postopcardiaccare

postopcardiaccare - UTHSCSA Pediatric Resident Curriculum...

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Unformatted text preview: UTHSCSA Pediatric Resident Curriculum for the PICU Postoperative Care in the Patient With Congenital Heart Disease Heart General Principles General Patient homeostasis Early – declining trends do not correct Early themselves themselves Late – time can be important diagnostic tool “The enemy of good is better” Specific Approaches Specific Cardiovascular principles Approach to respiratory management Pain control/sedation Metabolic/electrolytes Infection Effects of surgical interventions on these Effects parameters parameters NO PARAMETER EXISTS IN ISOLATION Cardiovascular Principles Cardiovascular Maximize O2 delivery/ O2consumption ratio Maximize delivery/ Oxygen delivery: Cardiac Output Ventilation/Oxygenation Hemoglobin Maximizing Oxygen Delivery Maximizing Metabolic acidosis is Metabolic the hallmark of poor oxygen delivery oxygen Maximizing Oxygen Delivery Maximizing OXYGEN DELIVERY = OXYGEN OXYGEN CONTENT CONTENT X CARDIAC CARDIAC OUTPUT OUTPUT Maximizing Oxygen Delivery Cardiac Output O2 Content = Saturation(O2 Capacity)+(PaO2)0.003 Saturation(O Oxygen Capacity = Hgb (10) (1.34) So . . Hemoglobin and saturations are determinants Hemoglobin of O2 delivery of Maximizing Oxygen Delivery Cardiac Output Gidding SS et al 1988 Gidding y=-0.26(x)+38 R=0.77 S.E.E.=1.6 23 21 19 17 15 Hemoglobin (gm/dl) 13 65 70 75 80 Saturation(%) 85 90 Maximizing Oxygen Delivery Maximizing Cardiac Output Cardiac Cardiac Output Output = Stroke Volume Contractility Diastolic Filling Afterload Stroke Volume X Heart Rate Heart rate Physiologic Response Non-physiologic Non-physiologic Response Response Sinus vs. junctional vs. Sinus paced ventricular rhythm paced Maximizing Oxygen Maximizing Oxygen consumption Decreasing metabolic demands Sedation/ paralysis Thermoregulation Ventilator Strategies Ventilator Respiratory acidosis/hypercarbia Oxygenation Physiology of single ventricle/shunt lesions Oxygen delivery! Atelectasis – 15-20 cc/kg tidal volumes. PEEP, inspiratory times Ventilator Strategies: Ventilator 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 Pulmonary Precipitating Event -Cold stress -Suctioning -Acidosis Metabolic Acidosis Hypercapnia Hypoxemia Low output Ischemia Increased PVR Decreased Pulmonary Blood Flow Decreased LV preload RV dysfunction Central Venous Hypertension Pain Control/Sedation Pain Stress response attenuation Limited myocardial reserve – decreasing Limited metabolic demands metabolic Labile pulmonary hypertension Analgesia/anxiolysis Pain Control/Sedation Pain Opioids MSO4 – Gold standard: better sedative effects MSO4 than synthetic opioids than Cardioactive – histamine release and limits Cardioactive endogenous catecholamines endogenous Fentanyl/sufentanyl Less histamine release More lipid soluble – better CNS penetration Pain Control/Sedation Pain Sedatives Chloral hydrate Can be myocardial depressant Metabolites include trichloroethanol and Metabolites trichloroacetic acid trichloroacetic Benzodiazepines Valium/Versed/Ativan Pain Control/Sedation Pain Muscle relaxants Depolarizing – Succinylcholine Bradycardia ( ACH) Non-depolarizing Pancuronium – tachycardia Vecuronium – shorter duration Atracurium Atracurium “spontaneously” metabolized Histamine release Pain Control/Sedation Pain Others: Barbiturates – vasodilation, cardiac depression Propofol – myocardial depression, metabolic Propofol acidosis acidosis Ketamine – increases SVR Etomidate – No cardiovascular effects Fluid and Electrolytes Fluid Effects of underlying cardiac disease Effects Effects of treatment of that disease Cardiopulmonary Bypass Cardiopulmonary “Controlled shock” Loss of pulsatile blood flow Capillary leak Vasoconstriction Renovascular effects Renin/angiotensin Cytokine release Endothelial damage and “sheer injury” Cardiopulmonary Bypass Cardiopulmonary Stress Response Lung Fluid Filtration Renal Insufficiency Microembolic Events SIRS =Κ Microvascular [(Hydrostatic Pressure )- σ( Fluid Administration Capillary Leak Syndrome Microvascular )] Oncotic Pressure Hemorrhage Feltes, 1998 Circulatory Arrest Circulatory Hypothermic protection of brain and other Hypothermic tissues tissues Access to surgical repair not accessible by CPB Access alone alone Further activation of SIRS/ worsened capillary Further leak. leak. Fluid and Electrolyte Principles Principles Crystalloid Total body fluid overload Maintenance fluid = 1500-1700 cc/m2/day Fluid advancement: POD 0 : 50-75% of maintenance POD 1 : 75% of maintenance Increase by 10% each day thereafter Fluid and Electrolyte Principles 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 Mix Sedation: (Used currently as carrier for drips) MSO4 2cc/hr = 0.1 mg/kg/hr MSO4 2cc/hr Fentanyl 2 cc/hr = 3 mcg(micrograms)/kg/hr Fentanyl cc/hr Cardiotonic medications: Dopamine/Dobutamine 50 mg/50 cc 50 Epi/Norepinephrine 0.5 mg/50 cc Epi/Norepinephrine 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 Principles Intravascular volume expansion/ Fluid challenges Colloid – osmotically active FFP 5% albumin/25% albumin PRBC’s HCT adequate: 5% albumin (HR, LAP, CVP) HCT inadequate: 5-10 cc/kg PRBC Coagulopathic: FFP/ Cryoprecipitate Ongoing losses: CT and Peritoneal frequently = 5% Ongoing albumin albumin Metabolic Effects Metabolic Glucose Neonates vs. children/adults Hyperglycemia in the early post-op period Metabolic Effects Metabolic Calcium Myocardial requirements Rhythm Contractility Vascular resistance NEVER UNDERESTIMATE THE POWER OF NEVER CALCIUM! CALCIUM! Calcium/inotropes Calcium/inotropes Alpha 1 DAG Adenylate Cyclase Beta 1 Na Phosphodiesterase Regulatory G Protein Ca IP3 Sarcoplasmic Reticulum cAMP-Dependent PK K Na SR Ca Ca Ca Ca Metabolic Effects Metabolic Potassium Metabolic acidosis Rhythm disturbances Thermal Regulation Thermal As a sign to watch, and an item to As manipulate… manipulate… Perfusion Junctional ectopic tachycardia Metabolic demands Oxygen consumption Infection Infection Infection Routine anti-staphylococcal treatment Effects of Surgical Interventions Interventions Cardiopulmonary Bypass vs. Non-Bypass Fluids and electrolytes Modified ultrafiltration Types of anatomic defects Overcirculated – increased blood volumes Overcirculated preoperatively preoperatively Undercirculated – reperfusion of area previously Undercirculated experiencing much reduced flow volumes. experiencing Summary Summary Optimize oxygen delivery by manipulation of cardiac Optimize output and hemoglobin output Sedation and pain control can aid in the recovery Appreciate effects of cardiopulmonary bypass and Appreciate circulatory arrest on fluid and electrolyte management circulatory Tight control of all parameters within the first 12 hours; Tight after that time, patients may be better able to declare trends that can guide your interventions. trends ...
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