post-op norwood pathway
TRANSCRIPT
Post-op Norwood v.2.0: Criteria and Overview
Executive Summary Explanation of Evidence Ratings
Test Your KnowledgeSummary of Version Changes
Inclusion Criteria
· Post-operative Norwood patient
Exclusion Criteria· Patient receiving Extracorporeal
Membrane Oxygenation (ECMO)
· Norwood procedure with BT Shunt
Phase I: Day of Surgery to Chest Closure
Phase II: Chest Closure to Extubation
Phase III: Extubation to Transfer to Ward
Shock
Hemostasis
Feeding Assessment
Feeding Ordering
Feeding Contraction
Last Updated: 08/15/2012
Valid until: 08/15/2015
For questions concerning this pathway,
contact: [email protected]© 2012, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
Pathway Overview
Interventions by System
Cardiovascular· Milrinone infusion (0.5 mcg/kg/min)
· Dopamine infusion (5 mcg/kg/min):
Once hemodynamics have
stabilized (typically POD #2-3),
titrate dopamine to maintain a MAP
(typically > 45 mmHg) that
promotes diuresis
· For signs and symptoms of Low
Cardiac Output, see Shock
algorithm
Post-op Norwood Phase I: Day of Surgery to Chest Closure v.2.0
Monitoring and Assessments
Monitoring· Cardiorespiratory monitor
· SaO2
· End-tidal CO2
· Cerebral/Renal NIRS
· Core/toe temperatures
· Consider continuous SvO2
Assessments· Vitals per CICU routine, Interval
physical exam
· Hourly urine output
· Hourly chest tube output
· 4 extremity blood pressure every
AM
· Daily assessment of possibility for
chest closure
· Chest X-ray-admission and daily
· ECG-admission: Atrial wire study
as necessary
· Vascular US as needed if:
1. Platelet count decreasing
2. High volume chest tube output
3. Signs of CVL malfunction
Lines and Tubes· Central venous catheter
· Arterial line
· PICC line
· Foley catheter
· Chest tubes
· NG tube to LIWS
· Atrial and ventricular pacing
wires
Laboratory· Admission: Lytes, Mg, Phos, BUN,
creatinine, CBC, PT/INR, aPTT,
fibrinogen, SVO2 POC: ABG,
lactate, iCa, glucose,
· Every 2 hours for 8 hours: SVO2
POC: ABG, lactate, iCa, glucose.
Then consider increasing interval,
but not less frequently than every 6
hours
· Daily at 0400: Lytes, Mg, Phos,
BUN, creatinine, CBC/diff, albumin,
POC: ABG, lactate, iCa, glucose
Respiratory· Mechanical ventilation-SIMV/PC
· Target: PaCo2 35-50 mmHg/pH
7.3-7.4, SaO2 > 75%
· If SaO2 < 75%: CXR, +/- ↑PEEP,
↑FiO2, +/- initiate iNO, consider
ECHO to r/o anatomic obstruction
to pulmonary bloodflow, consider
Shock
Hematologic· Monitor chest tube output. If
sanguinous output > 3 mL/kg/hr
(see hemostasis algorithm).
· Target: see hemostasis algorithm
*Hematocrit ≥ 40%
*Normal coagulation parameters
INR < 1.5
PTT < 40
Fibrinogen > 200
Platelet count > 200
· Day 2: if hemostasis achieved,
begin heparin infusion for central
line prophylaxis (target range 0.2-
0.3 International Units/mL)
1. Hold heparin 4 hours prior to
chest closure
Infectious Disease· Antibiotic prophylaxis (assure
timing related to most recent dose
in operating room)
· Routine: cefazolin-standard IV
dosing
· If MRSA or PCN allergy-
Vancomycin standard IV dosing
Neurologic· Morphine infusion-start at
20 mcg/kg/hr, and titrate per ICU
comfort protocol
· Target: ICU comfort score of 2
Last Updated: 08/15/2012
Valid until: 08/15/2015
For questions concerning this pathway,
contact: [email protected]© 2012, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
Interventions
Chest Closure
To Phase II: Chest Closure to Extubation
Admit from OR
Fluids, Electrolytes and Nutrition· NPO
· Day of surgery: IVF fluids- D10 ½ NS
@ total fluid limit of 50 ml/kg/day
· Post op day 1:
1. AM rounds: order TPN with TFL of
100 mL/kg/day, and begin
furosemide infusion of 0.05 mg/kg/hr
2. Continue IVF (50 mL/kg/d) until
new TPN arrives (e.g. 1600)
3. increase furosemide throughout
the day as indicated
4. If by 1600 I/O well balanced then
begin TPN (100 mL/kg/d), if I>>O
then begin TPN at fluid restricted rate
(e.g., 50-80 mL/kg/d) and/or continue
to increase furosemide to target even
fluid balance
· Post op day 2 → chest closure
Advance TPN and TFL (range:80-
120 mL/kg/day) to optimize nutrition
while minimizing fluid administration
to target negative fluid balance.
· Ranitidine- standard IV dosing; add
to TPN when possible
· Consider chlorothiazide IV 4-8 mg/kg/
day ÷ BID for synergy
· Post op day 1:
1. AM rounds: order TPN with TFL of
100 mL/kg/day, and begin furosemide
infusion of 0.05 mg/kg/hr
· Day of surgery: IVF fluids- D10 ½ NS
@ total fluid limit of 50 mL/kg/day
Post-op Norwood Phase II: Chest Closure to Extubation
(Goal duration 1-2 days), v.2.0
Last Updated: 08/15/2012
Valid until: 08/15/2015
For questions concerning this pathway,
contact: [email protected]© 2012, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
Interventions by System
Monitoring and Assessments
Monitoring· Cardiorespiratory monitor
· SaO2
· ETCO2
· Cerebral/Renal NIRS
· Core/toe temperatures
Assessments· Vitals per CICU routine; Interval
physical exam, including
assessment of surgical wound
· Hourly urine output
· Hourly chest tube output
· 4 extremity blood pressure every
AM
· Chest X-ray daily while intubated
and/or chest drains present
· Vascular US as needed if:
1. Platelet count decreasing
2. High volume chest tube output
3. Signs of CVL malfunction
Lines and Tubes· Central venous catheter
· Arterial line
· PICC line
· Foley catheter
· Chest tubes
· NG tube to LIWS
· Atrial and ventricular pacing
wires
Laboratory· Immediately after chest closure:
every 2 hours for 6 hours: POC
lactate, ABG. Then adjust interval
as indicated
· Daily: Lytes, Mg, Phos, BUN, creat,
CBC/diff, POC: ABG, lactate, iCa,
glucose
Fluids, Electrolytes and
Nutrition· NPO
· Once hemodynamically stable,
initiate post-op cardiac surgery
feeding protocol
· Continue TPN/ TFL to optimize
nutrition
· Continue furosemide infusion
Respiratory· Mechanical ventilation-SIMV/PC
· Daily extubation readiness testing
Cardiovascular· Continue milrinone infusion
· Wean dopamine infusion
· Wean epinephrine infusion
Hematologic· Maintain hematocrit > 40%
· Heparin infusion for central line/RV
to PA conduit prophylaxis
· Discontinue heparin infusion and
begin standard dosing of ASA when:
1. CVC has been removed (PICC
does not need to have been
removed) AND
2. Tolerating enteral feeds
· Enoxaparin if vascular thrombus
present: If using, do not start ASA
· Remove chest drains (if ≤ 1 mL/kg/
hr after discussion with CV surgeon)
Infectious Disease· Antibiotic prophylaxis for 48 hours
following chest closure
Neurologic· Wean morphine infusion to facilitate
extubation
Interventions
Extubation
To Phase III: Extubation to Transfer to Ward
Lines and Tubes· If PICC line present and
clinical status allows, remove
ASAP after chest closure
· +/- Remove chest tubes
· +/- DC foley
· Consider removing pacer
wires: Either at the time of
chest closure, or when patient
has been arrhythmia-free for
48 hours
Note: · Patients commonly have a mild-moderate form of
low cardiac output syndrome for 12-24 hours
following chest closure. This is usually managed
with fluid bolus administration and limited
escalation of inotropes.
· If low cardiac output syndrome persists or
worsens despite these interventions, consider re-
opening the patient’s sternum.
Post-op Norwood Phase III: Extubation to Transfer to Ward, v.2.0
Last Updated: 08/15/2012
Valid until: 08/15/2015
For questions concerning this pathway,
contact: [email protected]© 2012, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
Interventions by System
Monitoring and Assessments
Monitoring· Cardiorespiratory monitor
· SaO2
· Core/toe temperatures
Assessments· Vitals per CICU routine; Interval
physical exam
· Urine output
· Chest tube output
· Chest X-ray daily until chest drains
removed:
1. Assure that patient has had chest
X-ray following most recent chest
tube removal to r/o pneumothorax
2. Otherwise as indicated by clinical
status
· Vascular US if:
1. Platelet count decreasing
2. High volume chest tube output
3. Signs of CVL malfunction
Laboratory· Following extubation: POC ABG
· Daily: Lytes, Mg, Phos, BUN, Cr, glu,
POC iCa; consider POC ABG, lactate
· Weekly: CBC
· Consider trending CRP if concern for
infection
Fluids, Electrolytes and Nutrition· Begin feeding: Initiate post-op
cardiac surgery feeding protocol
· Wean TPN/IL
· Discontinue ranitidine when at 50%
goal feeding rate, and if no concern
for GERD
· OT swallow evaluation prior to
attempting PO
· Consider otolaryngology consultation
if specific concern for vocal cord
dysfunction
· Transition furosemide from drip to
enteral (dosing guideline: 1 mg/kg
every 8 hours)
Respiratory· Wean from non-invasive ventilation
· Wean from oxygen
Cardiovascular· Wean milrinone off
· Consider maintenance afterload
reduction with ACE inhibitor if:
1. Hypertension
2. Decreased myocardial function
3. AV valve regurgitation
Hematologic· Discontinue heparin infusion and
begin standard dosing of ASA when
1. CVC has been removed (PICC
does not need to have been
removed) AND
2. Tolerating enteral feeds
· Enoxaparin if vascular thrombus
present: If using, do not start ASA
Neurologic· Wean sedatives/analgesics
· Transition sedatives/analgesics to
enteral if has been on infusion
for > 7 days
Interventions
Evaluate readiness to transfer to ward
Transfer Criteria Met? (all must be met)
· SaO2 > 75% with NC O2 flow < 1 LPM for over 24 hours
· Tolerated 24 hours of feeding protocol
· Stable hemodynamics without need for vasoactive infusions
· Tolerating intermittent diuretics
· Invasive monitoring discontinued
· Chest X-ray stable following most recent chest tube removal
No: Continue
ICU careYes
Transfer to
Ward
Infectious Disease· Antibiotic prophylaxis for 48 hours
following chest closure
Lines and Tubes· Discontinue NIRS monitors
· Remove central venous catheter
· Remove arterial line
· PICC line-leave in place for
transfer to ward
Evaluate Central Venous
Pressure (CVP)
Post-op Norwood v.2.0: Shock
HR < 130
· Evaluate for dysrhythmia
· Consider atrial or
atrioventricular sequential
pacing
CVP ≤ 8 mmHg
· Consider fluid administration
(10 mL/kg NS). Repeat up to
2 times (e.g. total 30 mL/kg)
as needed, then consider
increasing dopamine infusion
· Reassessment of CVP
CVP > 8 mmHg
· Consider an initial fluid bolus
(10 mL/kg NS), and reassess
hemodynamics. If no
improvement and CVP
remains > 8 mmHg, consider
increasing dopamine infusion
Signs of shock in patients status-post Norwood procedureNote: all signs may not be present in all patients; numeric values are guidelines and must be considered in the clinical context.
· Serum lactate > 2 mmol/L
· SaO2-SvO2 > 30
· Cerebral or renal oximetry by NIRS < 40%
If shock is present, evaluate the following clinical parameters to determine appropriate intervention
No improvement Despite Dopamine
Dose of 10 mcg/kg/min
1. Initiate epinephrine infusion @ 0.05 mcg/kg/min, and titrate as
necessary
2. Consider muscle relaxation
3. Check serum cortisol level, and consider initiating
hydrocortisone 1 mg/kg/dose IV every 6 hours
4. Transfuse pRBC's to maintain Hct > 40%
5. Consider additional fluid boluses especially if CVP remains
< 8 mmHg
6. Consider echocardiogram to assess:
a. Pericardial effusion
b. Ventricular function
c. AV valve regurgitation
d. RV-PA conduit/ PA stenosis
e. Residual systemic outflow/arch obstruction
CVP ≤ 8mmHg CVP > 8mmHg
Evaluate Heartrate (HR)
HR > 180
· Primary fever: Antipyretics,
consider cooling to low-normal
temperature.
Note: Elevated core temperature due
to peripheral vasoconstriction is a
sign of shock. Therefore, specific
therapies to treat fever will often be
ineffective. Rather, efforts should be
focused on improving cardiac output.
· Evaluate and treat for dysrhythmia
· If SBP > 60 mmHg
(MAP > 45mmHg) consider
weaning chronotropic infusions
· Consider chest X-ray and ECHO to
rule out intrathoracic air/ fluid
collection
HR < 130 HR > 180
If no improvement despite
dopamine of 10 mcg/kg/min:
SBP > 75 mmHg
(MAP > 60 mmHg)
1. Consider weaning
vasoconstrictors
2. Assure sedation and analgesia
are adequate
3. Consider increasing vasodilation
a. increase milrinone to a maximum
dose of 1 mcg/kg/min
b. consider starting nitroprusside at
0.5 mcg/kg/min, and titrate up to
target goal BP
SaO2 > 85%: try to optimize
balance of Qp:Qs by:
1. Decreasing FiO2 as tolerated to
0.21
2. Increasing milrinone to maximum
dose of 1 mcg/kg/min
3. Consider echocardiogram to
assess:
a. Pericardial effusion
b. Ventricular function
c. AV valve regurgitation
d. RV-PA conduit/ PA stenosis
e. Residual systemic outflow/arch
obstruction
4. If elevated BP, consider initiating
nitroprusside infusion @ 0.5 mcg/kg/
min and titrate to forged goal BP
Evaluate Systolic Blood
Pressure (SBP)
Evaluate Arterial Oxygen
Saturation (SaO2)
!Frequent
reassessment
to determine the
adequacy of the
intervention is essential
Return to Phase I
· Cool or mottling of extremities (Toe temp < 28 degrees)
· Urine output < 1mL/kg/hr
Last Updated: 08/15/2012
Valid until: 08/15/2015
For questions concerning this pathway,
contact: [email protected]© 2012, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
Common Causes of Shock
· Low cardiac output syndrome
· Pericardial tamponade
· Pneumothorax
· Arrhythmia
· Residual cardiac lesion
· Infection
· Bleeding/anemia
· Ventricular dysfunction
· Tachycardia (HR > 180 bpm)
· Hypotension (SBP < 55 mmHg, MAP < 40 mmHg)
· Desaturation (SaO2 < 75%)
Post-op Norwood v.2.0: Hemostasis
Last Updated: 08/15/2012
Valid until: 08/15/2015
For questions concerning this pathway,
contact: [email protected]© 2012, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
Monitor Chest Tube Output (hourly)
General Approach
Initial management of post-operative bleeding is focused on normalizing the patient's coagulation profile using
the appropriate blood products. If bleeding is minimal or seems to be decreasing, one may take a more
conservative approach to blood product replacement. However, the general parameters to maintain are:
1. INR < 1.5
2. PTT ≥ 40
3. Fibrinogen > 200
4. Platelet count > 200
5. Hematocrit ≥ 40%
Maintain
1. INR < 1.5
2. PTT < 40
3. Fibrinogen > 200
4. Platelet count > 200
Monitor
· Coagulation profile
· Hematocrit
· Consider
Thromboelastography
· Continue to monitor chest
tube output
Transition from sanguinous to serous
over first several post-operative hours
Sanguinous
Output > 3 mL/kg/hr
Continue to monitor
chest tube output
Continued serous output
Maintain
1. INR < 1.3
2. PTT < 40
3. Fibrinogen > 200
4. Platelet count > 200
Continued sanguinous
output past several post-
operative hours
!Notify surgeon for
bleeding > 10mL/kg/hr
or 5mL/kg/hr for 2
consecutive hours
Bloody Output
> 10 mL/kg/hr or
> 5 mL/kg/hr
for 2 consecutive hours
Bloody Output
> 10 cc/kg/hr or > 5 mL/kg/hr
for 2 consecutive hours
Return to Phase I
Post-op Norwood v.2.0: Enteral Feeding: Assessment
Inclusion Criteria· Term Neonate (< 30 days)
· Cardiac Surgery Service
Exclusion Criteria· Small for gestational age
!
Chest closed
Soft Abdomen
Well Perfused
Functional GI Tract
Feed via Total
Parenteral Nutrition
(TPN)
Place Nasoduodenal
(ND) Tube
Feed ND + TPN
Place Nasogastric (NG)
Tube
Feed NG + TPN
Ready for Enteral
Feeds?
Gastric Feeding OK?
Intubated?
Place Nasogastric
(NG)Tube
Feed PO/NG + TPN
No
No
No
Yes
Yes
Yes
Last Updated: 08/15/2012
Valid until: 08/15/2015
For questions concerning this pathway,
contact: [email protected]© 2012, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
To Feeding Ordering
Return to Phase III
Post-op Norwood v.2.0: Enteral Feeding: Ordering
90mL/kg/day: to
24 kcal/oz
120mL/kg/day: to
27 kcal/oz; stop
intralipids
Increase
concentration per
above table
Advance feeds 0.5mL/
kg/hr(12 mL/kg/day)
Provide additional
TPN as needed while
advancing feeds
Check Residuals
Start with 0.5 mL/kg/hr
(12mL/kg/day)
Tolerated Feeds for 6
hours?
At Full Feeds?
(120mL/kg/day
Off
Pathway
!
22 kcal/oz
1. Breast milk fortified
with Alimentum OR
2. Alimentum
!
Diarrhea
Bloody Stools
Incr. abd girth
Emesis/lg. residuals
Bloody/bilious residuals
Yes
Yes, contract feeds
No
No
Last Updated: 08/15/2012
Valid until: 08/15/2015
For questions concerning this pathway,
contact: [email protected]© 2012, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
To Feeding
Contraction
Return to Phase III
Post-op Norwood v.2.0: Enteral Feeding: Contraction
!
Tachycardia
Irritable with feeds
Prior NEC or ECMO
Prior feeding intolerance
!
Normal perfusion
Tolerates 110-140
mL/kg/day
Ready for Bolus
Feeds?
High Risk?
Contract to 2 hour
bolus for 1 feed
Contract to 1.5 hour
bolus for 1 feed
Contract to 1 hour
bolus for 1 feed
Contract to 30 minute
bolus feeds
Contract to 2 hour
bolus for 3 feeds
Contract to 1.5 hour
bolus for 3 feeds
Contract to 1 hour
bolus for 3 feeds
Contract to 45 minute
bolus for 3 feeds
Contract to 2.5 hour
bolus for 3 feeds
Continual
Reassessment
Yes
No
No
Yes
Last Updated: 08/15/2012
Valid until: 08/15/2015
For questions concerning this pathway,
contact: [email protected]© 2012, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
Return to Phase III
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Post-Op Norwood pathway: Inclusion Criteria
Neonates admitted to the
Cardiac ICU following the
Norwood operation
Return to Home To Pg 2
Ductal Dependent Systemic Blood Flow
Infants with ductal dependent systemic blood flow have left
ventricular outflow obstruction
• Hypoplastic left heart syndrome (HLHS)
• Interrupted aortic arch
• Critical aortic stenosis
HLHS
• HLHS and related functional single ventricle conditions remain
the highest risk and costliest group of lesions among the
commonly occurring congenital heart defects
• No congenital heart defect has undergone a more dramatic
change in diagnostic approach, management, and outcomes
than hypoplastic left heart syndrome (HLHS)
• Outcome data is highly regarded and often synonymous with
overall programmatic success
• Tend to have long lengths of stay
o Provides scope to make measurable improvements that are significant
(days not hours)
o Potential for increased risk of iatrogenic harm
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Norwood Procedure
In HLHS the single ventricle must be
connected to both the systemic and
pulmonary circulations
Systemic circulation
• The main pulmonary artery is separated from
the pulmonary artery branches and connected to
the ascending aorta. The remainder of the aorta
is reconstructed using homograft material. Blood
is now pumped from the single right ventricle out
the “neo-aorta” to the systemic circulation.
Pulmonary circulation
• Since the pulmonary artery is now committed to
the systemic circulation there needs to be a
source pulmonary blood flow. The Sano shunt is
a Gore-Tex conduit that connects the lungs to
the single ventricle via an incision made in the
anterior wall of the right ventricle.
Image source:
http://radiology.rsna.org/content/247/3/617/F7.expansion
Post-Operative Management Strategies
Optimizing oxygen delivery
• Goal: to achieve normal systemic oxygen delivery. This requires
that the Pulmonary to systemic blood flow ratio (Qp:Qs) is close
to 1
o SvO2 to SaO2 difference of ~25% suggests adequate O2 delivery
Balancing the pulmonary and systemic circulations
• Univentricular output is apportioned by the balance of systemic
and pulmonary resistances
This image has been
removed
Return to Home Return to Pg 2
Post-Operative Norwood Algorithm
The algorithm is divided into three phases with each phase
having specific targets:
• Phase I: Day of surgery to chest closure
• Phase II: Chest closure to extubation
• Phase III: Extubation to ward transfer
• Ward transfer is based on achieving specific transfer criteria
Post-Operative Norwood Algorithm (Cont’d)
Each phase is presented in a system based fashion. There
are two additional sub phases of the algorithm:
• Shock
• Hemostasis
Return to Home Return to Phase 1
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Utility of Continuous SvO2 Monitoring in Post-op
CQ: What is the utility of continuous SvO2 monitoring in
post-op Norwood/cardiac surgery patients?
Continuous Sv02 monitoring should be considered in the management
of post- operative Norwood patients.
[ Low quality] (Hoffman, et al., 2000; Hoffman, et al., 2004; Tweddell, et al., 2002)
Routine use of continuous SvO2 monitoring catheters is not
recommended at this time because of the limited experience with the
use of these catheters in this patient population.
Return to Home Return to Phase 1
Optimal Fluid Management Post-op
CQ: What is the optimal fluid management of post-op
Norwood patients?
During the first postoperative day and night, patients should receive a
½ maintenance rate of IV fluid, using additional bolus fluid
administration to optimize hemodynamics.
(No evidence/Local consensus opinion)
Return to Home Return to Phase 1
Optimal Diuretic Management Post-op
CQ: What is the optimal diuretic management for post-op
Norwood patients?
Diuretic therapy should be initiated the first post-operative morning
[ Low quality evidence] (Luciani et al., 1997; local consensus opinion)
Return to Home Return to Phase 1
Return to Home Return to Phase 2
Phase II: Chest Closure to Extubation
Primary objective:
• Hemodynamic stability with ongoing diuresis in preparation for
chest closure
Protocols:
• Once hemodynamically stable initiate post-op cardiac surgery
feeding protocol
Return to Home Return to Phase 3
Phase III: Extubation to Ward Transfer
Primary objective:
• Wean support in preparation for ward transfer
Recommendations:
• Patient should be given H2 blockers until they are at 50% of their
goal enteral feeds. The drug should be discontinued unless there
is concern for ongoing stress gastritis or evidence of
gastroesophageal reflux.
[No evidence] (Local consensus opinion)
Transfer to Ward Criteria
• O2 saturation > 75% with NC O2 flow < 1 LPM for over 24 hours
• Tolerated 24 hours of feeding protocol
• Stable hemodynamics without need for vasoactive infusions
• Tolerating intermittent diuretics
• Invasive monitoring discontinued
• Chest X ray stable following most recent chest tube removal
Return to Home Return to Shock
Subphase: Shock
• Primary objective:
o Recognize shock and intervene in a timely fashion
• Recognition:
o Includes standard clinical parameters of poor perfusion:
– Tachycardia, hypotension, desaturation, mottling, decreased urine
output and acidosis
• Intervention:
o Standardized interventions based on distortions of heart rate, central
venous pressures, arterial saturation and blood pressure
Subphase: Shock (Cont’d)
Cardiogenic shock (“Low cardiac output”)
• Common after Norwood palliation
• Definition: inadequate systemic O2 delivery
• Clinical picture: Tachycardia, hypotension, desaturation,
mottling, decreased urine output and acidosis
• Common causes:
o Low cardiac output syndrome
o Arrhythmia
o Pericardial tamponade
o Hemorrhage/anemia
o Pneumothorax
o Ventricular dysfunction
o Residual cardiac lesion
Return to Home Return to Hemostasis
Subphase: Hemostasis
• Primary objective:
o Normalize coagulation profile to reduce bleeding
• Recognition:
o High volume chest tube output or tension of the membrane covering
the open chest
– Bleeding that may require surgical exploration
– Coagulopathy
• Intervention:
o Frank bleeding > 10cc/kg in one hour or > 5cc/kg/hr for 2 consecutive
hours -> notify surgery
o Otherwise target normal parameters for:
– INR, PTT, Fibrinogen, Platelet count, and HCT
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Executive Summary
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Executive Summary
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Self-Assessment
· If you are taking this self-assessment as a part of required departmental training, you will need to logon to
the Learning Center (for SCH only) to receive credit. Completion also qualifies you for 1 hour of Category II
CME credit.
1. Which of the following is not part of the surgical Norwood procedure?a. Aortic reconstruction using pulmonary artery and homograft materialb. Creation of a source of pulmonary blood flowc. Enlargement of atrial communicationd. Aortic valve replacement
2. What is the standard IV fluid rate the first postoperative day and night?a. 25%b. 50% c. 75%d. 100%
3. Which of the following is considered a marker of frank bleeding and is an indication to contact surgery?a. 3 cc/kg in one hourb. 5-10 cc/kg in one hourc. > 10 cc/kg in one hour
4. Which are the following are considered findings in low cardiac output state?a. Tachycardia (HR > 180 bpm)b. Hypotension (SBP < 55 mmHg, MAP < 40 mmHg)c. Desaturation (SaO2 < 75%)d. SaO2-SvO2 > 30e. All the above
5. Infants on ECMO can be enrolled in the pathwy:a. Trueb. False
6. The post-operative Norwood patient diuretics are typically initiated:a. Upon admission to the CICU immediately after surgeryb. The first morning after surgery c. Post operative day 5d. Never
7. In an infant without evidence of gastroesophageal reflux, H2 blockers can be discontinued when:a. Feeds are startedb. Feeds achieve 25% of enteral goalc. Feeds achieve 50% of enteral goal d. Upon transfer to the ward
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Answer Key
1. Which of the following is not part of the surgical Norwood procedure?d. Aortic valve replacement
2. What is the standard IV fluid rate the first postoperative day and night?b. 50%
3. Which of the following is considered a marker of frank bleeding and is an indication to contact surgery?c. > 10 cc/kg in one hour
4. Which are the following are considered findings in low cardiac output state?e. All the above
5. Infants on ECMO can be enrolled in the pathway:b. False
6. The post operative Norwood patient diuretics are typically initiated:b. The first morning after surgery
7. In an infant without evidence of gastroesophageal reflux, H2 blockers can be discontinued when:c. Feeds achieve 50% of enteral goal
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Evidence Ratings
We used the GRADE method of rating evidence quality. Evidence is first assessed as to
whether it is from randomized trial, or observational studies. The rating is then adjusted in the following manner:
Quality ratings are downgraded if studies:• Have serious limitations
• Have inconsistent results• If evidence does not directly address clinical questions• If estimates are imprecise OR
• If it is felt that there is substantial publication bias
Quality ratings can be upgraded if it is felt that:• The effect size is large• If studies are designed in a way that confounding would likely underreport the magnitude
of the effect OR• If a dose-response gradient is evident
Quality of Evidence: High quality
Moderate quality
Low quality
Very low quality
Expert Opinion (E)
Reference: Guyatt G et al. J Clin Epi 2011: 383-394
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Summary of Version Changes
§ Version 1.0 (8/15/2012): Go-Live
§ Version 2.0 (11/21/2012): Added Exclusion Norwood procedure with BT Shunt
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Medicine is an ever-changing science. As new research and clinical experience
broaden our knowledge, changes in treatment and drug therapy are required.
The authors have checked with sources believed to be reliable in their efforts to
provide information that is complete and generally in accord with the standards
accepted at the time of publication.
However, in view of the possibility of human error or changes in medical sciences,
neither the authors nor Seattle Children’s Healthcare System nor any other party
who has been involved in the preparation or publication of this work warrants that
the information contained herein is in every respect accurate or complete, and
they are not responsible for any errors or omissions or for the results obtained
from the use of such information.
Readers should confirm the information contained herein with other sources and
are encouraged to consult with their health care provider before making any
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Bibliography
1084 records identified through database searching
27 additional records identified through other sources
1111 records after duplicates removed
1093 records screened 1066 records excluded
27 full-text articles assessed for eligibility8 full-text articles excluded, 8 did not answer clinical question 0 did not meet quality threshold
19 studies included in pathway
Identification
Screening
Elgibility
Included
Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535
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Bibliography
Ando, M., Park, I.S., Wada, N. & Takahashi, Y. (2005). Steroid supplementation: a legitimate pharmacotherapy after neonatal open heart surgery. Annals of Thoracic Surgery, 80(5), 1672-1678. doi:10.1016/j.athoracsur.2005.04.035
Bronicki, R.A. (2010). Is cardiac surgery sufficient to create insufficiency?. Pediatric Critical Care Medicine, 11(1), 150-151. doi: 10.1097/PCC.0b013e3181ae4cc4
Bronicki, R.A. & Chang, A.C. (2011). Management of the postoperative pediatric cardiac surgical patient. Critical Care Medicine, 39(8), 1974-1984. doi: 10.1097/CCM.0b013e31821b82a6
Furqan, M., Hashmat, F., Amanullah, M., Khan, M., Durani, H.K. & Anwar-ul-Haque. (2009). Venoarterial PCO2 difference: a marker of postoperative cardiac output in children with congenital heart disease. Journal of the College of Physicians & Surgeons – Pakistan, 19(10), 640-643.
Graham, E.M., Atz, A.M., Butts, R.J., Baker, N.L., Zyblewski, S.C., Deardorff, R.L., DeSantis, S.M., Reeves, S.T., Bradley, S.M. & Spinale, F.G. (2011). Standardized preoperative corticosteroid treatment in neonates undergoing cardiac surgery: results from a randomized trial. Journal of Thoracic & Cardiovascular Surgery, 142(6), 1523-1529. doi: 10.1016/j.jtcvs.2011.04.019
Green, A., Pye, S. & Yetman, A.T. (2002). The Physiologic basis for and nursing considerations in the use of sub atmospheric oxygen in HLHS. Advances in Neonatal Care, 2(4), 177-186. doi: 10.1053/adnc.2002.33542 (Note: this article was duplicated in literature search as REF ID 102)
Hoffman, G.M., Ghanayem, N.S., Kampine, J.M., Berger, S., Mussatto, K.A., Litwin, S.B. & Tweddell, J.S. (2000). Venous saturation and the anaerobic threshold in neonates after the Norwood procedure for hypoplastic left heart syndrome. Annals of Thoracic Surgery, 70(5), 1515-1520. http://dx.doi.org/10.1016/S0003-4975(00)01772-0
Hoffman, G.M., Mussatto, K.A., Brosig, C.L., Ghanayem, N.S., Musa, N., Fedderly,R.T., Jaquiss,R.D. & Tweddell, J.S. (2005). Systemic venous oxygen saturation after the Norwood procedure and childhood neurodevelopmental outcome. Journal of Thoracic & Cardiovascular Surgery, 130(4), 1094-1100. doi:10.1016/j.jtcvs.2005.06.029
Hoffman, G.M., Tweddell, J.S., Ghanayem, N.S., Mussatto, K.A., Stuth, E.A., Jaquis, R.D. & Berger, S. (2004). Alteration of the critical arteriovenous oxygen saturation relationship by sustained afterload reduction after the Norwood procedure. Journal of Thoracic & Cardiovascular Surgery, 127(3), 738-745. doi:10.1016/S0022-5223(03)01315-1
Luciani, G.B., Nichani, S., Chang, A.C., Wells, W.J., Newth, C.J. & Starnes, V.A. (1997). Continuous versus intermittent furosemide infusion in critically ill infants after open heart operations. Annals of Thoracic Surgery, 64(4), 1133-1139. doi: http://dx.doi.org/10.1016/S0003-4975(97)00714-5
Naito, Y., Aoki, M., Watanabe, M., Ishibashi, N., Agematsu, K., Sughimoto, K. & Fujiwara, T. (2010). Factors Affecting Systemic Oxygen Delivery After Norwood Procedure With Sano Modification. Annals of Thoracic Surgery, 89(1), 168-173. doi:10.1016/j.athoracsur.2009.09.032
Pasquali, S.K., Hall, M., Li, J.S., Peterson, E.D., Jaggers, J., Lodge, A.J., Marino, B.S., Goodman, D.M. & Shah, S.S. (2010). Corticosteroids and outcome in children undergoing congenital heart surgery: analysis of the Pediatric Health Information Systems database. Circulation, 122(21) 2123-2130. doi: 10.1161/CIRCULATIONAHA.110.948737
Pasquali, S.K., Li, J.S., He, X., Jacobs, M.L., O'Brien, S.M., Hall, M., Jaquiss, R.D., Welke, K.F., Peterson, E.D., Shah, S.S., Gaynor, J.W. & Jacobs, J.P. (2012). Perioperative methylprednisolone and outcome in neonates undergoing heart surgery. Pediatrics, 129(2), e385-91. doi: 10.1542/peds.2011-2034
Photiadis, J., Sinzobahamvya, N., Fink, C., Schneider, M., Schindler, E., Brecher, A.M., Urban, A.E. & Asfour, B. (2006). Optimal pulmonary to systemic blood flow ratio for best hemodynamic status and outcome early after Norwood operation. European Journal of Cardio-Thoracic Surgery, 29(4), 551-556. doi:10.1016/
j.ejcts.2005.12.043
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Ranucci, M., Isgro, G., De La Torre, T., Romitti, F., De Benedetti, D., Carlucci, C., Kandil, H. & Ballotta, A. (2008). Continuous Monitoring of Central Venous Oxygen Saturation (Pediasat) in Pediatric Patients Undergoing Cardiac Surgery: A Validation Study of a New Technology. Journal of Cardiothoracic & Vascular Anesthesia, 22(6), 847-852. doi:10.1053/j.jvca.2008.04.003
Robertson M.S., Afrane, B. & Elbarbary, M. (2009). Prophylactic steroids for pediatric open heart surgery. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD005550. DOI: 10.1002/14651858.CD005550.pub2
Santos, A.R., Heidemann, S.M., Walters, H.L., 3rd & Delius, R.E. (2007). Effect of inhaled corticosteroid on pulmonary injury and inflammatory mediator production after cardiopulmonary bypass in children. Pediatric Critical Care Medicine, 8(5), 465-469. doi: 10.1097/01.PCC.0000282169.11809.80
Sasidharan, P. (1998). Role of corticosteroids in neonatal blood pressure homeostasis. Clinics in perinatology, 25(3), 723-740.
Shore, S., Nelson, D.P., Pearl, J.M., Manning, P.B., Wong, H., Shanley, T.P., Keyser, T. & Schwartz, S.M. (2001). Usefulness of corticosteroid therapy in decreasing epinephrine requirements in critically ill infants with congenital heart disease. American Journal of Cardiology, 88(5), 591-594. doi: http://dx.doi.org/10.1016/S0002-9149(01)01751-9
Suominen, P.K., Dickerson, H.A., Moffett, B.S., Ranta, S.O., Mott, A.R., Price, J.F., Heinle, J.S., McKenzie, E.D., Fraser, C.D., Jr & Chang, A.C. (2005). Hemodynamic effects of rescue protocol hydrocortisone in neonates with low cardiac output syndrome after cardiac surgery. Pediatric Critical Care Medicine, 6(6), 655-659. doi:10.1097/01.PCC.0000185487.69215.29
Tweddell, J.S., Ghanayem, N.S., Mussatto, K.A., Mitchell, M.E., Lamers, L.J., Musa, N.L., Berger, S., Litwin, S.B. & Hoffman, G.M. (2007). Mixed venous oxygen saturation monitoring after stage 1 palliation for hypoplastic left heart syndrome. Annals of Thoracic Surgery, 84(4), 1301-1310. doi:10.1016/j.athoracsur.2007.05.047
Tweddell, J.S., Hoffman, G.M., Fedderly, R.T., Berger, S., Thomas, J.P., Jr, Ghanayem, N.S., Kessel, M.W. & Litwin, S.B. (1999). Phenoxybenzamine improves systemic oxygen delivery after the Norwood procedure. Annals of Thoracic Surgery, 67(1), 161-167. http://dx.doi.org/10.1016/S0003-4975(98)01266-1
Tweddell, J.S., Hoffman, G.M., Fedderly, R.T., Ghanayem, N.S., Kampine, J.M., Berger, S., Mussatto, K.A. & Litwin,S.B. (2000). Patients at risk for low systemic oxygen delivery after the Norwood procedure. Annals of Thoracic Surgery, 69(6), 1893-1899. http://dx.doi.org/10.1016/S0003-4975(00)01349-7
Tweddell, J.S., Hoffman, G.M., Mussatto, K.A., Fedderly, R.T., Berger, S., Jaquiss, R.D., Ghanayem, N.S., Frisbee, S.J. & Litwin, S.B. (2002). Improved survival of patients undergoing palliation of hypoplastic left heart syndrome: lessons learned from 115 consecutive patients. Circulation, 106(12 Suppl 1), 82-89. doi:10.1161/
01.cir.0000032878.55215.bd
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