Erin A. Gottlieb

Bilateral monitoring of cerebral oxygen saturation results in recognition of aortic cannula malposition during pediatric congenital heart surgery.

Congenital heart surgery is associated with a 2–25% reported incidence of neurological complication. Near‐infrared spectroscopy (NIRS) can detect changes in regional cerebral saturation index (rSO2i) during cardiac surgery. If rSO2i decreases significantly, treatment algorithms are used to restore baseline values, potentially avoiding neurological complications. The efficacy of bilateral NIRS monitoring in pediatric congenital heart surgery has been debated. We report a case in which bilateral NIRS monitoring detected an abrupt decrease in rSO2i (right greater than left) after initiation of bypass without abnormalities detected by standard monitors. This resulted in prompt surgical intervention that restored rSO2i, potentially preventing neurological injury.

Implantation of Total Artificial Heart in Congenital Heart Disease

In patients with end-stage heart failure (HF), a total artificial heart (TAH) may be implanted as a bridge to cardiac transplant. However, in congenital heart disease (CHD), the malformed heart presents a challenge to TAH implantation. In the case presented here, a 17 year-old patient with congenital transposition of the great arteries (CCTGA) experienced progressively worsening HF due to his congenital condition. He was hospitalized multiple times and received an implantable cardioverter defibrillator (ICD). However, his condition soon deteriorated to end-stage HF with multisystem organ failure. Due to the patients grave clinical condition and the presence of complex cardiac lesions, the decision was made to proceed with a TAH. The abnormal arrangement of the patients ventricles and great arteries required modifications to the TAH during implantation. With the TAH in place, the patient was able to return home and regain strength and physical well-being while awaiting a donor heart. He was successfully bridged to heart transplantation 5 months after receiving the device. This report highlights the TAH is feasible even in patients with structurally abnormal hearts, with technical modification.

Anesthesia for the patient with congenital heart disease presenting for noncardiac surgery.

Purpose of review To summarize recent publications emphasizing the changes in the population of patients with congenital heart disease and trends in the anesthetic and perioperative care of these patients presenting for noncardiac procedures. Recent findings It has been reported that children with congenital heart disease presenting for noncardiac surgery are at an increased anesthetic risk. This risk has become better defined. The patients at highest risk are infants with a functional single ventricle and patients with suprasystemic pulmonary hypertension, left ventricular outflow tract obstruction or dilated cardiomyopathy. Familiarity with the physiology and perioperative implications of the stages of single ventricle palliation is critical. The anesthetic approach, monitoring, conduct of surgery and postoperative care and outcomes are variable in this patient population. Recent literature reflects the growing number of children with ventricular assist devices and the management of these patients for noncardiac procedures. Cardiac imaging modalities provide diagnostic information, and strategies for reducing anesthetic risk for these procedures are of great interest. Pharmacologic trends and the application of technology are reviewed. Summary The identification of high-risk patients, multidisciplinary decision-making and planning and careful anesthetic management and monitoring are critical for optimizing outcomes in children with congenital heart disease presenting for noncardiac procedures.

Limitations of Cerebral Oxygenation Monitoring by Near-Infrared Spectroscopy in Children With Cyanotic Congenital Heart Disease and Profound Polycythemia

In this case series, a group of 10 patients with significantly high preoperative hematocrit secondary to congenital cardiovascular disease for whom regional cerebral oxygen saturation was unmeasureable via nearinfrared spectroscopy were identified. Institutional review board approval was obtained for the review of records and data collection for patients with failure of intraoperative NIRS detection. In a period of 1 year (2010), 10 of 1,820 (0.55%) patients were identified intraoperatively and in the cardiac catheterization laboratory with failed NIRS monitoring and profound polycythemia (ie, hematocrit values significantly above the laboratory reference range). After the induction of anesthesia, appropriate-sized bilateral INVOS 5100 sensors (Somanetics Corp, Troy, MI) were placed on the patient’s forehead. If the rSO2 was unobtainable (failure to display a value on the monitor screen), the probes were removed and placed on the attending anesthesiologist to confirm that the probes and equipment were functional. The probes were replaced onto the patient’s forehead, and again an rSO2 value failed to display. Data collection included demographics, hematocrit, hemodynamic variables, and ventilatory variables, and the presence or absence of rSO2 detection was recorded with every arterial blood gas analysis.

Current and future trends in coagulation management for congenital heart surgery

From the Arthur S. Keats Division of Pediatric Cardiovascular Anesthesiology and Department of Anesthesiology, Texas Children’s Hospital; and Department of Anesthesiology Baylor College of Medicine, Houston, Tex. Received for publication Sept 14, 2016; revisions received Nov 9, 2016; accepted for publication Nov 15, 2016; available ahead of print March 14, 2017. Address for reprints: Erin A. Gottlieb, MD, 6621 Fannin WT 17-417B, Houston, TX 77030 (E-mail: eagottli@ texaschildrens.org). J Thorac Cardiovasc Surg 2017;153:1511-5 0022-5223/

Cardiopulmonary Bypass and Management

36.00 Copyright 2017 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2016.11.075

The Critical Triangle of Trust in Congenital Heart Surgery: Surgeon, Anesthesiologist, and Perfusionist

Abstract Cardiopulmonary bypass (CPB) is an imminent element of todays cardiac surgery. Major differences not only exist in setup and materials, but also in management strategies. The phases of CPB are similar to the adult, but the effects on the body and the physiological disturbances are far more pertinent. Hemodilution is the major hematologic disturbance that leads to coagulation deficiencies and challenges the oxygen transport capacities of the body. Hemodilution and the membrane oxygenator itself change the pharmacokinetics and pharmacodynamics of most anesthetics in use. Physiological limits are permanently reached during pediatric cardiac surgery and are most obvious during the care of Jehovas Witness patients. Lower body temperatures than in adults are routinely used which influences acid base management. Special techniques applied are deep hypothermic circulatory arrest and selective cerebral perfusion which enable a broad spectrum of todays congenital cardiac surgery. Despite technical advances widespread effects on the body systems remain and these changes can prolong the postoperative course and endanger a primarily successful repair.

Elevated arterial blood pressure after superior cavo-pulmonary anastomosis is associated with elevated pulmonary artery pressure and cerebrovascular dysautoregulation

The outcomes of pediatric cardiovascular surgery are dependent on the accuracy and completeness of the operation itself, precise anesthetic and hemodynamic management, and physiologic conduct of cardiopulmonary bypass. No one person can manage all of these aspects on his/her own, nor can each person do his/her own part alone. The triangle of trust comprised of the surgeon, anesthesiologist, and perfusionist is a critical collaborative effort that optimizes patient safety and outcome. This collaborative concept begins with mutual respect through an integrated understanding of what each member of the team brings to the table. A shared standard for bypass management, transfusion, anesthesia, and basic conduct of the operation is requisite. Planning for the case involves all parties, and the preoperative discussion includes the plan for the operation, including cannulation sites and cannulae selection, anticipated depth of cooling, special bypass techniques including deep hypothermic circulatory arrest or antegrade cerebral perfusion, blood product management strategies, and plan for early or delayed extubation. Detailed planning and advance communication, much akin to a flight plan used in the aviation industry, optimizes safety. Intraoperatively, communication is clear, unambiguous, concise, scripted, and in a read-back format. This methodology is facilitated by reverence to a quiet, organized operating room environment. If a member of the team has a concern, it is voiced. This strategy is built on trust. Each team member trusts that each person is doing what is best for the patient and sharing his/her concerns in order to protect the patient from harm. During cardiopulmonary bypass, the anesthesiologist and perfusionist are working together to optimize conditions on bypass. For example, if the cerebral oxygenation measured by near-infrared spectroscopy is suboptimal, the perfusionist and anesthesiologist troubleshoot the low value using previously agreed-upon methods and standards after making the surgeon aware. This collaborative strategy has likely helped to prevent adverse outcomes. The surgeon is kept well informed about issues that may indicate concerns about suboptimal perfusion including reservoir volume loss/inadequacy, accumulation of lactate, marginal urine output, or other deviations from agreed-upon physiologic expectations. A significant benefit of operating at a high level in which communication and collaboration are routine is effectiveness of team response in an unplanned misadventure in the period before the institution of cardiopulmonary bypass (acute arterial desaturation suggesting thrombosis of a systemic-topulmonary arterial shunt, cardiac injury during repeat sternotomy, unheralded hemodynamic instability, or other untoward event). In these challenging circumstances, which are not infrequent in congenital heart surgery, effective, predictable team communication and understanding of role responsibility translate into optimized outcomes. Postoperative debriefing provides an opportunity for feedback for each member of the team and allows for growth and improvement. Regular team meetings provide a forum for sharing new ideas, technologies, and concepts, as it is critical for all members of the team to be aware of practice changes before their introduction into the operating room.

Anesthesia for Pediatric Lung Transplantation: Case Presentation and Review of the Literature

BackgroundElevated arterial blood pressure (ABP) is common after superior bidirectional cavopulmonary anastomosis (BCPA). The effects of elevated ABP after BCPA on cerebrovascular hemodynamics are unknown. We sought to determine the relationship between elevated ABP and cerebrovascular autoregulation after BCPA.MethodsProspective, observational study on infants with single-ventricle physiology after BCPA surgery. Continuous recordings of mean ABP, mean cavopulmonary artery pressure (PAP), near-infrared spectroscopy measures of cerebral oximetry (regional cerebral oxygen saturation (rSO2)), and relative cerebral blood volume index were obtained from admission to extubation. Autoregulation was measured as hemoglobin volume index (HVx). Physiologic variables, including the HVx, were tested for variance across ABP.ResultsSixteen subjects were included in the study. Elevated ABP post-BCPA was associated with both, elevated PAP (P<0.0001) and positive HVx (dysautoregulation; P<0.0001). No association was observed between ABP and alterations in rSO2. Using piecewise regression, the relationship of PAP to ABP demonstrated a breakpoint at 68 mm Hg (interquartile range (IQR) 62–70 mm Hg). Curve fit of HVx as a function of ABP identified optimal ABP supporting robust autoregulation at a median ABP of 55 mm Hg (IQR 51–64 mm Hg).ConclusionsElevated ABP post-BCPA is associated with cerebrovascular dysautoregulation, and elevated PAP. The effects, of prolonged dysautoregulation within this population, require further study.

Anesthesia for Cardiac Surgery in Neonates

The first pediatric lung transplant was performed in 1987 at the University of Toronto in a 15-year-old with familial pulmonary fibrosis. Since that time, over 2000 children have received lung transplants worldwide, with an annual number ranging between 99 and 137 over the past decade. For the anesthesiologist charged with managing these rare patients, an understanding of the indications that lead to transplantation, their pathophysiology, and the physiology of the transplanted lungs are critical. To provide a context for the anesthetic management of the child undergoing lung transplantation, we discuss the case of a 2-month-old who underwent bilateral lung transplantation for intractable respiratory failure. Both the unique aspects of this case and pediatric lung transplantation, in general, are presented. Then a review of the literature is discussed.