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CONGENITAL HEART DISEASE

The effects of carbon dioxide on oxygenation and systemic, cerebral, and pulmonary vascular hemodynamics after the bidirectional superior cavopulmonary anastomosis

Aparna Hoskote, MD^*, Jia Li, PhD^,, Chantal Hickey, MD, Simon Erickson, MD^*, Glen Van Arsdell, MD^||,¶, Derek Stephens, MSc^#, Helen Holtby, MD, Desmond Bohn, MD^* and Ian Adatia, MBChB^*,,,*

^* Department of Critical Care Medicine, Population Health Sciences, The Hospital for Sick Children, Toronto, Canada
Department of Pediatrics, Population Health Sciences, The Hospital for Sick Children, Toronto, Canada
Department of Anesthesia, Population Health Sciences, The Hospital for Sick Children, Toronto, Canada
^|| Department of Surgery, Population Health Sciences, The Hospital for Sick Children, Toronto, Canada
Department of Cardiology, Population Health Sciences, The Hospital for Sick Children, Toronto, Canada
^¶ Department of Cardiovascular Surgery, Population Health Sciences, The Hospital for Sick Children, Toronto, Canada
^# Department of Biostatistics, Population Health Sciences, The Hospital for Sick Children, Toronto, Canada

Manuscript received February 8, 2004; revised manuscript received April 10, 2004, accepted June 7, 2004.

^* Reprint requests and correspondence: Dr. Ian Adatia, UCSF Children's Hospital, 505 Parnassus Avenue, Room M-655, San Francisco, California 94143-0106 (Email: iadatia{at}pedcard.ucsf.edu).

OBJECTIVES: We investigated the effects of different CO₂ tensions on oxygenation, pulmonary blood flow (Qp), cerebral blood flow, and systemic blood flow (Qs) after the bidirectional superior cavopulmonary anastomosis (BCPA).

BACKGROUND: Hypoxemia refractory to management of a high pulmonary vascular resistance index (PVRI) may complicate recovery from the BCPA.

METHODS: After BCPA, CO₂ was added to the inspired gas of mechanically ventilated patients. The Qp, Qs, PVRI, and systemic vascular resistance index (SVRI) were calculated from oxygen consumption, intravascular pressures, and oxygen saturations. Cerebral blood flow was estimated by near infrared spectroscopy and transcranial Doppler.

RESULTS: In nine patients (median age 7.1, range 2 to 23 months), arterial oxygen tension increased significantly (p < 0.005) from 36 ± 6 mm Hg to 44 ± 6 to 50 ± 7 mm Hg at arterial carbon dioxide tensions (PaCO₂) of 35, 45, and 55 mm Hg, respectively and decreased to 40 ± 8 mm Hg at PaCO₂ 40 mm Hg. At a PaCO₂ of 55 and 45 compared with 35 mm Hg, Qp, cerebral blood flow, and Qs increased significantly, PVRI, Qp/Qs, and the ratio of Qp to inferior vena caval blood flow were unchanged, but SVRI decreased.

CONCLUSIONS: We have demonstrated that after the BCPA, systemic oxygenation, Qp, Qs, and cerebral blood flow increased and SVRI decreased at CO₂ tensions of 45 and 55 mm Hg compared with 35 mm Hg. We suggest that hypoxemia after the BCPA is ameliorated by a higher PaCO₂ and that low PaCO₂ or alkalosis may be detrimental. Hypercarbic management strategies may allow earlier progression to the BCPA, which may contribute to reducing the interval morbidity in patients with a functional single ventricle.

Abbreviations and Acronyms   BCPA = bidirectional superior cavopulmonary anastomosis   FV = femoral venous/vein   IVC = inferior vena cava   JVB = jugular venous bulb   PaCO2 = arterial carbon dioxide tension   PaO2 = arterial oxygen tension   PVRI = pulmonary vascular resistance index   Qivc = inferior vena caval blood flow   Qp = pulmonary blood flow   Qs = systemic blood flow   SVC = superior vena cava   SVRI = systemic vascular resistance index   VO2 = oxygen consumption

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