**5.6.3 Grown up congenital heart (GUCH)**

#### **Pregnancy**

64 Perioperative Considerations in Cardiac Surgery

show metabolic acidosis and pulmonary edema respectively. Patients are usually on

digoxin, diuretics and ionotropes. Anaesthetic considerations includes

2. Preoperative CBC and electrolytes

5. Maintain normal sinus rhythm 6. Maintain preload during anaesthesia. 7. After load reduction in certain situations

**5.6 Miscellaneous concerns 5.6.1 Neurological outcome** 

**5.6.2 Coagulation disturbances** 

1. Decreased platelet count and function

3. Impaired coagulation factors production

polycythaemic patient.

2. Primary fibrinolysis

4. Contracted serum volume

tranexamic acid has increased.

a. Ionotopes b. Diuretics c. Digoxin

depression

1. Preoperative optimization of following before surgery

causing ischaemia/reperfusion injury may also play a part19.

Coagulation derangement associated with polycythaemia includes:

d. Antiarrhythmics or ablation in patients with arrhythmia

3. Etomidate and fentanyl provide cardiovascular stability at the time of induction

4. Avoid or limit the use of inhalation anaesthetics due to associated myocardial

There is growing concern about their quality of life and neurocognitive function, as the long term survival of these children is now possible. 20 -50% may develop neurological impairment due to chronic hypoxaemia, prolong deep hypothermic circulatory arrest and prolong exposure to anaesthetics. Non pulsatile low flow during cardiopulmonary bypass

Brain adapts to chronic hypoxia due to presence of NMDA 2B receptors in early life. Cortical neurons may reduce by 30% due to chronic hypoxia causing reduction in brain volume. But this reduction is compensated when normoxia develops after surgery. Although most of the article have supported the use of high dose narcotics in over all outcome but at present there

Coagulation abnormalities are very common in CHD patients particularly in cyanosed and

Use of blood products is common in paediatric cardiac surgery due to coagulopathy during surgery and several strategies have been instituted to minimize this practice. Preoperative exchange transfusion of 20 ml/kg FFP to replace same amount of blood is an effective method to counter coagulopathy. Antifibrinolytics like aprotinin and tranexamic acid20 have been used for this purpose. Aprotinin is no longer recommended in cardiac surgery due to higher incidence of renal failure, stroke and myocardial infarction while the use of

Tranexamic acid as a part of blood saving strategy is given as a bolus of 100mg/kg followed by 10 mg/kg/hr infusion. Whole blood transfusion is quite effective in coagulopathic

is no concrete evidence about best anaesthetic agents for congenital heart surgery.

Increased in blood volume during pregnancy may further aggravate the situation and patient may develop arrhythmias, pulmonary congestion and heart failure. Consideration during pregnancy ranges from termination of pregnancy to the safe delivery by caesarean section. A multidisciplinary approach involving obstetrician, paediatric cardiac surgeon, paediatric cardiologist, intensivist, anaesthetist and neonatologist is essential in decision making process.

Anaesthetic challenges and considerations include


#### **Eisenmenger**

Most of the patients with Eisenmenger started with simple correctable cardiac defects but eventually leads to severe pulmonary hypertension (PVR > 800 dynes/cm-5) which does not respond to pulmonary vasodilators. Hypoxaemia, myocardial dysfunction and arrhythmia is a common finding.

Perioperative risk includes


Anaesthetic management includes

