Low cardiac output syndrome.ppt

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LOW CARDIAC OUTPUT SYNDROM IN CHILDREN AFTER CARDIAC SURGERY Hala EL-Mohamady, professor of anaesthesia, Ain Shams University

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Low cardiac output syndrome (LCOS) is a clinical syndrome seen commonly (25%) after pediatric cardiac surgery but also occurring secondary to acute myocarditis and septic shock.

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Regardless of aetiology, the resulting effects are shock and inadequate organ perfusion organ dysfunction Coincide With Postoperative decrease in cardiac index and increases in SVR and PVR reducing cardiac output

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This occurs typically 6–18 h after cardiopulmonary bypass, which is usually in the middle of the night!

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Causes of postoperative LCOS

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-Inflammatory cascade triggered by (CPB) -Aortic cross-clamp -Hypothermia -Reperfusion injury -Pericardial tamponade -Residual cardiac lesions, even when minor

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PREVENTION Because LCOS is common and contributes to postoperative morbidity and mortality, prevention of this predictable hemodynamic deterioration may have significant implications for clinical outcome

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Diagnosis OF LCOP SYNDROM

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Anticipation is the key to the diagnosis and management of LCOS So Diagnosis relies on anticipation, clinical features and investigation

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CLINICAL Features OF LOW COP SYNDROM - tachycardia - oliguria (0.5 ml/kg/h) - poor peripheral perfusion - low blood pressure

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The ability of clinicians to assess cardiac output from clinical examination alone is poor

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INVESTIGATIONS

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- Metabolic acidosis - Lactate - Mixed venous oxygen saturation - Echocardiography

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Management aimed at achieving the optimal balance between oxygen delivery and oxygen consumption

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A check list of immediately treatable causes is useful, as is a flow diagram to lead staff through a logical approach.

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Check list of causes of postoperative LCOS

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-Adequate airway (tube position, size and patency) and ventilation (atelectasis, pneumothorax) -Pericardial tamponade -Pulmonary hypertensive crisis -Arrhythmias (loss of AV synchrony, tachycardia or bradycardia) -Significant residual lesion -Electrolyte abnormality (e.g. hypocalcaemia)

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PreloadPreload is traditionally assessed by: measuring filling pressures from right and left atrial lines. In addition, venous capacitance also affects venous return. Venodilatation often occurs on rewarming and may be exacerbated by drugs Finally, positive pressure ventilation (PPV) will tend to reduce RV preload by inhibiting venous return.

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Left ventricular afterloadReduction in LV afterload will improve cardiac output, as long as an adequate diastolic pressure is maintained for coronary perfusion.

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Right ventricular afterload pulmonary hypertension

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Preventive treatment strategies For PULMONARY HYPERTENSION

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-optimal sedation -neuromuscular blockade -induced respiratory or metabolic alkalosis -hyper-oxygenation -Avoiding or ablating stimuli (trigger pulmonary hypertensive crises(e.g. administering fentanyl bolus prior to airway suction). -Nitric oxide

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Nitric Oxidea potent endogenous vasodilator that produces vascular relaxation via increases in the intracellular concentration of guanosine 3,5-cyclic monophosphate. It is a specific pulmonary vasodilator when delivered by inhalation (iNO), RV afterload is reduced, thereby improving RV ejection fraction and cardiac output.

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Nitric Oxide? Rebound pulmonary hypertension

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Pharmacological treatment of systolic and diastolic dysfunction

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Last Updated: 8th March 2018

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