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

2. 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

3. 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

4. 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

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

6. 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

7. 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%

8. 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 : – 0,1 μg/kg/min

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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+

15. 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

16. THANK YOU