title: Anesthesia for noncardiac procedures for children with a Berlin Heart EXCOR Pediatric Ventricular Assist Device: a case series.
abstract: OBJECTIVE
  To report our experience of providing anesthesia for noncardiac procedures in children with in situ Berlin Heart EXCOR Pediatric ventricular assist devices and to suggest principles of anesthetic management.
  
  
  BACKGROUND
  With the initiation of the first North American training and support center for Berlin Heart at our institution in 2006, we have been asked to provide anesthesia for noncardiac procedures to these children. No current anesthetic approach to these children has been reported.
  
  
  METHODS
  Anesthetic records for all noncardiac procedures for children with Berlin Heart between August 2006 and February 2009 in a tertiary care pediatric hospital were retrospectively reviewed. Charts were reviewed for demographic and clinical data, perioperative management, and occurrence of hypotension.
  
  
  RESULTS
  Twenty-nine procedures were performed on 11 patients. Hypotension was a common occurrence with all anesthetic induction and maintenance agents even at low doses. Ketamine induction, however, was less likely to produce hypotension, odds ratio for hypotension 0.1333 (95% confidence range 0.021-0.856). Hypotension was responsive to fluid bolus (60%) and alpha-receptor agonists (100%). Preoperative stability and presence of biventricular ventricular assist device (BiVAD) did not predict intraoperative hemodynamic course.
  
  
  CONCLUSIONS
  Unlike patients with other ventricular assist devices, these children do not tolerate reductions in systemic vascular resistance (SVR) because of the relatively fixed cardiac output of this device. Agents that reduce SVR should be avoided where possible. Preoperative stability is not predictive. Fluids and alpha-agonists should be first-line response to hypotension in this population. Further study of this unusual population is warranted to further delineate best anesthetic practice.
authors.affiliation: Department of Anesthesiology and Pain Medicine, University of Alberta, Stollery Children's Hospital, Edmonton, AB, Canada. dcave@ualberta.ca
authors.forename: Dominic A
authors.initials: DA
authors.lastname: Cave
authors.forename: Kathryn M
authors.initials: KM
authors.lastname: Fry
authors.forename: Holger
authors.initials: H
authors.lastname: Buchholz
mesh_terms: D000293:Adolescent; D000328:Adult; D000758:Anesthesia / Q000379:methods*; D000778:Anesthetics, Dissociative / Q000008:administration & dosage / Q000009:adverse effects; D018686:Anesthetics, Intravenous / Q000008:administration & dosage / Q000009:adverse effects; D002648:Child; D002675:Child, Preschool; D005260:Female; D006353:Heart-Assist Devices; D006801:Humans; D007022:Hypotension / Q000175:diagnosis / Q000209:etiology / Q000628:therapy; D007223:Infant; D007431:Intraoperative Complications / Q000175:diagnosis / Q000209:etiology / Q000628:therapy; D007649:Ketamine / Q000008:administration & dosage / Q000009:adverse effects; D008297:Male; D016017:Odds Ratio; D010880:Piperidines / Q000008:administration & dosage / Q000009:adverse effects; D000077208:Remifentanil; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative; D055815:Young Adult
chemical_list: D000778:Anesthetics, Dissociative; D018686:Anesthetics, Intravenous; D010880:Piperidines; D007649:Ketamine; D000077208:Remifentanil