Fixing pediatric hearts
Pediatric Cardiac Surgery
Ah, the pediatric heart room. I remember the slight trepidation I had as a young resident whenever I saw my name assigned to the room where the next day a 6 month old would be having cardiac surgery on bypass, wondering if I was up to the challenge. Really that’s the way I felt any time I started any new rotation I wasn’t familiar with, but pediatric heart cases can have some added difficulties associated with them.
The physiology can be so diverse, syndromes so obscure, and cardiac lesions so unique that sitting down with the attending the day before when possible really helps to understand the current physiology, genetic abnormalities, and the proposed procedure intended to either begin, modify, or complete a correction. This understanding really helps you to tackle the case head-on, and be confident that you can correct physiologic abnormalities as they come up, with the added bonus of having the attending available at all times should questions or necessary changes to the anesthetic plan arise.
Jeff Wright, CA3
As a resident here at UVA, you might find yourself in the peds heart room when you’re on a pediatric rotation, a cardiac rotation, or an upper level assigned to the main OR when there are a lot of TCV cases for the day. Here’s a sample of a case I did recently.
Replacing a pulmonic valve
6:25 I show up to start setting up the room. I’ll be getting a child who had a former truncus arteriosis repair who now has free flowing pulmonic regurgitation. His ventricle is dilating enough over time for his cardiologist and surgeon to recommend replacing his pulmonic valve. I get all my emergency drugs ready—always paying attention to drawing up weight based doses of drugs--then head to see the patient.
6:50 This kid looks like he’ll be trouble away from his parents, so I give him some oral midazolam for when I come back to take him to the room. His parents look pretty nervous about this, so I think it would be better if they don’t come back with him. Gotta love that oral midazolam, too bad the parents can’t have some too...
7:20 The nurse and surgical team have now signed their paperwork, and I take the kid back to the OR. He’s calm and acting a little drunk, so I’m happy he’s not screaming or crying. We get in the OR and have a smooth inhalational induction. Time to start lining up the patient
8:20 I’m feeling pretty proud of myself. I got the peripheral IV, ET tube, A-line, central line, and did a caudal to place some epidural morphine in a little over 50 minutes. Pretty good for one of these cases. The attending placed another peripheral IV as well, so we’re good to go for access. We place the TEE probe and cardiology comes in to do their exam.
9:45 While the surgeons are taking their time to get to the heart as it’s a repeat sternotomy, the attending draws out a picture of the truncus with and without repair to solidify some of the principles we discussed yesterday.
11:00 We’re on bypass with nothing much going on, so the attending sends me out for a half an hour to get some lunch.
12:10 We’re coming off a longer than expected bypass run, but the valve looks great on echo. This kid is pretty resilient, and tolerating coming off bypass on a low dose of epinephrine and milrinone.
13:30 We were able to extubate the patient in the operating room, and he looks great. I’m glad we added the epidural morphine, and the nurses thank us for that as well as we drop the kid off in the PICU.
I go and see the patient and his parents in the PICU. He’s doing great, and he’s scheduled to go to the floor tomorrow. All in all, great case.