UTHSCSA Pediatric Resident Curriculum for the PICU

Postoperative Care in the Patient With Congenital Heart Disease

General Principles
Patient homeostasis

Early declining trends do not correct themselves Late time can be important diagnostic tool

The enemy of good is better

Specific Approaches
Cardiovascular principles Approach to respiratory management Pain control/sedation Metabolic/electrolytes Infection Effects of surgical interventions on these parameters

NO PARAMETER EXISTS IN ISOLATION

Cardiovascular Principles
Maximize O2 delivery/ O2consumption ratio

Oxygen delivery:
Cardiac

Output Ventilation/Oxygenation Hemoglobin

Maximizing Oxygen Delivery

Metabolic acidosis is the hallmark of poor oxygen delivery

Maximizing Oxygen Delivery

OXYGEN DELIVERY =

OXYGEN CONTENT

CARDIAC OUTPUT

Maximizing Oxygen Delivery Cardiac Output

O2 Content = Saturation(O2 Capacity)+(PaO2)0.003 Oxygen Capacity = Hgb (10) (1.34) So . . Hemoglobin and saturations are determinants of O2 delivery

Maximizing Oxygen Delivery Cardiac Output

23 21 19 17
Hemoglobin (gm/dl)
Gidding SS et al 1988 y=-0.26(x)+38 R=0.77 S.E.E.=1.6

15 13

65

70

75

80

85

90

Saturation(%)

Maximizing Oxygen Delivery Cardiac Output

Cardiac Output = Stroke Volume X Heart Rate

Stroke Volume Contractility Diastolic Filling Afterload

Heart rate Physiologic Response Non-physiologic Response Sinus vs. junctional vs. paced ventricular rhythm

Maximizing Oxygen
Oxygen consumption

Decreasing metabolic demands

Sedation/

paralysis Thermoregulation

Ventilator Strategies
Respiratory acidosis/hypercarbia Oxygenation

Physiology of single ventricle/shunt lesions Oxygen delivery!

Atelectasis 15-20 cc/kg tidal volumes. PEEP, inspiratory times

Ventilator Strategies: Pulmonary Hypertension

Sedation/neuromuscular blockade High FiO2 no less than 60% FiO2 Mild respiratory alkalosis

pH 7.50-7.60 pCO2 30-35 mm Hg

Nitric Oxide

Ventilator Strategies: Pulmonary Hypertension

Precipitating Event
-Cold stress -Suctioning -Acidosis Metabolic Acidosis Hypercapnia Increased PVR

Hypoxemia Low output Ischemia

Decreased Pulmonary Blood Flow

Decreased LV preload RV dysfunction Central Venous Hypertension

Pain Control/Sedation
Stress response attenuation Limited myocardial reserve decreasing metabolic demands Labile pulmonary hypertension Analgesia/anxiolysis

Pain Control/Sedation
Opioids
MSO4 Gold standard: better sedative effects than synthetic opioids

Cardioactive histamine release and limits endogenous catecholamines Less histamine release More lipid soluble better CNS penetration

Fentanyl/sufentanyl

Pain Control/Sedation
Sedatives
Chloral hydrate

Can be myocardial depressant Metabolites include trichloroethanol and trichloroacetic acid Valium/Versed/Ativan

Benzodiazepines

Pain Control/Sedation
Muscle relaxants
Depolarizing Succinylcholine

Bradycardia ( ACH) Pancuronium tachycardia Vecuronium shorter duration Atracurium

spontaneously metabolized Histamine release

Non-depolarizing

Pain Control/Sedation
Others:
Barbiturates vasodilation, cardiac depression Propofol myocardial depression, metabolic acidosis Ketamine increases SVR Etomidate No cardiovascular effects

Fluid and Electrolytes

Effects of underlying cardiac disease Effects of treatment of that disease

Cardiopulmonary Bypass
Controlled shock Loss of pulsatile blood flow

Capillary leak Vasoconstriction Renovascular effects

Renin/angiotensin

Cytokine release Endothelial damage and sheer injury

Cardiopulmonary Bypass
Stress Response Lung Fluid Filtration = SIRS
Microvascular [( Hydrostatic Pressure

Microembolic Events )-(

Microvascular )] Oncotic Pressure

Renal Insufficiency

Fluid Administration Capillary Leak Syndrome

Hemorrhage

Feltes, 1998

Circulatory Arrest
Hypothermic protection of brain and other tissues Access to surgical repair not accessible by CPB alone Further activation of SIRS/ worsened capillary leak.

Fluid and Electrolyte Principles

Crystalloid

Total body fluid overload Maintenance fluid = 1500-1700 cc/m2/day POD 0 : 50-75% of maintenance POD 1 : 75% of maintenance Increase by 10% each day thereafter

Fluid advancement:

Fluid and Electrolyte Principles

Flushes and Cardiotonic Drips

Remember: Flushes and Antibiotics = Volume

UTHSCSA protocol to minimize crystalloid: Standard Drip Concentration

Mix in dextrose or saline containing fluid to optimize serum glucose & electrolytes Sedation: (Used currently as carrier for drips) MSO4 2cc/hr = 0.1 mg/kg/hr Fentanyl 2 cc/hr = 3 mcg(micrograms)/kg/hr Cardiotonic medications: Dopamine/Dobutamine 50 mg/50 cc Epi/Norepinephrine 0.5 mg/50 cc Milrinone 5 mg/50 cc Nipride (Nitroprusside) 0.5 mg/50 cc Nitroglycerin 50 mg/50 cc PGEI 500 mcg/50 cc

Fluid and Electrolyte Principles

Intravascular volume expansion/ Fluid challenges

Colloid osmotically active

FFP 5% albumin/25% albumin PRBCs

HCT adequate: 5% albumin (HR, LAP, CVP) HCT inadequate: 5-10 cc/kg PRBC Coagulopathic: FFP/ Cryoprecipitate Ongoing losses: CT and Peritoneal frequently = 5% albumin

Metabolic Effects
Glucose

Neonates vs. children/adults Hyperglycemia in the early post-op period

Metabolic Effects
Calcium

Myocardial requirements
Rhythm Contractility

Vascular resistance

NEVER UNDERESTIMATE THE POWER OF CALCIUM!

Calcium/inotropes

Alpha 1

DAG
Beta 1
Adenylate Cyclase Regulatory G Protein cAMP-Dependent PK K Na Phosphodiesterase

Na Ca

IP3 Sarcoplasmic Reticulum

Ca Ca

SR

Ca

Ca

Metabolic Effects
Potassium
Metabolic acidosis Rhythm disturbances

Thermal Regulation
As a sign to watch, and an item to manipulate
Perfusion Junctional ectopic tachycardia Metabolic demands Oxygen consumption Infection

Infection
Routine anti-staphylococcal treatment

Effects of Surgical Interventions

Cardiopulmonary Bypass vs. Non-Bypass

Fluids and electrolytes

Modified ultrafiltration Types of anatomic defects

Overcirculated increased blood volumes preoperatively Undercirculated reperfusion of area previously experiencing much reduced flow volumes.

Summary
Optimize oxygen delivery by manipulation of cardiac output and hemoglobin Sedation and pain control can aid in the recovery Appreciate effects of cardiopulmonary bypass and circulatory arrest on fluid and electrolyte management Tight control of all parameters within the first 12 hours; after that time, patients may be better able to declare trends that can guide your interventions.