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Peds - Exam 4 > Topic 16: HLHS HRHS > Flashcards

Topic 16: HLHS HRHS Flashcards

1
Q

Sano shunt size?

A

5.0 mm shunt size-average

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2
Q

Mod BT shunt - average size

A

3.5 mm shunt size average

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3
Q

Norwood procedure is what stage?

A

Stage 1

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4
Q

During circ arrest what should the perfusionist be doing?

A

Take blood gases
stay cold
recirc through hemofilter
balance your electrolytes bc your K will probably be high

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5
Q

Norwood Procedure

A

Close PDA
enlarge aorta (create neo-aorta)
Add systemic PA shunt during warming (Mod BT or Sano)

Common atrium
One ventricle

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6
Q

Sano Shunt

A

In the RV to the PA, (gor-tex - extracardiac)
think about diastolic run off
you have dynamic movement/pulsatility bc its in the heart so there is less clotting

Distally, the graft is connected to the main PA between
the right and left pulmonary artery takeoffs. The proximal end of the shunt is connected to a limited infundibular incision in the RV

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7
Q

Rastelli Shunt

A

extra-cardiac

RV to PA aswell. Like same think as a sano shunt

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8
Q

Sano Modification of the Norwood involves what?

A

The Sano Modification of the Norwood involves the

placement of a conduit between the RV and the PA instead of the Modified BT Shunt

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9
Q

What should you always bring with you for a redo procedure ?

A

Femoral cannulas incase you have to crash back on

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10
Q

Sano shunt is constructed out of what?

A

The shunt is constructed from a slightly larger Gortex tube graft than that used for the modified BT shunt. Generally a 5 mm tube graft is selected in contrast to the 3.5 mm graft

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11
Q

Sano Shunt history

A

A number of centers around the world have begun to adopt a modification of the Norwood procedure.
Introduced by Shunji Sano, MD, who was trained in congenital
cardiac surgery in Melbourne, Australia; this new modification showed improvement in the survival of newborn babies with HLHS

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12
Q

MBTS (subclavian -> PA) different than Sano?

A

May have preferential right PA flow
Smaller shunt that may clot post-op
Rocky course in the OR
More stable in the PICU post-op

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13
Q

HLHs is kinda like in left heart bypass – what is SVR ?

A

control systemic arterial pressure

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14
Q

QP/QS – if you have a bigger shunt what will happen?

A

Qp/Qs will go up

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15
Q

increase PVR what is happening to Qp/Qs

A

its going down

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16
Q

Sano (RV -> PA) how is it different than MBTS

A 
More centrally located on PA
Higher pressure shunt
Larger shunt
More stable in the OR
Rocky course in the PICU
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17
Q

single ventricle kids have what hct usually when coming off bypass?

A

greater than 40% bc need to keep the oxygen delivery up

blood prime

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18
Q

Survival rate for Norwood Procedure ?

A

Today, about 90 percent of babies presenting with
HLHS can be expected to survive their Norwood
operation; truly a success given that 20+ years ago the outlook was hopeless

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19
Q

Post Norwood – so now I have new pulmonary (MBTS) and systemic blood flow (Neo-aorta), how can I manage it?

A

By controlling PVR and SVR you can control the
preferential flow of blood
The surgery set the flow parameters (conduit size)
Post-op manipulates the resistance (PVR/SVR)

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20
Q

Blood flow is ________ to resistance that is,

A

inversely proportional

when resistance in blood vessels decreases, blood flow through these vessels increases

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21
Q

What is the difference between Fistula and Fenestration ?

A

God made fistula

Surgeons create fenestration’s

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22
Q

Fontans can become disfunctional by an increase in what?

A

HIGH PVR

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23
Q

Blood Flow Balance in HLHS?

A

In HLHS, total blood flow coming from the heart can
be considered to be a zero sum game.
Thus, when more blood is directed to one circulation,
less is available for the competing circuit.
Sound a little like left heart bypass

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24
Q

Parallel Circulation – pulmonary and systemic
blood flow is determined by what?
Qp/Qs describes what?

A

the ratio of Pulmonary vascular resistance (PVR) to Systemic vascular resistance (SVR).

Qp/Qs describes how the cardiac output from the single ventricle is partitioned.
If a marked discrepancy occurs in blood flow to the
pulmonary and systemic circulations, rapid onset of
hemodynamic instability will occur

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25
Q

What blood gases are key to live with these HLHS kida?

A

7.4 - ph
40 - CO2
40 - HCT

26
Q

Dont ever take a single ventricle kid and bag them with 100% O2 why???
—(this is not on bypass – just transport)

A

bc it will knock out their drive to breath and they will circ arrest
So have anesthesia set the ventilation Fi02 to .17 (17%)

27
Q

The BT shunt/Sano connecting the systemic circulation to the pulmonary circulation is what??

A

the single largest component of resistance

28
Q

Surgical Shunt (Bt/ Sano) - when is Qp/Qs calculated?

A

The Qp/Qs ratio is calculated after cardiopulmonary bypass is discontinued.
As in preoperative management, the goal is to achieve a Qp/Qs ratio of 1.0.

29
Q

Qp/Qs is a modified what?

A

Fick Equation

CO= oxy consumption/(systemic art sat-systemic venous O2 sat) x 1.36 x 10

30
Q

perioperative management of the Norwood procedure - -what would you draw and look at?

A

Recent articles indicate the usefulness of mixed
venous oxygen saturation (SvO2) monitoring to estimate pulmonary-to-systemic blood flow ratio (Qp/Qs) in perioperative management of the Norwood procedure

31
Q

Surgical shunt - (BT/Sano) – Although increased pulmonary blood flow results in higher oxygen saturation, systemic blood flow is decreased.
what happens to perfusion? acid base status?

A

Perfusion becomes poor, and metabolic acidosis and

oliguria may develop

32
Q

Surgical shunt - (BT/Sano)
If PVR is significantly higher than SVR, systemic blood flow is increased at the expense of pulmonary
blood flow. - may result in what?

A

This may result in profound hypoxemia

33
Q

What can increase PVR?

A

↓FiO2
↑CO2
↓pH
PEEP

34
Q

What can decrease PVR?

A

↑FiO2
↓CO2
↑pH
iNO (inhaled nitric oxide)

35
Q

What can increase SVR?

A

↑Ph
↑FiO2
Vasoconstrictors

36
Q

What can decrease SVR?

A

↑CO2*

Vasodilators

37
Q

PVR can also be increased by maintaining the hematocrit at what?

A

at greater than 40%, a state that optimizes oxygen-carrying capacity and increases the viscosity of the blood increased viscosity

38
Q

if you put a VAD in a kid – what happens to the hearts geometry?

A

the ventricular septum will migrate towards the VAD and ruin the hearts natural geometry

39
Q

Bidirectional Glenn or Hemi Fontan (Stage II)
when done?
CPB?
Do what?

A

Preformed at around 6 months of age
Larger child now, this will increase pulmonary blood flow
Cyanosis increasing between stages I and II would shorten the duration of time between surgeries
Done w/ DHCA or off CPB
Take down systemic-PA shunt
Occlude SVC flow
Anastamosis done right PA to the SVC

40
Q

Stage III choices? – Single Ventricle

A

Two choices:
Intracardiac Baffle Lateral Tunnel (after HFP)

Extracardiac ConduitExternal Conduit (after BDG)

41
Q

So where does the energy for Fontan blood flow to the lungs come from ?

A

After a Fontan operation, the pressure in the veins will be
higher than normal, to overcome this resistance and maintain blood flow.
(high CVP = 14-25+ mmHg)

“Any fluid flowing in a tube will continue to move, becoming slower and slower, until the resistance offered by the tube makes it stop.”

42
Q

When can the Fontan not be completed?

A

When PVR is too high

43
Q

High CVP after fontan– That CVP propels blood through what circulation?

A

capillaries →veins → RA→lungs

44
Q

In a Fontan circulation blood goes:

A

LV → aorta → organs.

45
Q

Hybrid treatment of HLHS - where? what?

A 
Hybrid Cath Lab/OR room
Palliation to ensure survival
      PDA stent
      Atrial Septal Stent (Balloon if needed first)
      Bilateral PA Banding
46
Q

HLHS – Surgical Mortality/Morbidity:

A

.75 x .95 x .9 = 64% overall survival
* Following the Norwood procedure (stage I), overall success (survival to hospital discharge) is approximately 75%.
Some centers have reported stage I survival rates in excess of 90%. (related, in part, to institutional surgical volume)
The overall success following the hemi-Fontan procedure (stage II) approaches 95%.
Success after completing the Fontan procedure (stage III)
approaches 90%.

47
Q

Orthotopic heart transplantation surgical mortality/morbidity

A

results in early and long-term success similar to that of staged reconstruction. Among low-risk patients who undergo staged reconstruction or transplantation, actuarial survival at 5 years is approximately 70%.

48
Q

Ideal Post-op blood gases?

pCO2, pH, PaO2, SaO2

A

PaCO2: 35–45 mm Hg
pH: 7.35–7.40
PaO2: 30–45 mm Hg
SaO2: 70–85%

7.4 / 40 / 40 is key Hematocrit >40 % , SAO2 = 75%

49
Q 
PaCO2: 36
pH: 7.23
PaO2: 49
SaO2% 88%
BE:-7.8
A

Too much shunt flow?

50
Q 
PaCO2: 48
pH: 7.19
PaO2:23
SaO2: 58%
BE:-11.8
A

Too little shunt flow

51
Q

Management strategies Post Norwood?

A

Increased inspired nitrogen (hypoxia-FiO2=.17)
OR
Increased inspired carbon dioxide (hypercarbia).

There are no studies directly comparing these2 therapies in humans

52
Q

CPB considerations for HLHs – how do they do?

A

Fragile OR and post-op course
May need ECMO
May need NOMO (ECMO with no oxygenator in line)
May need a VAD
Hemi-and Fontan are redo surgeries (femoral cannula?)

53
Q

Norwood Pocedure –
Cannulation
Temp?
CPG?

A 
Arterial: Pulmonary artery (what?)
Venous: Single atrial
Hypothermia: DHCA (possibly antegrade cerebral/retrograde cerebral perfusion)
Cardioplegia: One shot antegrade 
Thru arterial cannula  
Aortic root if possible
54
Q

Norwood Procedure – pump run? 2 options

A

On →cool: 20 min →XC/CP/arrest →warm: on 23 min →off CPB →MUF 10 min
*(On DHCA: let venous exsanguination occur before clamping the venous line )

OR
On →cool: 20 min →Arrest/XC/CP →warm: on 23 min →off CPB→MUF 10 min
Typical times:
CPB time = 43” XC time= 48 Arrest time= 45

55
Q

Bidirectional Glenn
Cannulation? Temp? CPG?

What till follow?

A 
Arterial: Neo-aorta
Venous: Single Atrial
Hypothermia: Moderate –continuous CPB
Cardioplegia: No cardioplegia
An extra-cardiac 
Fontan will follow this procedure
56
Q

Hemi Fontan
Cannulation? Temp? CPG?

what will follow?

A 
Arterial: Neo-aorta
Venous: Single Atrial
Hypothermia: DHCA
Cardioplegia: With cardioplegia
A lateral tunnel Fontan will follow this procedure
57
Q

Fontan

Cannulation, Temp, CPG?

A

Arterial: Neo-aorta
Venous: Single atrial
Hypothermia: Mild
Cardioplegia: With or without cardioplegia

58
Q

Redo surgeries can take a while to get in ?

A

(be ready to use emergent femoral cannulation)

59
Q

Options w/ HLHS if pt cant come off of bypass?

A

ECMO
NOMO
Pediatric VAD

60
Q

The Berlin Heart- how driven, pump sizes?

A

The Berlin Heart™ is a pneumatically driven, pulsatile para-corporeal device that can offer either LVAD, RVAD or (BIVAD) support.
The pump sizes are 10, 25, 30, 50 and 60 mls, meaning that it can be used to support any size of child from 3-100 kg.
The LVAD drains blood from the LV via a cannula inserted into the apex and returns it to the aorta
The RVAD drains from the RA and returns blood to the PA

VADS can be time consuming to the staff (perfusion may have to be in-house or bedside)
Other VADS are used with a BSA > 0.7
Most Peds centers have ECMO staffs that already are made to staff 24/7

61
Q

Berlin Heart - what size patient?

A

> 0.7 BSA

Peds - Exam 4 (5 decks)

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