hypoxic spell - ped.si. · pdf file• correct metabolic acidosis : sodium bicarbonate 1-2...
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Patient managementPatient management
Hypoxic spellHypoxic spell
พญ.สนนาต ฑฆวาณชพญ.ภทรพร จาปาสก
คณสพรรณ หอมชะเอมอ.พญ. ชดชนก วจารสรณ
22/4/58
HistoryHistory
HistoryHistory
Case เดกหญงอาย 11 เดอน
• Underlying disease TOF with severe PS base line O2 • Underlying disease TOF with severe PS, base line O2
sat = 60-65%
• เคยม hypoxic spell มาแลว 3 ครง ICU
on propranolol 1 mg/kg/dayon propranolol 1 mg/kg/day
• 4 days : ม fever with URI อาการเขยวพอๆเดม ไมเหนอย
• 2 days : หอบมากขน กนไดนอย อาเจยน
• 30 mins: เหนอยมากขน เขยวมากขน มารพ ศรราช• 30 mins: เหนอยมากขน เขยวมากขน มารพ. ศรราช
Physical examinationPhysical examinationPhysical examinationPhysical examination
• V/S : T 38 ºC, RR 40/min, PR 170/min,
BP 118/80 BW 6 kBP 118/80, BW 6 kg
O2 sat 10 % on canula 5 LPM O sat 0 % o ca u a 5
O2 sat 40-50%
• GA : generalized cyanosis (central+peripheral)
marked agitation, not pale
• CVS: normal S1 single S2 no murmurCVS: normal S1, single S2, no murmur
Physical examinationPhysical examinationPhysical examinationPhysical examination
• RS : coarse crepitation both lung,
subcostal and suprasternal
retractionretraction
• Abd : soft , liver 1 cm BLCM
• Ext : equal movement
• POCT 122 mg %
P bl li tP bl li tProblem listProblem list
• U/D TOF with previous hypoxic p yp
spell
• Tachypnea and more cyanosis
• No murmur
• Fever with crepitation both lungs
Q ti ?Q ti ?Questions?Questions?
What is the most likel diagnosis?• What is the most likely diagnosis?
Wh t th i t • What are the appropriate
management?management?
Common congenital cyanotic Common congenital cyanotic Common congenital cyanotic Common congenital cyanotic heart diseaseheart disease
• Tetralogy of Fallot (TOF)
• Transposition of great arteries (TGA)
• Truncus arteriosus
• Total anomalous pulmonary venous
return (TAPVR)
• Tricuspid valve abnormalities (TVA)
Common congenital cyanotic heart Common congenital cyanotic heart Common congenital cyanotic heart Common congenital cyanotic heart diseasedisease
Emergency in Pediatric Emergency in Pediatric di l di idi l di iCardiovascular ConditionsCardiovascular Conditions
• Cardiogenic shock
• Congestive heart failure
Hypoxic spell• Hypoxic spell
• Cardiac arrhythmia:y– Tachyarrhythmia
– Bradyarrhythmia
• Pulmonary hypertensive crisis• Pulmonary hypertensive crisis
Congenital cyanotic heart disease Congenital cyanotic heart disease Congenital cyanotic heart disease Congenital cyanotic heart disease with hypoxic spellwith hypoxic spell
• TOF• TOF
• Tricuspid atresiaTricuspid atresia
• Ebstein’s anomalyEbstein s anomaly
• PA/IVS
• Severe PS
Hypoxic spellHypoxic spellHypoxic spellHypoxic spell
• Paroxysmal hypoxic spell
• Hypercyanotic spell
• Tetralogy spell
• Paroxysmal dyspnea• Paroxysmal dyspnea
Required Required immediatedimmediated treatment treatment
due to serious CNS complicationdue to serious CNS complication
Pediatric cardiology for practitioners by Myung K.Park
Hypoxic spellHypoxic spell
D fi iti
Hypoxic spellHypoxic spell
• Definition : Sudden and transient uncompensated
hypoxia in cyanotic heart diseases ( Rt. to Lt. shunt)
• TOF is the prototype
• Self limited in 15-20 mins.
• Depend on balance between pulmonary and systemic • Depend on balance between pulmonary and systemic
pressure and resistance
• Precipitating factors: crying, defecation , exercise, sudden fright
• Common in infants and young children
Hypoxic spellHypoxic spellHypoxic spellHypoxic spell
• Mechanism
– Infundibular spasm
– Decreased SVR
– Tachycardia
H– Hyperpnea
Hypoxic spellHypoxic spellHypoxic spellHypoxic spell
Pediatric cardiology for practitioners by Myung K.Park
Sign and symptomsSign and symptomsg y pg y p
• Increase in cyanosis
• Hyperpnea, dyspneaHyperpnea, dyspnea
• Decrease intensity of SEM or murmur
disappear
• Squatting • Squatting
• Hypotension
• Syncope, concious change
• Convulsion
Management in hypoxic spell Management in hypoxic spell Management in hypoxic spell Management in hypoxic spell crisiscrisis
P i i l • Principle :
– Decrease RVOT obstruction (decrease Decrease RVOT obstruction (decrease
Rt to Lt shunt)
– Decrease sympatetic
I SVR– Increase SVR
Management in hypoxic spell crisisManagement in hypoxic spell crisis
K t h t iti ลด t เพม SVR
Management in hypoxic spell crisisManagement in hypoxic spell crisis
• Knee-to-chest position : ลด venous return, เพม SVR
• Oxygen supplement : ลด hypoxia
• Sedation :
- Morphine 0.05-0.1 mg/kg/dose dilute IV slowly push:
ลด venous return, infundibular muscle คลายตว
- Ketamine 1-3 mg/kg/dose IV : เพม SVR
t t i BP it i d i d ti- protect airway, BP monitoring during sedation
• Correct metabolic acidosis : Sodium bicarbonate
1-2 mEq/kg IV
Management in hypoxic spell crisisManagement in hypoxic spell crisis
P l l 0 1 /k IV i f dib l l
g yp pg yp p
• Propranolol 0.1 mg/kg IV : infundibular muscle
คลายตวอาจลด SVR (monitor HR)( )
• Correct anemia
• Correct hypovolemia : Keep normal systemic BP :
IV load/ inotropeIV load/ inotrope
• Correct hypoglycemia : 25% glucose 1-2 cc/kg/dose
IV push
C i f i• Correct infection
Management in hypoxic spell crisisManagement in hypoxic spell crisis
• In severe case need deep sedation
( Paralyze and ventilate )
• Consult CVT for eemergencymergency shuntshunt
surgerysurgery
• Close follow up blood gas, correct acidosis
Management at ERManagement at ER
• Knee-chest position : ชวงแรกรองมากทาไมได ตอน
Management at ERManagement at ER
• Knee-chest position : ชวงแรกรองมากทาไมได ตอน
หลงสงบลง ทาไดโดยมารดา
ไ• Oxygen supplement : mask with bag 10 LPM ไมยอม
รองมาก corrugated tube 10 LPM
• Sedation :
- Chloral hydrate 1 ml/kg/dose oral บวนทง
- Morphine 0.1 mg/kg/dose IV x 3 dosesp g g
- Ketamine 1mg/kg/dose IV x 1 dose
- Valium 0.3mg/kg/dose IV x 1 dose
Management at ERManagement at ERManagement at ERManagement at ER
• Correct acidosis: 7.5%NaHCO3 1
mEq/kg/dose x 2 dosemEq/kg/dose x 2 dose
• Correct hypovolemia
- NSS 20 ml/kg IV load x 1 dose then MT
HR 150/min, BP 100/50 mmHg, oxygen sat 84%
Admit CCU• Admit CCU
Proper management after Proper management after hypoxic spell crisis hypoxic spell crisis hypoxic spell crisis hypoxic spell crisis
improveimprove
ป ป การพยาบาลผปวยเดกการพยาบาลผปวยเดกhypoxic spellhypoxic spellhypoxic spellhypoxic spell
สพรรณ หอมชะเอม
PCCU (อน.7) งานการพยาบาลกมารเวชศาสตร( )
N iN iNursing care at Nursing care at ccuccu To monitor the oxygenation & cardiovascular status
• รบกวนผปวยใหนอยทสด ลดสงกระตน (pain) ส ส (pa )
• ใหออกซเจน : cannula, blow-by
M it S O RR HR EKG BP & ti f i• Monitor : SpO2,RR, HR, EKG, BP & tissue perfusion
• ปลอบใหสงบ , Knee - chest position
• ดแลใหยาและสารนา chloral hydrate, morphine, dormicun, fentanyl
NaHCO3, esmolol, vasopressor, Inotrope, IVF
Nursing care at Nursing care at ccuccuNursing care at Nursing care at ccuccu
• ตดตามผลตรวจทางหองปฏบตการ : ABG, BS , CBC
• ดแลใหญาตเขาเยยม ใหและรบขอมลจากญาตผปวย ญ ญ
• Severe case (progressive hypoxemia)
i b i il CPR เตรยม intubation , ventilator, เตรยมพรอม CPR
ยา sedate, inotrope IV. Drip
ตดตอประสานงานกบหนวยงานทเกยวของ, ญาต
ป ป ป ไป เตรยมผปวย อปกรณ บคลากร เพอเคลอนยายผปวยไปผาตด
Proper Proper management at management at wardwardProper Proper management at management at wardward
• Minimal interrupt patient
• Need parent help to calm down patient• Need parent help to calm down patient
- Irritable/severe crying severe hypoxic spell
severe hypoxia convulsion/CVA, sudden cardiac arrestcardiac arrest
- Need sedation before procedure eg. chloral
hydrate before IV access
• Monitor oxygen saturation : keep > 75%
Proper Proper management at management at wardwardProper Proper management at management at wardward
• Monitor BP : keep normal BP, normal volume
statusstatus
• Work up cause
Infection : CBC,UA,CXR
Acidosis : blood gas keep pH 7.35—7.45
Anemia : Hct keep 50 60%Anemia : Hct keep 50-60%
Echocardiographyg p y
Pediatric cardiology for practitioners by Myung K.Park
Consequence and severe Consequence and severe Consequence and severe Consequence and severe complicationcomplication
• Brain abscess
• Cerebral infarction
• Thrombosis• Thrombosis
• Infective endocarditis
• Coagulopathy
• Polycythemia
Growth/development/nutrition• Growth/development/nutrition
Pediatric cardiology for practitioners by Myung K.Park
Proper management at wardProper management at ward
• Adequate Fe supplement: keep Hct 50-60%
p gp g
dequate e supp e e t eep ct 50 60%
(stop Fe if Hct >= 60%)
• Total correction
• Propranolol 1-2 mg/kg/day: prevent spellsPropranolol 1 2 mg/kg/day: prevent spells
• If discharge
- Teach parent how to detect hypoxic spells
and initial managementg
- IE prophylaxis before invasive procedure
- Good oral hygiene care : correct dental caries
P iP iProgressionProgression
• Streptococcus pneumoniae pneumonia
PIP/TAZ x 14 day- PIP/TAZ x 14 day
- Ventolin + Combivent NB
• Deep sedation
- Fentanyl IV drip
Mid l IV d i- Midazolam IV drip
- Rocuronium IV dripp
ProgressionProgressionProgressionProgression
• Set OR for RMBTSRMBTS no complication
• Post op : heparin IV drip x 3 day
then ASA(81) ½ tab oral OD
• Oxygen saturation 91%
SurgerySurgerySurgerySurgery
• Palliative (systemic to pulmonary shunt)
f Modified Blalock-Taussig shunt
(subclavian artery - pulmonary artery)(subclavian artery - pulmonary artery)
• Definite ( total correction )( )
- BW > 10 kg
- McGoon ratio > 1.5
Common cardiovascular diseases from pediatrics to adults,รศ.พญ.จารพมพ สงสวาง, รศ.นพ. กฤตยวกรม ดรงคพสษฏกล
P lli ti P lli ti M difi d Bl l kM difi d Bl l kPalliative Palliative Modified BlalockModified Blalock--TaussigTaussig shuntshunt
IndicationIndicationIndicationIndication
• BW < 2.5 kg + severe cyanosisBW 2.5 kg severe cyanosis
• Hct >= 65%
• Pulmonary artery ขนาดเลก
• Severe hypoxic spell
Common cardiovascular diseases from pediatrics to adults,รศ.พญ.จารพมพ สงสวาง, รศ.นพ. กฤตยวกรม ดรงคพสษฏกล
Post operation MBTSPost operation MBTSPost operation MBTSPost operation MBTS
• Size graft selection: 3.5-6 mm
• If graft <= 4 mm : Heparin IV 10 unit/kg/hr allIf graft <= 4 mm : Heparin IV 10 unit/kg/hr all
graft = 5 mm : Heparin IV 10 unit/kg/hr in
high risk case
graft >= 6 mm: no heparing p
• ASA 5 mkday
• Keep oxygen saturation: < 6 mo 85-90%
> 6 mo 90-95%
Congenital heart disease,พรเทพ เลศทรพยเจรญ,วชย เบญจชลมาศ
Early complication post shuntEarly complication post shunt
• Bleeding : Hemothorax
y p py p p
g
Cardiac tamponade
• Pneumothorax
• Shunt thrombosis• Shunt thrombosis
• Low flow shunt: hypoxia, acidosis
• High flow shunt: CHF
• Aspiration, hoarseness of voice
• SeromaSeroma
Congenital heart disease,พรเทพ เลศทรพยเจรญ,วชย เบญจชลมาศ
Late complication post shuntLate complication post shunt
• Pericardial effusion, delayed cardiac , y
tamponade
• Recurrent pleural effusion (seroma)
• Shunt thrombosis or stenosis
• Infective endocarditis
Congenital heart disease,พรเทพ เลศทรพยเจรญ,วชย เบญจชลมาศ
Nursing Nursing care post RMBTScare post RMBTSNursing Nursing care post RMBTScare post RMBTS
Assess, monitor to intervene effectively – Respiratory care : oxygenationRespiratory care : oxygenation– Hemodynamic status– Wound ICD : bleeding?Wound , ICD : bleeding?– Pain management– CNS : consciousness seizureCNS : consciousness, seizure– Fluid & elecrtrolyte replacement– Renal function– Renal function– Thermal regulation
Nursing Nursing care post RMBTScare post RMBTSNursing Nursing care post RMBTScare post RMBTS
Clinical monitoring (shunt thrombosis)
SpO2 < 80%
BP <คาปกต pulse pressure <20 or 1/3 SBP BP <คาปกต, pulse pressure <20 or 1/3 SBP
sign of irritable, hyperpnea ti f i poor tissue perfusion urine output < 1 ml/kg/hr
SirirajSiriraj concurrent trigger toolconcurrent trigger toolSirirajSiriraj concurrent trigger toolconcurrent trigger tool
• การบรหารความเสยงเชงรก เพอเพมความ
ปลอดภยใหกบผปวย
โ • จดทาเครองมอโดยทมสหสาขา
• กาหนด Modified Early Warning Sign (MEWS) กาหนด Modified Early Warning Sign (MEWS)
และจดทาแนวทางเพอบรหารความเสยงนนๆ
Acute SystemicAcute Systemic--Pulmonary Shunt ThrombosisPulmonary Shunt ThrombosisAcute SystemicAcute Systemic Pulmonary Shunt ThrombosisPulmonary Shunt Thrombosis
Post operation MBTSPost operation MBTSPost operation MBTSPost operation MBTS
• Monitor sign of shunt thrombosis
- Shunt murmur decreased/absent
- DesaturationDesaturation
- CXR : decrease blood flow
• Mx: loading heparin 1 unit/kg/hr IV
NaHCO3 keep BE > -3
Inotropic drugInotropic drug
Congenital heart disease,พรเทพ เลศทรพยเจรญ,วชย เบญจชลมาศ
Long term complication after surgeryLong term complication after surgery
• Endocarditis
Long term complication after surgeryLong term complication after surgery
• Endocarditis
• Aortic regurgitation, Residual pulmonary
regurgitation
• LV dysfunction, RV dysfunctiony , y
• Residual RVOT obstruction
• Exercise intolerance
• Heart block, tachyarrhythmia, ventricular y y
tachycardia
S dd di d th• Sudden cardiac death
Risk factor for morbidity and Risk factor for morbidity and Risk factor for morbidity and Risk factor for morbidity and mortality after total correctionmortality after total correction
• Age < 8 mo
• Transannular patch ผาน pulmonic annulus
• Abnormal pulmonic valve/size < 50%• Abnormal pulmonic valve/size < 50%
• ผาตดผาน ventricle เปนรอยใหญ
• RV pressure/LV pressure in post op 24 hr >0.7
(residual RVOTO)(residual RVOTO)
• Pulmonary regurgitation
Common cardiovascular diseases from pediatrics to adults,รศ.พญ.จารพมพ สงสวาง, รศ.นพ. กฤตยวกรม ดรงคพสษฏกล
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