Hypoplastic left heart syndrome: anesthetic care prior to transplantation or surgical palliation

Perioperative management of infants undergoing fundoplication and gastrostomy after stage I palliation of hypoplastic left heart syndrome

Infants with hypoplastic left heart syndrome (HLHS) represent a high-risk population when they present for noncardiac surgery. To assist clinicians in the care of these infants, we present our experience of 36 HLHS patients who underwent abdominal surgery after stage I palliation. We reviewed patients with HLHS who underwent gastrostomy and/or fundoplication after stage I palliation during an 18-month period. We assessed the impact of preoperative echocardiographic predictors and regional anesthesia on use of intraoperative inotropes, extubation in the OR, perioperative instability, postoperative escalation of care, and length of hospital and intensive care unit stay. Of 39 abdominal operations, all but 2 were performed with open laparotomy. There was a positive association between regional anesthesia and instability during induction. Escalation of respiratory care occurred in 9 (23.1%) cases, and escalation of hemodynamic care occurred in 6 (15.4%) cases. Neoaortic valve insufficiency was associated with increased length of stay, and ventricular outflow obstruction was associated with escalation of hemodynamic care. Extubation in the OR was successful in 31 cases (79.5%). In-hospital death occurred in 1 patient (2.7%). HLHS infants often undergo abdominal surgery, but intraoperative instability and need for escalation of care is common. Specific echocardiographic findings were associated with length of stay and escalation of care. Regional anesthesia was associated with transient intraoperative instability but not with other adverse outcomes.

Anesthetic Management of Pediatric Cardiac Transplantation

Cardiac transplantation has become a widely accepted ther apy for a variety of end-stage cardiac diseases in pediatric patients. From November 1985 to November 1999, 347 pe diatric cardiac transplantations were performed at Loma Linda University Medical Center (LLUMC), including 235 in children younger than 6 months of age. It is essential to be familiar with the physiologic and anatomic characteristics of the recipient. Hypoplastic left heart syndrome is the most frequent congenital disorder leading to transplant in neo nates at LLUMC, with diseases presenting with left ventric ular failure accounting for the majority of the remainder of patients. We have assessed many variables for a possible relationship to intraoperative or postoperative compli cations, including anesthetic induction and maintenance agents, pH and base excess, as determined by arterial blood gas analysis before cardiopulmonary bypass (CPB), and he modynamic changes requiring treatment before CPB. Al though we have noticed an association between low patient temperature or mechanical stimulation at the time of ster notomy, and hemodynamic complications before CPB, in our experience no single anesthetic technique or intraoper ative event, including ventricular fibrillation, predicts early mortality. We believe anesthetic management of pediatric cardiac transplant recipients should be tailored to fit the pathophysiology present.