RESUMO
Enhanced techniques for single-ventricle palliation (SVP), in which the Fontan procedure is the final phase, have improved the survival and quality of life in patients not eligible for biventricular repair (BiVR). However, Fontan physiology also is associated with predictable long-term consequences that ultimately affect quality of life and freedom from adverse events. Given this harsh reality, the advances in ventricular rehabilitation strategies and the conversion from SVP increasingly are being used to achieve biventricular circulation in patients with left-heart hypoplasia who previously were considered to be marginal or unacceptable candidates for BiVR. The techniques for ventricular recruitment include restriction of the atrial septal defect (ASD), atrioventricular valve repair, repair of left ventricular outflow obstruction, endocardial fibroelastosis resection, an augmented pulmonary blood flow, and catheter-based interventions. In addition, reverse double-switch surgery has been used as an option for patients with a left ventricle of insufficient size and function to support the systemic circulation, who would otherwise require a Fontan surgery. Despite improved management and surgical technique, the outcomes after biventricular staging repair and conversion remain variable, and the complications ultimately may exclude patients from future single-ventricle palliation or transplant. The anesthesiologist should have a basic understanding of the anatomy and physiology of this growing patient population in order to develop adequate perioperative management options.
Assuntos
Técnica de Fontan , Síndrome do Coração Esquerdo Hipoplásico , Anestesiologistas , Criança , Ventrículos do Coração/anormalidades , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/cirurgia , Humanos , Síndrome do Coração Esquerdo Hipoplásico/cirurgia , Lactente , Qualidade de Vida , Resultado do TratamentoAssuntos
Betacoronavirus/patogenicidade , Cardiologia/normas , Infecções por Coronavirus/terapia , Prestação Integrada de Cuidados de Saúde/normas , Acessibilidade aos Serviços de Saúde/normas , Cardiopatias Congênitas/terapia , Pediatria/normas , Pneumonia Viral/terapia , COVID-19 , Teste para COVID-19 , Técnicas de Laboratório Clínico/normas , Consenso , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/transmissão , Infecções por Coronavirus/virologia , Necessidades e Demandas de Serviços de Saúde/normas , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/fisiopatologia , Interações Hospedeiro-Patógeno , Humanos , Recém-Nascido , Controle de Infecções/normas , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Transmissão Vertical de Doenças Infecciosas/prevenção & controle , Avaliação das Necessidades/normas , Pandemias , Equipamento de Proteção Individual/normas , Pneumonia Viral/diagnóstico , Pneumonia Viral/transmissão , Pneumonia Viral/virologia , Medição de Risco , Fatores de Risco , SARS-CoV-2 , Tempo para o Tratamento/normasAssuntos
Midazolam , Leitura , Ansiedade , Criança , Humanos , Hipnóticos e Sedativos , Unidades de Terapia Intensiva , Massagem , Dor , Projetos PilotoRESUMO
BACKGROUND: Blood transfusion has well-documented adverse effects. As part of a blood conservation initiative at our center, we began routine use of cell saver for all congenital heart surgery performed on cardiopulmonary bypass since 2014. AIMS: This study aimed to compare transfusion rates prior to, and in the first and second year after this initiative. We hypothesized that cell saver use would decrease transfusion requirements in second year after use of the cell saver compared to the pre cell saver group. METHODS: Consecutive patients under 18 years undergoing congenital heart surgery on cardiopulmonary bypass were retrospectively analyzed as 3 one-year cohorts defined above. We excluded patients who required mechanical support or reoperation at index admission. Baseline characteristics, and use of blood intraoperatively and postoperatively were compared between groups. RESULTS: The 3 groups had similar baseline characteristics. Blood use was significantly lower in year 2 after cell saver initiation as compared to the pre cell saver group both intra- and postoperatively. The median difference in volume of intraoperative blood transfusion was lower by 138 mL/m2 (-266, -10 mL/m2 ) in year 2 when compared to the pre cell saver group. Similarly, the proportion of subjects requiring red blood cell transfusion postoperatively on day of surgery was lower by 10% (-15%, -6%). CONCLUSION: Standardized use of cell saver significantly decreased perioperative blood use in children undergoing cardiac surgery at our center. A risk-adjusted transfusion threshold for children undergoing heart surgery needs to be developed to further decrease exposure to blood products and associated costs.
Assuntos
Preservação de Sangue/métodos , Transfusão de Sangue Autóloga/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Transfusão de Eritrócitos/métodos , Eritrócitos , Cardiopatias Congênitas/cirurgia , Adolescente , Perda Sanguínea Cirúrgica , Ponte Cardiopulmonar/métodos , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Período Pós-Operatório , Estudos Retrospectivos , Albumina Sérica Humana/administração & dosagemAssuntos
Cateterismo de Swan-Ganz/métodos , Ecocardiografia Transesofagiana/métodos , Adulto , Anestesia Local/métodos , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/complicações , Transfusão de Sangue/métodos , Bradicardia/complicações , Ponte Cardiopulmonar/métodos , Evolução Fatal , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Hipotensão/complicações , Masculino , Complicações Pós-Operatórias/terapia , Hemorragia Pós-Operatória/complicações , Hemorragia Pós-Operatória/terapia , Artéria Pulmonar/diagnóstico por imagem , Valva Pulmonar/diagnóstico por imagem , Estenose da Valva Pulmonar/complicações , Disfunção Ventricular Direita/complicaçõesRESUMO
PURPOSE: To establish a protocol for credentialed pediatric radiology nurses, with radiologist supervision, to administer ketamine to induce sedation and analgesia during interventional radiologic procedures. MATERIALS AND METHODS: This study was conducted in two phases. The goal of the first phase was to develop a sedation protocol to replace that of using general anesthesia for specified pediatric interventional procedures. Ketamine was administered intravenously (with intermittent bolus or continuous infusion) or intramuscularly. Sedation induction times, adverse events, doses, and sedation and recovery durations were recorded. In phase 2, the results of phase 1 were reviewed and a formal ketamine protocol was developed. RESULTS: Neither sedation failures nor substantial adverse events occurred in phase 1. Mean duration of all sedations was 52 minutes, and median recovery room time was 0 minutes. In phase 2, the results of phase 1 were reviewed and a sedation protocol was proposed to a hierarchy of hospital committees before final approval from the medical staff executive committee. Subsequently, standard order forms for radiology nurse administration of ketamine with radiologist supervision were prepared for exclusive use by the pediatric interventional radiology department. CONCLUSION: Ketamine-induced sedation may be a safe and effective alternative to general anesthesia for some interventional radiologic procedures in pediatric patients. Collaboration between anesthesia and radiology departments is important for development of a safe and successful ketamine sedation program. To the authors' knowledge, this is the first report describing the intravenous infusion of ketamine for sedation in pediatric patients and the only report describing the establishment of a protocol for ketamine administration by credentialed radiology nurses with radiologist supervision.