Anesthetic Consideration in a Neonate with Congenital Heart Disease for Noncardiac Surgery

Abstract

Congenital heart defects (CHD) are the most common types of birth defects, accounting for nearly 30% of all birth defects, with a high mortality and morbidity, due to late presentation and delay in diagnosis, management, especially in critical defects. Reported infant mortality in untreated CHD is 10%. CHDs are also a leading cause of birth defect-associated deaths, amounting to nearly 4.2% of neonatal deaths. Presence of CHD further increases the risk for both cardiac and noncardiac surgeries. Routine cardiac reparative surgery is usually delayed to beyond the neonatal age, except in those with critical defects, who may undergo palliative procedures, such as cardiac catheterization and BT shunt surgery. More than 30% undergo noncardiac surgeries within the first year of life, and surgery for TEF, CDH, gut exteriorization for anorectal anomalies, wide cleft lip repair, inguinal herniorrhaphy, pyloromyotomy are performed within the neonatal period, with very high risk of morbidity and mortality, especially preterm, who are still struggling to adapt to the extra uterine environment. Anesthesiologists’ chief concern in management is to avoid factors that may reverse cardiac shunts (foramen ovale, ductus arteriosus) or allow persistence of fetal circulation (PFC). Besides this, there is a potential risk of shunt reversal in those neonates who have had normal transition, by various factors prevalent in the perioperative period of a surgical neonate. Anesthetic management involves a critical balance between SVR and PVR, as both excess increase and excess decrease are equally harmful. Common CHDs in neonates presenting for surgery are ASD, VSD, PDA, and TOF. Risk is further increased because of other congenital abnormalities, and at times, the CHD is a component of a major syndrome, chiefly, CHARGE, VATER, VACTERL, and Down’s, to name a few, and because of concomitant drug therapy (digoxin, diuretics, β blockers, antibiotics, vasomimetics, etc.) with risk of interaction with the anesthetic drugs. Almost any anesthetic technique can be used in neonates with CHD, provided anesthesiologist understands the pathophysiology and hemodynamic changes of the defect, ready to prevent and manage complications, and tailor changes in SVR and PVR. Such neonates can be managed at nonspecialty setups; they are still high-risk category requiring HDU/ICU care, and hence should preferably be taken up in tertiary care centers with cardiac and neonatology setup.