Perioperative Management of Children Undergoing Surgery for Congenital Heart Disease

Abstract

In this paper, the perioperative management of children undergoing surgery for congenital heart disease is reviewed. Although midazolam is the most popular premedication sedative, the dosage must be tailored to each child’s condition. Opioids are the most suitable anesthetic drugs for the management of pediatric heart surgery, as they have very little cardiodepressant effect. Opioids should be used to stabilize the hemodynamic condition of patients during surgery; however, controlling pulmonary blood flow is essential not to exacerbate heart failure. It is necessary to keep Qp/Qs as close as possible to a one to one ratio by manipulating systemic and pulmonary vascular resistance, with the former having a greater effect on the ratio. Although the alveoli of younger children are susceptible to collapse, especially under general anesthesia, using low level positive end-expiratory pressure along with performing recruitment maneuvers is effective in avoiding and treating atelectasis. It remains uncertain whether low tidal volume ventilation, which is considered to be lung protective in adults, is also beneficial in younger children. Monitoring regional cerebral oxygen saturation is useful to detect cerebral ischemia as soon as possible and also as a measure of hemodynamic status. Although transesophageal echocardiography (TEE) provides useful information for evaluating the surgical procedure and also as a means of hemodynamic monitoring, it should be noted that TEE is clearly not a non-invasive procedure, and a low threshold not to use it in the presence of a clinical concern is warranted.