Andersons pediatric cardiology 1839

NeonatalStabilization,Surgical
Strategies,andPostoperative
Management
PreoperativeManagementoftheNeonate
Thegeneralphysiologicfactorsinfluencingadequatesystemicoxygendelivery
(DO2)inneonateswitha“multidistribution”circulationarediscussedindetailin
Chapter70.Itisbeyondthescopeofthischaptertodiscusspalliativecareand
noninterventionforinfantsbornwithanyofthecomplexanomaliesinthe
spectrumofafUVH.Detaileddiscussionsoftheethicsandcontroversiesmaybe
foundelsewhere.8,25–30Inaddition,thischapterfocusesonsurgicalstrategies
leadingtowardaplannedFontanoperation.Cardiactransplantationisdiscussed
inChapter67.
Theprincipalgoalofpreoperativemanagementandstabilizationinthe
neonatewithafUVHistominimizetheriskoffuturesurgicalmanagement.This
generalprinciplecontainsanumberofkeycomponents(Box71.2).


Box71.2

KeyElementsofPreoperativeStabilization
andManagement
■Monitoringandvascularaccess
■Presentationinshock
■Effectsofpositive-pressureventilation
■Nursingconsiderationsandfamilysupport
■Feedingandnutrition
■Timingofsurgery

MonitoringandVascularAccess

Despitesignificantvariabilityinpractice,monitoringoftheneonatewitha
fUVHhassimilarfundamentalgoals.2Physiologicmonitoringgivesthebedside
cliniciananoverviewofthedynamicphysiologicstateofthepreoperative
multidistributionphysiology.Stablevascularaccessallowsforinfusionsof
prostaglandinE1(PGE1),vasoactivemedications,andparenteralnutrition.In
addition,appropriatevasculardevicesaccessprovidecrucialinformation
regardingintravascularpressures,includingsystolicanddiastolicarterialand
centralvenouspressures.Co-oximetrydatafromindwellingvascularcatheters
canprovidevaluableestimatesofcardiacoutputandmixing.Finally,continuous
tracingsfromvascularlinescanprovidecluestothephysiologicconsequences
ofimportantresidualfunctionaloranatomicabnormalities.
Therisksandbenefitsofindividualmonitoringsystemsandvascularaccess
devicesmustbecarefullyconsidered.Althoughbasicdevicessuchas
electrocardiography(ECG)andpulseoximetryposelittlerisktothepatient,
invasivedevicessuchasintravascularlinescarrytheriskofvascularinjury,
thromboemboliccomplications,bloodstreaminfection,andfuturevascular
occlusions.Devicesmustbecarefullyconsideredinthecontextofpatientacuity
andfuturevascularneeds(Table71.1).
Table71.1
CommonMonitoringforthePreoperativeNeonateWitha
FunctionallyUniventricularHeart
MonitoringDevice
Electrocardiograph
Pulseoximetry
Noninvasiveblood
pressure
Invasivearterial
catheter

Location

Rightshoulder,left
shoulder,leftleg
Righthand,lower
extremity
Rightupperextremity,
lowerextremitycalf

Umbilicalartery,
femoralartery,radial
artery
Invasivecentralvenous Umbilicalvein,
catheter
femoralvein,internal
jugularvein
Nearinfrared
Multisite
spectroscopy
iDO2index
N/A
Electroencephalography Head

Indication
All

Risks
Skinirritation

All

None

All

Irritationofthe
extremity,peripheral
nervedamage
Vascularinjury,
bleeding,infection

Needforcontinuousassessmentof
bloodpressureandfrequentarterial
bloodsampling
Centralvenouspressuremonitoring,
hyperosmolarinfusions,frequentblood
sampling
Adjunctiveassessmentofadequate
oxygendelivery
Evolving
Evaluationofepileptiformactivity

Vascularinjury,
bleeding,infection
Skinirritation
None
Skinirritation


Electrocardiography.
ContinuousECGmonitoringshouldbeusedinallpatientswithcongenitalheart
diseaseadmittedtothecardiacintensivecareunit(CICU).Astandardthreeelectrodesystemwithleadsontherightarm,leftarm,andleftleg(rightandleft

shoulderandleftabdomeninneonates)canprovideasingle-lead(leadI,II,or
III)continuousECGtracingthataccuratelydetectschangesintheheartrateand
rhythmalongwithischemicchanges.ContinuousmonitoringoftheECGtracing
canalsobeutilizedintheearlydetectionofelectrolytedisturbances,including
potassiumandcalcium.
NoninvasiveBloodPressureMonitoring.
Anocclusivecuffaroundthearmandlegofapreoperativeneonateisan
essentialnoninvasivemonitoringdevice.Inneonates,anappropriatelysizedcuff
ontheupperarmandcalfmaybeusedtomonitorarmandcalfpressures;these
shouldbeessentiallyidentical.Noninvasivebloodpressuremeasurementscanbe
madebyauscultatorymethodsorbytheuseofautomatedcuffsthatuse
oscillometricmethods.Itshouldbenotedthatoscillometricautomatedcuffs
measuresystolicandmeanarterialbloodpressuresdirectlyandcalculatethe
diastolicbloodpressure.Thusinterpretationofthediastolicbloodpressure
calculatedbytheseautomatedcuffsshouldbeinterpretedwiththisinmind,
particularlyinwithpatientswherethereisdiastolicrunoffintothepulmonary
arteryviaapatentarterialduct.
IndwellingVascularCatheters.
Oneofthemainadvantagesofanindwellingvascularcatheteristhemonitoring
ofpressureinanarterialorvenousvascularstructure.Pressuremonitoring
requirestheintroductionofanend-holecatheterintothevesseltobe
interrogated.Experttechnicalskillisnecessarytoplacethesecathetersin
preoperativeneonatestoavoidinjurytovascularstructures.Suchcathetersare
commonlyinsertedintotheumbilicalvein,femoralvein,jugularvein,umbilical
artery,femoralartery,orradialartery.Onceplaced,thecatheterisconnectedtoa
pressuretransducerviaacouplingsystemthatissubsequentlyconnectedtothe
monitor.Couplingsystemscontaintubingfilledwithasalinesolutionandaport
forzeroingthecathetertoatmosphericpressureandwithdrawingbloodsamples.
Moderntransducerscontainsiliconcrystalsthatchangeresistanceinproportion
tothechangesinpressurefromthecouplingsystem'sfluid.Thesesystemsmust

beproperlycalibratedfortheaccurateassessmentofintravascularpressures.