3/8/2019 Conflict of Interest Anesthetic Approach for cardiac • Current and Past Clinical researcher for Masimo Inc and non-cardiac surgery in the • Past Researcher for Nonin inc. PH patient • Speaker for Somanetics Inc Chandra Ramamoorthy MD Professor, Anesthesiology Stanford University School of Medicine Division of Pediatric Anesthesia Stanford Childrens Hospital Palo Alto CA 94305 Email: chandrar@stanford.edu Dedicated to Rebecca Atherton Rebecca’s Odyssey 10/09/1992-10/11/2018 Born with TOF, PA, MAPCAs-multiple sternotomies Came to Stanford in 2006 with RV dysfunction 2007 -AICD for A fib, VT Annual Cardiac Caths and tune ups 2016 –generator change-20 medications/day Transplant Evaluation 2017-Wisdom teeth extracted 1
3/8/2019 Causes of Anesthesia related Anesthesia and heart DZ: High Cardiac Arrests RISK • Cardiomyopathy with low EF • Left Sided Obstructive lesions • Single Ventricle Physiology • Pulmonary Hypertension: Moderate, Severe Ramamoorthy C et al. Anesth Analg 2010;110:1376-1382 Ramamoorthy C et al. Anesth Analg 2010;110:1376-1382 Outcomes in Children with Postoperative mortality in children after 101,885 anesthetics at a tertiary pediatric hospital. PH @Stanford Pediatric Anesthesia 2010 20: 28–37 o Highest mortality was in neonates • Periop complications during Gen Anesthesia at Stanford o Cardiac surgery carried a higher mortality than ( WILLIAMS GD et al ) NCS o The incidence of anesthesia-related death was 1 • PAP>25 mmHg, PVRI>3WU, 6 year period in 10,188. In all 10 cases, preexisting medical • Risk Factors: Airway instrumentation, major surgery, conditions were identified as being a significant opioid administration factor in the patient's death. Five of these cases (50%) involved children with pulmonary • Cardiac Arrest : 0.8%; 0 mortality hypertension . Anesth Analg, VanderGriend BF, 2011,104, 521) 2
3/8/2019 Evolving Practice ? Procedures in patients with pulmonary hypertension [2015-2018] 250 225 # of procedures =421 # of patients = 347 200 # of procedures 150 153 100 43 50 0 Cardiac Catheterization Cardiac Surgery Non-Cardic Cases Sicker they are more procedures become necessary Non-Cardiac Procedures in Imaging Studies [2015-2018] Patients with PH [2015-2018] 12 50 10 40 # of procedures total=153 # of procedures 8 30 6 20 4 10 2 0 0 3
3/8/2019 ENT procedures Non-Cardiac Surgical Cases [2015- 2018] 25 30 25 # of procedures 20 20 15 15 10 10 5 5 0 0 Serious Adverse Events Surgical Cases with QI events 6 Reported Events: ( 1.4%) # of ENT Procedure (1 event) # of patients patients 3yo; ASA Status 3 # of # of Non- with multiple with QI Cardiac Cardiac surgeries with events >1 Cardiac Catheterization (3 separate events) cases cases QI events surgery 22mo; ASA Status 4 4yo; ASA Status 3 2016 12 0 6 0 1yo; ASA Status 4 2017 5 6 8 1 Cardiac Surgery (2 separate events) 2018 [Q1-Q3] 5 3 7 2 26yo; ASA Status 3 Total 22 9 21 3 4yo; ASA Status 4 Why? 4
3/8/2019 Limitations of the ASA Physical ASA PHYSICAL STATUS Status • Although a great indicator of severity of patients disease • ASA 1: No organic disturbance • ASA 2:Mild to moderate systemic Dz • Does not include risk associated with the procedure eg., cardiac catheterization vs Spinal fusion vs abdominal • ASA 3: Severe systemic Dz surgery • ASA 4: Life threatening systemic disorder • Does not account for experience of the operators • ASA 5: Moribund patient Intraoperative Risk Factors - Preop Risk factors in PH pts Anesthetic Medications “The principle hemodynamic effect of • Age: neonates propofol in children with congenital heart • Syncopal episode disease is a decrease in systemic vascular • Home Oxygen use resistance” • Elevated RA pressure Williams GD, 1999 Anesth-Analg, 89 • Decreased RV function Snoring : independent risk factor for GA (APRICOT Venodilation : In those with Vent. trial, Lancet , 2017) Dysfunction 5
3/8/2019 Ketamine in PH Volatile Anesthetics • Maintains SVR • In the presence of low dose volatile anesthetic no change in PVR noted • Avoids airway instrumentation • Normocapnia and normoxia • Ref: Williams , 2007 ; Friesen , 2016 Negative Inotrope but nonspecific Pulmonary Vasodilators Dexmedetomidine Heart Surgery and PH Identify cases The hemodynamic response to dexmedetomidine loading dose in children with and without pulmonary Surgeon in the room at the time of induction hypertension. CPB primed and ready to go Friesen RH 1 , Nichols CS, Twite MD, Cardwell KA, Pan Z, Pietra B, Miyamoto SD, Auerbach SR, Darst JR, Ivy DD Use of TTE during induction Anesth Analg. 2013 Oct;117(4):953-9. doi: Availability of NO during weaning from CPB 10.1213/ANE.0b013e3182a15aa6. Epub 2013 Aug 19. Although higher incidence of SAE in OR, better rescue rate 6
3/8/2019 Nitric Oxide-Use or Misuse? TTE invaluable adjunct Location of Use Hours of Use Cath lab and Periop 40 CVICU 1072 PICU 920 NICU 3407** L and D 39 Over a 6 month period Anesthetic Challenges During Improving Safety in High Risk Imaging Patients –Ask Questions • Monitoring: • What information will be provided by diagnostic procedure ? • ECG quality varies: loss of early ischemia detection • How will this new information affect management/care • Pulse oximeter & BP : poor design for neonates and infants • Targeted vs Comprehensive Imaging and Tests • Breatholds for imaging • Can any other procedure be combined –Reduce fasting, multiple GA’s and admissions. • CV effects of Anesthesia and Sedation • Duration of GA increases risk of AE • Resuscitation challenges in MRI suite 7
3/8/2019 Be ready to resuscitate Pilot Study of Epi, AVP and Phenylephrine in PH pts presenting for cardiac catheterization Goal: Raise SVR and maintain coronary perfusion Siehr S, PCCM, 2016:17;428-37 Drug of choice is AVP: 0.03 unit/Kg and start an infusion Epinephrine 0.5-1µg/kg -avoid tachycardia Phenylephrine 1-10 µg/kg Calcium Chloride 10-20 mg/kg : raise SVR Early Chest compression and consider ECLS PCCM, AHA & ATS Stanford Approach Recommendation Radiology office: ECHO images; cardiology note, “ Elective surgery for pediatric PH patients relevant information should be performed at hospitals with expertise in PH and in consultation with pediatric PH Cardiac Anesthesiology: Review echo and findings, call family/ cardiologist service and anesthesiologists with experience in the perioperative management of children with Arrange cardiac consult at LPCH PH” Abman et al, 2015, Circulation Inpatients: Examine and review with cardiologist 2015:132; 2037-2099 8
3/8/2019 Conclusion Processes and protocols that set up the caregiver for best patient outcomes . 9
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