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Zhang H, Song H. A 1-month-old infant with pulmonary hypertensive crisis after cardiac surgery was successfully rescued with connection of left atrial and right ventricular pressure measurement tubes: a case report. Eur Heart J Case Rep 2023; 7:ytad527. [PMID: 38025123 PMCID: PMC10665012 DOI: 10.1093/ehjcr/ytad527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 08/19/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023]
Abstract
Background Pulmonary hypertensive crisis is a complication with extremely high mortality after surgery of congenital heart disease. However, there are still no treatment guidelines or expert consensus on the standard treatment of pulmonary hypertensive crisis, and the effect of conventional treatment is still unsatisfactory. We present a case of a patient who developed pulmonary hypertensive crisis after cardiac surgery, and was successfully rescued with a pioneering method, which has never been reported so far. Case summary An infant with congenital heart disease had undergone cardiac surgery successfully. Due to obvious myocardial oedema, sternal closure was delayed. The left atrial and right ventricular pressure monitoring tubes, both of which were connected through a triplet, were inserted into right pulmonary vein and pulmonary artery, respectively, and the triplet was in closed condition. On the night of the surgery, pulmonary hypertensive crisis occurred. Emergency bedside thoracotomy was given, and the triplet was turned on urgently to make the left atrial and right ventricular pressure monitoring tubes connected. Meantime, conventional treatment was performed. Eventually, the pulmonary hypertensive crisis was quickly relieved, and the infant was discharged 9 days later. Discussion The left atrial and right ventricular pressure monitoring tubes are placed intraoperatively in patients who both need delayed sternal closure and have high risk factors for pulmonary hypertensive crisis, by which could not only monitor the pressure of left atrium and right ventricle in real time but also effectively relieve the right ventricular pressure instantaneously when pulmonary hypertensive crisis occurs, as well as remedy ischaemia of systemic and coronary circulation.
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Affiliation(s)
- Huijun Zhang
- Cardiac Surgery, The First Hospital of Hebei Medical University, Hebei Medical University, 89 Donggang Road, Shijiazhuang, Hebei 050031, China
| | - Hailong Song
- Cardiac Surgery, The First Hospital of Hebei Medical University, Hebei Medical University, 89 Donggang Road, Shijiazhuang, Hebei 050031, China
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Li Q, Zhang C, Wang R, Keller BB, Gu H. Pulmonary hypertensive crisis in children with pulmonary arterial hypertension undergoing cardiac catheterization. Pulm Circ 2022; 12:e12067. [PMID: 35514786 PMCID: PMC9063957 DOI: 10.1002/pul2.12067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/20/2022] [Accepted: 03/01/2022] [Indexed: 11/28/2022] Open
Abstract
Pediatric patients with pulmonary arterial hypertension (PAH) are considered to be at risk for pulmonary hypertensive crisis (PHC) or even death during right heart catheterization (RHC). This retrospective study was designed to identify the risks and clinical characteristics associated with PHC in pediatric PAH patients. We included 163 consecutive procedures from 147 pediatric patients diagnosed with PAH who underwent diagnostic RHC in Beijing Anzhen Hospital between January 2007 and December 2020. The average patient age was 9.0 ± 4.7 years and 84 (51.5%) were females. Before RHC, over 20% of patients were in New York Heart Association (NYHA) class III-IV. Sedation or general intravenous anesthesia was used in 103 procedures (63.2%), with spontaneous breathing in 93.2%. PHC occurred in 19 patients (11.7%), 5 (3.1%) required cardiac compression, and 1 died (0.6%). Compared to patients without PHC, those who experienced PHC were more likely to be in NYHA class III-IV (p = 0.012) before RHC, require sedation (p = 0.011), had echocardiographic indices of higher peak tricuspid regurgitation velocity (p = 0.018), and right ventricle (RV) to left ventricle (LV) ratio (p < 0.001). Multivariate logistic regression for PHC identified the need for sedation and a higher RV/LV ratio as independent predictors. In conclusion, the risk of RHC remains significant in children with PAH, particularly in those with severe RV dilation who require sedation during cardiac catheterization. Comprehensive evaluation, close monitoring, and appropriate treatment before and during the procedure are essential for reducing mortality.
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Affiliation(s)
- Qiangqiang Li
- Department of Pediatric Cardiology, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Chen Zhang
- Department of Pediatric Cardiology, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Rong Wang
- Center for Anesthesiology, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Bradley B. Keller
- Greater Louisville and Western Kentucky PracticeCincinnati Children's Heart InstituteLouisvilleKentuckyUSA
| | - Hong Gu
- Department of Pediatric Cardiology, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
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3
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Odegard KC, Vincent R, Baijal RG, Daves SM, Gray RG, Javois AJ, Love BA, Moore P, Nykanen D, Riegger LQ, Walker SG, Wilson EC. SCAI/CCAS/SPA Expert Consensus Statement for Anesthesia and Sedation Practice. Anesth Analg 2016; 123:1201-1209. [DOI: 10.1213/ane.0000000000001608] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Odegard KC, Vincent R, Baijal R, Daves S, Gray R, Javois A, Love B, Moore P, Nykanen D, Riegger L, Walker SG, Wilson EC. SCAI/CCAS/SPA expert consensus statement for anesthesia and sedation practice: Recommendations for patients undergoing diagnostic and therapeutic procedures in the pediatric and congenital cardiac catheterization laboratory. Catheter Cardiovasc Interv 2016; 88:912-922. [DOI: 10.1002/ccd.26692] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 07/11/2016] [Indexed: 11/12/2022]
Affiliation(s)
| | - Robert Vincent
- Emory University School of Medicine, Children's Healthcare of Atlanta; Atlanta GA
| | | | - SuAnne Daves
- Vanderbilt University Medical Center; Nashville TN
| | | | - Alex Javois
- University of Illinois and Advocate Children's Hospital; Chicago IL
| | | | - Phil Moore
- University of California; San Francisco CA
| | | | - Lori Riegger
- University of Michigan, Department of Anesthesiology; Ann Arbor MI
| | | | - Elizabeth C. Wilson
- Emory University School of Medicine, Children's Healthcare of Atlanta; Atlanta GA
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Friesen RH, Twite MD, Nichols CS, Cardwell KA, Pan Z, Darst JR, Wilson N, Fagan TE, Miyamoto SD, Ivy DD. Hemodynamic response to ketamine in children with pulmonary hypertension. Paediatr Anaesth 2016; 26:102-8. [PMID: 26564806 DOI: 10.1111/pan.12799] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND The safety of ketamine in children with pulmonary hypertension has been debated because of conflicting results of prior studies in which changes in mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) have been widely variable. The goal of this prospective study was to quantitate the effects of ketamine on pulmonary hemodynamics in a cohort of children with pulmonary hypertension under conditions in which variables such as airway/ventilatory management, FiO(2), and use of vasodilating anesthetics were controlled. METHODS The IRB approved this study of 34 children undergoing cardiac catheterization for pulmonary hypertension studies. Following anesthetic induction with sevoflurane and tracheal intubation facilitated by the administration of rocuronium 0.7-1 mg·kg(-1) iv, sevoflurane was discontinued and anesthesia was maintained with midazolam 0.1 mg·kg(-1) iv (or 0.5 mg·kg(-1) po preoperatively) and remifentanil iv infusion 0.5-0.7 mcg·kg(-1) ·min(-1). Ventilation was mechanically controlled to maintain PaCO(2) 35-40 mmHg. When endtidal sevoflurane was 0% and FiO(2) was 0.21, baseline heart rate (HR), mean arterial pressure (MAP), mPAP, right atrial pressure (RAP), pulmonary artery occlusion pressure (PAOP), right ventricular end-diastolic pressure (RVEDP), cardiac output, and arterial blood gases were measured, and indexed systemic vascular resistance (SVRI), indexed pulmonary vascular resistance (PVRI), and cardiac index (CI) were calculated. Each child then received a bolus of ketamine 2 mg·kg(-1) infused over 2 min. Measurements and calculations were repeated 2 min after the conclusion of the infusion. RESULTS The mean (95% CI) increase in mPAP following ketamine was 2 mmHg (0.2, 3.7), which was statistically significant but clinically insignificant. PVRI and PVRI/SVRI did not change significantly. Hemodynamic changes did not differ among subjects with differing severity of pulmonary hypertension or between subjects chronically treated with pulmonary vasodilators or not. CONCLUSION Ketamine is associated with minimal, clinically insignificant hemodynamic changes in sedated, mechanically ventilated children with pulmonary hypertension.
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Affiliation(s)
- Robert H Friesen
- Departments of Anesthesiology and Pediatrics (Cardiology) and the Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Denver, CO, USA
| | - Mark D Twite
- Departments of Anesthesiology and Pediatrics (Cardiology) and the Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Denver, CO, USA
| | - Christopher S Nichols
- Departments of Anesthesiology and Pediatrics (Cardiology) and the Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Denver, CO, USA
| | - Kathryn A Cardwell
- Departments of Anesthesiology and Pediatrics (Cardiology) and the Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Denver, CO, USA
| | - Zhaoxing Pan
- Departments of Anesthesiology and Pediatrics (Cardiology) and the Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Denver, CO, USA
| | - Jeffrey R Darst
- Departments of Anesthesiology and Pediatrics (Cardiology) and the Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Denver, CO, USA
| | - Neil Wilson
- Departments of Anesthesiology and Pediatrics (Cardiology) and the Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Denver, CO, USA
| | - Thomas E Fagan
- Departments of Anesthesiology and Pediatrics (Cardiology) and the Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Denver, CO, USA
| | - Shelley D Miyamoto
- Departments of Anesthesiology and Pediatrics (Cardiology) and the Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Denver, CO, USA
| | - D Dunbar Ivy
- Departments of Anesthesiology and Pediatrics (Cardiology) and the Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Denver, CO, USA
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Lam JE, Lin EP, Alexy R, Aronson LA. Anesthesia and the pediatric cardiac catheterization suite: a review. Paediatr Anaesth 2015; 25:127-34. [PMID: 25331288 DOI: 10.1111/pan.12551] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/04/2014] [Indexed: 01/06/2023]
Abstract
Advances in technology over the last couple of decades have caused a shift in pediatric cardiac catheterization from a primary focus on diagnostics to innovative therapeutic interventions. These improvements allow patients a wider range of nonsurgical options for treatment of congenital heart disease. However, these therapeutic modalities can entail higher risk in an already complex patient population, compounded by the added challenges inherent to the environment of the cardiac catheterization suite. Anesthesiologists caring for children with congenital heart disease must understand not only the pathophysiology of the disease but also the effects the anesthetics and interventions have on the patient in order to provide a safe perioperative course. It is the aim of this article to review the latest catheterization modalities offered to patients with congenital heart disease, describe the unique challenges presented in the cardiac catheterization suite, list the most common complications encountered during catheterization and finally, to review the literature regarding different anesthetic drugs used in the catheterization lab.
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Affiliation(s)
- Jennifer E Lam
- Department of Anesthesia/Cardiac Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Twite MD, Friesen RH. The anesthetic management of children with pulmonary hypertension in the cardiac catheterization laboratory. Anesthesiol Clin 2014; 32:157-173. [PMID: 24491655 DOI: 10.1016/j.anclin.2013.10.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Children need cardiac catheterization to establish the diagnosis and monitor the response to treatment when undergoing drug therapy for the treatment of pulmonary arterial hypertension (PAH). Children with PAH receiving general anesthesia for cardiac catheterization procedures are at significantly increased risk of perioperative complications in comparison with other children. The most acute life-threatening complication is a pulmonary hypertensive crisis. It is essential that the anesthesiologist caring for these children understands the pathophysiology of the disease, how anesthetic medications may affect the patient's hemodynamics, and how to manage an acute pulmonary hypertensive crisis.
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Affiliation(s)
- Mark D Twite
- Department of Anesthesiology, University of Colorado School of Medicine, CO, USA.
| | - Robert H Friesen
- Department of Anesthesiology, University of Colorado School of Medicine, CO, USA
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8
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Williams GD, Friesen RH. Administration of ketamine to children with pulmonary hypertension is safe: pro-con debate: Pro Argument. Paediatr Anaesth 2012; 22:1042-52. [PMID: 25631695 DOI: 10.1111/pan.12033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2012] [Indexed: 11/27/2022]
Affiliation(s)
- Glyn D Williams
- Department of Anesthesia, Lucile Packard Children's Hospital at Stanford, Stanford University, Stanford, CA, USA.
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9
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Cardiac catheterization laboratory: catheterization, interventional cardiology, and ablation techniques for children. Int Anesthesiol Clin 2009; 47:63-99. [PMID: 19590287 DOI: 10.1097/aia.0b013e31819417d7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Abstract
Pulmonary arterial hypertension (PAH) is associated with significant perioperative risk for major complications, including pulmonary hypertensive crisis and cardiac arrest. Several mechanisms of hemodynamic deterioration, including acute increases in pulmonary vascular resistance (PVR), alterations of ventricular contractility and function and coronary hypoperfusion can contribute to morbidity. Anesthetic drugs exert a variety of effects on PVR, some of which are beneficial and some undesirable. The goals of balanced and cautious anesthetic management are to provide adequate anesthesia and analgesia for the surgical procedure while minimizing increases in PVR and depression of myocardial function. The development of specific pulmonary vasodilators has led to significant advances in medical therapy of PAH that can be incorporated in anesthetic management. It is important that anesthesiologists caring for children with PAH be aware of the increased risk, understand the pathophysiology of PAH, form an appropriate anesthetic management plan and be prepared to treat a pulmonary hypertensive crisis.
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Affiliation(s)
- Robert H Friesen
- Department of Anesthesia, Children's Hospital, Aurora, CO 80045, USA.
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11
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Williams GD, Philip BM, Chu LF, Boltz MG, Kamra K, Terwey H, Hammer GB, Perry SB, Feinstein JA, Ramamoorthy C. Ketamine does not increase pulmonary vascular resistance in children with pulmonary hypertension undergoing sevoflurane anesthesia and spontaneous ventilation. Anesth Analg 2007; 105:1578-84, table of contents. [PMID: 18042853 DOI: 10.1213/01.ane.0000287656.29064.89] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The use of ketamine in children with increased pulmonary vascular resistance is controversial. In this prospective, open label study, we evaluated the hemodynamic responses to ketamine in children with pulmonary hypertension (mean pulmonary artery pressure >25 mm Hg). METHODS Children aged 3 mo to 18 yr with pulmonary hypertension, who were scheduled for cardiac catheterization with general anesthesia, were studied. Patients were anesthetized with sevoflurane (1 minimum alveolar anesthetic concentration [MAC]) in air while breathing spontaneously via a facemask. After baseline catheterization measurements, sevoflurane was reduced (0.5 MAC) and ketamine (2 mg/kg IV over 5 min) was administered, followed by a ketamine infusion (10 microg x kg(-1) x min(-1)). Catheterization measurements were repeated at 5, 10, and 15 min after completion of ketamine load. Data at various time points were compared (ANOVA, P < 0.05). RESULTS Fifteen patients (age 147, 108 mo; median, interquartile range) were studied. Diagnoses included idiopathic pulmonary arterial hypertension (5), congenital heart disease (9), and diaphragmatic hernia (1). At baseline, median (interquartile range) baseline pulmonary vascular resistance index was 11.3 (8.2) Wood units; 33% of patients had suprasystemic mean pulmonary artery pressures. Heart rate (99, 94 bpm; P = 0.016) and Pao2 (95, 104 mm Hg; P = 007) changed after ketamine administration (baseline, 15 min after ketamine; P value). There were no significant differences in mean systemic arterial blood pressure, mean pulmonary artery pressure, systemic or pulmonary vascular resistance index, cardiac index, arterial pH, or Paco2. CONCLUSIONS In the presence of sevoflurane, ketamine did not increase pulmonary vascular resistance in spontaneously breathing children with severe pulmonary hypertension.
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Affiliation(s)
- Glyn D Williams
- Department of Anesthesia, Stanford University School of Medicine, Stanford, California 94305-5640, USA.
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12
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Gayatri P, Suneel PR, Sinha PK. Evaluation of propofol-ketamine anesthesia for children undergoing cardiac catheterization procedures. J Interv Cardiol 2007; 20:158-63. [PMID: 17391225 DOI: 10.1111/j.1540-8183.2007.00238.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The aim of this study was to assess the safety and efficacy of the continuous intravenous administration of a combination of propofol and ketamine for children undergoing cardiac catheterization procedures (CCP). Thirty-two children scheduled for CCP in a university teaching hospital were included in this prospective randomized study. Patients in group 1 (n = 15) were given a combination of propofol (25 microg/kg per minute) and ketamine (25 microg/kg per minute), whereas patients in group 2 (n = 17) received a combination of propofol (25 microg/kg per minute) and ketamine (12.5 microg/kg per minute) for the maintenance of anesthesia. There were no statistically significant differences with age, weight, duration of the procedure, and the number of diagnostic and interventional procedures between the two groups. There was no hemodynamic instability, airway compromise, excessive salivation, or arterial desaturation in either of the two groups. There was more incidence of movements in patients who received less dose of ketamine; however, it did not reach to statistically significant level. The total dose of ketamine used in group 1 was 309.25 +/- 90.97 microg/min, whereas in group 2, it was 148.06 +/- 34.05 microg/min. The time to awakening was significantly less in group 2 (P < 0.05). We conclude that a combination of propofol (25 microg/kg per minute) and two different doses of ketamine (25 and 12.5 microg/kg per minute, respectively) are safe and efficacious for CCP in children. Although the time to awaken was more in patients receiving 25 microg/kg per minute of ketamine compared to those receiving 12.5 microg/kg per minute of ketamine, it was well within acceptable limits.
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Affiliation(s)
- Parthasarathi Gayatri
- Department of Anesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India.
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13
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Carmosino MJ, Friesen RH, Doran A, Ivy DD. Perioperative complications in children with pulmonary hypertension undergoing noncardiac surgery or cardiac catheterization. Anesth Analg 2007; 104:521-7. [PMID: 17312201 PMCID: PMC1934984 DOI: 10.1213/01.ane.0000255732.16057.1c] [Citation(s) in RCA: 141] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) can lead to significant cardiac dysfunction and is considered to be associated with an increased risk of perioperative cardiovascular complications. METHODS We reviewed the medical records of children with PAH who underwent anesthesia or sedation for noncardiac surgical procedures or cardiac catheterizations from 1999 to 2004. The incidence, type, and associated factors of complications occurring intraoperatively through 48 h postoperatively were examined. RESULTS Two hundred fifty-six procedures were performed in 156 patients (median age 4.0 yr). PAH etiology was 56% idiopathic (primary), 21% congenital heart disease, 14% chronic lung disease, 4% chronic airway obstruction, and 4% chronic liver disease. Baseline pulmonary artery pressure was subsystemic in 68% patients, systemic in 19%, and suprasystemic in 13%. The anesthetic techniques were 22% sedation, 58% general inhaled, 20% general IV. Minor complications occurred in eight patients (5.1% of patients, 3.1% of procedures). Major complications, including cardiac arrest and pulmonary hypertensive crisis, occurred in seven patients during cardiac catheterization procedures (4.5% of patients, 5.0% of cardiac catheterization procedures, 2.7% of all procedures). There were two deaths associated with pulmonary hypertensive crisis (1.3% of patients, 0.8% of procedures). Baseline suprasystemic PAH was a significant predictor of major complications by multivariate logistic regression analysis (OR = 8.1, P = 0.02). Complications were not significantly associated with age, etiology of PAH, type of anesthetic, or airway management. CONCLUSION Children with suprasystemic PAH have a significant risk of major perioperative complications, including cardiac arrest and pulmonary hypertensive crisis.
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Affiliation(s)
- Mario J Carmosino
- Department of Anesthesiology, The Children's Hospital and University of Colorado School of Medicine, Denver, Colorado 80218, USA
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14
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Davis DP, Patel RJ. Noninvasive capnometry for continuous monitoring of mental status: a tale of 2 patients. Am J Emerg Med 2006; 24:752-4. [PMID: 16984855 DOI: 10.1016/j.ajem.2006.02.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2006] [Accepted: 02/26/2006] [Indexed: 11/19/2022] Open
Affiliation(s)
- Daniel P Davis
- UCSD Emergency Medicine, Mercy Air Medical Services, UCSD Neuroanesthesia Laboratory, San Diego/UCSD Resuscitation Research Group, CA 92103-8676, USA
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15
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Akin A, Esmaoglu A, Guler G, Demircioglu R, Narin N, Boyaci A. Propofol and propofol-ketamine in pediatric patients undergoing cardiac catheterization. Pediatr Cardiol 2005; 26:553-7. [PMID: 16132313 DOI: 10.1007/s00246-004-0707-4] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We investigated the effects of propofol and propofol-ketamine on hemodynamics, sedation level, and recovery period in pediatric patients undergoing cardiac catheterization. We performed a prospective, randomized, double-blind study. The study included 60 American Society of Anesthesiologists physical status II or III (age range, 1 month-13 years) undergoing cardiac catheterization for evaluation of congenital heart disease. Propofol and ketamine were prepared in 5% glucose solution to a final concentration of 5 and 1 mg/ml, respectively; similar injectors containing 5% glucose solution only were prepared. Fentanyl (1 microg/kg) and propofol (1.5 mg/kg) were given to both groups. Then, group 1 received 0.5 ml/kg of 5% glucose and group 2 0.5 ml/kg of ketamine solution by an anesthesiologist who was unaware of the groups of patients. Local anesthesia with 1% lidocaine was administered before intervention in all patients. The noninvasively measured mean arterial pressure, heart rate, respiratory rate, and peripheral oxygen saturation were recorded at the baseline, following drug administration, at 3, 5, 10, 15, 20, and 30 minutes and then at 15-minute intervals until the end of the procedure. Additional drug and fentanyl requirements to maintain a sedation level of 4 or 5 were recorded. After the procedure, the time to a Steward recovery score of 6 and adverse effects in the first 24 hours were recorded. The number of patients with more than a 20% decrease in mean arterial pressure was 11 in group 1 and 3 in group 2 (p < 0.05). The number of patients who experienced more than a 20% decrease in heart rate was 12 in group 1 and 5 in group 2 (p = 0.054). Ten patients in group 1 and 3 patients in group 2 required additional fentanyl doses (p = 0.057). The number of additional propofol doses was lower in group 2 (p < 0.05). Propofol combined with low-dose ketamine preserves mean arterial pressure better without affecting the recovery and thus is a good option in pediatric patients undergoing cardiac catheterization.
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Affiliation(s)
- A Akin
- Department of Anesthesiology, Erciyes, University School of Medicine, Kayseri, Turkey.
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16
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Katznelson R, Mishaly D, Hegesh T, Perel A, Keidan I. Spinal anesthesia for diagnostic cardiac catheterization in high-risk infants. Paediatr Anaesth 2005; 15:50-3. [PMID: 15649164 DOI: 10.1111/j.1460-9592.2004.01393.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The main goals of diagnostic cardiac catheterization (DCC) in infants are to evaluate the anatomy and physiology of congenital and acquired cardiac defects while maintaining normal respiratory and hemodynamic variables. The aims of anesthesia for infants undergoing DCC are to prevent pain and movement during the procedure. General anesthesia (GA) or deep sedation could have undesirable respiratory and hemodynamic effects for conducting such studies. Furthermore, GA is associated with increased risks, especially in high-risk infants. Spinal anesthesia (SA) is a successful alternative to GA in surgery on infants with a history of prematurity and respiratory problems, with minimal respiratory and hemodynamic changes. METHODS We studied whether those advantages were applicable to DCC, and used a predetermined SA protocol in a cohort of 12 infants with compromised respiratory status. Success rate, study completion, complications, hemodynamic and respiratory effects and recovery profile were recorded. RESULTS Failure rate was significantly higher in infants older than 6 months. There was no significant difference between baseline and intraprocedure hemodynamic and respiratory parameters. The time to discharge was relatively short (33 +/- 12 min). CONCLUSIONS Spinal anesthesia apparently provides stable hemodynamics and respiratory variables, rapid recovery and discharge time, and may be a viable alternative to GA or deep sedation in high-risk infants <6 months old undergoing DCC.
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Affiliation(s)
- Rita Katznelson
- Pediatric Anesthesia Division, Department of Anesthesia and Intensive Care, Sheab Medical Center, Tel Hashomer 52621, Israel
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17
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Sacchetti A, Turco T, Carraccio C, Hasher W, Cho D, Gerardi M. Procedural sedation for children with special health care needs. Pediatr Emerg Care 2003; 19:231-9. [PMID: 12972819 DOI: 10.1097/01.pec.0000086232.54586.ce] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Children with special health care needs represent a growing percentage of pediatric patients treated in all emergency departments. Substantial literature exists concerning the medical treatment of these patients, but there is little written describing the management of procedural sedation or analgesia in this population. This article examines the unique anatomic and physiologic implications of procedural sedation or analgesia management in children with special health care needs.
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Affiliation(s)
- Alfred Sacchetti
- Department of Emergency Medicine, Our Lady of Lourdes Medical Center, Camden, NJ 08103, USA.
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18
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Bernath MA, Sekarski N. Management of paediatric patients undergoing diagnostic and invasive cardiology procedures. Curr Opin Anaesthesiol 2001; 14:441-6. [PMID: 17019128 DOI: 10.1097/00001503-200108000-00011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Since diagnostic cardiac catheterization in children with congenital heart disease was first reported in 1947, echocardiography has been used as a non-invasive diagnostic tool in congenital heart disease, resulting in a decrease in diagnostic cardiac catheterizations. However, the total number of cardiac catheterizations remained at a steady level until the mid-1980s and has since increased progressively. This is a result of the introduction of interventional transcatheter techniques to improve or correct congenital heart malformations. Since the first description of balloon atrial septostomy, the range of indications for such techniques has steadily increased, particularly in the past 15 years. 'Deep' sedation or general anaesthesia is essential for the conduct of cardiac catheterization in children, particularly in the younger age group.
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Affiliation(s)
- M A Bernath
- Anesthesiology Department, CHUV, CH-1011 Lausanne, Switzerland.
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Schulze-Neick I, Penny DJ, Rigby ML, Morgan C, Kelleher A, Collins P, Li J, Bush A, Shinebourne EA, Redington AN. L-arginine and substance P reverse the pulmonary endothelial dysfunction caused by congenital heart surgery. Circulation 1999; 100:749-55. [PMID: 10449698 DOI: 10.1161/01.cir.100.7.749] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The increase in pulmonary vascular resistance (PVR) seen in children after cardiopulmonary bypass has been attributed to transient pulmonary endothelial dysfunction (PED). We therefore examined PED in children with congenital heart disease by assessing the L-arginine-nitric oxide (NO) pathway in terms of substrate supplementation (L-arginine [L-Arg]), stimulation of endogenous NO release (substance P [Sub-P]), and end-product provision (inhaled NO) before and after open heart surgery. METHODS AND RESULTS Ten patients (aged 0.62+/-0.27 years) with pulmonary hypertension undergoing cardiac catheterization who had not had surgery and 10 patients (aged 0.65+/-0.73 years) who had recently undergone cardiopulmonary bypass were examined. All were sedated and paralyzed and received positive-pressure ventilation. Blood samples and pressure measurements were taken from catheters in the pulmonary artery and the pulmonary vein or left atrium. Respiratory mass spectrometry was used to measure oxygen uptake, and cardiac output was determined by the direct Fick method. PVR was calculated during steady state at ventilation with room air, during FIO(2) of 0.65, then during additional intravenous infusion of L-Arg (15 mg. kg(-1). min(-1)) and Sub-P (1 pmol. kg(-1). min(-1)), and finally during inhalation of NO (20 ppm). In preoperative patients, the lack of an additional significant change of PVR with L-Arg, Sub-P, and inhaled NO suggests little preexisting PED. Postoperative PVR was higher, with an additional pulmonary endothelial contribution that was restorable with L-Arg and Sub-P. CONCLUSIONS Postoperatively, the rise in PVR suggested PED, which was restorable by L-Arg and Sub-P, with no additional effect of inhaled NO. These results may indicate important new treatment strategies for these patients.
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Affiliation(s)
- I Schulze-Neick
- Department of Paediatrics, Royal Brompton and Harefield NHS Trust, National Heart and Lung Institute (Imperial College of Science, Technology and Medicine), London, UK
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Friesen RH, Alswang M. End-tidal PCO2 monitoring via nasal cannulae in pediatric patients: accuracy and sources of error. J Clin Monit Comput 1996; 12:155-9. [PMID: 8823636 DOI: 10.1007/bf02078136] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the correlation and accuracy of end-tidal PCO2 (PetCO2) sampled via nasal cannulae in pediatric patients by comparison to the criterion standard PaCO2, and to identify sources of error during PetCO2 monitoring via nasal cannulae. METHODS PetCO2 was monitored continuously by sampling end-tidal gas through nasal cannulae that had been designed and manufactured for this purpose in spontaneously breathing children undergoing conscious or deep sedation during either cardiac catheterization (n = 43) or critical care (n = 54). When both the capnographic wave form and the PetCO2 value had been stable for at least 10 minutes, the PetCO2 value was recorded while blood was drawn from an indwelling arterial line for PaCO2 measurement. The effects of age, weight, respiratory rate, oxygen delivery system, airway obstruction, mouth breathing, and cyanotic heart disease were evaluated by linear regression analysis and calculation of absolute bias (PaCO2-PetCO2). RESULTS Mouth breathing, airway obstruction, oxygen delivery through the ipsilateral nasal cannula, and cyanotic heart disease adversely affected accuracy. In patients without those factors, PetCO2 correlated well with PaCO2 (R2 = 0.994), and absolute bias was 3.0 +/- 1.8 mmHg. CONCLUSIONS Several factors-some controllable and all recognizable-affect the accuracy of PetCO2 monitored via nasal cannulae in pediatric patients. When these factors are not present, PetCO2 correlates well with PaCO2 and appears to be a useful monitor of ventilatory status during conscious or deep sedation.
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Affiliation(s)
- R H Friesen
- Department of Anesthesiology and Pediatrics (Critical Care), Children's Hospital, Denver, Colorado 80218, USA
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