Jordan Holloway, MD (she/her) Profile picture
Apr 13, 2023 10 tweets 4 min read Read on X
Board things: Fontan Circulation goals 🧵

Fontan physiology is usually the end-result of palliative procedures (of which there are several variations) for patients born with single-ventricle physiology.

#MedTwitter #MedEd #FOAMEd #Anesthesia #PedsAnes #CardsAnes Image Credit: https://kidsh...
Examples of single ventricular physiology:
- Hypoplastic left heart syndrome
- Pulmonary atresia
- Tricuspid atresia
- Ebstein anomaly
- Double outlet RV
Etc.
This is usually completed step wise, starting with a Norwood procedure/Sano shunt hybrid (reconstructs a neoaorta and provides shunt connection from RV to PA), followed by a Glenn (shunt takedown with connection of SVC to PA), then a Fontan (IVC also connected to PA). Image Credit: https://www.s...
Given that more and more of these kiddos are living into adulthood (🎉), the likelihood of seeing these patients for noncardiac surgery is increasing.

Important to try to review a pre-op echo! Consider invasive monitoring (TEE/art line). Most are anticoagulated - consider labs!
Goal 1: Maintain preload. These patients are very preload dependent. Minimize NPO time. Augment w volume if dehydrated. TEE can be helpful for assessment of volume status. Image Source: https://docto...
Goal 2: Minimize PVR. These patients do not have an effective RV and their pulmonary blood flow is all passive. Increases in PVR (hypercarbia, acidosis, hypoxia, pain, high PEEP etc) can be disastrous. Image Credit: https://www.r...
Goal 3: Maintain sinus rhythm as able. These patients benefit from optimized diastolic filling. That said, it is not uncommon for them to have arrhythmia histories, particularly if their Fontan begins to fail.
Goal 4: Minimize intrathoracic pressure. If able, keeping patient spontaneous will optimize pulmonary blood flow (think regional, MAC, LMA etc). If GETA with paralysis is absolutely necessary, utilize lowest possible pressures for ventilation. Image Credit: https://www.r...
Goal 4 ctd: That said, remember spontaneous ventilation under sedation/GA with LMA may risk hypercarbia. Important to weigh the risks/benefits of PPV with normocarbia vs. spontaneous vent and pain/hypercarbia. Image Credit: https://www.s...
Goal 5: For most, the goals for contractility and afterload will be to just maintain both at homeostasis. Failing Fontans (which are a topic all their own) may likely require inotropic support. Image Credit: https://www.o...

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More from @jholloway_MD

Oct 13, 2023
#Match2024 and a🧵 on questions I wish I would/wouldn’t have asked at interviews and pre-interview socials:
#Anesthesiology #Anesthesia #GasGang @FutureAnesRes (1/
❌What is the call schedule?
✅What is call like & do you get supervisory opps on call?
Why?
Unlikely you base your ranklist based on whether you have night float vs 24 hour call or something else entirely (or you shouldn’t!). Every residency will have call. (2/
What’s important is how it’s structured - Do you have graduated autonomy? What kind of cases are you doing? Are you covering for emergency airways? Do you get to do any “pre-tending” or board running at night? etc. (3/
Read 17 tweets
Nov 11, 2022
An INCREDIBLY intimidating part of the ICU can be the patient exam in the AM:
A 🧵on what to assess at bedside while taking care of an intubated/sedated patient.

(Because @tammamtu made an excellent point on another 🧵)
#MedTwitter #MedEd #Medicine #CritCare #ICU #CriticalCare
1. Talk to the patient, no matter their mental status. You should introduce yourself & announce what you’re doing during a physical exam. Sometimes we forget that there’s a loved one surrounded by all those machines & forget to act the same way we would if they were awake. Don’t.
2. Mental status: If they’re relatively responsive this one is much easier. If they’re not, this one is tough.

Assess sedation level. RASS is a commonly used descriptor. Most patients (not all) should be +1 to -1. If they’re -5 and on max sedation, you should explore that. Image credit: https://inten...
Read 16 tweets
Nov 10, 2022
ICU pre-rounding tips:
I feel like early on, knowing what matters in the ICU is REALLY tough. So here’s what I typically do:
A 🧵 inspired by @akhadilkarMD’s pre-round thread (you should check that one out too!)

#MedTwitter #MedEd #CritCare #ICU #medicine #criticalcare
1. If you can get at least some of this information automated for a printout, that can be invaluable. Whether that’s an updateable .dotphrase or a printable page from EPIC/Cerner etc. — save the carpal tunnel for later and just make notes on the data!
2. Start with a page that allows you to trend vitals. Particularly helpful is one with vitals and vasoactive gtts :
Is the MAP the same all night but the levo is down OR struggle to get a MAP >65 & escalate to a second pressor?
The #’s are important, but the TREND is essential.
Read 14 tweets

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