Aortic Coarctation repair
Clinical Procedure
 
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Considerations as for cardiac surgery-pediatric and the neonate with aortic coarctation

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Sep 26, 2012
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May be performed via a thoracotomy with a short aortic cross clamp time without the need for bypass.
If a longer length of aortic arch is involved, an aortic arch repair with sternotomy and bypass may be required.

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Oct 24, 2012
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3-4hrs including anaesthetic time.

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Dec 19, 2012
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Central venous-line

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Dec 19, 2012
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At least one good peripheral volume line

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Jan 22, 2013
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A right sided arterial line will give the most reliable indication of cerebral perfusion pressure.

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Oct 24, 2012
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If performed via a thoracotomy, some surgeons may still want heparin anticoagulation immediately prior to aortic cross clamping to avoid thrombus formation in the aorta during the cross clamp.
Confirm the dose of heparin they require.

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Nov 02, 2012
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During aortic cross-clamping, retraction of the lungs may interfere with ventilation.
Consider increasing ventilation pressures transiently if required.
#AS

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Oct 24, 2012
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Surgical access for short segment coarcts is frequently via a thoracotomy off bypass, otherwise longer segments usually require a midline sternotomy and bypass.

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Jan 22, 2013
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Titrate a total of fentanil 20-40mcg/kg plus morphine 0.1mg/kg.

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Sep 26, 2012
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Propofol is a convenient antihypertensive agent at the time of aortic cross-clamping
#BT

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Jan 22, 2013
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An alternative to the use of volatile anaesthesia to reduce blood pressure during aortic cross clamping is a sodium nitroprusside infusion.
This has the advantage of having a shorter duration of action and can be quickly turned off when the cross clamp is removed.
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Dec 19, 2012
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Aortic cross clamping when peformed via a thoracotomy usually lasts 10-20min.

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Oct 24, 2012
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At induction and prior to skin incision aim to maintain a near normal mean arterial blood pressure ( eg within 10% ) to provide an adequate perfusion pressure to the lower half of the body.
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Dec 19, 2012
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Consider minimising the amount of volatile anaesthetic given prior to skin incision to allow you more leeway with the blood pressure to administer sufficient fentanil.
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Dec 19, 2012
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Following release of the aortic cross clamp the release of ischaemic byproducts from organs distal to the clamp will result in an acidemic and vasodilated state.

Consider preempting telease of the cross-clamp with a 20ml/kg fluid load and hyperventilation.

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Jan 22, 2013
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Hypertension will frequently be seen immediately following the repair.

Consider drawing up a vasodilator such as phentolamine to administer as a bolus where required.

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Jan 22, 2013
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When performed via a thoracotomy, during aortic cross clamp consider increasing the concentration of volatile agent to counter the increased systemic vascular resistance.

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Oct 24, 2012
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If it turns out to be more than a simple coarct repair (eg aortic arch repair) consider administering platelets and cryoprecipitate coming off bypass.
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Nov 02, 2012
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Allow passive cooling to 35 degrees celsius as a protective measure for the brief cross-clamping

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Sep 26, 2012
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For a straight forward Coarct repair:
Thoracotomy
Right sided arterial line
CVC
Peripheral line
Fentanyl 20-40mcg/kg
Morphine 0.1mg/kg
Pancuronium
methylprednisolone
Local anaesthetic block by surgeon
Allow passive cooling to 35 degrees
Phenoxybenzamine 0.1mg/kg

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Sep 27, 2012
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