Andersons pediatric cardiology 1850

BostChild, Boston Children's Hospital; BirmChild, Birmingham Children's Hospital, United Kingdom; CCHMC, Cincinnati Children's Hospital Medical Center; CHOP, Children's Hospital of Philadelphia; CNMC, Children's National Medical Center; CSMott, C.S Mott Children's Hospital; GOS, Great Ormond Street Hospital, United Kingdom; HSK, Hospital for Sick Kids, Canada; iDO2, inadequate oxygen delivery index; N/A, not applicable; NIRS, near infrared spectroscopy; RCH, Royal Children's Hospital, Australia; TCH, Texas Children's Hospital Table 71.5 Typical Frequency and Type of Laboratory and Radiographic Testing Following Surgical Palliation of Functionally Univentricular Hearts Frequency STAGE I NORWOOD, SHUNT, ETC Laboratory Arterial blood gas Serum lactate Mixed venous oxygen saturation BUN/creatinine Serum electrolytes Liver function tests Radiographic Chest radiograph Abdominal radiograph Head ultrasound HYBRID PROCEDURE Laboratory Arterial blood gas Serum lactate Mixed venous oxygen saturation BUN/Cr Serum electrolytes Liver function tests Radiographic Chest radiograph Abdominal radiograph Head ultrasound SUPERIOR CAVOPULMONARY CONNECTION Laboratory Arterial blood gas Serum lactate Mixed venous oxygen saturation BUN/creatinine Serum electrolytes Liver function tests Radiographic Chest radiograph Abdomnial radiograph Head ultrasound q2–4 q2–4 q4–6 q24 q6 no q24 no no q2–4 q2–4 q4–6 q24 q6 no q24 no no q4–6 q4–6 q6–12 q24 q12 no q24 no no TOTAL CAVOPULMONARY CONNECTION (FONTAN) Laboratory Arterial blood gas Serum lactate Mixed venous oxygen saturation BUN/creatinine Serum electrolytes Liver function tests Radiographic Chest radiograph Abdominal radiograph Head ultrasound q4–6 q4–6 q6–12 q24 q12 q24 q24 no no The monitoring considerations for the postoperative neonate with a fUVH are similar to monitoring considerations in the preoperative period (see earlier) with several exceptions It must be emphasized that all venous catheters, whether central or peripheral, carry the risk of embolization of air or particulate matter to the brain; therefore close monitoring of the catheter tubing is important in all patients with a fUVH and an obligate right-to-left shunt Electrocardiography Continuous monitoring and display of heart rate and ECG waveforms is essential following surgical palliation Waveform data may be used to detect ischemia (although sensitivity and specificity in this patient population is lacking), and heart rate trends are often early indicators of adequacy of ventricular function The neonatal myocardium has limited ability to augment cardiac output by recruiting stroke volume; thus subtle increases in heart rate and/or sustained sinus tachycardia are helpful indicators of contractility and functional reserve Pulse Oximetry Pulse oximetry monitoring is utilized following any cardiac surgery in the neonate; any extremity may be utilized in the great majority of patients Arterial oxygen saturations are an important indicator of adequate mixing, cardiac output, pulmonary congestion, and anemia Noninvasive Blood Pressure Monitoring In general, intermittent noninvasive blood pressure monitoring is considered supplementary to continuous invasive assessment via an arterial catheter Indwelling Vascular Catheters In all cases the invasive arterial line is placed for continuous monitoring of blood pressure in the operating room in either a peripheral or central location The ideal positioning of the line must take into consideration the initial anatomy, proposed surgical intervention, size of the patient, and risk of vascular injury Placement of a central venous catheter occurs in the operating room in the majority of neonates The most common location for central venous line placement is in the right internal jugular vein, although some centers (though not all) specifically avoid this in neonates with fUVH for two reasons: (1) to minimize the risk of thrombus in a patient who will have a planned SCPC and (2) to keep this vascular site patent for future catheter access Serial or continuous measurements of SVC saturations are helpful to assess the adequacy of systemic DO2 Intraoperative placement of an intracardiac line into the atrium under direct visualization is often performed The common atrial line may be placed in the right atrial bypass cannulation site or in a separate location via direct puncture Intracardiac lines are then tunneled through the chest wall and attached to a coupling system and transducer Intracardiac lines are particularly helpful for the direct measurement of atrial pressures and direct visualization of atrial waveforms Common atrial lines may be used for infusions, although this practice is variable Given the low complication rate and the advantage of preserving other central and peripheral vessels, the intracardiac catheter will often remain in situ for a week or more Central venous catheters are also used as stable sites for the administration of vasoactive agents and hyperosmolar infusions such as parenteral nutrition and electrolyte replacement Near Infrared Spectroscopy NIRS is used in the operating room in all neonates on cardiopulmonary bypass Upon return to the CICU, trends in cerebral NIRS may be used as a surrogate for SVC saturation; multisite monitoring is utilized is many though not all centers (see Table 71.1) Electroencephalography The use of routine continuous electroencephalography (EEG) monitoring following neonatal palliation is variable across institutions Recent data suggest the incidence of postoperative seizures to be 8% to 12%, the majority of which are sustained and subclinical in nature EEG tracings must be interpreted in the context of the postoperative physiologic state and the concomitant use of medications that affect the findings Signals reflect the effect of sedation and