Anesthesia for Left‐Sided Obstructive Lesions

Perioperative and Anesthetic Management of Coarctation of the Aorta

“…Continuous epidural infusions and paravertebral nerve blockade have also been suggested as helpful adjuncts for pain control. 38,53 The recently described erector spinae plane block has found utility for thoracic surgery and postthoracotomy pain, and unpublished data from our institution have shown encouraging results in coarctation surgery. 54,55 Neuraxial blockade has the potential to either delay postoperative assessment of spinal cord function or rarely cause neurological injury itself.…”

“…For older children or adults with well-developed collaterals and preserved ventricular function, either an inhalational or intravenous induction is typically well tolerated. 38,44 Single-lumen endotracheal tubes provide adequate exposure in neonates and infants, whereas lung isolation with a double lumen tube or bronchial blocker can be considered in older children and adults to assist with surgical exposure. Even though a bronchial blocker can usually be placed in a patient of almost any size, surgeons generally retract the lung in babies, which provides sufficient exposure without a significant drop in arterial saturation.…”

“…Hyperthermia (>38°C) should be assiduously avoided because it may increase the risk of spinal cord injury and paraplegia, with many centers allowing patients to passively cool to 35°C in an attempt to decrease this risk. 38,45 Aortic Cross-clamping A cross-clamp is applied above and below the coarctation site to perform the repair. Application of the aortic crossclamp further increases myocardial afterload.…”

“…Other agents such as sodium nitroprusside, nicardipine, and esmolol may be used; however, nitroprusside has also been implicated in worsening spinal cord perfusion because of steal. 38,40,46 In the setting of a failing ventricle, inotropes may be needed to support cardiac output while the aorta is cross-clamped. Renal NIRS, NIBP, or a second invasive arterial line in the lower body will provide information regarding postclamp arterial pressure and/or perfusion.…”

“…50 Prior to cross-clamp removal, vasodilator and/or volatile anesthetic doses should be preemptively decreased, and volume expansion and vasopressor boluses available in preparation for the period of hypotension that often follows cross-clamp removal. 38 Gentle hyperventilation can be used in anticipation of the release of carbon dioxide and lactic acid from distal tissues. 44 This period of hypotension is typically short-lived and often transitions to hypertension during the conclusion of the case, requiring administration of vasodilator therapy.…”