Anesthetic considerations during caval inflow occlusion in children with congenital heart disease

Abstract Objective: Caval inflow occlusion (IO) was introduced to facilitate surgical pulmonary and aortic valvotomy without cardiopulmonary bypass (CPB). Although a technique that is used infrequently today, it remains useful in some patients with complex single-ventricle congenital cardiac defects who require an atrial septectomy. The potential for complications and anesthetic considerations have not been described previously. Design: Retrospective review. Setting: A tertiary care university teaching children’s hospital. Participants: Eleven children, median age 3 months (range 3 days-3 years) who underwent (IO) technique for atrial septectomy. Interventions: Atrial septectomy under IO in patients with restrictive atrial septum. Measurements and Main Results: Eleven children, median age 3 months (range 3 days-3 years), underwent IO for atrial septectomy. Mean duration of IO was 87.7 ± 25.5 seconds. There was 1 intraoperative death (9%). After release of the caval clamps, inotropic support was necessary in 7 of 11 patients, arrhythmias occurred in 4 of 11 patients (2 atrial and 2 ventricular fibrillation), and 10 of 11 patients required blood transfusion along with boluses of calcium gluconate and sodium bicarbonate to support the circulation immediately post-IO. Duration of postoperative mechanical ventilation was 2.2 ± 1.6 days; 10 of 11 patients (91%) survived to discharge with mean length of intensive care unit stay 3.7 ± 2.2 days. Conclusion: IO is an effective technique for short intracardiac procedures without the need for CPB. Close collaboration between anesthesia and surgical staff is essential to keep the duration of IO as short as possible and because of the potential for hemodynamic instability.