ANESTHESIA CONSIDERATIONS FOR THE CONGENITAL HEART PARTURIENT Sharon Orbach-Zinger Department of Anesthesia
Honeymoon in Venice
Gondola
Husband
Vaporetto
Anesthesia Boat = Boat
Vaporetto is NOT a Gondola
How to make anesthesia elegant and smooth sailing
How to make anesthesia elegant and smooth sailing GONDOLA
GONDOLA Group- Multidisciplinary team Department of medicine instituted weekly meeting with multiple disciplines treating patients Eldrodt G, Crrit Pathw Cardiol, 2007
GONDOLA Group- Multidisciplinary team During time this was instituted: 35.4% decrease in mortality Eldrodt G, Crrit Pathw Cardiol, 2007
Cardiologist Anesthesiologist Gynecologist
GONDOLA Group- Cardiologist Hemodynamic goals Anticoagulation NYHA Classification Expected problems Limitation (air, fluid)
GONDOLA Group- Cardiologist DRAW A PICTURE!!
GONDOLA Group- Gynecologist Gynecological Issues Plan A&B Expected Problems Tocolytics needed Position
GONDOLA Output monitoring
GONDOLA Output monitoring Minimally invasive Thermodilution (LIDCO) Pulse contour analysis (LIDCO plus,picco,flow tract Vigileo) Noninvasive Suprasternal aortic dopler velocimetry (USCOM) Transthoracic echocardiography Biopimpedence/Bioreactance (NICCOM) Pulse Contour (Nexfin) Dennis, IJOA 2013 Armstrong, IJOA 2011
Uscom Cheetah NICCOM Nexfin
GONDOLA Output monitoring Woman with severe pulmonary hypertension for cesarean delivery Epidural inserted with gradual increments of local anesthesia
GONDOLA Output monitoring Baseline: BP: 110/73 pulse 74 After epidural insertion: BP 125/71 pulse 72 BP: 120/73 pulse 70 BP: 128/68 pulse 71 BP: 121/69 pulse 68
GONDOLA Output monitoring Flow Trac Baron et al, IJOA 2013
GONDOLA Neuroaxial anesthesia Advantages Abolishes CVS response to pain Can mitigate Valsalva reflex Adaptable to different stages of labor Disadvantages Using standard techniques, symapathethetic blockade occurs
GONDOLA Neuroaxial anesthesia 12 yr retrospective study Stanford University Cohort of 107 cases in 65 women 83%-95% Neuroaxial anesthesia rate Maxwell, Anesthesia, 2013
GONDOLA Neuroaxial anesthesia Surgically Corrected Tetrology of Fallot 78%- Vaginal Delivery- 100% Neuroaxial 22% CS- 100% Neuroaxial Arendt, Anes Analg 2011
GONDOLA Neuroaxial anesthesia What type of neuraxial anesthesia???
GONDOLA Neuroaxial anesthesia Most anesthetic literature favors epidural or low dose sequential combined spinal epidural Maitra, Ann Card Anaesth, 2010 Ortman, Semin Cardiothorac Vasc Anesth 2012
GONDOLA Drugs Phenylepherine vs Ephedrine for neuraxial induced hypotension Phenylepherine now considered drug of choice to due improved fetal acid base outcomes Habib, Anesth Analg 2012
D- Drugs- Bolus
Stewart, Anesth Analg 2010 GONDOLA Drugs- Infusion
GONDOLA Oxytocin
GONDOLA Oxytocin- Bolus vs Infusion Thomas, BJA 2006
GONDOLA Oxytocin- Cardiac patients Langesaeter, AAS 2010
GONDOLA Left Uterine Displacement Cardiac Index in term, healthy, nonlaboring parturients 3.2 3.15 3.1 3.05 3 2.95 2.9 2.85 CI Supine Left Lateral Armstrong, Anesth Analg 2011
GONDOLA Left Uterine Displacement Parturient with Left Ventricular Outflow Obstruction Baird, Anesthesiology 2012
Increased cardiac output Pain control Anticoagulation Early mobilization GONDOLA AFTER
Summary Group- multidisciplinary O N D O L A
Summary Group-multidisciplinary Output monitoring N D O L A
Summary Group-multidisciplinary Output monitoring Neuroaxial anesthesia D O L A
Summary Group-multidisciplinary Output monitoring Neuroaxial anesthesia Drugs O L A
Summary Group-multidisciplinary Output monitoring Neuroaxial anesthesia Drugs Oxytocin L A
Summary Group-multidisciplinary Output monitoring Neuroaxial anesthesia Drugs Oxytocin Left uterine displacement A
Summary Group-multidisciplinary Output monitoring Neuroaxial anesthesia Drugs Oxytocin Left uterine displacement After
Summary G O N D O L Alternate
GONDOLA Alternate It is impossible to make anything foolproof because fools are so damn ingenious. Murphy
Thank you!!!!!! Sharonorbach@yahoo.com