8/5/2020 1 Post-Operative Care for Cardiac Defects By Laura Curl RN Objectives • Discuss physiology of coarctation of the aorta (CoA), Tetrology of Fallot (TOF) and hypoplastic heart syndrome (HLHS). • Determine the pre-operative monitoring of cardiac defects. • Describe surgical repairs for the coarctation of the CoA, TOF, and HLHS. • Recognize post-operative considerations when caring for children with congenital heart surgery. 1 2
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8/5/2020
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Post-Operative Care for Cardiac Defects
By Laura Curl RN
Objectives
• Discuss physiology of coarctation of the aorta (CoA), Tetrologyof Fallot (TOF) and hypoplastic heart syndrome (HLHS).
• Determine the pre-operative monitoring of cardiac defects.
• Describe surgical repairs for the coarctation of the CoA, TOF, and HLHS.
• Recognize post-operative considerations when caring for
children with congenital heart surgery.
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CoarctationoftheAorta
• Narrowing of the aorta– “Speed bump”
– Left ventricle works hard to “pump across bump”
• Left ventricular hypertrophy
CoArc
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NewbornPre‐OperativeCare• Some coarcs are not found until the child gets older
– Ex. Child has school physical and murmur is found
• 4 pt blood pressures– New newborn screening– Can have decreased pulses and circulation
• Alprostadil (prostaglandins) are used to increase pulmonary blood flow and alternatively decreased the amount of blood flow back to the heart
• PGE also helps left ventricle by off loading blood flow by diversion across the PDA
SurgicalRepair
• End to end anastomosis
• Flap repair
– Large coarc
• Balloon Angioplasty
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Post‐OperativeCare• Left ventricle continues to pump hard (no one tells it to chill out
after coming out of the OR)
• Needs time to remold
– Amount of time depends on how long the coarc has been there
• Pt will need antihypertensives
1. Nipride with Sodium Thiosulfate (*byproduct of breakdown is cyanide)
2. Phentolamine
3. Nicardipine
Post‐OperativeCareCont.
• Arterial Lines
– Upper and lower extremity
– To monitor the gradient across the surgical site
– Gradient may still be there post-op but should lessen
• NPO
– Digestive organs need to get used to the new flow of blood
– Have been used to “living” in a decreased blood flow state
– If fed to soon may have a reperfusion injury
– NPO status determined usually by TCV
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TetralogyofFallot• Tetra, Meaning “4”
1. VSD2. Pulmonary Stenosis3. Overriding Aorta4. Right ventricle
hypertrophy
• Pink or Blue Tets– Depends on the degree
of pulmonary stenosis
Pre‐OperativeCare
• Cyanotic or “blue” tetsrequire PGE
• Babe too small– BT Shunt then home to
grow
– Repair @ 4-6 months
BT Shunt
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Pre‐OperativeCareCont.• Tet Spells
– Cyanotic spells that occur with
• Extreme crying
• Stress
• Dehydration
• Fever
– Pulmonary beds clamp down causing worsening right to left shunting across VSD
– Treatment
• Calm patient
• Give O2
• Sedation
– “These babes are spoiled”
Repair
• VSD Closure– Fixes overriding aorta
• Repair pulmonary stenosis
• Right ventricle will remold over time
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Post‐OperativeCare
• May need anti-hypertensives
• Give O2 to help dilate pulmonary bed
• May show signs of pulmonary hypertension – Right ventricle pumping hard– Pre-Op “speed bumps” causes increased lung pressure
• Good pain control
• Babe can still have “Tet spells”
SingleVentricles• Hypoplastic Left Heart Syndrome
– Hypoplastic left ventricle, open PDA, hypoplastic aorta, ASD
• Hypoplastic Right Heart Syndrome
– Hypoplastic right ventricle, open PDA, pulmonary atresia, ASD
– Better prognosis than hypoplastic left
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SingleVentricles• Can be caused by numerous defects
• Babes with defect may seem normal until the PDA closes
• Alprostadil (Prostaglandins)– Can cause increased body temp and apnea– May need intubated to control breathing, saturations and apnea
• PVR high and systemic resistance low– Prevents pulmonary overcirculation which in turn causes decreased systemic
circulation (as shown by BP)
• DO NOT NEED O2– Oxygen floods the lungs and decreases PVR which steals blood from the systemic
blood flow (as shown by BP)– To keep PVR increased- keep O2 sats between 75-85%
• May need sedated and paralyzed– ↑RR > ↑Sats > ↓ PVR
Repair:FirstStageSurgery
BT Shunt– Blalock Taussig Shunt
– Movie on HBO & Youtube: “Something the Lord Made”
– Gortex tube sown between R subclavian to pulmonary artery
– Mostly seen in hypoplastic right
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Repair:FirstStageSurgeryNorwood with Sano
– Used in hypoplastic left when arch is compromised
– Norwood• Rebuild the arch• The main PA is used to rebuild the arch• Pulmonary blood flow is established
through the sano
– Sano Shunt• Central shunt• Gortex tube from RV to PA• Preferred d/t higher velocity flow• “Less likely to clot”