Conflict of Interest Anesthetic Approach for cardiac Current and - - PowerPoint PPT Presentation

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Anesthetic Approach for cardiac and non-cardiac surgery in the PH patient

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

Conflict of Interest

• Current and Past Clinical researcher for Masimo Inc
• Past Researcher for Nonin inc.
• Speaker for Somanetics Inc

Dedicated to Rebecca Atherton 10/09/1992-10/11/2018

Rebecca’s Odyssey

 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

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Ramamoorthy C et al. Anesth Analg 2010;110:1376-1382

Causes of Anesthesia related Cardiac Arrests Anesthesia and heart DZ: High 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

Postoperative mortality in children after 101,885 anesthetics at a tertiary pediatric hospital.

• Highest mortality was in neonates
• Cardiac surgery carried a higher mortality than

NCS

• The incidence of anesthesia-related death was 1

in 10,188. In all 10 cases, preexisting medical conditions were identified as being a significant factor in the patient's death. Five of these cases (50%) involved children with pulmonary hypertension.

Anesth Analg, VanderGriend BF, 2011,104, 521)

Outcomes in Children with PH @Stanford

• Periop complications during Gen Anesthesia at Stanford

(WILLIAMS GD et al )

• PAP>25 mmHg, PVRI>3WU, 6 year period
• Risk Factors: Airway instrumentation, major surgery,
• pioid administration
• Cardiac Arrest : 0.8%; 0 mortality

Pediatric Anesthesia 2010 20: 28–37

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Evolving Practice ?

Procedures in patients with pulmonary hypertension [2015-2018]

225 43 153

50 100 150 200 250 Cardiac Catheterization Cardiac Surgery Non-Cardic Cases

# of procedures

# of procedures =421 # of patients = 347 Sicker they are more procedures become necessary

Non-Cardiac Procedures in Patients with PH [2015-2018]

10 20 30 40 50

# of procedures

total=153

Imaging Studies [2015-2018]

2 4 6 8 10 12 # of procedures

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ENT procedures

5 10 15 20 25 30

Non-Cardiac Surgical Cases [2015-

2018]

5 10 15 20 25

# of procedures

Surgical Cases with QI events

# of Cardiac cases # of Non- Cardiac cases # of patients with multiple surgeries with QI events # of patients with QI events >1 surgery

2016

12 6

2017

5 6 8 1

2018 [Q1-Q3]

5 3 7 2

Total

22 9 21 3

Serious Adverse Events

6 Reported Events: ( 1.4%) ENT Procedure (1 event) 3yo; ASA Status 3 Cardiac Catheterization (3 separate events) 22mo; ASA Status 4 4yo; ASA Status 3 1yo; ASA Status 4 Cardiac Surgery (2 separate events) 26yo; ASA Status 3 4yo; ASA Status 4 Why?

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ASA PHYSICAL STATUS

• ASA 1: No organic disturbance
• ASA 2:Mild to moderate systemic Dz
• ASA 3: Severe systemic Dz
• ASA 4: Life threatening systemic disorder
• ASA 5: Moribund patient

Limitations of the ASA Physical Status

• Although a great indicator of severity of patients disease
• Does not include risk associated with the procedure eg.,

cardiac catheterization vs Spinal fusion vs abdominal surgery

• Does not account for experience of the operators

Preop Risk factors in PH pts

• Age: neonates
• Syncopal episode
• Home Oxygen use
• Elevated RA pressure
• Decreased RV function

 Snoring : independent risk factor for GA (APRICOT trial, Lancet , 2017)

Intraoperative Risk Factors - Anesthetic Medications

Venodilation : In those with Vent. Dysfunction

 “The principle hemodynamic effect of propofol in children with congenital heart disease is a decrease in systemic vascular resistance”  Williams GD, 1999 Anesth-Analg, 89

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Ketamine in PH

• 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

Volatile Anesthetics Dexmedetomidine

 The hemodynamic response to dexmedetomidine loading dose in children with and without pulmonary hypertension.  Friesen RH1, Nichols CS, Twite MD, Cardwell KA, Pan Z, Pietra B, Miyamoto SD, Auerbach SR, Darst JR, Ivy DD  Anesth Analg. 2013 Oct;117(4):953-9. doi: 10.1213/ANE.0b013e3182a15aa6. Epub 2013 Aug 19.

Heart Surgery and PH

 Identify cases  Surgeon in the room at the time of induction  CPB primed and ready to go  Use of TTE during induction  Availability of NO during weaning from CPB  Although higher incidence of SAE in OR, better rescue rate

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TTE invaluable adjunct

Nitric Oxide-Use or Misuse?

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 Imaging

• Monitoring:
• ECG quality varies: loss of early ischemia

detection

• Pulse oximeter & BP : poor design for neonates

and infants

• Breatholds for imaging
• CV effects of Anesthesia and Sedation
• Resuscitation challenges in MRI suite

Improving Safety in High Risk Patients –Ask Questions

• What information will be provided by diagnostic

procedure ?

• How will this new information affect management/care
• Targeted vs Comprehensive Imaging and Tests
• Can any other procedure be combined –Reduce fasting,

multiple GA’s and admissions.

• Duration of GA increases risk of AE

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Be ready to resuscitate

 Goal: Raise SVR and maintain coronary perfusion  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

Pilot Study of Epi, AVP and Phenylephrine in PH pts presenting for cardiac catheterization

PCCM, Siehr S, PCCM, 2016:17;428-37

Stanford Approach

 Radiology office: ECHO images; cardiology note, relevant information  Cardiac Anesthesiology: Review echo and findings, call family/ cardiologist  Arrange cardiac consult at LPCH  Inpatients: Examine and review with cardiologist

AHA & ATS Recommendation

“Elective surgery for pediatric PH patients

should be performed at hospitals with expertise in PH and in consultation with pediatric PH service and anesthesiologists with experience in the perioperative management of children with PH”

Abman et al, 2015, Circulation 2015:132; 2037-2099

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Conclusion

 Processes and protocols that set up the caregiver for best patient

• utcomes .