Hypoxic spell - ped.si. · PDF file• Correct metabolic acidosis : Sodium bicarbonate 1-2...

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?

DiagnosisDiagnosis

• TOF with hypoxic spell

• Pneumonia

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 g yg ydiseasedisease

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


D fi iti


• 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


• Mechanism

– Infundibular spasm

– Decreased SVR

– Tachycardia

H– Hyperpnea

PA AO

PVR SVR

RV LV


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

In estigationIn estigationInvestigationInvestigation

• Oxygen saturation

• CBC

• UA

• CXR

• EKG

Management in hypoxic Management in hypoxic spell crisisspell crisisspell crisisspell crisis

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


• 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

Squatting/KneeSquatting/Knee toto chestchestSquatting/KneeSquatting/Knee--toto--chestchest


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


• In severe case need deep sedation

( Paralyze and ventilate )

• Consult CVT for eemergencymergency shuntshunt

surgerysurgery

• Close follow up blood gas, correct acidosis

In this patientIn this patientIn this patientIn this patient

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


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


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


Modified BlalockModified Blalock--TaussigTaussig shuntshunt

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

DesaturationDesaturation after MBTSafter MBTS

• Diferrential diagnosis ?

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


Late complication post shuntLate complication post shunt

• Pericardial effusion, delayed cardiac , y

tamponade

• Recurrent pleural effusion (seroma)

• Shunt thrombosis or stenosis

• Infective endocarditis


M t h M t h Management when Management when desaturationdesaturation

• V/S

• BP

• CXR

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


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


Hypoxic spell - ped.si. · PDF file• Correct metabolic acidosis : Sodium bicarbonate 1-2...

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