Chapter 23 Congenital Heart Disease
Fundamental pathophysiology in congenital heart disease
1. When does shunting occur in congenital heart disease?
2. What is the usual limitation to the direction and amount of shunt flow?
3. When does a left-to-right shunt occur?
4. What is the physiologic effect of a left-to-right shunt on the pulmonary blood flow (Qp) relative to the systemic blood flow (Qs)?
5. What are the long-term effects of increased pulmonary blood flow that occurs in a left-to-right shunt?
6. Give an example of a congenital heart defect that results in a left-to-right shunt.
7. When does a right-to-left shunt occur? What is the physiologic effect of this?
8. Give an example of a congenital heart defect that results in a right-to-left shunt.
9. What are mixing lesions in congenital heart disease? How do mixing lesions affect the systemic arterial oxygen saturation?
10. What determines the Qp:Qs ratio in mixing lesions?
11. What is the ideal Qp:Qs ratio in mixing lesions? Why?
12. What are some factors that can increase systemic vascular resistance?
13. What are some factors that can decrease systemic vascular resistance?
14. What are five factors that increase pulmonary vascular resistance?
15. What are five factors that decrease pulmonary vascular resistance?
Perioperative management
17. What are some ways an anesthesiologist can prepare for a patient requiring surgery for congenital heart disease?
18. What preexisting conditions might be important to the care of patients with congenital heart disease?
19. What information might be gained from preoperative echocardiograms or magnetic resonance imaging (MRI)?
20. What is a risk factor from a previous sternotomy?
21. What are the fasting recommendations for infants and children scheduled for congenital heart surgery?
22. What is the most important feature of the intravenous administration set up for the patient scheduled for congenital heart surgery?
23. What are some common side effects of the induction of anesthesia using inhaled agents, such as sevoflurane or halothane?
24. What are some side effects of an intravenous induction of anesthesia using opioids such as fentanyl?
25. What are some side effects of an intravenous induction of anesthesia using ketamine, a drug that preserves sympathetic nervous system tone?
26. What are some general principles for the induction of anesthesia that might apply to all patients with congenital heart disease?
27. What are the goals for the anesthetic management in patients with a left-to-right shunt?
28. What are the goals for the anesthetic management in patients with a right-to-left shunt?
29. What are some considerations for the ventilatory management in patients with congenital heart disease?
30. For lesions with excessive pulmonary blood flow such as ventricular septal defects or atrioventricular septal defects, how should the pulmonary vascular resistance be managed prior to cardiopulmonary bypass?
31. For critically ill patients such as those with truncus arteriosus, what is an important feature of ventilator management prior to cardiopulmonary bypass?
32. For the Norwood procedure for hypoplastic left heart syndrome, what is an important aspect of anesthetic management prior to cardiopulmonary bypass?
33. During the Glenn procedure, what is an important aspect of anesthetic management?
34. What are poor prognostic factors of a successful Fontan procedure?
35. What are some common congenital lesions that result in inadequate pulmonary blood flow? What would be an important aspect of ventilatory management of patients with these lesions?
36. Where is the appropriate placement of an arterial line during surgery for coarctation of the aorta?
37. During induction of anesthesia for patients with obstructive lesions such as aortic stenosis, what is the most important to avoid?
38. What are some common abnormalities seen in patients with Williams syndrome?
39. How should the size of the endotracheal tube be selected?
40. What are some monitors that might be required for children undergoing surgery for congenital heart disease?
41. What are some general requirements for the selection of blood products for infants requiring cardiac surgery?
42. What are some antifibrinolytic drugs used in congenital heart surgery?
43. How is anesthesia maintained prior to cardiopulmonary bypass?
44. What patients may be able to have early extubation of the trachea?
45. What is a useful way to monitor the cardiac output and circulatory system?
46. How is anticoagulation for cardiopulmonary bypass achieved?
47. What is the target activated clotting time (ACT) value?
48. How are flow rates adjusted during cardiopulmonary bypass for infants and children?
49. How does the perfusionist control oxygenation and ventilation during cardiopulmonary bypass?
50. How is blood temperature adjusted during cardiopulmonary bypass?
51. How is mechanical quiescence and myocardial protection provided during cardiopulmonary bypass?
52. What is the lowest acceptable level of anemia during cardiopulmonary bypass?
53. What measures are used to provide cerebral and myocardial protection during cardiopulmonary bypass?
54. Which surgical repairs require the use of deep hypothermic circulatory arrest?
55. What are some potential negative effects of persistent hypothermia after cardiopulmonary bypass?
56. How can relative bradycardia and atrioventricular node conduction failure during separation from cardiopulmonary bypass be treated?
57. How are patients with long-standing excessive pulmonary blood flow treated on separation from bypass?
58. What is the best approach to the management of a patient who has had a palliative procedure and is left with a mixing lesion? What is an effective monitoring tool in these patients?
59. What are some common vasoactive drugs used during separation from cardiopulmonary bypass?
60. What are some causes of difficulty in separation from cardiopulmonary bypass in congenital heart surgery?
61. What rescue measure can be used if a patient cannot be weaned from cardiopulmonary bypass?
62. What are important complications of protamine administration?
63. What are contributors to postoperative coagulopathy in congenital heart surgery?
64. What is the best method to replace blood components in infants?
65. What is a common side effect of the administration of citrated blood products?
66. What agents can be used for refractory bleeding after cardiopulmonary bypass?
67. What are common parameters to be actively managed after pediatric cardiac surgery in the intensive care unit?
