Pediatric cardioplegic techniques.
We use warm induction and reperfusion with amino acid enhancement on all neonates and preoperatively stressed patients to induce arrest without contracture and to replete high-energy substrates. Blood cardioplegia is used in all age groups. We then employ hypothermia in the majority of patients (all neonates), ranging from deep (18 degrees C), to moderate (26 degrees to 28 degrees C), with warm or near normothermia used in only simpler anatomic repairs. The clear benefits of hypothermia in conferring additional cardiac and systemic ischemic protection along with the relatively greater ease of cooling and rewarming in the pediatric patient warrant its continued use in the majority of open-heart cases. Calcium levels are maintained in the 0.3 to 0.5 mM/L range during the conduct of the operation and reperfusion phase. Before removal from bypass, calcium is administered through either bolus or continuous drip technique to provide a normocalcemic level of 1 to 1.2 mM/L. This close attention is particularly important in the neonate to avoid contracture injuries and to maximize cardiac function, and is warranted if citrate-phosphate-dextrose (CPD)-containing transfusion or prime components are used. Preoperative evaluation for aortopulmonary collaterals with coil embolization is routinely performed, and is particularly important in single ventricle physiology where preserved myocardial function is so vital to a favorable outcome. The opportunity to perform some surgeries off bypass, such as on the RV outflow tract, may be used whenever it represents a viable alternative in very young or ill patients. Similarly, the majority of Glenn shunts, for example, are performed using a caval-RA shunt without formal cardiopulmonary bypass.(ABSTRACT TRUNCATED AT 250 WORDS)
Drinkwater
D C
DC
Division of Cardiothoracic Surgery, University of California, Los Angeles Medical Center 90024.
Laks
H
H
D002315:Cardiopulmonary Bypass; D002648:Child; D006324:Heart Arrest, Induced / Q000379:methods*; D006330:Heart Defects, Congenital / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D015425:Myocardial Reperfusion