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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3612_Библиотеки_им_академика_М_И_Перельмана
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120
Key Questions in CONGENITAL CARDIAC SURGERY
depression of the central nervous system, occasional excitatory
phenomena.
Dose:
•
a) for induction of anaesthesia using 0.5% or 1% injection (by
slow intravenous injection or by intravenous infusion):
i) child (1 month-17 years): 2.5-4mg/kg;
ii) child (17-18 years): 1.5-2.5mg/kg at a rate of 20-40mg
every 10 seconds until response;
b) for maintenance of anaesthesia using 1% injection by
continuous intravenous infusion:
i) child (1 month-17 years): 9-15mg/kg/hour;
ii) child (17-18 years): 4-12mg/kg/hour adjusted according
to response.
36 What are the pharmacological properties of muscle
relaxants?
Mechanism of action: muscle relaxants act by specific blockade of
•
the neuromuscular junction, such that it enables light anaesthesia to
be used with adequate relaxation of the muscles of the abdomen and
diaphragm. They also relax the vocal cords and allow the passage of
a tracheal tube. They are subdivided into:
a) non-depolarising neuromuscular blocking agents — which
compete with acetylcholine for receptor sites at the
neuromuscular junction. Their action can be reversed with
anticholinesterases, such as neostigmine, and can be divided
into:
i) aminosteroid group — such as pancuronium,
rocuronium and vecuronium;
ii) benzylisoquinolinium group — such as atracurium,
cisatracurium and mivacurium;
b) depolarising neuromuscular blocking agents. An example is
suxamethonium chloride, which has the most rapid onset of
action of any of the neuromuscular blocking drugs and is ideal
if a fast onset and brief duration of action are required, such as
with tracheal intubation. Neonates and young children are less
sensitive to suxamethonium chloride and a higher dose may be
required. Unlike the non-depolarising neuromuscular blocking
drugs, its action cannot be reversed and recovery is
spontaneous. Anticholinesterases, such as neostigmine,
potentiate the neuromuscular block.
3 Congenital cardiac pharmacology
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Dose:
•
a) suxamethonium (intravenous injection):
i) neonate: 2mg/kg;
ii) child (1-11 months): 2 mg/kg;
iii) child (1-17 years): 1 mg/kg;
b) rocuronium — initially 600µg/kg IV, then 300-600µg/kg/hour IV
infusion, adjusted according to response.
37 What are the pharmacological properties of midazolam?
Class of drug: benzodiazepine with a rapid onset of action.
•
Mechanism of action: midazolam enhances the affinity of the
•
inhibitory neurotransmitter, GABA, for its receptor site.
Indications: to comfort neonates during stressful procedures;
•
sedation during ventilation; control of agitation and seizures.
Cautions: when used in association with other sedatives.
•
Side effects: in neonates, intravenous midazolam may cause
•
respiratory depression, with hypotension and a fall in cerebral blood
flow. Myoclonus is sometimes seen, and paradoxical agitation has
been reported.
Dose:
•
121
a) sedation: 50 and 400µg/kg per hour;
b) ventilation: 200µg/kg bolus, then 60µg/kg/hour infusion.
38 What are the pharmacological properties of sevoflurane?
Class of drug: volatile anaesthetic agent.
•
Mechanism of action: sevoflurane acts by interfering with the release
•
and reuptake of neurotransmitters at the postsynaptic terminals,
and/or by altering the ionic conductance following receptor activation
by a neurotransmitter.
Indications: induction and maintenance of anaesthesia.
•
Cautions: drowsiness, fever, hypothermia; uncommonly, asthma,
•
atrioventricular block, confusion.
Dose (by inhalation):
•
a) induction of anaesthesia:
i) neonate: up to 4 %, adjusted according to response, to
be administered using a specifically calibrated vaporiser;
ii) child: initially 0.5-1 %, then increased gradually up to
8%, according to response, using a specifically
calibrated vaporiser;
Key Questions in CONGENITAL CARDIAC SURGERY
b) maintenance of anaesthesia:
i) neonate: 0.5-2 %, adjusted according to response and
administered using a specifically calibrated vaporiser;
ii) child: 0.5-3 %, adjusted according to response and
administered using a specifically calibrated vaporiser.
39 What are the pharmacological properties of opiates?
Mechanism of action: opiates and their derivatives act on mu-opioid
•
receptors in the central nervous system, producing analgesic and
some sedative effects.
Indications: severe pain.
•
Cautions: existing respiratory depression, urinary retention, bowel
•
obstruction, ileus and biliary colic are relative contraindications.
Side effects: respiratory depression, constipation, addiction,
•
tolerance, withdrawal syndrome.
Dose:
•
122
a) morphine — Oramorph®(immediate release):
i) child (1 month-11 years): 200µg/kg every 4-6 hours
(maximum 5mg per dose);
ii) child (12-17 years): 5mg every 4-6 hours;
b) PCA:
i) neonates and infants <5kg: bolus 10µg /kg, lockout 20
minutes;
ii) child (<50kg): 10-20µg/kg bolus, 0-5µg/kg/hr
background infusion, lockout 5-10 minutes;
iii) child (>50kg): 1mg demand bolus, 0-0.2mg/hr
background infusion, lockout 5-10 minutes;
c) codeine — child (12-17 years): 30-60mg q.d.s. p.o.
40 What are the pharmacological properties of
remifentanyl?
Class of drug: µ-opioid agonist.
•
Mechanism of action: remifentanyl is short acting with a rapid onset
•
and peak effect.
Indications: analgesia and enhancement of anaesthesia at induction,
•
assisted ventilation, pain control.
Cautions: not licensed to be used in children under 1 year of age.
•
Side effects: respiratory depression, central nervous system effects
•
(such as confusion, dizziness, drowsiness, headache), hypotension,
dry mouth, arrhythmias, constipation, pupillary constriction, nausea
and vomiting, urinary retention.
3 Congenital cardiac pharmacology
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Dose:
•
a) child (1 month-12 years) for assisted ventilation: 0.1-1µg/kg in
30 seconds, then 3-78µg/kg/hour intravenous infusion;
b) child (12-18 years) for assisted ventilation: 0.1-1µg/kg in 30
seconds, then 3-120µg/kg/hour intravenous infusion.
41 What are the pharmacological properties of cefuroxime?
Class of drug: second-generation cephalosporin.
•
Mechanism of action: inhibits the synthesis of the peptidoglycan layer
•
of the bacterial cell wall. They are less sensitive to bacterial
penicillinases than penicillins.
Indications: surgical prophylaxis and infection caused by Gram-
•
positive and Gram-negative organisms, such as
йеЙмгзеб~Й, pн~йЬудзЕзЕЕмл= ~мкЙмл, kЙбллЙкб~= ЦзезккЬзЙ~Й
e~ЙгзйЬбдмл=беСдмЙет~Й
Cautions: renal impairment, hypersensitivity to other beta-lactam
•
antibiotics
Side effects: hypersensitivity/anaphylaxis, gastrointestinal
•
disturbance, Stevens-Johnson syndrome, toxic epidermal necrolysis,
transient hepatitis.
Dose:
•
and
bлЕЬЙкбЕЬб~=Ездб
.
pнкЙйнзЕзЕЕмл
,
123
a) surgical prophylaxis:
i) 50mg/kg IV (maximum per dose 1.5g), up to 30 minutes
before the procedure, then 30mg/kg IV t.d.s. for up to 3
doses if required (for high-risk procedures);
b) oral:
i) child (3 months-1 year): 10mg/kg b.d. (maximum 125mg
per dose);
ii) child (2-11 years): 15mg/kg twice daily (maximum
250mg per dose);
iii) child (12-17 years): 250mg b.d.;
c) IV:
i) child: 20mg/kg t.d.s. (maximum 750mg per dose);
increased to 50-60mg/kg every 6-8 hours (maximum
1.5g per dose) in severe infections.
42 What are the pharmacological properties of gentamicin?
Class of drug: aminoglycoside antibiotic.
•
Mechanism of action: crosses the bacterial cell wall to inhibit
•
ribosome activity, thereby preventing bacterial protein synthesis.
124
Key Questions in CONGENITAL CARDIAC SURGERY
Indications: Gram-negative organisms, particularly anaerobes (such
•
as
mлЙмЗзгзе~л
Cautions: renal impairment, hearing impairment, myasthenia gravis.
•
Side effects: ototoxicity, nephrotoxicity.
•
Dose:
•
a) by intravenous infusion: initially 7mg/kg, to be given in a once-
daily regimen, with subsequent doses adjusted to serumgentamicin concentration;
b) by slow intravenous injection:
i) child (1 month-11 years): 2.5mg/kg t.d.s. (over at least 3
ii) child (12-17 years): 2mg/kg t.d.s. (over at least 3
).
minutes);
minutes).
43 What are the pharmacological properties of
vancomycin?
Class of drug: glycopeptide antibiotic.
•
Mechanism of action: inhibits cell wall synthesis by preventing the
•
formation and cross-linking of the structural polymer chains.
Indications: surgical prophylaxis for patients at risk of MRSA
•
infection (such as MRSA carriers), endocarditis or other serious
infection. It is also useful in the treatment of MRSA and
ЗбССбЕбдЙ
Cautions: renal impairment.
•
Side effects: nephrotoxicity, ototoxicity, hypersensitivity,
•
neutropoenia, agranulocytosis, thrombocytopaenia.
Dose:
•
colitis.
`дзлнкбЗбмг
a) Severe infections:
i) child (1 month-11 years): 10-15mg/kg IV q.d.s., adjusted
according to plasma concentration monitoring;
ii) child (12-17 years): 15-20mg/kg IV b.d. or t.d.s.
(maximum 2g per dose), adjusted to plasma
concentration monitoring;
b)
`дзлнкбЗбмг=ЗбССбЕбдЙ
i) child (1 month-11 years): 10mg/kg q.d.s. for 10 days,
p.o.;
ii) child (12-17 years): 125mg q.d.s. for 10 days, increased
if necessary to 500mg q.d.s. for
infection.
infection:
`дзлнкбЗбмг= ЗбССбЕбдЙ
3 Congenital cardiac pharmacology
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Recommended reading
1. Waleh N, Kajino H, Marrache AM, Ginzinger D, Roman C, Seidner SR, Moss TJ,
Fouron JC, Vazquez-Tello A, Chemtob S, Clyman RI. Prostaglandin E2-mediated
relaxation of the ductus arteriosus: effects of gestational age on g protein-coupled
receptor expression, signaling, and vasomotor control.
2326-32.
2. He J, Ren Y, Chen Y, Feng Y. Bosentan treatment for pulmonary arterial hypertension
due to patent ductus arteriosus and Down’s syndrome in an infant.
177(3): 1054-5.
3. Angadi U, Westrope C, Chowdhry MF. Is levosimendan effective in paediatric heart
failure and post-cardiac surgeries?
710-4.
fенЙк~Ен= `~кЗбзо~лЕ= qЬзк~Е= pмкЦ
`бкЕмд~нбзе
2004; 110(16):
fен=g=`~кЗбзд
2013; 17(4):
2014;
125
126
Key Questions in CONGENITAL CARDIAC SURGERY
Chapter 4
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Congenital echocardiography
Sian Chivers, Carles Bautista, Nitha Naqvi
1 What are the principles of echocardiography used for
the assessment of congenital heart disease?
Hearts with congenital malformation present with an extraordinary
•
variability of lesions. Moreover, these can undergo important
modification over time, given the progression of the disease and the
natural compensatory adaptation of the heart to the resulting
physiological changes.
Echocardiography remains the mainstay of diagnosis, pre-operative
•
work-up, intra-operative assessement of correction and medical
follow-up.
It is therefore of paramount importance that a systematic approach to
•
scanning congenitally malformed hearts is adopted.
This fundamental approach uses sequential segmental analysis,
•
which is applied to the description of all congenitally malformed
hearts.
It relies on the recognition of the three morphological cardiac
•
segments (atria, ventricles and arterial trunks), and how the
segments are connected to each other.
Whenever possible, this principle should be adopted in all scans,
•
although focused interrogations are used in specific circumstances.
127
2 What are the different types of echocardiography used
for the assessment of congenital heart disease?
Transthoracic echocardiography (TTE) — which uses a handheld
•
transducer, containing a piezoelectric crystal to transmit the
ultrasound beam, that is applied directly to the chest or abdomen to
obtain the image. It is the commonest type of echocardiography.
Transoesophageal echocardiography (TOE) — which uses a
•
specialised probe consisting of a long shaft with both a rigid and
mobile component, and a tip containing the piezoelectric crystal for
ultrasound image transduction. The probe has controls for adjusting
128
Key Questions in CONGENITAL CARDIAC SURGERY
rotation and angulation of its tip and is passed down into the
oesophagus and stomach, where images are taken at different
levels. Adult, paediatric and neonatal size probes are available. In
children, TOE is carried out under general anaesthesia. It can be
used to:
a) give a detailed assessment of valve morphology, both pre- and
intra-operatively;
b) ascertain cardiac function during intra-operative imaging;
c) assess for intracardiac air post-bypass;
d) guide transcatheter procedures in congenital heart disease,
such as device closure of an atrial or ventricular septal defect.
Epicardial echocardiography — where the standard smallest
•
transthoracic probe (in a sterile plastic sleeve) is placed directly on
the epicardium with the chest open and manipulated to image the
internal cardiac structures. It can be used intra-operatively or on the
paediatric intensive care unit when the patient’s chest is open.
3 What are the different modes of two-dimensional
echocardiography?
B-mode echocardiography — where multiple ultrasound reflections
•
are processed by the machine to produce a live moving 2D image of
the structure of interest.
M-mode echocardiography (Figure 1) — where a single chosen
•
ultrasound line is displayed that gives a time motion display of that
specific region. This technique is most often used to assess left
ventricular function, including fractional shortening, and myocardial
thickness.
Doppler echocardiography — which utilises the principle of the
•
Doppler effect to assess the direction and velocity of blood flow. The
image can be presented in colour using the BART nomenclature
(Blue Away, Red Towards) of blue colour implying blood flow away
from the transducer and red colour implying blood flow towards the
transducer (Figure 2). The image may also be shown as a waveform
around a baseline, showing blood flow towards the transducer as
above the baseline and blood flow away from the transducer as
below the baseline. Blood flow velocity (m/s) can be estimated by the
transducer and calculations can then be made to estimate pressure
gradients (mmHg).
4 Congenital echocardiography
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fspÇ
isfaÇ
ismtÇ
fspë
isfaë
ismtë
Figure 1. M-mode image of the the left ventricle
taken from a parasternal short-axis view. IVSd =
interventricular septum in diastole; LVIDd = left
ventricular internal diameter in diastole; LVPWd =
left ventricular posterior wall in diastole; IVSs =
interventricular septum in systole; LVIDs = left
ventricular internal diameter in systole; LVPWs =
left ventricular posterior wall in systole.
129
Figure 2. Colour flow Doppler map. Slow velocity
away from the probe appears blue and towards is
red. The fastest velocity away from the probe
appears cyan and towards the probe is yellow.
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