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Grown up Congenital Heart Disease Patient Presenting for Non Cardiac Surgery: Anaesthetic Implications Mohammad Hamid Aga Khan University

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Grown up Congenital Heart Disease Patient Presenting for Non Cardiac Surgery: Anaesthetic Implications Mohammad Hamid Aga Khan University eCommons@AKU Department of Anaesthesia Medical College, Pakistan November 2010 Grown up congenital heart disease patient presenting for non cardiac surgery: anaesthetic implications Mohammad Hamid Aga Khan University Mansoor Ahmed Khan Aga Khan University Mohammad Irfan Akhtar Aga Khan University Hameedullah Aga Khan University Saleemullah Aga Khan University See next page for additional authors Follow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_anaesth Part of the Anesthesiology Commons, and the Surgery Commons Recommended Citation Hamid, M., Khan, M., Akhtar, M., Hameedullah, ., Saleemullah, ., Samad, K., Khan, F. (2010). Grown up congenital heart disease patient presenting for non cardiac surgery: anaesthetic implications. Journal of the Pakistan Medical Association, 60(11), 955-9. Available at: http://ecommons.aku.edu/pakistan_fhs_mc_anaesth/19 Authors Mohammad Hamid, Mansoor Ahmed Khan, Mohammad Irfan Akhtar, Hameedullah, Saleemullah, Khalid Samad, and Fazal Hameed Khan This article is available at eCommons@AKU: http://ecommons.aku.edu/pakistan_fhs_mc_anaesth/19 Review Article Grown up Congenital Heart Disease patient presenting for non cardiac surgery: Anaesthetic implications Mohammad Hamid, Mansoor Ahmed Khan, Mohammad Irfan Akhtar, Hameedullah, Saleemullah, Khalid Samad, Fazal Hameed Khan Department of Anaesthesia, Aga Khan University Hospital, Karachi. Abstract chances of survival6 and reduces complications associated with heart defects. Congenital heart disease patients surviving to adulthood have increased over the years due to various reasons. Presence of grown up congenital heart (GUCH) disease These patients are admitted in the hospital for non cardiac poses increased risk of mortality and morbidity under surgeries and other procedures more often than normal adult anaesthesia.7 Anaesthetic management of these patients population. Management of grown up congenital heart disease particularly the uncorrected group, in the operating room is patient presents a challenge during perioperative period for challenging in several respects. Firstly, some heart defects are cardiologists, surgeons, intensivists and particularly for the so complex that involvement of paediatric cardiologists and anaesthetist. Management issues include psychological and intensivists is necessary for complete understanding of the physiological impact on the patient, complexity of defects, anatomy and pathophysiology. Additionally the management is presence of previous palliative procedure, impact of quite complex and the anaesthetist needs to make an 8 anaesthetic agents on shunting and myocardium, endocarditis individualized anaesthetic plan after several considerations. prophylaxis and associated extra cardiac anamolies. These essentially look at the effect of anaesthetic drugs on the heart and shunt, fluid management, effect of ventilatory Introduction changes on shunts and how to avoid pulmonary hypertension. Population of adults with congenital heart disease Most of these CHD defects can be categorized into (CHD) has increased over the years1 due to improvement in those associated with increased pulmonary flow, reduced paediatric cardiology, improved surgical and anaesthetic pulmonary flow and obstructive lesions. Other factors which techniques2 and better postoperative care. Expectations are that should be considered are age of the patient, cardiac lesion, soon there will be more adults than children with CHD who previous surgery performed (palliative or corrective), presence have undergone some sort of palliative or corrective surgery.3 of cardiac complication and associated congenital anomalies. Incidence of CHD is about 0.8% of all live births4 and 85% of these CHD patients are expected to survive to adulthood in Preoperative Considerations: USA.5 Early surgical intervention has also improved their GUCH patients coming to preoperative clinic can be 955 J Pak Med Assoc grouped into three categories: Non operated patient; patient consumption in the doses of 0.5 mg/kg orally half hour before with previous palliative surgery9 and patient with previous surgery. If IV is present then incremental doses of 0.1 - 0.25 mg corrective surgery. Patients with total corrective surgery midazolam can be given. may still have residual defects. These patients may have Endocarditis prophylaxis has recently been revised12,13 single ventricle physiology, single RV or complex intra For dental procedures AHA recommend prophylaxis in cardiac baffles. patients is a follows: Detailed information should be obtained about cardiac When gingival tissues manipulated, or periapical region of lesion, altered physiology and its implications under teeth or perforation of oral mucosa anaesthesia. Information about the age is very important as some lesions require early repair. Delayed surgery may Prior history of infective endocarditis otherwise lead to complications like pulmonary HTN, poor Non-repaired cyanotic congenital heart disease (CHD), development of pulmonary vessels and failure to gain weight, including shunts and conduits which indicate cardio respiratory decompensation. Poor Complete CHD repair within the previous six months exercise tolerance is indicated by fatigue and dyspnoea on Repaired CHD with residual defects feeding, irritability and failure to gain weight. Previous cardiac and non cardiac surgeries and prolonged intubation should be Antibiotic for infective endocarditis prophylaxis is no longer enquired as they suggest subglottic stenosis. indicated in patients with Cyanosis and congestive heart failure (CHF) are major Aortic stenosis, mitral stenosis, or symptomatic or manifestations of CHD. Cyanosis occurs due to decreased asymptomatic mitral valve prolapse. pulmonary flow anatomically or functionally (Mixing lesion). Genitourinary and gastrointestinal tract Cyanosis may be permanent or appears intermittently. Central procedures (transesophageal echocardiography, cyanosis is recognizable when deoxygenated haemoglobin in esophagogastroduodenoscopy, colonoscopy, etc.) do arterial blood is > 3 gm/dl. not warrant infective endocarditis prophylaxis Along with left ventricular function, the right unless active infection is present. ventricular function should also be assessed as it is equally Investigation: important in the paediatric CHD patient. Patients with high pulmonary flow may present with tachycardia, tachypnoea, Complete blood count and coagulation profile should irritability, cardiomegaly and hepatomegaly. History of always be checked. Polycythaemia14 increases blood viscosity wheezing, frequent respiratory infection and pneumonia is also which leads to thrombosis and infarction in cerebral, renal and common. The amount of cardiac reserve is assessed by pulmonary region. PT and PTT are usually abnormal in the exercise tolerance in older children. Pregnant patients with polycythaemic patient. Coagulation abnormalities also occur GUCH require special attention on preoperative evaluation. due to platelet dysfunction, hypofibrinogenaemia and factor These patients need regular follow up, early involvement of deficiencies. Preoperative phlebotomy15 is performed in anaesthetist, assessment of degree of cardiovascular symptomatic hyperviscosity and HCT > 65%. Dehydration impairment and optimization of pulmonary vascular resistance. may further aggravate symptoms and should be corrected High foetal mortality10 is seen in mothers particularly with low before deciding about phlebotomy. WBC count and CRP gives saturation and very high haematocrit levels. clue to the diagnosis of infection. Associated non cardiac congenital anomalies include Serum electrolytes should be checked in patients musculoskeletal abnormalities 8.8%, neurologic defects 6.9% receiving diuretics. Hypocalcaemia is commonly found in and genito urinary irregularities 5.3%. Downs syndrome patients with Di George syndrome. Recent ECG, ECHO and patients may have atlanto -occipital subluxation. catheterization findings are very important to decide about Drug history can show the use of warfarin, anaesthesia management. ECG may show ventricular strain or antidepressants, diuretics and anti arrhythmics with their hypertrophy. ECHO used for doppler and colour flow mapping associated side effects. Laboratory investigation should be while catheterization is used for information about pressures in tailored accordingly. different chambers, magnitude of shunt and coronary anatomy. NPO orders should be clearly written with timing if The chest X-Ray shows the heart position possible. Dehydration should be avoided in cyanotic GUCH (Dextrocardia) and size, atelectasis, acute respiratory infection, patients. If timing of surgery is uncertain then an IV line should vascular markings and elevated hemidiaphragm. Patients with be placed and fluids started. diminished pulmonary blood flow show reduced pulmonary Midazolam11 is the preferred sedative to reduce oxygen markings. Vol. 60, No. 11, November 2010 956 Intraoperative Considerations: diastolic blood pressure. Therefore DBP should be monitored during surgery. Modified Blalock Taussig shunt (BT shunt) is All intravenous tubings, free of air bubble and an artificial shunt between subclavian artery (usually right) and preferably filters,16 should be placed in patients with pulmonary artery. Its dimension is fixed so its output is Eisenmenger's syndrome. Hypothermia should be avoided and. proportional to SVR and in case of systemic hypotension, the Polycythaemic patient must be well hydrated17 before pulmonary blood
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