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Advanced Principles C > Pediatric Cardiac Anesthesia > Flashcards

Pediatric Cardiac Anesthesia Flashcards

1
Q

Name the three branches of the aortic arch.

A
  • Brachiocephalic (Innominate) Artery
  • Left common carotid artery
  • Left subclavian artery
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2
Q

What two arteries does the brachiocephalic artery split into?

A
  • Right common carotid artery
  • Right subclavian artery
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3
Q

What percentage of ventricular output will go to the lungs with a fetal heart?

A

5-10%

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4
Q

Limitation of blood flow to the lungs in a fetus is due to high __________.

A

PVR

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5
Q

How does blood flow bypass the lungs in a fetus?

A
  • Foramen Ovale
  • Ductus Arteriosus
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6
Q

What other organ has limited blood flow besides the lungs in a fetus?

A

Liver

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7
Q

How does blood flow bypass the liver in a fetus?

A

Ductus Venosus

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8
Q

Fetal Circulation Chart

A

Fetal Circulation Chart

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9
Q

What are three major changes in blood flow at birth?

A
  • Marked decrease in PVR
  • Increase blood flow through pulmonary veins
  • Decrease placental blood flow
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10
Q

During birth, as blood flow to the lungs increases, what happens to Alveolar PCO2 and Alveolar PO2?

A
  • Alveolar PCO2 Decreases
  • Alveolar PO2 Increases

Usually occurs within minutes after birth

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11
Q

During birth, as blood flow increases through the pulmonary veins, ________ pressure becomes higher than ________ pressure.

A

During birth, as blood flow increases through the pulmonary veins, LEFT ATRIAL PRESSURE becomes higher than RIGHT ATRIAL PRESSURE.

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12
Q

During birth, as blood flow increases through the pulmonary veins, the atrial septum closes over the _____________.

A

Foramen Ovale

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13
Q

The foramen ovale is anatomically patent in _____% of children less than five years old.

A

50%

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14
Q

What happens to SVR as placental flow ceases during birth?

A

SVR increases

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15
Q

What happens to IVC flow and RA Pressure as placental flow ceases during birth?

A
  • IVC flow decreases
  • RAP decreases
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16
Q

What happens to the blood flow through the ductus arteriosus as placenta flow ceases during birth?

A

Blood flow through the ductus arteriosus reverses and fills with oxygenated blood.

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17
Q

What substances can be given to keep the ductus arteriosus open?

A

Prostaglandin

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18
Q

The ductus arteriosus is mostly closed by day ________ and usually completely closed by day _________.

A
  • Mostly closed by day 2
  • Completely closed by day 7
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19
Q

What communicates between the placenta, portal vein, and IVC?

A

Ductus Venosus

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20
Q

As the ductus venosus remains patent for several days after birth, how does this affect metabolism?

A

Delays Metabolism d/t reduce liver circulation

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21
Q

Fetal to Neonatal Circulation Chart

A

Fetal to Neonatal Circulation Chart

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22
Q

During transitional circulation, if hypoxia occurs, what will happen to PVR?

A

PVR increases

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23
Q

During transitional circulation, what will happen to the foramen ovale and ductus arteriosus if hypoxia occurs?

A

Foramen Ovale and Ductus Arteriosus may reopen → will cause a significant proportion of blood to bypass the lungs

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24
Q

List conditions that can prolong transitional circulation

A
  • Prematurity
  • Pulmonary Disease
  • Hypothermia
  • High Altitude
  • Prolonged Stress
  • Sepsis
  • Acidosis
  • Hypercarbia
  • Congenital Heart Disease
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25
Q

What is unique about the RV wall of the neonatal heart?

A

RV wall thickness exceeds LV wall

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26
Q

What is the degree of axis of a neonatal heart?

A

180 degrees

30-90 degree axis for standard heart

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27
Q

Neonatal hearts have less contractile tissues, how does this affect SV and and CO?

A
  • Limited SV d/t ↓ compliance
  • CO will be rate-dependent
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28
Q

Why would a neonatal heart be more sensitive to CCB Drugs or Citrated Blood?

A

Immature myofibrils and sarcoplasmic reticulum will result in underdeveloped calcium handling mechanisms.

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29
Q

Due to neonatal hearts having immature myofibrils and sarcoplasmic reticulum, calcium exchange will be more dependent on the _____________-

A

Sarcolemma

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30
Q

Why does stress cause a compromised CO in a neonatal heart?

A

Immature Autonomic Innervation

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31
Q

What are the 4 types of congenital cardiac defects?

A
  • Shunts
  • Mixing Lesions
  • Flow Obstructions
  • Regurgitant Valves
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32
Q

What are the two categories of cardiac shunts?

A
  • Intracardiac Connections (Opening between chambers)
  • Extracardiac Connections (Opening between a systemic and pulmonary artery)
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33
Q

In Atrial Septal Defects (ASD) what is the direction and magnitude of blood flow related to?

A
  • Ventricular Compliance
  • AV Valve Function
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34
Q

In VSD and PDA what is the direction and magnitude of blood flow related to?

A
  • Resistance of the Pulmonary System
  • Resistance of the Systemic System
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35
Q

Is a Left-to-Right Shunt an Acyanotic or Cyanotic Heart Defect?

A

Acyanotic Heart Defect

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36
Q

Describe the PVR in a Left-to-Right Shunt.

A

Low PVR

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36
Q

Is a Right-to-Left Shunt an Acyanotic or Cyanotic Heart Defect?

A

Cyanotic Heart Defect

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37
Q

Pulmonary Blood Flow in Left-to-Right Shunt.

A

Pulmonary blood flow increases d/t low PVR → Volume overload for lungs

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38
Q

Effects on the LV from a Left-to-Right Shunt.

A
  • Less blood flow to the LV
  • Increase workload of LV to maintain adequate CO
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39
Q

Examples of Left-to-Right shunt

A
  • ASD
  • VSD
  • PDA
  • Coarctation of the Aorta
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40
Q

What to avoid in a Left-to-Right Shunt.

A
  • Vasodilators
  • 100% FiO2
  • ↓PCO2
  • Alkalosis
41
Q

Hemodynamic Consequences for Left-Right Shunt

A
42
Q

Hemodynamic Goals for Left-Right Shunt

A
43
Q

Pulmonary Blood Flow in Right-to-Left Shunt.

A

Decrease Pulmonary Blood Flow d/t PVR or Pulmonary Outflow Tract is greater than SVR → admixture of deoxygenated blood in the systemic circulation and systemic hypoxia.

44
Q

What kind of ventricular failure will result from Right-to-Left Shunt?

A

RV Failure

45
Q

Examples of Right-to-Left Shunt

A
  • Tetralogy of Fallot
  • Transposition
  • Truncus Arteriosus
  • Hypoplastic Left Heart
46
Q

What to avoid in a Right-to-Left Shunt

A
  • Sympathetic Stimulation
  • ↓ FiO2
  • ↑ PCO2
  • Acidosis
47
Q

Hemodynamic Consequences for Right-to-Left Shunt

A
48
Q

Hemodynamic Goals for Right-to-Left Shunt

A
49
Q

Effects of Volatile Anesthetics in a Right-to-Left Shunt

A

Inhaled Induction Prolonged (IV Induction would be preferred and much faster)

50
Q

Paradoxical emboli will most likely occur in which shunt? (Right-to-Left Shunt or Left-to-Right Shunt)

A

Right-to-Left Shunt

51
Q

What is the largest group of cyanotic lesions?

A

Mixing Lesions

52
Q

What are Mixing Lesions?

A
  • Congenital heart defects where oxygenated and deoxygenated blood mix together, often leading to lower levels of oxygen in the blood that circulates throughout the body.
  • Pulmonary and Systemic O2 sats almost identical
53
Q

Mixing Lesions are dependent on what factor?

A

Vascular Resistance (PVR or SVR)

54
Q

Example of Mixing Lesion

A

Truncus Arteriosus

55
Q

What are obstructive lesions?

A
  • Condition where a heart valve, is narrowed or blocked, impeding normal blood flow.
  • Conditions can range from mild to severe
56
Q

Obstructive lesions can lead to pressure-overloaded ventricles proximal to the obstruction. What can this result in?

A
  • Profound LV Failure
  • Impaired Coronary Artery Perfusion
  • Systemic Hypotension
  • Hypoxemia
57
Q

Examples of Obstructive Lesions

A
  • Aortic Stenosis
  • Coarctation of the Aorta
58
Q

What causes the significant decrease in PVR after birth?

A
  • Lung Expansion
  • Oxygenation
59
Q

How long does it take for a newborn’s PVR to reach the level of an adult?

A

6 months

60
Q

Reactive PVR can lead to this condition.

A

Pulmonary Hypertension.

61
Q

Factors that can increase PVR

A
62
Q

Factors that can decrease PVR

A
63
Q

What are the effects of nitric oxide on smooth vascular muscles?

A

Relaxes vascular smooth muscles

Can cause rebound hypertension after d/c

64
Q

Neonatal Congenital Heart Surgery Preoperative Plan

A
  • EKG
  • ETT (Often nasal to prevent extubation by TEE)
  • Pre/post ductal pulse ox
  • Art line (usually right radial)
  • Central line (usually right)
  • Cerebral oximetry
  • BIS
  • TEE
  • Pacemaker (ready)
  • Blood warmer
  • Level-1 infuser
65
Q

Signs and Symptoms of Congenital Heart Defect

A
66
Q

A patent foramen ovalis provides normal fetal communication between what two heart chambers?

A

RA and LA

67
Q

When does the PFO ordinarily close?

A

Soon after birth

68
Q

What is a Prium ASD?

A

ASD in the inferior part of the atrial septum, close to the AV valve.

69
Q

What is a Secundum ASD?

A

ASD close to the fossa ovalis, defect in septum secundum.

70
Q

What is Sinus Venosus?

A

ASD is high in the atrial septum, close to the SVC.

71
Q

Coronary Sinus ASD allows blood flow from the RA to the LA through the ____________

A

Coronary Sinus

72
Q

What is a common atrium?

A
  • ASD with an absence of an atrial septum.
  • May have some abnormal AV valves
73
Q

Many ASD and VSD can be closed with a __________ device

A

Percutaneous Catheter

74
Q

Anesthesia Considerations for ASD surgery

A
  • Use short-acting drugs
  • Often extubated on table
  • Postop pulmonary hypertension rare
75
Q

What is the most common congenital defect?

A

VSD accounts for 20% of CHD

76
Q

Decribe the flow in Restrictive vs Unrestrictive VSD

A
  • Restrictive: flow is small
  • Unrestrictive: flow is large
77
Q

Why may inotropic support be needed after a VSD surgery?

A
  • To prevent pulmonary hypertension if left to right shunt was significant.
  • The Right Heart may need some assistance to pump against the pulmonary pressure now the VSD is closed.
78
Q

During fetal circulation, what shunt extends from the descending aorta to the main pulmonary artery?

A

Patent Ductus Arteriosus (PDA)

79
Q

Why is PDA typical in preterm infants?

A
  • Decrease degradation/breakdown of PGE1
  • Increase production of PGE1
80
Q

Where would you place preductal and postductal pulse oximetry to assess PDA?

A
  • Preductal Pulse Ox on Right Hand
  • Postductal Pulse Ox on Left Foot

If Aorta is clamped inadvertently, lower limb data may be lost

81
Q

What is the most common cyanotic heart defect?

A

Tetralogy of Fallot

82
Q

What are the four different deformities involved in Tetralogy of Fallot?

A
  • VSD
  • Overriding Aorta
  • RV Outflow Obstruction
  • RV Hypertrophy
83
Q

What happens during a Tet Spell?

A

Increased sympathetic stimulation or oxygen demand (crying, surgery, feeding, metabolic acidosis) causes increased RV outflow obstruction, causing hyper cyanosis.

84
Q

What position can help increase SVR, reduce right-to-left shunting, and increase blood flow to the lungs during a Tet Spell?

A
  • Knee-to-chest position
  • Squatting
85
Q

Anesthesia Considerations for TOF

A
  • Preop Sedation
  • 100% O2
  • Beta Blockade
86
Q

What does a complete TOF repair consist of?

A

Closing VSD and applying transannular patch at the level of RV Outflow Obstruction

87
Q

What is a Blalock-Taussig Shunt?

A
  • Creating a shunt from the subclavian artery to the branch of the pulmonary artery
  • This will increase pulmonary blood flow in TOF patients
88
Q

What two arteries are switched in the Transposition of the Great Arteries?

A
  • Aorta coming from the RV
  • Pulmonary Artery coming from the LV
  • Some mixing of oxygenated and deoxygenated blood by PDA or VSD
89
Q

What issue can occur without a VSD in Transposition of the Great Arteries?

A
  • Inadequate mixing
  • Repair needed early (emergent)
  • LV only exposed to low pressure lung
90
Q

What issue can occur with a large VSD in Transposition of the Great Arteries?

A

At risk of pulmonary hypertension d/t high pulm blood flow

91
Q

What is the most common treatment for TGA?

A
  • Arterial Switch
  • Transection of arteries distal to valves
  • Disconnection of coronary arteries and re-anastamosis to aorta
  • A conduit inserted between RV and Pulmonary Artery if RV outflow is stenotic
92
Q

What is truncus arteriosis?

A
  • Congenital heart defect where a single common arterial trunk arises from the heart, instead of the usual two separate arteries (the aorta and pulmonary artery)
  • Common arterial outlet
  • Common valve
  • VSD

High pulmonary blood flow and pulmonary hypertension develops early

93
Q

What syndrome is associated with Truncus Arteriosis?

A

DiGeorge Syndrome

94
Q

Characteristics of DiGeorge Syndrome

A
  • Aortic arch abnormalities
  • Absent Parathyroids
  • Immune Deficiency
95
Q

Anesthesia Considerations for Truncus Arteriosis

A
  • Already intubated and on inotropes
  • Irradiated blood
  • Close watch of calcium levels
  • Circulation arrest may be required
  • Nitric oxide postop
96
Q

Characteristics of Hypoplastic Left Heart Syndrome (HLHS)

A
  • Hypoplastic LV
  • Mitral stenosis/ atresia (closed)
  • Aortic stenosis/ atresia
  • Hypoplastic Aortic Arch
  • ASD
97
Q

How many surgeries does it take to repair Hypoplastic Left Heart Syndrome?

A

3 stages (Norwood, Glenn, Fontan procedure)

98
Q

Typical O2 saturation of children with Hypoplastic Left Heart Syndrome

A

80’s

99
Q

Anesthesia Considerations for HLHS

A
  • Balance PVR and SVR
  • High PVR → Cyanosis
  • Low PVR → Pulmonary overload, systemic hypoperfusion (acidosis)
  • Keep PaCO2 high/Normal → Keep Vasodilation
  • Keep FiO2 low → Prevent Vasoconstriction

Advanced Principles C (11 decks)

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