goal of this technique?

A
  • Intravenous administration

- Maintain dequate oxygenation and CO

44
Q

With intravenous induction anesthesia, how does a left-to-right shunt effect the speed of induction?

A
  • Slower the speed of induction

- Drugs recirculate in the lungs, does not go systemically

45
Q

With intravenous induction anesthesia, how does a right-to-left shunt effect the speed of induction?

A
  • Faster induction

- Drug rapidly enters systemic circulation, enters brain rapidly

46
Q

With inhalational induction anesthesia, how does a left-to-right shunt effect the speed of induction?

A
  • Faster induction
  • A functionally low CO output state that “whisks away” less agent from the alveoli, allowing the rate of rise of Fa/Fi to build rapidly
47
Q

With inhalation induction anesthesia, how does a right-to-left shunt effect the speed of induction?

A
  • Slower induction

- Decreased pulmonary/alveolar blood flow rate of increase of arterial partial pressure of the agent

48
Q

In the neonate with CV disease, anesthesia can be maintained with inhalational or intravenous technique but what is the most common method?

A
  • High dosage opioid technique
49
Q

What is one of the most common CHD in children that manifests with an open foramen ovale? What type of shunt does it create?

A
  • Atrial Septal Defect (ASD)
  • Left-to-right shunt
  • Pressure in LV higher the RV, shunts blood through PFO back to the right heart
  • Increased blood flow to the lungs
  • Enlarged right ventricle
  • Most common in trisomy-21
50
Q

What is the single most common CHD in children? What type of shunt does it create?

A
  • Ventral Septal Defect
  • Normally a left-to-right shunt, pressures in LV higher than RV
  • Hemodynamic significance directly r/t size of defect
  • Increased blood flow to the lungs
  • Enlarged left and right ventricles
51
Q

What is the name of the CHD that consists of a VSD w/ pulmonary hypertension?

A
  • Eisenmenger Syndrome
  • Causes non-cyanotic heart disease, Left-to-right shunt
  • Eventually, built-up pulmonary congestion builds pressure in the RV and left-to-right shunt becomes right-to-left shunt
  • Key S/S:
  • Cyanosis
  • Clubbing of fingers
  • Polycythemia
52
Q

What is the vascular structure that connects the pulmonary trunk and the proximal descending aorta?

A
  • Ductus arteriosus
53
Q

Which CHD is at increased risk in premature infants? And what type of shunt can it produce?

A
  • Patent ductus arteriosus

- Increased pulmonary blood flow and LV work can eventually develop into PULMONARY HTN

54
Q

Which CHD in the neonate is characterized by a narrowing of the aortic lumen in the thoracic region?

A
  • Coarctation of the aorta
  • Often accompanied with other defects (bicuspid aortic valve, VSD, mitral valve abnormalities)
  • No obstruction to systemic flow
  • Increased LV afterload
  • Occurs w/ ventricular dilation and HF in infancy
  • LV hypertrophy and arterial HTN proximal to the aortic proximal to aortic obstruction (UE BP will differ from LE BP)
55
Q

What is the most common cyanotic heart lesion? What are the primary characteristics?

A
  • Tetralogy of Fallot
  • RV outflow tract obstruction (RVOTO, Infundibular pulmonary stenosis)
  • Intraventricular communication (VSD)
  • RV hypertrophy (Right-to-left shunt causes hypertrophy)
  • Overriding aorta
  • RV pressure at systemic levels and PA pressures are low, secondary to pulmonary outflow tract obstruction
56
Q

What causes cyanosis in Tetralogy of Fallot?

A
  • Limited pulmonary blood flow

- Right-to-left shunt in the VSD

57
Q

What are conditions that increase Right-to-left shunt in TOF?

A
  • Acidosis
  • Hypercarbia
  • Hypotension
  • Decreased SVR
  • Increased Afterload
58
Q

What is a controversial aspect of the surgical management of TOF?

A
  • Partial and then early complete repair vs. early complete repair
59
Q

Describe staged repair for TOF?

A
  • Palliation w/ systemic-to-pulmonary shunt FIRST
  • THEN Closure of the VSD
  • Relief of the RVOTO
60
Q

What are some of the complications after TOF surgical repair?

A
  • RV dysfunction
  • Pulmonary regurgitation
  • Junctional ectopic tachycardia
61
Q
  • 100% 02
  • Hyperventilation
  • NAHCO3
  • Adequate preop hydration
  • Decreased PVR and improved pulmonary blood flow
  • Treatment of hypercyanotic spells with volume and sedation are all anesthetic management componenets in the treatment of what CHD?
A
  • Tetralogy of Fallot
62
Q

What is an important aspect in the anesthetic management of TOF regarding perioperative HR?

A
  • Avoid increases in HR (Decrease in myocardial rest time and filling time)
  • Treat w/ B-Blockers (relaxes infundibular spasm and reduces HR)
  • Increased HR exacerbates infundibular pulmonary stenosis
  • Remember right-to-left may slow inhalational induction
63
Q 
What is characterized by:
- Hypercyanotic episodes
- Is caused by decreased pulmonary blood flow w/ significant RVOTO
- Occurs w/ hypovolemia
- Occurs w/ extreme vasodilation?
What is the treatment?
A
  • “Tet Spells”

- Treatment is to increase blood volume, Increase Fi02, Increase SVR (phenylephrine)

64
Q

What kind of induction is most desirable in the anesthesia management of TOF?

A
  • IV Induction
  • Ketamine useful
  • Fentanyl and Sufentanil blunts SNS during intubation and avoids increases in PVR
  • Volume expansion of 10-15mL/kg of albumin of NS
  • Give phenylephrine to reverse low 02 saturations
65
Q

The degree of hypoxemia in TOF is dependent on what?

A
  • Degree of RVOTO

- And SVR (Decreased SVR increases hypoxemia)

66
Q

What are two conditions associated w/ TOF?

A
  • DiGeorge Syndrome

- Trisomy-21

67
Q
  • Vasodilators
  • INH Agents
  • Histamine release
  • Ganglionic blockers
  • Alpha Blockers
  • AND NITROUS OXIDE!!!!!!!!!!!!!
    Are agents that are to be avoided in the management of what CHD? Why?
A
  • Tetralogy of Fallot

- They decrease SVR or increase PVR

68
Q
  • Hypoplastic RV due to an abnormal tricuspid valve
  • ASD or PFO
  • Enlarged RA
  • Are all components of what CHD?
  • What type of shunt does this create?
A
  • Ebstein Anomaly

- Right-to-left shunt (through ASD or PFO)

69
Q

What CHD is characterized by:

  • Connection of the aorta to the RV
  • Connection of the pulmonary artery to the LV
  • Creates to separate circulatory systems
A
  • Transposition of the Great Arteries
70
Q

What is the only way the neonate with Transposition of the Great Arteries can survive?

A
  • Ventral Septal Defect
  • Only way for blood mixing to happen
  • Even so, surgery has to happen within days
  • Done in stages, likely 3

Neonate (3 decks)

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