Precautions for cardiac catheterization in a cyanotic child

Precautions for cardiac catheterization in a cyanotic child

Pediatric diagnostic cardiac catheterizations have come down with the availability of better imaging modalities which can give most of the details needed for management non-invasively. Still cardiac catheterization may still be needed in selected cases, leave alone the catheterization prior to pediatric cardiac interventions. Cyanotic child presents more challenges during cardiac catheterization, mostly due to the presence of hypoxia and polycythemia.

Hospitalization on the previous day will be desirable along with 3-4 hour fasting prior to procedure. As there is a chance for hemoconcentration during fasting, adequate hydration by intravenous route is needed. Hemoconcentration increases the chance of stroke in cyanotic children. Attention to oxygen saturation during procedure is needed as the procedures are often done under deep sedation. Total contrast used for angiography should be limited to less than 3-4 ml/Kg [1].

Important reasons for cardiac catheterization in cyanotic congenital heart diseases are as follows:

1. Assessment of pulmonary arterial anatomy including size, confluence, any stenosis at the origin of vessels and peripheral pulmonary stenosis.
2. Assessment of pulmonary arterial pressures
3. Assessment of aortopulmonary collaterals
4. Assessment of post operative cases for pulmonary arterial pressures and to look for any distortion due to surgery
5. Assessment of coronary anomalies [2].

Post procedure monitoring in intensive care unit is for about 12 hours, after which they can be observed in the ward for 24 to 48 hours.

Catheterization in small children may be quite challenging due to the difficulty in getting vascular access. Doppler tipped introducer needle is a novel option in difficult cases. Fluoroscopy time should be kept as low as possible and usual radiation protection measures should be undertaken.

When the contrast load is likely to be exceeded while getting details of pulmonary anatomy and cardiac chambers, it is wise to perform the study in two sittings at an interval of 2 weeks. Close monitoring of renal function and adequate hydration are needed to avoid contrast induced acute kidney injury.

Some deeply cyanotic babies may develop recurrent cyanotic spells after cardiac catheterization. Most of these can be managed medically, but an occasional patient may have to be sent for emergency palliative shunt surgery [1]. Cyanotic spells can also occur during cardiac catheterization. Alerting the cardiac surgeons prior to procedures in sick cyanotic babies is a good precautionary measure. Ventricular arrhythmias can occur during the procedure due to the irritable hypertrophied right ventricle. Close monitoring and prompt management by the resuscitation team are needed [3].

Usual precautions as applicable to acyanotic patients like care of puncture site are also needed for cyanotic patients. There could be enhanced bleeding tendency in some cyanotic patients. Mortality risk is higher in cyanotic children than in acyanotic patients. Risk is more in interventional procedures, especially if the procedure time is prolonged and in critically ill children. Intubating a hemodynamically unstable patient and using general anaesthesia instead of conscious sedation may prevent airway related complications in sick patients [4].

Carbon dioxide inflated balloon flotation catheters may be useful in cases of difficult anatomy [3]. Use of carbon dioxide instead of air for inflation of balloon catheters will minimize the risk of air embolism in case of balloon rupture within the circulation.

Near- Infrared Spectroscopy (NIRS) Tissue Oximetry is an emerging  noninvasive method used to evaluate tissue oxygenation. Cerebral and renal NIRS parameters can be monitored during transcatheter interventions in the cardiac catheterization laboratory. In a study, it was found that when an arrhythmia develops, NIRS values fall simultaneously. When desaturation problem develops, NIRS falls 10-15 seconds earlier than pulse oximetry. On improving saturation, NIRS returns to earlier values 10-15 seconds before pulse oximetry readings. Thus it may provide an early warning [5]. A survey of the Congenital Cardiac Anesthesia Society in 2021 among its members showed the usage of NIRS by 34.7% in the cardiac catheterization laboratory and 97.1% in cardiac surgery with cardiopulmonary bypass [6].

References

1. Kumar P, Joshi VS, Madhu PV. Diagnostic pediatric cardiac catheterization: Experience of a tertiary care pediatric cardiac centre. Med J Armed Forces India. 2014 Jan;70(1):10-6. doi: 10.1016/j.mjafi.2013.01.002. Epub 2013 Apr 9. PMID: 24623940; PMCID: PMC3946461.
2. Dabizzi RP, Teodori G, Barletta GA, Caprioli G, Baldrighi G, Baldrighi V. Associated coronary and cardiac anomalies in the tetralogy of Fallot. An angiographic study. Eur Heart J. 1990 Aug;11(8):692-704. doi: 10.1093/oxfordjournals.eurheartj.a059784. PMID: 2397733.
3. Huang YC, Chang JS, Lai YC, Li PC. Importance of prevention and early intervention of adverse events in pediatric cardiac catheterization: a review of three years of experience. Pediatr Neonatol. 2009 Dec;50(6):280-6. doi: 10.1016/S1875-9572(09)60078-4. PMID: 20025142.
4. Tokel K, Gümüş A, Ayabakan C, Varan B, Erdoğan İ. Complications of cardiac catheterization in children with congenital heart disease. Turk J Pediatr. 2018;60(6):675-683. doi: 10.24953/turkjped.2018.06.008. PMID: 31365204.
5. Tanidir IC, Ozturk E, Ozyilmaz I, Saygi M, Kiplapinar N, Haydin S, Guzeltas A, Odemis E. Near infrared spectroscopy monitoring in the pediatric cardiac catheterization laboratory. Artif Organs. 2014 Oct;38(10):838-44. doi: 10.1111/aor.12256. Epub 2014 Jan 10. PMID: 24404951.
6. Zaleski KL, Staffa SJ, Kussman BD. A Survey of the Congenital Cardiac Anesthesia Society on the Use and Clinical Application of Near- Infrared Tissue Oximetry in Pediatric Cardiac Surgery. J Cardiothorac Vasc Anesth. 2022 Sep;36(9):3617-3625. doi: 10.1053/j.jvca.2022.05.015. Epub 2022 May 16. PMID: 35691856.