Pre & Post Operative Care (cardiac surgery) Pediatric Intensive Care Unit Emergency Division

Preoperative Care Special considerations for neonate Approximately one third of all children born with CHD become critically ill during first year of life & either die or receive surgical treatment Critical CHD that are palliated or not corrected can cause progressive & irreversible secondary organ damage, principally to the heart, lungs, & CNS Optimal management requires a multidisciplinary team approach : combining the disciplines of cardiology, cardiac surgery, cardiac anesthesia, neonatology, intensive care, and nursing

Optimal perioperative management involves : Initial stabilization, airway management, establishment of vascular access, and in most newborns, maintenance of a PDA Complete and thorough noninvasive delineation of anatomic defect(s) Evaluation & treatment of secondary organ dysfunction, particularly of the brain, kidneys, and liver Cardiac catheterization, if necessary Surgical management, if necessary, when cardiac, pulmonary, Renal, and CNS functions are optimized

Clinical presentations of CHD in neonate In the first week of life, the many heterogenous forms of heart Disesase present in a suprisingly limited number of ways. Sign & symptoms include : Cyanosis CHF or shock Asymptomatic heart murmur Arrhytmia

Evaluation of neonate with suspected CHD History Physical exam with four extremity blood pressure measurement Chest radiograph Electrocardiogram Hyperoxia test echocardiogram

Stabilization & transport Once diagnosis of CHD is suspected, the infant must be stabilized And arrangement made to make a definitive anatomic diagnosis Initial resuscitation - a stable airway - reliable venous access is essential - arterial line  acid-base status, oxygenation of patient - Blood glucose level - Sepsis work-up (cyanosis or circulatory failure) - Appropriate antibiotic

2. Airway management & Supplemental oxygen - if respiratory distress or profound cyanosis is present, infant should be intubated, sedated, and mechanically ventilated. - If possible, intubation should performed with neuromuscular blockade & sedation. - Suspected CHD should receive Supplemental oxygen to titrate oxygen saturation to 80 to 85%

3. Prostaglandin E1 - Administration of PGE1 has been shown to open ductus arteriosus and depending on the lesion, increase pulmonary blood flow, systemic blood flow, or intercirculatory mixing - Side effect : fever, apnea, pheripheral vasodilation, bradycardia, seizure, tachycardia, edema, cardiac arrest (1%) - Dose : 0.025 – 0,1 μg/kg/min

4. Inotropic agents - cont infusion of inotropic agent  improve myocardial contractility & thereby enhance tissue perfusion of the vital organs & periphery - Dopamin & dobutamin are recommended for the neonate with hypotension & tachycardia - Combination low dose dopamine up to 5 μg/kg/min and dobutamine 5-10 μg/kg/min, can be used to minimize the potential peripheral vasoconstriction induced by high doses of dopamine while maximizing the dopaminergic effects on renal perfusion

Transport After resuscitation & stabilization is complete, neonate with Suspected CHD often needs to be transferred to an institution That provides subspeciality care in pediatric cardiology and Cardiac surgery A successful transport involves : From referring hospital staff to transport team From transport staff to accepting hospital staff

Postoperative Care ICU functions in many centre as a RR, it is essential that patients can be tranported safely from the operating room within 5 min A pulse oxymeter for continous arterial oxygen sat monitoring at each bed space Portable, battery-operated, external single- and dual-chamber pacemakers are used for cardiac pacing with either temporary epicardial wires (atrial,ventricular, or both) or transvenous pacing catheters An echocardiography machine must be immediately available to the ICU for emergency situation (susp acute tamponade) Myocardial failure  mechanical support with either ECMO or VAD (vent assist device) with 30 to 45 min should exist Inhaled NO  treatment of pulmonary artery hypert in patient with CHD

Transition from operating room to ICU Patients are transported by anesthesiologist & at least one member of the surgical team & operating room nursing team Physical exam should focus primarily on CV & resp function e.g Post repair TOF  evidence of residual VSD, right ventr dysfunc, and residual right ventr outflow tract obstruct CPB can induce hemolysis, which may cause transient hemoglobinuria ventilatory requirement  anesthsiologist will recommended mode of mechanical vent support & initial setting

A comparison pre- and postop frontal chest radiograph  to evaluate heart size n shape, changes in appearance of lung parenchyma, pleural space, lung volumes & determine position of new hardware An ECG  for new abnormality, including BBB (after repair TOF) & myocardial ischemia Intubated patients, receive high fraction of FiO2 until an adequate PO2 on the first ICU ABG is confirmed

If an acidosis or alkalosis exists, the cause – metabolic, respiratory or mixed, should be determined & decision made about the necessity of intervention  metabolic acidosis occurs  poor cardiac output suspected, and evaluation of the cause of the acidosis initiated Determination of serum levels of Na+, K+ and ionozed Ca2+

Components of the Initial Postoperative Assessment in the ICU Laboratory evaluation Chest radiograph ECG Blood gas analysis (arterial) Serum Na+,K+, and Cl-, glucose level Ionized Ca2+ level Hb or Ht, WBC, Plt Postop Evaluation by ICU physician - Review of patient’s underlying cardiac defect(s), history of prior interventions, & preop pathophysiology & clinical status Review of anesthesia record & operative note Verifications of current medication dosages, ventilator settings & IV fluid rates Physical examinations focusing on the CV & resp systems Interpretation of data from bedside monitoring & initial lab testing Documentation in the medical record of physical exam & lab findings, evaluation of the adequacy of the procedure, and plans for the fisrt postop night

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