Managing SVT In PedS Postop Surgery for HLHS
Managing Supraventricular Tachycardia In Pediatric Patients Post Cardiac Surgery for Hypoplastic Left Heart Syndrome
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Background:
Supraventricular tachycardia poses a significant challenge in pediatric patients, especially those with complex congenital heart disease like hypoplastic left heart syndrome (HLHS). This blog post will delve into the intricacies of managing SVT in a pediatric patient who is post-Norwood surgery for HLHS, emphasizing key considerations and the Pediatric Advanced Life Support (PALS) algorithm.
Patients with HLHS undergo a series of staged surgeries, including
Norwood procedure
Glenn shunt
Fontan operation
These procedures work to reconstruct the hypoplastic left heart and improve systemic circulation. SVT is a known complication in these patients, often associated with low oxygen saturations (75-85%) and heart rates ranging from 190 to 220 beats per minutes.
Management Approach:
Upon presentation to the ED, the initial management of SVT in this patient follows the PALS algorithm:
Assessment: Evaluate airway, breathing, and circulation. Obtain a 12-lead ECG to confirm SVT and assess for underlying cardiac anomalies.
Vagal Maneuvers: Attempt simple vagal maneuvers such as ice to the face. Vagal maneuvers can be tried for any SVT rate, regardless of the heart rate, and may help in conversion to sinus rhythm.
Adenosine: Administer adenosine if vagal maneuvers fail or if the patient is unstable. The initial dose is 0.1 mg/kg rapid IV push, followed by a 0.2 mg/kg dose if necessary.
Synchronized Cardioversion: Consider synchronized cardioversion for unstable patients or those with inadequate response to adenosine. Start with a dose of 0.5 to 1 J/kg, followed by escalating doses of 2 J/kg if needed.
Consult Pediatric Cardiology: Involve pediatric cardiology early in the management of SVT in patients with complex congenital heart disease like HLHS. Consideration may be given to antiarrhythmic medications such as Amiodarone and Procainamide, or electrophysiology evaluation for long-term management.
Special Considerations:
● Low Oxygen Saturation: Patients with HLHS often have baseline low oxygen saturations. Supplemental oxygen should be administered judiciously to avoid exacerbating pulmonary vascular resistance. Parents should know baseline oxygen levels, and they are often between 75-85%. However, after a Fontan procedure, oxygen saturations are often 90% or higher due to circulation changes and less mixed oxygenated blood..
● SVT Rates: While SVT in infants typically presents with rates over 220 bpm, in patients with congenital heart disease and a history of cardiac surgery, lower rate SVTs at 190-220 bpm may be more common. Recognition of these lower rate SVTs is crucial for timely intervention.
● Chronicity of SVT: Patients with a history of SVT, like the case presented, may require more aggressive management strategies if episodes become refractory to initial interventions. They often require admission and/or transfer to a tertiary care center.
Case Conclusion:
This patient underwent multiple interventions to manage SVT with poor perfusion including ice on the face, adenosine x 7, electrical defibrillation x 3, procainamide, and esmolol as they went in and out of SVT with poor perfusion. They were successfully transferred to a tertiary care center and made a healthy recovery with plans to undergo the second step of their surgeries with the Glenn procedure.
Managing SVT in pediatric patients post-Norwood surgery for HLHS necessitates a systematic approach guided by the PALS algorithm and consideration of the patient's unique cardiac anatomy and physiology. Early involvement of pediatric cardiology is paramount for long-term arrhythmia management and optimizing outcomes in this complex patient population.
References:
Cashen, K., Gupta, P., Lieh-Lai, M., & Mastropietro, C. (2011). Infants with single ventricle physiology in the emergency department: are physicians prepared?. The Journal of pediatrics, 159(2), 273-277.
De Caen, A. R., Berg, M. D., Chameides, L., Gooden, C. K., Hickey, R. W., Scott, H. F., ... & Samson, R. A. (2015). Part 12: pediatric advanced life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 132(18_suppl_2), S526-S542.
Blog Post Title Two
It all begins with an idea.
It all begins with an idea. Maybe you want to launch a business. Maybe you want to turn a hobby into something more. Or maybe you have a creative project to share with the world. Whatever it is, the way you tell your story online can make all the difference.
Don’t worry about sounding professional. Sound like you. There are over 1.5 billion websites out there, but your story is what’s going to separate this one from the rest. If you read the words back and don’t hear your own voice in your head, that’s a good sign you still have more work to do.
Be clear, be confident and don’t overthink it. The beauty of your story is that it’s going to continue to evolve and your site can evolve with it. Your goal should be to make it feel right for right now. Later will take care of itself. It always does.
Blog Post Title Three
It all begins with an idea.
It all begins with an idea. Maybe you want to launch a business. Maybe you want to turn a hobby into something more. Or maybe you have a creative project to share with the world. Whatever it is, the way you tell your story online can make all the difference.
Don’t worry about sounding professional. Sound like you. There are over 1.5 billion websites out there, but your story is what’s going to separate this one from the rest. If you read the words back and don’t hear your own voice in your head, that’s a good sign you still have more work to do.
Be clear, be confident and don’t overthink it. The beauty of your story is that it’s going to continue to evolve and your site can evolve with it. Your goal should be to make it feel right for right now. Later will take care of itself. It always does.
Blog Post Title Four
It all begins with an idea.
It all begins with an idea. Maybe you want to launch a business. Maybe you want to turn a hobby into something more. Or maybe you have a creative project to share with the world. Whatever it is, the way you tell your story online can make all the difference.
Don’t worry about sounding professional. Sound like you. There are over 1.5 billion websites out there, but your story is what’s going to separate this one from the rest. If you read the words back and don’t hear your own voice in your head, that’s a good sign you still have more work to do.
Be clear, be confident and don’t overthink it. The beauty of your story is that it’s going to continue to evolve and your site can evolve with it. Your goal should be to make it feel right for right now. Later will take care of itself. It always does.