Chapter 51
- Anesthesia for Pediatric Cardiac Surgery
- William J. Greeley
- James M. Steven
- Susan C. Nicolson
Cardiac surgery is an established and effective treatment for
children with congenital heart defects. Early successes in surgical treatment have
led to a new therapeutic era in the management of congenital heart disease and have
fostered the development of the subspecialties pediatric cardiology and cardiac surgery
and their collaboration. Through this cooperative effort, tremendous progress in
medical diagnosis and surgical treatment has been achieved. In turn, these accomplishments
gave rise to the development of pediatric cardiac anesthesiologists, individuals
who understand the pathophysiology of congenital heart malformations, the diagnostic
and surgical procedures used to treat heart disease, and the principles of pediatric
and cardiac anesthesia as well as of intensive care medicine. Pediatric cardiac
anesthesia continues to evolve as an exciting and technically demanding subspecialty
in which anesthetic management is based on physiologic principles.
Congenital cardiovascular surgery and anesthesia are often performed
under unusual physiologic conditions. Rarely in clinical medicine are patients exposed
to such biologic extremes as during congenital heart surgery. Commonly, patients
are cooled to 18°C, are acutely hemodiluted by more than 50% of their extracellular
fluid volume, and undergo periods of total circulatory arrest lasting up to 1 hour.
The ability to manage patients under these physiologic extremes is a vital function
of the pediatric cardiovascular anesthesiologist. As with other areas of medicine,
the application and management of technology preceded a comprehensive understanding
of its physiologic effects.
Relevant clinical information, primarily generated from investigations in pediatric
intensive care units (ICUs) as well as in operating rooms and catheterization labs,
has been especially valuable in contributing to the understanding of anesthetic management
for children undergoing cardiac surgery.
Clearly, the perioperative management of these complex cases requires
a group of physicians (surgeon, anesthesiologist, cardiologist, critical care specialist),
nurses, and perfusionists to work as a team. This team orientation is essential
to the achievement of an optimal outcome. Although the quality of the surgical repair,
the effects of cardiopulmonary bypass (CPB), and postoperative care are the major
determinants of outcome, meticulous anesthetic management is also imperative. Ideally,
despite the complexity of the cases and the marked physiologic changes attributed
to CPB and the surgical procedures, anesthetic care should never contribute substantially
to morbidity or mortality.[1]
The challenge is
to understand the principles underlying the management of patients with congenital
heart disease and to apply them to clinical anesthesia. Assuming the reader already
understands the fundamentals of adult cardiac and general pediatric anesthesia, detailed
in Chapter 50
and Chapter
60
, respectively, the first section of this chapter provides an overview
of some of the unique features of the pediatric patient, congenital heart disease,
and surgical procedures, which are essential to understanding the anesthetic management
of children undergoing cardiac surgery. The second section addresses the perioperative
anesthetic management for procedures requiring CPB. The last section discusses closed-heart
procedures and anesthesia for interventional catheterization.
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