Written by an expert author team at the renowned Boston Children's Hospital, USA, The Pediatric Cardiac Anesthesia Handbook provides a comprehensive yet concise overview of the anesthetic management of pediatric patients with congenital heart disease.

This book is divided into two parts. The first part provides an introduction to the basic assessment of patients, including cardiovascular physiology, pathophysiology and the underlying concepts in coronary heart disease, preoperative evaluation, intraoperative management, and interpretation of cardiac catheterization data. The second part of the book addresses disorders and diseases in a templated manner covering the anatomical and physiological features, surgical therapies, anesthetic approach and postoperative management. Chapters on the heart and heart and lung transplantation consider the additional complexities of those patients and anesthetic considerations for non-cardiac surgery after heart transplantation.

The anesthesiologist caring for patients with congenital heart disease faces a myriad of challenges in the perioperative management of these complex individuals. This book provides:

* A concise and easily referable guide ideal for use during anesthesiology residency training and fellowships.

* A templated chapter layout ideal for easy referral by wider members of the multidisciplinary team, such as cardiologists, cardiac intensivists, perfusionists, and surgeons.

* Helpful illustrations and a bulleted content for rapid reference.

* Guidelines on specific lesions for the pediatric anesthesiologist caring for cardiac patients presenting for non-cardiac surgery.

This book is a valuable resource for all anesthesiology and cardiac critical care providers who manage patients with congenital heart disease, and an ideal study aid.

Viviane G. Nasr, MD graduated from Medical School at the American University of Beirut (AUB), Lebanon in 2003, and pursued a residency in anesthesiology at AUB and Tufts Medical Center, Boston. She completed a pediatric anesthesia fellowship at Children's National Medical Center (CNMC) in Washington DC and a pediatric cardiac anesthesia fellowship at Boston Children's Hospital. She is American Board certified in Anesthesiology and Pediatric Anesthesiology and an active member of the Congenital Cardiac Anesthesia Society.

James A. DiNardo, MD graduated from Dartmouth College and Dartmouth Medical School (with honors). He completed his anesthesia residency and fellowship in Cardiac Anesthesia at Beth Israel Hospital in Boston. He joined faculty at Boston Children's Hospital in 1999 where he currently serves as the Chief of the Division of Cardiac Anesthesia. He spends approximately one third of this clinical time as an Attending in the Cardiac ICU.
Dr DiNardo is certified in perioperative TEE and is former Chairman of the PTEeXAM Committee. He is also a Senior Oral Board Examiner for the ABA, a member of the ABA Pediatric Examination Writing Committee, and Chair of the Pediatric MOCA Examination Committee. He is Past-President of both the Congenital Cardiac Anesthesia Society and the Association of Cardiac Anesthesiologists. He is currently the Anesthesia and Analgesia Executive Editor for Pediatric Anesthesia.
He is the author of a major textbook on cardiac anesthesia and of more than 160 peer-reviewed articles and book chapters.

Preface xvii

Part I The Basics 1

1 Cardiovascular Development 3

Embryology 3

Cardiovascular Physiology 3

Fetal Circulation 3

Closure of the Ductus Arteriosus 5

Closure of the Foramen Ovale 6

Closure of the Ductus Venosus 6

Pulmonary Vascular Changes 6

Myocardial Performance in the Neonate 7

Hemodynamic Changes at Birth 7

2 Important Concepts in Congenital Heart Disease 9

Pathophysiology of CHD 9

Concepts of Shunting, Single-Ventricle Physiology, and Inter-Circulatory Mixing 9

Shunting 9

Effective Blood Flow 10

Total Pulmonary Blood Flow/Total Systemic Blood Flow 10

Single-Ventricle Physiology 10

Intercirculatory Mixing 13

Classification of Anatomic Shunts 15

Simple Shunts 15

Complex Shunts 15

Pulmonary Vascular Pathophysiology 18

Causes of Pre-Capillary PH in CHD 18

Causes of Post-Capillary PH in CHD 18

Control of Pulmonary Vascular Resistance 19

PaO₂ 19

PaCO₂ 19

pH 19

Variation in Lung Volumes 19

Vasodilator Agents 20

Sympathetic Nervous System Stimulation 20

Myocardial Ischemia 21

Aortic Diastolic Pressure 21

Subendocardial Pressure 21

Heart Rate 22

Anatomic Coronary Artery Lesions 22

3 Preoperative Evaluation 23

Clinical History 23

Physical Examination 23

Associated Congenital Abnormalities 24

Laboratory Data 25

Pregnancy 26

Psychological Considerations 26

Preoperative Preparation 27

Preoperative Fluid Therapy 27

Preoperative Medications 29

4 Intraoperative Management 31

Intraoperative Monitoring 31

ECG and Blood Pressure 31

Systemic Oxygen Saturation 32

End-Tidal CO₂ 32

Central Venous Pressure 32

Temperature 33

Near-Infra-Red Spectroscopy 33

Transcranial Doppler 34

Transesophageal Echocardiography (TEE) 35

Airway Management 35

Anesthesia Induction and Maintenance 36

Induction of Anesthesia 36

Mask Induction 36

Intravenous Induction 36

Maintenance of Anesthesia 37

5 Interpretation of Cardiac Catheterization Data 39

Right-Heart Catheterization 39

Right Atrial Pressure (RAP) Waveform 39

Right Ventricular Pressure (RVP) Waveform 39

Pulmonary Artery Pressure (PAP) Waveform 40

Left-Heart Catheterization 40

Left Atrial Pressure (LAP) Waveform 41

Left Ventricular Pressure (LVP) Waveform 41

Aortic Pressure Waveform 41

Left Ventriculography 41

Coronary Angiography 43

Coronary Anatomy 43

Anatomic Coronary Lesions 44

Coronary Collaterals 45

Cardiac Output Determination 45

Thermodilution Technique 45

Fick Determination 45

Evaluation of Cardiac Shunts 46

Shunt Location 46

Shunt Quantification 46

Saturation Data 48

Resistances 48

Assessment of Pulmonary Vascular Anatomy 48

Evaluation of the Pulmonary Vasculature 48

Pulmonary Artery Wedge Angiogram 48

Pulmonary Vein Wedge Angiogram 49

Assessment of Pulmonary Arterial Hypertension 49

Assessment of Valve Lesions 50

Stenotic Lesions 50

Regurgitant Lesions 50

6 Cardiopulmonary Bypass 51

The Cardiopulmonary Bypass Circuit 51

Differences Between Adult and Pediatric CPB 53

CPB Flow Rates 53

Anesthesia During CPB 53

Monitoring During CPB 54

Hemodilution 54

Priming Solution 54

Ultrafiltration 55

Conventional Ultrafiltration 55

Modified Ultrafiltration 55

Blood Gas Management 55

Deep Hypothermic Circulatory Arrest and Regional Perfusion Techniques 57

Anticoagulation 57

Protamine Reversal 58

7 Mechanical Support Devices 59

Extracorporeal Membrane Oxygenation (ECMO) 59

Indications 59

Relative Contraindications 59

Modes of ECMO Support 59

Veno-Venous (VV)-ECMO 59

Veno-Arterial (VA)-ECMO 59

Device and Patient Complications 60

Common Terminology Used During an ECMO Run 61

Intraoperative Considerations for Patients on ECMO 61

Ventricular Assist Devices (VA…