Pediatric Cardiac Surgery
Clinical Procedure
 
Aliases:
Paed cardiac
Ped cardiac
Paediatric cardiac surgery

Topic aliases are alternate phrasings for a particular topic.


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See pediatric cardiopulmonary-bypass for specific considerations related to this

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Dec 03, 2012
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Supraventricular tachycardia occurs not infrequently during dissection around the heart.
See the supraventricular tachycardia topic for several methods of managing this.

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Dec 11, 2012
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If an infant is haemodynamically unstable post cardiac surgery with a direct RA, LA, or PA line insitu consider the risk that this line may have migrated.

If no response is seen to administration of resuscitation drugs, administration of volume through these lines in this scenario may result in cardiac tamponade.

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Tell the parents that it is not unusual for procedures to take longer than expected, and if this happens it does not mean there has been a complication.

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The 3-2-1 rule for organising the central line infusions in paediatric cardiac surgery helps you identify them under the drapes.

- 3 three way taps on the medial (blue) lumen. Use for infusing vasoactives.

- 2 three way taps on the proximal (white) lumen and monitor pressure on this line (this pressure trace is the first to disappear if the line is inadvertantly withdrawn. This means that if this line is in the lumen, the medial and distal lumens are as well )

- 1 three way tap on the distal (brown) lumen. For infusing vasodilators or volume or spare.

#example

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Ensure at least one large bore peripheral volume line, preferably two, and a central venous-line

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If you're unable to insert a central line (and planning on letting the surgeons put in a direct atrial line), and are relying on a peripheral IVC for drugs and heparin anticoagulation, make sure that this line is bulletproof before draping the patient.
You don't want to deal with an unreliable line when you have limited access to the patient.

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Label all your lines clearly so its easy to determine which is which without needing to dive under the drapes.

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Arterial line, usually radial arterial-catheter

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Central venous-line, usually internal jugular-central-venous-line

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If you need to take a gas at a time when the patient is haemodynamically unstable, take it from the CVC rather than from the arterial line to avoid losing the arterial trace when you most need it. #IM

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Sep 06, 2012
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Cephazolin 50mg/kg at induction then 25mg/kg 4hrly intraoperatively #DM #RCH

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Methylprednisolone -
This multicenter observational analysis of 3180 neonates undergoing heart surgery did not find any benefit, and suggested increased infection in certain subgroups. These data reinforce the need for a large randomized trial in this population. www.ncbi.nlm.nih.gov/pubm...

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Administer appropriate antibiotic prophylaxis

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Consider intraoperative aprotinin infusion in neonates undergoing cardiac surgery with prolonged bypass times and with suturelines under high pressure (eg arterial switch, aortic arch-surgery )

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Dec 18, 2012
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Indications for keeping the chest open following cardiac surgery include:

1. Haemodynamic instability on sternal closure
2. Contamination requiring frequent washout
3. ECMO/VAD

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If child is > 1yr old, ketamine 10mg/kg plus
0.25mg/kg midazolam in 50ml Syringe. Running this at 10ml/hr gives an infusion of 2mg/kg/hr ketamine and 50mcg/kg/hr of midazolam)

If < 1yr old, midazolam 1mcg/kg/min.

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Mar 18, 2012
DM #RCH #duplicate
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If the patient has labile haemodynamics coming off pump despite what appears to be normal heart function, and is not related to administered drugs or blood products, consider supplementing analgesia with morphine. #BT

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Dec 13, 2012
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If the patient arrests on induction, CPR will need to be performed with sterile gloves while the surgeon preps the chest for emergent sternotomy and byass.

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Oct 18, 2012
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If the patient develops a narrow complex tachyarrhythmia while dissecting around the heart, applying sterile cold water to the heart may help resolve this.

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Aim for a core temperature coming off the table of 36-37 degrees celsius. Colder than this impairs coagulation, and warmer than this may result in haemodynamic instability. #DM #RCH

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Oct 02, 2012
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Its best to wait a couple of days before starting feeds in neonates and infants following cardiac surgery.

Enteral feeding in the context of borderline organ perfusion increases the risk of necrotising enterocolitis

#ref

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Apr 26, 2013
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Consider keeping drug infusions on the central line attached to the patient (even if they are turned off) so that when you get to ICU you can describe to the nursing staff what drugs are present in each line.
This will help prevent inadvertant bolusing of residual vasoactive drugs within the lines.

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For transfer to ICU following the procedure have at least the following available:
1. Adrenaline ampoule + appropriate sized syringe
2. Flush
3. Volume (pump blood if bypass, otherwise crytalloid)
#AS

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