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SEE Stuff > Neonate 3 - Congenital Heart Disease > Flashcards

Neonate 3 - Congenital Heart Disease Flashcards

1
Q

Ductus venous:

Function
Location

A

Function: allows umbilical blood to bypass the liver

Location: umbilical vein to inferior vena cava

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2
Q

Foramen ovale:

Function
Location

A

Function: shunts blood from RA to LA to bypass lungs to perfuse upper body (heart & brain)

Location: RA to LA

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3
Q

Ductus arteriosus:

Function
Location

A

Function: shunts blood from pulmonary trunk to aorta to perfuse lower body

Location: pulmonary artery to proximal descending aorta

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4
Q

When does the Ductus Venous close and what is the remnant?

A

Closes: clamping of umbilical cord

Remnant: Ligamentum Venosus (V/V)

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5
Q

When does the Foramen Ovale close and what is the remnant?

A

Closes: 3 days

Remnant: Fossa Ovalis (O/O)

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6
Q

When does the Ductus Arteriosus close and what is the remnant?

A

Closes: several weeks after birth

Remnant: Ligamentum Arteriosum (A/A)

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7
Q

List 5 ways fetal circulation its different from the adult circulation

A
  1. Placenta is organ of respiration (Adult = lungs)
  2. Circulation is arranged in parallel (Adult = series)
  3. Right to left shunt occurs across the foramen oval and ductus arteriosus
  4. PVR is high - lungs are collapsed and filled with fluid, so very little pulmonary blood flow
  5. SVR is low - placenta provides a large, low resistance vascular bed
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8
Q

Describe the 5 circulatory changed that occur during transition to extrauterine life

A
  1. First breath -> lung expansion -> increased PaO2 & decreased PaCO2 -> decreased PVR
  2. Placenta separates from uterine wall (or cord clamp) -> increased SVR
  3. Decreased PVR & increased PVR -> LA pressure > RA pressure = flap of foramen ovale closes
  4. Decreased PVR = reversal of blood flow through ductus arteriosus -> exposes DA to increased PO2 = DA closure
  5. Decreased circulating PGE 1 (released from placenta) -> DA closure
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9
Q

What is the risk of a patent foramen ovale?

A

PFO increases the risk of paradoxical air embolism (embolus goes to brain instead of lungs)

30% of adult population has a PFO

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10
Q

What drug can be used to CLOSE the ductus arteriosus?

A

indomethacin (this is an NSAID - also why pregnant mothers can not have NSAIDS)

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11
Q

What drug can be used to OPEN the ductus arteriosus?

A

prostaglandin E1

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12
Q

In a R to L shunt, how is PVR & SVR

A

PVR > SVR

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13
Q

In a L to R shunt, how is PVR and SVR

A

SVR > PVR

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14
Q

What is the equation for PVR?

Normal Range?

A

PVR = (PAP-PAOP)/CO X 80

Normal: 150-200 dynes/sec/cm^-5

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15
Q

What conditions INCREASE PVR

A 
Hypercarbia
Hypoxia
Acidosis
Collapsed alveoli
Trendelenburg position
Hypothermia
Vasoonstrictors
Increased SNS tone
Light anesthesia
Pain
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16
Q

Want conditions DECEASE PVR

A 
Hypocarbia
Adequate oxygenation
Alkalosis
Hemodilution
Vasodilators
Nitric oxide
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17
Q

What is the equation for SVR

Normal range?

A

SVR = (MAP-CVP)/CO X 80

normal 800-1500 dynes/sec/cm^-5

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18
Q

What conditions INCREASE SVR

A 
Vasoconstrictors
Fluid bolus
Increased SNS tone
Pain
Anxiety
19
Q

What conditions DECREASE SVR

A 
Volatile anesthetics
Propofol
Decreased SNS tone
Histamine
Anaphylaxis
Hemodilution
Sepsis
20
Q

What is a cyanotic shunt?

A

Right to left shunt

Venous blood bypasses the lungs. Since the blood is not exposed to oxygen in the lungs, it dilutes final PO2 of the blood ejected by LV

21
Q

What are the 5 examples of cyanotic shunts?

A

5 Ts!!!

Tetrology of Fallot
Transposition of the great arteries
Tricuspid valve abnormality (Ebstein anomaly)
Truncus arteriosus
Total anomalous pulmonary venous circulation

22
Q

What are the hemodynamic goals for the patient with a right to left shunt?

A

In a R to L shunt PVR>SVR so there is decreased pulmonary blood flow

Goals:
Maintain SVR
Decreased PVR
 - hyperoxia
 - hyperventilation
 - Avoid lung hyperinflation
23
Q

What is an acyonotic shunt?

A

Left to right shunt

Blood in the left side of the heart recirculates through the lungs instead of perfusing the body

24
Q

What are 4 examples of acyanotic shunt?

A

VSD (most common)
ASD
PDA
Coarctation of aorta (COA)

25
Q

What are hemodynamic goals for patient with left to right shunt

A

In L to R shunt, SVR>PRV (so decreased systemic blood flow because SVR is high and increased pulmonary blood flow which leads to pulmonary HTN and RVH)

Goals:
AVOID increase in SVR
AVOID decrease in PVR (decrease FiO2 and hypoventilation)

26
Q

How does a Right to Left shunt affect inhalation induction?

A

slower induction (anesthetic gases are bypassing lungs)

27
Q

How does a Right to Left shunt affect IV induction?

A

Faster induction (IV meds are bypassing lungs and getting to systemic circulation faster)

28
Q

How does a Left to Right shunt affect inhalation induction?

A

minimal effect

29
Q

How does a Left to Right shunt affect IV induction?

A

slower induction

30
Q

What is Eisenmenger Syndrome?

A

Can occur when a patient with a Left to Right shunt developed pulmonary HTN. This reverses flow through the shunt, which can cause a R to L shunt, hypoxemia, and cyanosis.

31
Q

What are the 4 defects associated with Tetralogy of Fallot

A

Think RA!!!

  1. RVOT obstruction
  2. RVH d/t high pressure load from RV obstruction
  3. Ventricular septal defect d/t petal malalignment
  4. Overriding aorta that receives blood form both ventricles

** ratio of PVR to SVR depends on how much blood travels to lungs and systemic circulation

32
Q

How does a TET spell present?

A

hypoxia and cyanosis

Classically the child presents with a history of squatting during activity. This kinks the arteries in the groin area and increased SVR, reduces right to left shunt, and improves oxygenation

33
Q

What situations increased the risk of TET spells?

A

STRESS increases myocardial contractility and may cause spasm of the infra-valvular region of the RVOT, so it should make sense that TET spells also occur during stressful circumstances such as:

exercise, crying, defecation, IV placement in awake child, induction

34
Q

What is treatment for TET spell that occurs during perioperative period?

A
  • FiO2 100%
  • Intravascular volume expansion
  • Increased SVR with phenylephrine to augment PVR to SVR ratio
  • Reduce SNS stimulation to improve RVOT obstruction (deepen anesthetic, short acting BB - esmolol)
  • Inotropes worsen REVOT (avoid!)
  • Avoid excess airway pressure
    Infant may be placed in knee-chest position to mimic squatting
35
Q

Hemodynamic goals for Tetrology of Fallot

A

INCREASE SVR (avoid vasodilation & treat with phenylephrine)

DECREASE PVR (avoid hypercarbia, hypoxia, acidosis & treat by reversing conditions and give nitric oxide)

MAINTAIN CONTRACTILITY AND HR (avoid SNS stimulation, ephedrine, dobutamine, epi & treat with esmolol)

INCREASE PRELOAD (avoid dehydration and treat with crystalloid and 5% albumin)

36
Q

What is the best IV induction agent in patient with Tetrology of Fallot

A

Ketamine (1-2mg IV or 3-4 mg IM) increases SVR and reduces shunting

Even though it increases contractility, this effect is minor compared tot he benefit of increasing SVR.

37
Q

What is the most common congenital cardiac anomaly in infants/children.

Adults?

A

Infants/Children - VSD (many close by age 2)

Adults - bicuspid aortic valve

38
Q

What is coarctation of the aorta?

A

Narrowing of the thoracic aorta, in the vicinity of the DA. It typically occurs just before or after the DA, in rare instances it occurs proximal to the left subclavian artery

39
Q

Which syndrome is highly associated with coarctation of aorta?

A

Turner syndrome

40
Q

How is BP affected in patient with coarctation fo aorta?

A

SBP elevated in upper ext

SBP reduced in lower ext

41
Q

Discuss Ebstein anomaly

A

The most common congenital defect of the tricuspid valve. There is usually an ASD or PFO.

Characterized by downward spiral of the tricuspid valve and atrialization of the RV

Tricuspid regurg can be severe
R to L shunt occurs between atria
SVT common
RV failure common in post-op period

42
Q

Discuss anesthetic management of the patient who has previously undergone Fontan completion

A

This patient has a SINGLE VENTRICLE that pumps blood into the SYSTEMIC circulation

There is no ventricle to pump blood into pulmonary circulation, so..

  • Blood flow into lungs is completely dependent on negative intrathoracic pressure during spontaneous breathing
  • PPV disrupts the and should be avoided/minimized
  • These pts are preload depended - do not let them get dry!
43
Q

What is truncus arteriosus?

A

Characterized by a SINGULAR ARTERY that give rise to PULMONARY, SYSTEMIC, and CORONARY CIRCULATIONS.

With only one artery, there is no specific pathway for blood to enter the pulmonary circulation before being pumped into the systemic circulation.

Usually a VSD as well.

Decreasing PVR or increasing pulmonary blood flow steals blood from the systemic and coronary circulations.

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