pancuronium and Hypertension--Pulmonary

Paediatric cardiac transplantation (pHTX) has gained widespread acceptance as a therapy in end-stage myocardial failure and some forms of congenital heart disease, particularly hypoplastic left heart syndrome (HLHS). The major problems to the anaesthesiologist in these patients are induction of anaesthesia in infants with HLHS and treatment of pulmonary hypertension in the early post-bypass period. PATIENTS AND METHODS. Anaesthesia for pHTX was performed in 15 children < 1 year of age (4-237 days); 12 suffered from HLHS, 2 from endocardial fibroelastosis, and 1 from dilatative cardiomyopathy. Induction of anaesthesia in patients with HLHS IS a challenge to the anaesthesiologist, as he has to maintain the delicate balance between pulmonary and systemic blood flow. Anaesthesia was induced with fentanyl (10-15 micrograms/kg) and pancuronium (0.2-0.4 mg/kg) and maintained with fentanyl (total dosage 70-100 micrograms/kg). Modification of ventilatory parameters such as FiO2, PaCO2, and airway pressure (PEEP, I:E ratio) was used to influence systemic and pulmonary blood distribution in the pre-bypass period according to changes in haemodynamics (target: O2 saturation approximately 75%-80%, PaCO2 45-50 mmHg). Treatment of pulmonary hypertension in the weaning and early post-bypass period consisted of respiratory (PaCO2 < 30 mmHg) and metabolic alkalinisation (pH 7.45-7.55, BE > +3 mmol/l), the use of prostaglandin E1 (3-6-12 micrograms/kg.h), and the phosphodiesterase inhibitor enoximone (10-15 micrograms/kg.min). Additional positive inotropic support was achieved with dobutamine (5-10 micrograms/kg.min), adrenaline (0.1-0.5 micrograms/kg.min), and/or orciprenaline (0.1-0.2 micrograms/kg.min) and calcium chloride (25-100 mg/kg). RESULTS. Two children died intraoperatively and 1 on the 1st postoperative day from overwhelming pulmonary vascular resistance and right ventricular failure. Three children died between 3 and 4 weeks postoperatively, 1 from cytomegalovirus infection, 1 from sepsis, and 1 from acute rejection. Nine patients survived and are well up to 5.5 years after transplantation. CONCLUSION. Pulmonary hypertension in the weaning and early post-bypass period is the main anaesthesiological problem of pHTX, particularly in children with HLHS. A polypragmatic approach to this problem consisting of alkalinisation, pulmonary vasodilatation, and inotropic support is presented and seems to be effective. Further improvements in concepts of pHTX are limited by

Topics: Anesthesia; Fentanyl; Heart Transplantation; Hemodynamics; Humans; Hypertension, Pulmonary; Hypoplastic Left Heart Syndrome; Infant; Infant, Newborn; Pancuronium

The purpose of this observational study was to determine whether hypercarbia or oxygen desaturation occurred during our current regimens of deep sedation or general anaesthesia of infants and children undergoing cardiac catheterization. Data were gathered prospectively from 50 consecutive infants and children aged 4 months to 12 years undergoing cardiac catheterization. Several anaesthetists used the following regimens, which were not randomized: 1) propofol. 1.5-2.0 mg.kg-1 and fentanyl 1 microgram.kg-1 IV over 2 min for induction, followed by propofol infusion of 100-150 micrograms.kg-1.min-1; 2) fentanyl 2-3 micrograms.kg-1 and midazolam 0.1-0.2 mg.kg-1 IV over 10-15 min; 3) ketamine 8 mg.kg-1 IM, or 4) same as regimens 1 or 2, plus pancuronium, intubation and controlled ventilation. Regimens 1, 2, and 3 were associated with spontaneous ventilation through the natural airway. End-tidal carbon dioxide tension (PetCO2), SpO2, and respiratory rate were monitored for 60 min. The three regimens employing spontaneous ventilation through the natural airway were associated with both statistically and clinically significant increases in PetCO2 and decreases in SpO2. This raises the possibility that acute exacerbation of PAP and PVR may occur in pulmonary hypertensive patients. In contrast, PetCO2 and SpO2 did not change significantly from baseline in the controlled ventilation group.

Topics: Anesthesia, Intravenous; Anesthetics, Dissociative; Anesthetics, Intravenous; Blood Pressure; Carbon Dioxide; Cardiac Catheterization; Child; Child, Preschool; Fentanyl; Humans; Hypertension, Pulmonary; Hypnotics and Sedatives; Infant; Intubation, Intratracheal; Ketamine; Midazolam; Neuromuscular Nondepolarizing Agents; Oxygen; Pancuronium; Propofol; Prospective Studies; Pulmonary Artery; Respiration; Respiration, Artificial; Tidal Volume; Vascular Resistance

Topics: Adult; Anesthesia, Intravenous; Cardiopulmonary Bypass; Cardiopulmonary Resuscitation; Diazepam; Fentanyl; Heart Arrest; Heart Failure; Heart-Lung Transplantation; Humans; Hypertension, Pulmonary; Male; Pancuronium; Succinylcholine

Topics: Child; Child, Preschool; Female; Heart Defects, Congenital; Humans; Hypertension, Pulmonary; Infant; Male; Muscle Contraction; Muscle Relaxation; Pancuronium; Postoperative Care; Tranquilizing Agents