anesthesia and the sick heart - dell children's … · anesthesia and the sick heart billy...

Anesthesia and

the Sick Heart

Billy Corbett MD FAAP

Capitol Anesthesiology Association

Dell Children’s Medical Center

Talk Overview

n The “safety” of anesthesia

n Preoperative evaluation and risk stratification

n Induction of anesthesia: how to safely put a sick

heart to sleep

n Putting it all together

Morray JP. Cardiac arrest in anesthetized children. Pediatric Anesthesia 2011; 22: 722-729.

Anesthesia-Related Cardiac

Arrest

How Safe is Pediatric

Anesthesia?

n Incidence of cardiac arrest: 1.4-4.6:10,000 (3-

6X higher in children <1 year old, increased risk

for ASA physical status > III)

n Overall incidence of anesthesia-related death

1:10,000-1:40,000

Paterson N et al. Risk in pediatric anesthesia. Pediatric Anesthesia 2011; 21: 848-857.

van der Griend BF et al. Postoperative Mortality in Children After 101,885 Anesthetics at a Tertiary Pediatric

Hospital. Anesthesia & Analgesia 2011; 112: 1440-1447.

Odegard KC et al. The Frequency of Anesthesia-Related Cardiac Arrests in Patients with Congenital Heart

Disease Undergoing Cardiac Surgery. Anesthesia & Analgesia 2007; 105: 335-343.


American Society of Anesthesiologists

Physical Status

n ASA physical status

n 1. Normal healthy patient

n 2. Mild systemic disease

n 3. Severe systemic disease

n 4. Severe systemic disease that is constant threat to life

n 5. Moribund - not expected to survive the operation

n 6. Brain dead for organ donation

ASA Status and

Complications


n Retrospective chart review

n 129 patients with cardiomyopathy undergoing 236

anesthetics

n 4 cardiac arrests (in 2 patients)

n Fractional shortening <= 16% in both patients

n Many different combinations of induction drugs

with no ideal choice

n All successfully resuscitated

Take-Home Points

n 26 patients undergoing 34 general anesthetics

n Non-cardiac surgical

n 18 complications in 12 patients (38% complication

rate for 34 anesthetics)

n Stratified into 3 groups based on preoperative

shortening fraction

Echocardiographic Function

Function Shortening

Fraction Ejection Fraction

Normal > 28% >55-63%

Mild 23-28% >45%

Moderate 16-22% 20-45%

Severe <16% <20%

Dilated Cardiomyopathy

Periprocedural Complications

n 15 (83%) occurred in patients with severe

ventricular dysfunction

n Patients with shortening fraction < 16% are at the

highest risk for perioperative morbidity and

mortality

n 14 of 21 patients (67%) with severe ventricular

dysfunction observed in ICU postoperatively

n Importance of a multispecialty team approach to

caring for these patients

Take-Home Points

Cardiac Arrest in Children

with Cardiomyopathy

n Incidence of cardiac arrest after induction:

170:10,000 (40-120 times more likely than

with healthy patients)

n Patients with severe ventricular dysfunction at

the highest risk

Lynch J et al. Cardiac arrest upon induction of anesthesia in children with cardiomyopathy: an analysis of

incidence and risk factors. Pediatric Anesthesia 2011; 21: 951-957.

Kipps AK et al. Children with cardiomyopathy: complications after noncardiac procedures with general

anesthesia. Pediatric Anesthesia 2007; 17: 775-781.

Types of Cardiomyopathies

n Dilated (60%)

n Hypertrophic (30%)

n Restrictive (3%)

n Left Ventricular Noncompaction (rare)

Anesthetic Goals for

Hypertrophic Cardiomyopathy

n Dynamic left ventricular outflow tract

obstruction

n Maintain or increase afterload

n Ensure adequate volume loading

n Decrease heart rate

n Decrease contractility

Plan of Attack

n Beta blockade perioperatively often

n Establish good venous access

n Preinduction fluid bolus (10ml/kg)

n Avoid decreases in afterload: Etomidate or

Ketamine

Lake, C and Booker P. Pediatric Cardiac Anesthesia 4th ed. 2005: 530-535.

Anesthetic Goals for Dilated

Cardiomyopathy

n Avoid increases in SVR

n Maintain or augment contractility

n Appropriate volume load

n Plan for invasive monitors

n For most severe cases, consider ECMO

backup

Plan of Attack

n Continuation of preoperative inotropes

n Adequate premedication to facilitate placement

of good intravenous access +/- arterial

monitoring

n Gentle induction

n Ensure adequate anesthesia depth prior to

laryngoscopy to avoid sudden increases in SVR

Preinduction Questions?

n Does the child have intravenous access or can

it easily be obtained?

n Does the patient need preoperative anxiolysis?

n Intravenous or mask induction?

Premedication =

n Mode of delivery: intravenous, oral, nasal,

intramuscular

n Most commonly: midazolam 0.5-1 mg/kg po or

0.05-0.1 mg/kg iv

n Relieves anxiety and provides amnesia

The Art of Induction

n The ideal induction agent

n Preserve hemodynamic stability

n Minimal depression of contractility

n Maintain relationship between pulmonary

and systemic vascular resistances

Surgur Z et al. Comparison of sevoflurane and ketamine for anesthetic induction in children with congenital

heart disease. Pediatric Anesthesia 2008; 18: 715-721.

silver bullet: a straightforward

solution perceived to have

extreme effectiveness

Anesthesia Induction Drugs

HR CO Contractility SVR PVR/SVR

Sevofluran

e

Propofol

Ketamine

Etomidate

Fentanyl-

Midazolam

Sevoflurane

n Sweet smelling anesthetic gas

n Predominant hemodynamic effect is decrease

in SVR, leading to decreased arterial pressure

n PVR:SVR maintained

n Single ventricle with stable ventricular

function no decrease in myocardial

performance index

Rosenthal DN et al. Heart failure in children: anesthetic implications. Pediatric Anesthesia 2011; 21: 577-

584.

Williams GD. The Hemodynamic Effects of Propofol in Children with Congenital Heart Disease.

Anesthesia & Analgesia 1999; 89: 1411-1416.

n “Milk of amnesia”

n Decreases preload (dilates venous capacitance

vessels) and afterload (15% decrease in SVR)

leading to hypotension (30% decrease in ABP)

n Dose- and rate-dependent decrease in cardiac

index, especially with preexisting cardiac

dysfunction

n Decreases Qp:Qs

Propofol

n Hemodynamic effects of propofol in 30 children

n 3 groups: No shunt, L R and R L

n Decreased Qp:Qs lead to statistically significant

arterial desaturation in patients with cyanotic heart

disease (Qp:Qs < 1)

n In 2 patients oxygen saturations decreased >10%

n Situations where decreased afterload is BAD

(severe aortic stenosis and hypertrophic

cardiomyopathy)

n Cyanotic patients where systemic and

pulmonary vascular resistances need to be

balanced (HLHS after Norwood or TOF)

n Any significant cardiomyopathy

Avoid Propofol In...

Ketamine:

The Good n Noncompetitive NMDA receptor antagonist

n “Dissociates” cortex from the limbic system

n “Cocaine-like” effect: Increases circulating NE and

reduces neuronal reuptake maintenance of

SVR

n Analgesic, bronchodilator, maintains HR

Cave DA et al. Anesthesia for noncardiac procedures for children with a Berlin Heart EXCOR Pediatric

Ventricular Assist Device: a case series. Pediatric Anesthesia 2010; 20: 647-659.

Consider mentioning good

SVR effects in kids with

Berlin Hearts - might be

drug of choice

Ketamine: The Bad

n Increased secretions/salivation, bad dreams,

emergence agitation

n Negative inotropic effects in human heart muscle

n Chronic illness, prolonged hyperdynamic state or

patients on drugs like dopamine (depletes

catecholamine stores) can lead to worsened

cardiac performance

Sprung J et al. Effects of ketamine on the contractility of failing and nonfailing human heart muscles in vitro.

Anesthesiology 1998; 88: 1202-1210.

Schecter WS et al. Anaesthetic induction in a child with end-stage cardiomyopathy. Can J Anaesth. 42; 1995: 404-

408.

Bovill JG. Intravenous Anesthesia for the Patient with Left Ventricular Dysfunction. Seminars in Cardiothoracic and

Vascular Anesthesia 2006; 10: 43-48.

Ketamine: The Ugly

Amy Winehouse Overdoses on

Ketamine and much more...

Etomidate

n GABAA receptor agonist

n Excellent hemodynamic stability, even in the

failing heart

n No good studies in children with severe

ventricular dysfunction

Sarker M et al. Hemodynamic responses to etomidate on induction of anesthesia in pediatric patients.


Sprung J et al. The effects of etomidate on the contractility of failing and nonfailing human heart muscle.


n 12 children with SVT or ASD for cardiac

catheterization

n 0.3 mg/kg bolus etomidate

n No significant changes in hemodynamics

n Further studies needed in children with

cardiomyopathies

n Improved myocardial oxygen supply/demand

ratio

n Lack of histamine release

n Absence of malignant hyperthermia

n Lack of effect on hepatic and renal function

n Lack of dissociative hallucinogenic side effects

Etomidate Pros

Sarker M et al. Hemodynamic responses to etomidate on induction of anesthesia in pediatric patients.

Anesthesia & Analgesia 2005; 101: 645-50

Etomidate Cons n Dose-dependent adrenocortical

suppression

n Pain on injection (acidic pH)

n Myoclonus

n Tremors and seizures

n Anaphylactoid reaction

n Possible platelet inhibition Sarker M et al. Hemodynamic responses to etomidate on induction of anesthesia in pediatric patients.

Anesthesia & Analgesia 2005; 101: 645-50

Fentanyl-Midazolam

n Analgesia and amnesia

n Hemodynamically stable

n Decreased HR, despite preserved contractility

leads to decreased cardiac index

n Decreased sympathetic tone

n Combination use increases risk of circulatory

depression

Monday Morning, 7:30am...

\\

n Eight-year-old boy with dilated cardiomyopathy

(DCM), skeletal myopathy and hepatic fibrosis

secondary to juvenile polysaccharidosis

presents for percutaneous placement of a

gastrostomy tube for nutritional support

n What are the risks and how do you proceed?

Schecter WS et al. Anaesthetic induction in a child with end-stage cardiomyopathy. Can J Anaesth 1995;

42: 404-408.

On children with end-stage

cardiomyopathies...

“The only procedure for which

they should have an anesthetic

is cardiectomy for

transplantation.”

Preoperative Evaluation

n Echo: DCM, shortening fraction of 15%

n ECG: SR, First degree AV block, left bundle

branch block, lateral ST-T segment

abnormalities

n History of ventricular tachycardia

n On 10-day course dobutamine to optimize

ventricular function

Facing the Charging Bull

Case Induction

n Dobutamine infusing at 7.5 mcg/kg/min

n Midazolam (0.1 mg/kg), Ketamine (1.5 mg/kg),

Vecuronium (0.15 mg/kg) and Fentanyl (5

mcg/kg)

n Hypotension, loss of pulse, CPR with return of

perfusion and eventual extubation in PICU later

that night

Putting It All Together

n Eight-year-old boy returns to

operating room for PEG

n What might have gone wrong last

time and what do you do now?

Learning from our mistakes...

n Primary myocardial depression from ketamine?

n Decreased HR from combination of opioid and

vecuronium leading to decreased cardiac

output

n Sympatholysis from opioid/benzodiazepine

combination leading to decreased LV filling

n Decreased beta receptor density and sensitivity

from chronic stimulation (dobutamine infusion)

Schecter WS et al. Anaesthetic induction in a child with end-stage cardiomyopathy. Can J Anaesth 1995; 42: 404-408.

Take Two n Dobutamine infusion increased prior to

induction

n Etomidate (0.3 mg/kg), midazolam (0.05

mg/kg), rocuronium (0.6 mg/kg)

n No change in blood pressure or heart rate

n Anesthesia maintained with isoflurane 0.25%

and fentanyl (total dose 8 mcg/kg)

n Extubated and transferred to PICU in stable

condition

Take Home Points

n Adequate preparation and risk stratification can

help minimize anesthetic risk and facilitate a

smoother perioperative course

n Taking care of children with cardiomyopathies

requires a coordinated approach with multiple

pediatric specialists

Thank you!

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