Post on 05-Apr-2018
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Postoperative Care in thePostoperative Care in thePatient With CongenitalPatient With CongenitalHeart DiseaseHeart Disease
UTHSCSA Pediatric Resident Curriculum for the PICUUTHSCSA Pediatric Resident Curriculum for the PICU
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General PrinciplesGeneral Principles
Patient homeostasisPatient homeostasis Early declining trends do not correctEarly declining trends do not correct
themselvesthemselves Late time can be important diagnostic toolLate time can be important diagnostic tool
The enemy of good is betterThe enemy of good is better
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Specific ApproachesSpecific Approaches
Cardiovascular principlesCardiovascular principles
Approach to respiratory managementApproach to respiratory management
Pain control/sedationPain control/sedation
Metabolic/electrolytesMetabolic/electrolytes
InfectionInfection
Effects of surgical interventions on theseEffects of surgical interventions on theseparametersparameters
NO PARAMETER EXISTS IN ISOLATIONNO PARAMETER EXISTS IN ISOLATION
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Cardiovascular PrinciplesCardiovascular Principles
Maximize OMaximize O22 delivery/ Odelivery/ O22consumption ratioconsumption ratio
Oxygen delivery:Oxygen delivery:Cardiac OutputCardiac Output
Ventilation/OxygenationVentilation/Oxygenation
HemoglobinHemoglobin
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Maximizing Oxygen DeliveryMaximizing Oxygen Delivery
Metabolic acidosis isMetabolic acidosis is
the hallmark of poorthe hallmark of poor
oxygen deliveryoxygen delivery
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Maximizing Oxygen DeliveryMaximizing Oxygen Delivery
OXYGENOXYGENDELIVERYDELIVERY OXYGENOXYGENCONTENTCONTENTCARDIACCARDIACOUTPUTOUTPUTXX==
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OO22 Content =Content =
Saturation(OSaturation(O22 Capacity)+(PaOCapacity)+(PaO22)0.003)0.003
Oxygen Capacity = Hgb (10) (1.34)Oxygen Capacity = Hgb (10) (1.34)
So . .So . .
Hemoglobin and saturations are determinantsHemoglobin and saturations are determinants
of Oof O22 deliverydelivery
Maximizing Oxygen DeliveryMaximizing Oxygen DeliveryCardiac OutputCardiac Output
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Gidding SS et al 198Gidding SS et al 198
y=-0.26(x)+3y=-0.26(x)+3
R=0.7R=0.7
S.E.E.=1.S.E.E.=1.
Maximizing Oxygen DeliveryMaximizing Oxygen DeliveryCardiac OutputCardiac Output
13
15
17
19
21
23
65 70 75 80 85 90
Saturation(%)
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Maximizing Oxygen DeliveryMaximizing Oxygen DeliveryCardiac OutputCardiac Output
Stroke VolumeStroke Volume ContractilityContractility
Diastolic FillingDiastolic Filling
AfterloadAfterload
Heart rateHeart rate Physiologic ResponsePhysiologic Response Non-physiologicNon-physiologic
ResponseResponse Sinus vs. junctional vs.Sinus vs. junctional vs.
paced ventricular rhythmpaced ventricular rhythm
CardiacCardiacOutputOutput
StrokeStrokeVolumeVolume
HeartHeartRateRate== X
X
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Maximizing OxygenMaximizing Oxygen
Oxygen consumptionOxygen consumption Decreasing metabolic demandsDecreasing metabolic demands
Sedation/ paralysisSedation/ paralysisThermoregulationThermoregulation
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Ventilator StrategiesVentilator Strategies
Respiratory acidosis/hypercarbiaRespiratory acidosis/hypercarbia
OxygenationOxygenation
Physiology of single ventricle/shunt lesionsPhysiology of single ventricle/shunt lesions
Oxygen delivery!Oxygen delivery!
Atelectasis 15-20 cc/kg tidal volumes.Atelectasis 15-20 cc/kg tidal volumes.
PEEP, inspiratory timesPEEP, inspiratory times
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Ventilator Strategies:Ventilator Strategies:Pulmonary HypertensionPulmonary Hypertension
Sedation/neuromuscular blockadeSedation/neuromuscular blockade
High FiO2 no less than 60% FiO2High FiO2 no less than 60% FiO2
Mild respiratory alkalosisMild respiratory alkalosis pH 7.50-7.60pH 7.50-7.60
pCOpCO22 30-35 mm Hg 30-35 mm Hg
Nitric OxideNitric Oxide
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Ventilator Strategies:Ventilator Strategies:Pulmonary HypertensionPulmonary Hypertension
Precipitating
Event-Cold stress
-Suctioning
-Acidosis
Metabolic Acidosis
Hypercapnia
Increased
PVR
Decreased Pulmonary Blood FlowDecreased LV preload
RV dysfunction
Central Venous Hypertension
HypoxemiaLow output
Ischemia
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Pain Control/SedationPain Control/Sedation
Stress response attenuationStress response attenuation
Limited myocardial reserve decreasingLimited myocardial reserve decreasing
metabolic demandsmetabolic demands
Labile pulmonary hypertensionLabile pulmonary hypertension
Analgesia/anxiolysisAnalgesia/anxiolysis
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Pain Control/SedationPain Control/Sedation
OpioidsOpioids MSO4 Gold standard: better sedative effectsMSO4 Gold standard: better sedative effects
than synthetic opioidsthan synthetic opioids Cardioactive histamine release and limits endogenousCardioactive histamine release and limits endogenous
catecholaminescatecholamines
Fentanyl/sufentanylFentanyl/sufentanyl Less histamine releaseLess histamine release
More lipid soluble better CNS penetrationMore lipid soluble better CNS penetration
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Pain Control/SedationPain Control/Sedation
SedativesSedatives
Chloral hydrateChloral hydrate
Can be myocardial depressantCan be myocardial depressant Metabolites include trichloroethanol and trichloroaceticMetabolites include trichloroethanol and trichloroacetic
acidacid
BenzodiazepinesBenzodiazepines
Valium/Versed/AtivanValium/Versed/Ativan
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Pain Control/SedationPain Control/Sedation
Muscle relaxantsMuscle relaxants Depolarizing SuccinylcholineDepolarizing Succinylcholine
Bradycardia ( ACH)Bradycardia ( ACH)
Non-depolarizingNon-depolarizing Pancuronium tachycardiaPancuronium tachycardia Vecuronium shorter durationVecuronium shorter duration AtracuriumAtracurium
spontaneously metabolizedspontaneously metabolized Histamine releaseHistamine release
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Pain Control/SedationPain Control/Sedation
Others:Others:
Barbiturates vasodilation, cardiac depressionBarbiturates vasodilation, cardiac depression
Propofol myocardial depression, metabolicPropofol myocardial depression, metabolic
acidosisacidosis
Ketamine increases SVRKetamine increases SVR
Etomidate No cardiovascular effectsEtomidate No cardiovascular effects
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Fluid and ElectrolytesFluid and Electrolytes
Effects of underlying cardiac diseaseEffects of underlying cardiac disease
Effects of treatment of that diseaseEffects of treatment of that disease
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Cardiopulmonary BypassCardiopulmonary Bypass
Controlled shockControlled shock
Loss of pulsatile blood flowLoss of pulsatile blood flow Capillary leakCapillary leak
VasoconstrictionVasoconstriction
Renovascular effectsRenovascular effects Renin/angiotensinRenin/angiotensin
Cytokine releaseCytokine release
Endothelial damage and sheer injuryEndothelial damage and sheer injury
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Cardiopulmonary BypassCardiopulmonary Bypass
StressResponse SIRS
MicroembolicEvents
RenalInsufficiency
FluidAdministration Hemorrhage
Capillary Leak SyndromeFeltes, 1998
Lung Fluid
Filtration= [( )-( )]
Microvascular
Hydrostatic Pressure
Microvascular
Oncotic Pressure
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Circulatory ArrestCirculatory Arrest
Hypothermic protection of brain and otherHypothermic protection of brain and other
tissuestissues
Access to surgical repair not accessible by CPBAccess to surgical repair not accessible by CPB
alonealone
Further activation of SIRS/ worsened capillaryFurther activation of SIRS/ worsened capillary
leak.leak.
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Fluid and ElectrolyteFluid and ElectrolytePrinciplesPrinciples
CrystalloidCrystalloid Total body fluid overloadTotal body fluid overload Maintenance fluid = 1500-1700 cc/mMaintenance fluid = 1500-1700 cc/m22/day/day
Fluid advancement:Fluid advancement: POD 0 : 50-75% of maintenancePOD 0 : 50-75% of maintenance POD 1 : 75% of maintenancePOD 1 : 75% of maintenance Increase by 10% each day thereafterIncrease by 10% each day thereafter
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Fluid and ElectrolyteFluid and ElectrolytePrinciplesPrinciples
Flushes and Cardiotonic DripsFlushes and Cardiotonic Drips Remember: Flushes and Antibiotics = VolumeRemember: Flushes and Antibiotics = Volume
UTHSCSA protocol to minimize crystalloid: Standard Drip ConcentrationUTHSCSA protocol to minimize crystalloid: Standard Drip Concentration
Mix in dextrose or saline containing fluid to optimize serum glucose & electrolytesMix in dextrose or saline containing fluid to optimize serum glucose & electrolytes
Sedation: (Used currently as carrier for drips)Sedation: (Used currently as carrier for drips)MSO4MSO4 2cc/hr = 0.1 mg/kg/hr2cc/hr = 0.1 mg/kg/hr
FentanylFentanyl 2 cc/hr = 3 mcg(micrograms)/kg/hr2 cc/hr = 3 mcg(micrograms)/kg/hr
Cardiotonic medications:Cardiotonic medications:
Dopamine/DobutamineDopamine/Dobutamine 50 mg/50 cc50 mg/50 cc
Epi/NorepinephrineEpi/Norepinephrine 0.5 mg/50 cc0.5 mg/50 cc
MilrinoneMilrinone 5 mg/50 cc5 mg/50 cc
Nipride (Nitroprusside)Nipride (Nitroprusside) 0.5 mg/50 cc0.5 mg/50 cc
NitroglycerinNitroglycerin 50 mg/50 cc50 mg/50 cc
PGEIPGEI 500 mcg/50 cc500 mcg/50 cc
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Fluid and ElectrolyteFluid and ElectrolytePrinciplesPrinciples
Intravascular volume expansion/ Fluid challengesIntravascular volume expansion/ Fluid challenges Colloid osmotically activeColloid osmotically active
FFPFFP
5% albumin/25% albumin5% albumin/25% albumin PRBCsPRBCs
HCT adequate: 5% albumin (HR, LAP, CVP)HCT adequate: 5% albumin (HR, LAP, CVP) HCT inadequate: 5-10 cc/kg PRBCHCT inadequate: 5-10 cc/kg PRBC Coagulopathic: FFP/ CryoprecipitateCoagulopathic: FFP/ Cryoprecipitate
Ongoing losses: CT and Peritoneal frequently = 5%Ongoing losses: CT and Peritoneal frequently = 5%albuminalbumin
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Metabolic EffectsMetabolic Effects
GlucoseGlucose Neonates vs. children/adultsNeonates vs. children/adults Hyperglycemia in the early post-op periodHyperglycemia in the early post-op period
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Metabolic EffectsMetabolic Effects
CalciumCalcium Myocardial requirementsMyocardial requirements
RhythmRhythm
ContractilityContractility Vascular resistanceVascular resistance
NEVER UNDERESTIMATE THE POWER OFNEVER UNDERESTIMATE THE POWER OF
CALCIUM!CALCIUM!
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Calcium/inotropesCalcium/inotropes
SarcoplasmicReticulum
cAMP-Dependent PK
Ca
Ca
CaCa
Ca
PhosphodiesterasePhosphodiesteraseAdenylateAdenylateCyclaseCyclase
RegulatoryG Protein
Na
Alpha 1Alpha 1
Beta 1
DAG
IP3
Na
KSR
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Metabolic EffectsMetabolic Effects
PotassiumPotassium Metabolic acidosisMetabolic acidosis Rhythm disturbancesRhythm disturbances
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Thermal RegulationThermal Regulation
As a sign to watch, and an item toAs a sign to watch, and an item to
manipulatemanipulate
PerfusionPerfusion Junctional ectopic tachycardiaJunctional ectopic tachycardia
Metabolic demandsMetabolic demands
Oxygen consumptionOxygen consumption
InfectionInfection
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InfectionInfection
Routine anti-staphylococcal treatmentRoutine anti-staphylococcal treatment
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Effects of SurgicalEffects of SurgicalInterventionsInterventions
Cardiopulmonary Bypass vs. Non-BypassCardiopulmonary Bypass vs. Non-Bypass Fluids and electrolytesFluids and electrolytes
Modified ultrafiltrationModified ultrafiltration
Types of anatomic defectsTypes of anatomic defects Overcirculated increased blood volumesOvercirculated increased blood volumes
preoperativelypreoperatively
Undercirculated reperfusion of area previouslyUndercirculated reperfusion of area previously
experiencing much reduced flow volumes.experiencing much reduced flow volumes.
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SummarySummary
Optimize oxygen delivery by manipulation of cardiacOptimize oxygen delivery by manipulation of cardiac
output and hemoglobinoutput and hemoglobin
Sedation and pain control can aid in the recoverySedation and pain control can aid in the recovery
Appreciate effects of cardiopulmonary bypass andAppreciate effects of cardiopulmonary bypass and
circulatory arrest on fluid and electrolyte managementcirculatory arrest on fluid and electrolyte management
Tight control of all parameters within the first 12 hours;Tight control of all parameters within the first 12 hours;
after that time, patients may be better able to declareafter that time, patients may be better able to declare
trends that can guide your interventions.trends that can guide your interventions.