Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
Can J Anaesth. 2024 Oct;71(10):1417-1422. doi: 10.1007/s12630-024-02833-y. Epub 2024 Sep 18.
Fontan circulation is created when a baby is born with only one functioning cardiac ventricle. A series of surgeries are performed to allow the ventricle to provide oxygenated blood to the systemic circulation and to create passive flow of venous blood to the pulmonary circulation via a conduit. Laparoscopic surgery poses several hemodynamic challenges to a patient with Fontan physiology attributable to carbon dioxide insufflation, positive pressure ventilation, and reverse Trendelenburg positioning.
A 39-yr-old male with a Fontan physiology was referred to our tertiary care centre because of repeated bouts of cholecystitis requiring a percutaneous drain and now elective laparoscopic cholecystectomy. Because of repeated cardiac surgeries, the patient also had complete heart block and was pacemaker dependent. We placed an arterial catheter prior to induction of general anesthesia with tracheal intubation. Transesophageal echocardiography allowed for real-time intraoperative assessment of venous blood flow through the patient's extracardiac diversion system throughout the surgery. This information was used to guide management and determine circulation tolerance during the various stages of laparoscopy. Inhaled milrinone resulted in the shunt fraction returning to the patient's baseline. Intraperitoneal pressure was kept below 10 mm Hg, and systemic blood pressure was supported with a low-dose norepinephrine infusion.
Intraoperative transesophageal echocardiography is a useful monitoring device during laparoscopic surgery when a patient has Fontan circulation. Knowing how to administer inhaled milrinone is a useful skill to decrease the shunt fraction through a patient's conduit, increasing pulmonary blood flow while avoiding hypotension.
当婴儿出生时只有一个功能心室时，就会产生 Fontan 循环。通过一系列手术，使心室将含氧血液输送到体循环，并通过导管创建静脉血向肺循环的被动流动。腹腔镜手术对 Fontan 生理学患者造成了一系列血流动力学挑战，归因于二氧化碳充气、正压通气和反向特伦德伦伯格体位。
一名 39 岁男性，具有 Fontan 生理学，因反复发作胆囊炎需要经皮引流而被转诊到我们的三级护理中心，现在需要择期进行腹腔镜胆囊切除术。由于反复进行心脏手术，该患者还患有完全性心脏阻滞，依赖起搏器。我们在全身麻醉诱导前放置了动脉导管，并进行气管插管。经食管超声心动图允许在整个手术过程中实时评估患者体外分流系统中的静脉血流。这些信息用于指导管理，并确定腹腔镜各个阶段的循环耐受性。吸入米力农导致分流分数恢复到患者的基线水平。保持腹腔内压力低于 10mmHg，并通过低剂量去甲肾上腺素输注来支持全身血压。
当患者具有 Fontan 循环时，术中经食管超声心动图是腹腔镜手术期间有用的监测设备。了解如何施用吸入米力农是一种有用的技能，可以通过患者的导管减少分流分数，同时增加肺血流量，避免低血压。
