**Anaesthetic considerations**

68 Perioperative Considerations in Cardiac Surgery

Pulmonary valve is removed or dilated accordingly and a transannular patch is placed. VSD is also closed at the same setting. Main Pulmonary artery and its branches are also inspected for narrowing. Some centres creates small ASD to counteract high right sided pressures. There is trend towards early total correction rather than palliative surgery which is followed

Goal of anaesthetic management is to avoid low SVR and ionotropes before bypass. If patient is on prostaglandin E1 then it should be continued in pre bypass period. Avoid catecholamine release in preoperative phase and at the time of induction by providing good

Induction can be done with ketamine and fentanyl if intravenous line is in place. Inhalation induction can also be performed while maintaining SVR. Remember infundibular stenosis increased by increasing contractility and heart rate, so minimize noxious stimulus avoid catecholamine release. This is achieved by high dose fentanyl at the maintenance phase.

Acute desaturation at any time should be considered as tet spell and treated by analgesics and volume. Phenylephrine should also be available to treat low systemic vascular resistance and hypotension. Steroids given at the time of induction can help in reducing

TEE is helpful in assessing residual VSD and infundibular stenosis and degree of pulmonary regurgitation. In case of tet spell, give 100% O2, Phenyl ephrine, volume, increase depth of anaesthesia, hyperventilate and give bicarbonate. In addition esmolol or proponol can be

During postbypass period be ready for arrhythmias and heart block, RV dysfunction and coagulopathy. Ionotrpic support is mandatory in postbypass period along with high filling pressure particularly if right ventriculotomy was performed. Blood products should be

Ductus arteriosus is a normal communication in fetus, which constrict and closes within 10- 15 hrs of birth and later closed anatomically by fibrosis in 2 – 3 weeks. Various mechanism have been described for initial functional closure, which includes increased PaO2, absence of placental derived prostaglandins and presence of catecholamines and bradykinins in new

Ductus venosus provides a communication between junction of main and left pulmonary artery and lesser curvature of descending aorta after left subclavian artery origin. Higher incidence of patent ductus arteriosus is seen in premature, females, children living at high

It provides left to right shunt causing high pulmonary flow and volume load on left atrium and ventricle. Pulmonary congestion and recurrent infection is commonly seen if remain

Medical management includes three doses of indomethacin. If medical management fails then either transcatheter or surgical closure becomes necessary. Surgical techniques include

ligation via left thoracotmyn sternotomy or recently by video assisted thoracoscopy.

Arterial line and central line should be placed after induction and intubation.

release of inflammatory markers during cardio pulmonary bypass.

available and antifibrinolytics should be started for coagulopathy.

by total correction.

**Anaesthetic management** 

tried to reduce infundibular spasm.

**6.4 Patent ductus arteriosus (PDA)** 

altitude and associated with maternal rubella.

born.

open.

premedication and adequate analgesia and anaesthesia.

Anaesthesia management is planned according to prematurity, degree of pulmonary congestion and PVR and surgical technique. During surgery aorta, left pulmonary artery and left main bronchus can be mistakenly ligated instead of ductus arteriosus. Remember to place a pulse oximeter at lower extremity to diagnose ligation of aorta. In addition, DBP will rise as soon as PDA is ligated, which will confirm the identification.

Invasive monitoring is not essential in uncomplicated PDA but arterial line can be placed in patients with comorbids to check beat to beat pressure and diagnosis and correction of acidosis. Limit Left to right shunt by keeping FiO2 low and PaCO2 between 40–50 mmHg. Blood should be available in the room as bleeding is a possibility.
