Andersons pediatric cardiology 1890
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InterstageManagement
NancyS.Ghanayem,NancyA.Rudd,DavidW.Brown,JamesS.Tweddell
Abstract
Historically,interstagemanagementofinfantsfollowingNorwoodorstage
Ipalliation,andpriortostageIIpalliation,hadbeenlimitedbywide
variationincareandinadequatemonitoring.Physiologicchangesresulting
fromresidualorrecurrentlesionsorthedevelopmentofintercurrentillness
havebeenlinkedtointerstagemortalityratesof10%to20%.Interstage
homemonitoringprogramsthatengagefamiliesandprovidersforhome
monitoringofphysiologicvarianceshasledtoimprovedinterstagesurvival.
Dischargeplanning,caregivereducation,andcarecoordinationarekey
elementsforsuccessfultransitiontohome.Keycomponentsofhome
surveillancemonitoringprogramsincludetrackingofoxygensaturation,
infantfeeding,andweightathome;adedicatedinterstagecareteam;
weeklycontactwithfamily;andspecializedinterstageclinics.The
additionalvalueofinterstagehomemonitoringprogramshasbeenthe
growingcollaborationbetweenhealthcareprovidersandparentswitha
goalofnotonlyimprovingsurvivalbutalsooptimizinggrowthand
developmentaloutcomesforinfantsbornwithhypoplasticleftheartand
otherformsoffunctionallyuniventricularcongenitalheartdisease.
Keywords
hypoplasticleftheartsyndrome;stage1Norwoodpalliation;interstage;
homemonitoring
Introduction
Severalfundamentalsofperioperativecareforshunt-dependentdual-distribution
circulation(seeChapter70)extendtotransitionalcarefromtheintensivecare
unitandthroughouttheinterstageperiodinanefforttopreserveorganfunction
andpromotesomaticgrowth.Conventionaloutpatientsurveillancelimitedto
vitalsignsandroutinegrowthassessmenthashistoricallybeenassociatedwith
highinterstagemortalityratesafterdischargefromNorwoodorstageIpalliation
andpriortostageIIpalliation.1,2(Forthepurposesofthischapter,stageII
palliationreferstothegeneralconceptsofasuperiorcavopulmonaryconnection,
thespecifictypeofwhichdependsontheindividualpatient'sanatomyand
surgicalpreference.)Interstageprogramsthatleverageengagementoffamilies
andprovidersforvigilantmonitoringofphysiologicvarianceshasledto
improvedinterstagesurvival.1,3–7Theinitialreportofinterstagemonitoring
notedareductionofinterstagedeathwithasustainedsingle-centerinterstage
survivalrateforinfantsdischargedtohomeof98%overa10-yearperiod.3,8
Overthepast15years,theunanticipatedbenefitsofinterstagemonitoringhave
includedimprovementinsomaticgrowth9,10andlessarbitrarytimingofstageII
palliation.11,12Additionalvaluehasbeenthegrowingcollaborationbetween
numeroushealthcaredisciplinesandparentadvocates13–16forthesolepurpose
ofnotonlyimprovingsurvivalbutalsoqualityoflifeforinfantsbornwith
hypoplasticleftheartsyndromeandrelatedvariants.
