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Heart transplantation in children: Anaesthesia & intraoperative management
HEART TRANSPLANTATION IN CHILDREN: ANAESTHESIA & INTRAOPERATIVE MANAGEMENT J.NEIDECRER. P.BRULE, J.B. CAILLET. C. VEDRINNE. M.GRE%IER. J.NlNET, G. CIIAMPSADR HOPlTAL CARD10vAscDIAIRE & PNEDMOUIGQIJB Lours PRADEL - LYON (FRANCE)
Improvements of survival rate in heart transplantation in adults has lead a number of transplantation teams to consider transplantation as a possible solution for children with untreatable congenital heart disease. This study analyses retrospectively the anaesthetic and intraoperative management of children undergoing heart transplantation. PATIENTS
AND METHOD
Premeditation was not given before anaesthesia (except for immunosuppressive treatment: 3 rngncg azathioprine). After a 20G peripheral venous catheter has been introduced using sedation with 2% halothane, anaesthesia was induced with 15 to 25 mcg/kg fentanyl and muscular relaxation was obtained using pancuronium bromide 0.15 mg/kg. Then either a 22 G catheter (body weight <8kg) or a 20 G catheter (boby weight >8kg) was inserted into the radial artery, a 18G triple lumen catheter was introduced into the right jugular vein. Maintenance of anaesthesia fentanyl 5 to 10 m$kg when necessary, and 5 mg/kg thiopental were iniected iust before skin incision. Patients were ventilated u&ng ati Oz-N20 50% mixture monitored by pulse oximeter. Cardiopulmonary bypass was conducted using a membrane oxygenator with a core cooling up to 25’C. Before weaning from bypass, continuous infusion of isoprenaline was started to maintain a sufficient heart rate depending on the age of the child, other inotropic or vasodilating agents were added if necessary. RESULTS:
Between March 1987 and July 1991, 10 children were transplanted. Indications and physical data are reported in table 1. Three intraoperative deaths were encountered in children where weaning from bypass was impossible. The other seven survived Four patients received preoperative inotropic drugs and one prostaglandin El. Induction of anaesthesia was uneventful in all cases except case no6 who entered into the operating theatre under cardiac massage, and cases no4 8c 5 who were already anaesthetised because of recent operation. In 2 cases, total circulatory arrest was necessary because of aortic arch repair (case n’7) and Potts’ anastomosis closure (case n’2). Duration of cardiopulmonary bypass ranged from 88 min to 121 min (mean 106). Isoprenaline was infused to a rate ranging from 0.1 to 0.2 mcg/kg/min. In addition 4 patients received 7 mcg/kg/min dobutamine (case #1,2,3,10) and three 0.2 mcg/kg/min (case n’8,9,10). The 3 patients who were unweanable from the bypass, received a combination of high dose adrenaline, dobutamine, dopamine. isoprenaline and vasodilators (prostaglandin El, sodium nitroprusside, tolazoline). DISCUSSION:
Experience in transplantation in infants and children is limited (l).When we set up our transplantation programme we decided to use an operative management similar to that in conventional paediatric cardiac surgery. No premeditation was prescribed because of the poor clinical status. Like others authors this anaesthetic technique provided a satisfactory haemodynamic stability (2,3). Such patients
referred for transplantation have a poor haemodynamic status which explains the large amounts of inotropic drugs which are required perioperatively (2,3) Postoperative endomyocardial biopsies are not routinely performed. Rejection episodes are detected using echocardiography. Hence, right jugular vein catherization can be performed for haemodynamic monitoring. Some teams use routinely a pulmonary artery catheter(3). We, like Boldt, feel that these measurements are not necessary according to the pathophysiology and prefer left atria1 pressure (2). Nevertheless these catheters are useful1 when weaning from cardiopulmonary bypass is impossble, for evaluation of pulmonary vascular obstruction and particularly, to infuse vasodilating drug diictly into the pulmonary artery. CONCLUSIONS:
Heart transplantation in children seems to be an attractive treatment for end stage congenital heart disease. Anaesthesia can be conducted safely using a high dose fentanyl technique, and in most of the cases sophisticated monitoring of patients is not compulsory. Systematic inotropic support seems desirable regarding the poor preoperative status of the patients.
REFERENCES: l-BAILEY L , ASSAAD A.N.. TR1MMR.F.. & AL : Orthotopic transplantation during early infancy as therapy for incurable congenital heart disease . Ann. Surg. 1988; 208: 279-286 2-BOLDT J.. ZICRMANN B., NFIZ H., & AL. : Heart uansplantation in children : anaesthetic considerations. Paediauic Anaesthesia 1991; 1:119-124. 3-LOWE D.A. Anesthetic considerations in pediatric cardiac transplantation. in Heart transplantation in children - Fumra Pub. New-York (USA) - 1990 - pp39-69.
CASE
AGE
WEIGHT
DIAGNOSIS
1
13Y
24 kg
Single ventricle
2
11Y
25 kg
Tricuspid atresia
3
7Y
l8kg
Dilated myocardiopathy
4
6Y
16kg
5
8Y
15kg
Tricuspid auesia (Poslop. failure) Dilated myocardiopathy
6
3Y
9kg
Dilated myocardiopathy
7
2 days
2.8 kg
8
1Y
7.4 kg
9
13Y
28 kg
10
9M
6kg TABLE1
Hypoplasdc left heart syndrome Leiomyoma Teualogy of Fallot (postop. failure) Dilated myocardiopathy
: GENERAL DATA
Improvements of survival rate in heart transplantation in adults has lead a number of transplantation teams to consider transplantation as a possible solution for children with untreatable congenital heart disease. This study analyses retrospectively the anaesthetic and intraoperative management of children undergoing heart transplantation. PATIENTS
AND METHOD
Premeditation was not given before anaesthesia (except for immunosuppressive treatment: 3 rngncg azathioprine). After a 20G peripheral venous catheter has been introduced using sedation with 2% halothane, anaesthesia was induced with 15 to 25 mcg/kg fentanyl and muscular relaxation was obtained using pancuronium bromide 0.15 mg/kg. Then either a 22 G catheter (body weight <8kg) or a 20 G catheter (boby weight >8kg) was inserted into the radial artery, a 18G triple lumen catheter was introduced into the right jugular vein. Maintenance of anaesthesia fentanyl 5 to 10 m$kg when necessary, and 5 mg/kg thiopental were iniected iust before skin incision. Patients were ventilated u&ng ati Oz-N20 50% mixture monitored by pulse oximeter. Cardiopulmonary bypass was conducted using a membrane oxygenator with a core cooling up to 25’C. Before weaning from bypass, continuous infusion of isoprenaline was started to maintain a sufficient heart rate depending on the age of the child, other inotropic or vasodilating agents were added if necessary. RESULTS:
Between March 1987 and July 1991, 10 children were transplanted. Indications and physical data are reported in table 1. Three intraoperative deaths were encountered in children where weaning from bypass was impossible. The other seven survived Four patients received preoperative inotropic drugs and one prostaglandin El. Induction of anaesthesia was uneventful in all cases except case no6 who entered into the operating theatre under cardiac massage, and cases no4 8c 5 who were already anaesthetised because of recent operation. In 2 cases, total circulatory arrest was necessary because of aortic arch repair (case n’7) and Potts’ anastomosis closure (case n’2). Duration of cardiopulmonary bypass ranged from 88 min to 121 min (mean 106). Isoprenaline was infused to a rate ranging from 0.1 to 0.2 mcg/kg/min. In addition 4 patients received 7 mcg/kg/min dobutamine (case #1,2,3,10) and three 0.2 mcg/kg/min (case n’8,9,10). The 3 patients who were unweanable from the bypass, received a combination of high dose adrenaline, dobutamine, dopamine. isoprenaline and vasodilators (prostaglandin El, sodium nitroprusside, tolazoline). DISCUSSION:
Experience in transplantation in infants and children is limited (l).When we set up our transplantation programme we decided to use an operative management similar to that in conventional paediatric cardiac surgery. No premeditation was prescribed because of the poor clinical status. Like others authors this anaesthetic technique provided a satisfactory haemodynamic stability (2,3). Such patients
referred for transplantation have a poor haemodynamic status which explains the large amounts of inotropic drugs which are required perioperatively (2,3) Postoperative endomyocardial biopsies are not routinely performed. Rejection episodes are detected using echocardiography. Hence, right jugular vein catherization can be performed for haemodynamic monitoring. Some teams use routinely a pulmonary artery catheter(3). We, like Boldt, feel that these measurements are not necessary according to the pathophysiology and prefer left atria1 pressure (2). Nevertheless these catheters are useful1 when weaning from cardiopulmonary bypass is impossble, for evaluation of pulmonary vascular obstruction and particularly, to infuse vasodilating drug diictly into the pulmonary artery. CONCLUSIONS:
Heart transplantation in children seems to be an attractive treatment for end stage congenital heart disease. Anaesthesia can be conducted safely using a high dose fentanyl technique, and in most of the cases sophisticated monitoring of patients is not compulsory. Systematic inotropic support seems desirable regarding the poor preoperative status of the patients.
REFERENCES: l-BAILEY L , ASSAAD A.N.. TR1MMR.F.. & AL : Orthotopic transplantation during early infancy as therapy for incurable congenital heart disease . Ann. Surg. 1988; 208: 279-286 2-BOLDT J.. ZICRMANN B., NFIZ H., & AL. : Heart uansplantation in children : anaesthetic considerations. Paediauic Anaesthesia 1991; 1:119-124. 3-LOWE D.A. Anesthetic considerations in pediatric cardiac transplantation. in Heart transplantation in children - Fumra Pub. New-York (USA) - 1990 - pp39-69.
CASE
AGE
WEIGHT
DIAGNOSIS
1
13Y
24 kg
Single ventricle
2
11Y
25 kg
Tricuspid atresia
3
7Y
l8kg
Dilated myocardiopathy
4
6Y
16kg
5
8Y
15kg
Tricuspid auesia (Poslop. failure) Dilated myocardiopathy
6
3Y
9kg
Dilated myocardiopathy
7
2 days
2.8 kg
8
1Y
7.4 kg
9
13Y
28 kg
10
9M
6kg TABLE1
Hypoplasdc left heart syndrome Leiomyoma Teualogy of Fallot (postop. failure) Dilated myocardiopathy
: GENERAL DATA