ABSTRACT
Perioperative management in a paediatric patient undergoing open-heart surgery The unique approach to an infant or a child undergoing cardiac surgery begins in the operating room. Surgery and, in particular, surgery involving the use of cardiopulmonary bypass (CPB) has a significantly more pronounced effect in
a young patient, and early recognition of those individuals who are at an increased risk is the key to improved outcomes. Detrimental effects of the CPB are well documented. It is associated with complement activation, exaggerated sympathetic response, capillary leak, disturbance in fluid balance and abnormalities in the distribution of cardiac output.1-6 In addition, whereas some procedures can be performed with CPB alone, other ones may require the use of hypothermia with low-flow or deep hypothermic circulatory arrest (DHCA). Whichever of these measures may be used and whatever associated sequelae a patient may face, a state of temporary low cardiac output is a predictable postoperative occurrence in all patients requiring cardiac arrest. This low cardiac output syndrome has been shown to be proportional to the length of myocardial ischaemic period and inversely proportional to the age of the patient.7 Early recognition and aggressive treatment of this phenomenon is critical to improved survival and reduced morbidity in such an individual.8 Therefore, every step in the care of an infant or a child after open-heart surgery entails meticulous monitoring of parameters of cardiac performance. This may include simple clinical assessment such as measurement of the capillary refill or a number of invasive steps such as monitoring lactate levels, mixed-venous O2 saturation or central venous pressure.7,8 Abnormality in any of these parameters should prompt immediate action aimed at optimising the underlying contributing factors: contractility, rhythm, rate, preload and afterload.7
