Andersons pediatric cardiology 1850

BostChild,BostonChildren'sHospital;BirmChild,BirminghamChildren'sHospital,United
Kingdom;CCHMC,CincinnatiChildren'sHospitalMedicalCenter;CHOP,Children'sHospitalof
Philadelphia;CNMC,Children'sNationalMedicalCenter;CSMott,C.S.MottChildren'sHospital;
GOS,GreatOrmondStreetHospital,UnitedKingdom;HSK,HospitalforSickKids,Canada;iDO2,
inadequateoxygendeliveryindex;N/A,notapplicable;NIRS,nearinfraredspectroscopy;RCH,
RoyalChildren'sHospital,Australia;TCH,TexasChildren'sHospital.

Table71.5
TypicalFrequencyandTypeofLaboratoryandRadiographicTesting
FollowingSurgicalPalliationofFunctionallyUniventricularHearts
Frequency
STAGEINORWOOD,SHUNT,ETC.
Laboratory
Arterialbloodgas
Serumlactate
Mixedvenousoxygensaturation
BUN/creatinine
Serumelectrolytes
Liverfunctiontests
Radiographic
Chestradiograph
Abdominalradiograph
Headultrasound
HYBRIDPROCEDURE
Laboratory
Arterialbloodgas
Serumlactate
Mixedvenousoxygensaturation
BUN/Cr
Serumelectrolytes
Liverfunctiontests

Radiographic
Chestradiograph
Abdominalradiograph
Headultrasound
SUPERIORCAVOPULMONARYCONNECTION
Laboratory
Arterialbloodgas
Serumlactate
Mixedvenousoxygensaturation
BUN/creatinine
Serumelectrolytes
Liverfunctiontests
Radiographic
Chestradiograph
Abdomnialradiograph
Headultrasound

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


TOTALCAVOPULMONARYCONNECTION(FONTAN)
Laboratory
Arterialbloodgas
Serumlactate
Mixedvenousoxygensaturation
BUN/creatinine
Serumelectrolytes
Liverfunctiontests
Radiographic
Chestradiograph
Abdominalradiograph
Headultrasound

q4–6
q4–6
q6–12
q24
q12
q24
q24
no
no

ThemonitoringconsiderationsforthepostoperativeneonatewithafUVHare
similartomonitoringconsiderationsinthepreoperativeperiod(seeearlier)with
severalexceptions.Itmustbeemphasizedthatallvenouscatheters,whether
centralorperipheral,carrytheriskofembolizationofairorparticulatematter
tothebrain;thereforeclosemonitoringofthecathetertubingisimportantinall
patientswithafUVHandanobligateright-to-leftshunt.
Electrocardiography.
ContinuousmonitoringanddisplayofheartrateandECGwaveformsisessential
followingsurgicalpalliation.Waveformdatamaybeusedtodetectischemia
(althoughsensitivityandspecificityinthispatientpopulationislacking),and
heartratetrendsareoftenearlyindicatorsofadequacyofventricularfunction.
Theneonatalmyocardiumhaslimitedabilitytoaugmentcardiacoutputby
recruitingstrokevolume;thussubtleincreasesinheartrateand/orsustained
sinustachycardiaarehelpfulindicatorsofcontractilityandfunctionalreserve.
PulseOximetry.
Pulseoximetrymonitoringisutilizedfollowinganycardiacsurgeryinthe
neonate;anyextremitymaybeutilizedinthegreatmajorityofpatients.Arterial
oxygensaturationsareanimportantindicatorofadequatemixing,cardiac
output,pulmonarycongestion,andanemia.

NoninvasiveBloodPressureMonitoring.
Ingeneral,intermittentnoninvasivebloodpressuremonitoringisconsidered
supplementarytocontinuousinvasiveassessmentviaanarterialcatheter.
IndwellingVascularCatheters.
Inallcasestheinvasivearteriallineisplacedforcontinuousmonitoringofblood


pressureintheoperatingroomineitheraperipheralorcentrallocation.The
idealpositioningofthelinemusttakeintoconsiderationtheinitialanatomy,
proposedsurgicalintervention,sizeofthepatient,andriskofvascularinjury.
Placementofacentralvenouscatheteroccursintheoperatingroominthe
majorityofneonates.Themostcommonlocationforcentralvenousline
placementisintherightinternaljugularvein,althoughsomecenters(thoughnot
all)specificallyavoidthisinneonateswithfUVHfortworeasons:(1)to
minimizetheriskofthrombusinapatientwhowillhaveaplannedSCPCand
(2)tokeepthisvascularsitepatentforfuturecatheteraccess.Serialor
continuousmeasurementsofSVCsaturationsarehelpfultoassesstheadequacy
ofsystemicDO2.
Intraoperativeplacementofanintracardiaclineintotheatriumunderdirect
visualizationisoftenperformed.Thecommonatriallinemaybeplacedinthe
rightatrialbypasscannulationsiteorinaseparatelocationviadirectpuncture.
Intracardiaclinesarethentunneledthroughthechestwallandattachedtoa
couplingsystemandtransducer.Intracardiaclinesareparticularlyhelpfulforthe
directmeasurementofatrialpressuresanddirectvisualizationofatrial
waveforms.Commonatriallinesmaybeusedforinfusions,althoughthis
practiceisvariable.Giventhelowcomplicationrateandtheadvantageof
preservingothercentralandperipheralvessels,theintracardiaccatheterwill
oftenremaininsituforaweekormore.Centralvenouscathetersarealsousedas
stablesitesfortheadministrationofvasoactiveagentsandhyperosmolar
infusionssuchasparenteralnutritionandelectrolytereplacement.

NearInfraredSpectroscopy.
NIRSisusedintheoperatingroominallneonatesoncardiopulmonarybypass.
UponreturntotheCICU,trendsincerebralNIRSmaybeusedasasurrogatefor
SVCsaturation;multisitemonitoringisutilizedismanythoughnotallcenters
(seeTable71.1).
Electroencephalography.
Theuseofroutinecontinuouselectroencephalography(EEG)monitoring
followingneonatalpalliationisvariableacrossinstitutions.Recentdatasuggest
theincidenceofpostoperativeseizurestobe8%to12%,themajorityofwhich
aresustainedandsubclinicalinnature.EEGtracingsmustbeinterpretedinthe
contextofthepostoperativephysiologicstateandtheconcomitantuseof
medicationsthataffectthefindings.Signalsreflecttheeffectofsedationand