Manual of Pediatric Cardiac Intensive Care Prashant Shah
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Receiving Patient from Operation Theater, Assessment, Preparation and Handing-over Process1

Sachin S Patil,
Kamlesh Tailor
 
POSTOPERATIVE INTENSIVE CARE MANAGEMENT OF THE CARDIAC SURGICAL PATIENT
A multidisciplinary approach with coordination of multi­ple services (cardiac surgeon, cardiologist, intensivist, anesthetist, pediatrician, respiratory therapist, cardiac critical care-trained nurse) is the key to a successful outcome in the postoperative intensive care management of any cardiac surgical patient, who has undergone a palliative or corrective procedure for congenital heart disease.
The surgical procedure comprises anesthetic induction, prebypass period, and the cardiopulmonary bypass (CPB) and postbypass period.
 
TEN COMMANDMENTS FOR POSTOPERATIVE CARE IN THE PEDIATRIC INTENSIVE CARE UNIT (PICU)
  • Constant vigil is the key to a successful outcome. The PICU is never like an unmanned level crossing.
  • Multidisciplinary approach in providing quality care services is mandatory.
  • Frequent clinical monitoring is as vital as high tech bedside monitors.
  • Sudden untoward event (e.g. cardiac arrest) necessi­tating prompt action, though rare, is not uncommon.
  • Problems should be anticipated and complications prevented by instituting appropriate therapy.
  • There is a cause for everything, and these causes should be identified for appropriate management.
  • Two management parameters should not be altered at the same time.
  • There should be no hesitation in calling seniors for assistance in difficult situations.
  • 2 Establishment of standard protocols in management and refinement of communication skills should be adhered to for maintaining continuity of care. Seniors should be consulted when change is contemplated.
  • Common things should be thought about first.
 
POSTOPERATIVE CARE FOR CARDIAC SURGICAL PATIENTS
Inadequate postoperative care can nullify the benefits of a meticulously carried out complex cardiac repair and result in morbidity or even mortality.
Effective postoperative care includes:
  • Continuous monitoring of functions of cardiac hemodynamic, pulmonary and other vital organs such as liver, kidney and central nervous system (CNS).
  • Prompt appropriate corrective measures to restore normal function when deviations from normal are identified.
 
Checklist of Items that Need to be Always Available
  • Central O2 delivery, suction line with optimal functioning.
  • Airways, laryngoscope, endotracheal (ET) tubes, suction catheters and ventilator.
  • Defibrillator with appropriately sized pediatric paddles and cardiac monitors.
  • Ambu bag with masks for various age groups, including neonates.
  • Intravenous access tray including central line.
  • Peritoneal dialysis (PD) tray with catheter and instruments.
  • Chest tubes for decompression of pneumothorax/draining pleural effusions.
  • Cardiac pacemakers.
  • Syringe pumps and infusion pumps.
  • Nasogastric (NG) tubes.
  • Urine collection system with Foley's catheters.
  • Syringes, medicuts, three ways, stop cocks, suction catheters, etc.
  • All emergency medications (see Appendix 1).
  • Stethoscope for individual patients.
  • Thermometer.
 
Preparation to be Done Before Receiving Patient
  • Prepare case sheet, ICU sheet.
  • Calculate inotropes according to patient's weight.
  • Check ventilators, syringe pump, infusion pump, defi­brillator, pacing cables and pacemaker.
  • 3 Check air, O2, suction line.
  • Check that emergency drugs are loaded, and that the intubation and extubation tray checks are done.
  • Keep drainage bottle ready.
  • Prepare mentally for the particular case and read or discuss with team or senior staff.
 
Transferring Patient from Operating Room
  • Transfer of the pediatric cardiac surgical patient from the operating room to the ICU is a critical phase when destabilization can occur. Problems such as displacement of the endotracheal tube or intravenous lines, alteration in drug infusion rates or hypothermia from exposure to ambient temperature may contribute to sudden deterioration.
  • Several measures should be taken to ensure a well-organized transfer from the operating room.
    • The child should be hemodynamically stable before transfer.
    • All catheters and tubes must be sutured and secured to the skin and reinforced with tape. If nasotracheal tube is used, it should be secured to the upper lip.
    • Monitoring of electrocardiogram (ECG) and arterial pressure is essential.
    • Pulseoximeter is helpful in assessing oxygen saturation and peripheral perfusion.
    • All medication should be infused using portable infusion control devices whose battery function is ensured before transfer.
    • Equipment for reintubation and management of a cardiac arrest (medication, pacemaker, portable monitor/defibrillator) must be available.
    • Adequate volume of blood products should be available during transport.
  • The ICU should be aware in advance of the type of ventilator support that will be required, the intracardiac lines that have been placed and the cardiac medication that has been used.
 
Transfer of Patient to ICU
  • Follow a standard acceptance protocol to ensure a safe transition to the ICU. An individual well versed in pediatric intensive care who is an expert in intubation, line insertion, pharmacologic intervention and monitoring techniques should supervise the patient's arrival in the ICU.
  • 4 Airway/ventilator:
    • Check breathing sounds by auscultation and chest wall movement during manual and mechanical ventilation.
    • Select initial ventilator settings:
      • ⇒ FiO2 = according to requirements.
      • ⇒ Tidal volume = 10–15 mL/kg.
      • ⇒ Peak pressure < 25 cm H2O.
      • ⇒ Positive end-expiratory pressure (PEEP) = 2–5 cm H2O.
      • ⇒ Respiratory rate:
        • Newborn: 30–40/min.
        • Infant: 20–30/min.
        • Older than 1 year: 18–28/min.
    • I/E ratio = 1:2 (use a 1:1 ratio in neonates and young infants, who benefit from a longer inspiratory phase to minimize airway resistance).
  • Vital signs:
    • Confirm rate, rhythm and ECG morphology using a portable monitor and then connect the leads to the bedside monitor.
    • Check blood pressure manually by auscultation or by Doppler method.
    • Check the femoral arterial pulse; if these parameters are satisfactory, connect the arterial line to the cali­brated bedside monitor and correlate side play with manual readings.
    • Connect intracardiac line to a calibrated bedside monitor and record the reading. Consider the air filter for both intracardiac and peripheral IV line in small infants.
    • Record the temperature.
  • Observe the initial amount of chest tube drainage in the collection chamber and examine the amount of blood within the chest tube.
  • Physical examination:
    • Auscultate for bilateral breath sound.
    • Examine the extremities for pulse, capillary refill and temperature.
    • Check all intracardiac lines, chest tubes and pacing electrodes for security.
    • Check for pupil reaction.
  • The anesthesia and surgical teams should give a comprehensive report to the ICU physician and nursing staff.
  • Write postoperative order for fluids and drug therapy.
  • Perform supine chest X-ray to know the ET tube position, lung fields, location of intracardiac lines and NG tube position.
5
 
The Handover Process
  • The handover begins once the child is shifted from the OT to the PCICU, the ventilator is connected, settings are checked, monitors are attached and the bed is parked.
  • The handover is given by the anesthesiologist conducting the case to the PCICU team.
  • The following personnel are present during the hand­over:
    • Anesthesiologist shifting the child.
    • Consultant intensivist on day/night (if the patient is shifted after 6 pm) call.
    • Pediatric registrar on duty.
    • Operating surgeon.
    • Nurse taking charge of the patient.
    • Nursing team leader for that shift.
  • The handover is started by the anesthesiologist as per the pocket guide.
  • The pediatric registrar starts writing the points discussed in a separate sheet provided on similar lines to those mentioned in the bedside writing pad.
  • There are no interruptions from the team till the hand­over is complete.
  • Questions are asked only after completion of handover, i.e., once the anesthesiologist finishes his/her handover.
 
POSTOPERATIVE HANDOVER PROFORMA
 
OT to PCICU
  • Patient details:
    • Name, age, sex, weight, UHID NO.
    • Preoperative status.
    • Planned and performed operation.
  • Has the anesthesiologist discussed:
    • Issues during induction.
    • ETT size, route, fixed at.
    • Concerns regarding airway management.
    • Concerns regarding invasive lines.
    • Duration: CPB, ACC, TCA.
    • Concerns regarding weaning from CPB.
    • HR/ ABP/ CVP/ LA/ PA/ SpO2/ PIP.
    • Modified ultrafiltration and post-MUF hematocrit.
    • Ionotropes.
    • Rhythm and pacemaker settings.
    • TEE/epicardial echo findings.
    • Blood products transfused/remaining.
    • Last antibiotic dose.
  • 6 Has the surgeon discussed:
    • Surgery performed.
    • Issues with the procedure.
    • Risk of further bleeding and transfusions required.
    • Concerns regarding postoperative recovery.
    • Plan for ventilation.
    • Gauze count or number if chest kept open.
  • Has the anesthesiologist, surgeon, intensivist summarized: “all in agreement” and nurses clear about:
    • Plan for next 12–24 hours: Volume/ionotropes/sedation
    • Anticipated problems.
    • Labs/imaging over next 24 hours.
  • Questions and answers.
 
ACTION PLAN ON PATIENT'S ARRIVAL IN PICU
  • Fix ECG monitor leads—ascertain rate and rhythm.
  • Connect central monitoring lines—arterial, left/right atrial (arterial BP, CVP).
  • Check on ventilator connections to patient and ventilator settings.
  • Connect chest drain tubes to lower suction; check for air leaks and milk, and ensure that tubes are clear.
  • Connect urinary catheter to urinary bag.
  • Connect pacing wires to pacemaker. Check with surgeon about pacemaker mode and settings.
  • Insert Nasogastric tube, if patient is on ventilator and otherwise of ordered.
  • Check on clinical profile. Check on level of sensorium, chest drainage, dressing for soaking, peripheries for level of warmth, capillary refill time for perfusion, and auscultate both chest and abdomen for liver and fluid.
  • Check core temperature.
  • Check on orders about fluid therapy, analgesics, sedatives, diuretics, antibiotics, inotropes, etc.
  • Investigations:
    • Immediate chest X-ray and, if indicated, 4 hours later; otherwise after 24 hours.
    • Arterial blood gases, electrolytes, Na+, K+, Ca2+, Mg2+.
    • ECG—all 12 leads for open heart repairs.
    • Hematological: Hb, HCT, TC, DC, ESR.
    • APTT/PT/INR.
    • ACT (if increased drainage).
    • Biochemical: Liver function tests, serum bilirubin, SGOT, SGPT and blood glucose, protein, albumin
    • Renal: Blood urea and serum creatinine.
    • CPK-MB if Anomalous left coronary artery from pulmonary artery (ALCAPA), switch procedure (0h, 4h, 12h and 1 day).
7
 
Things to Check
  • Preoperative clinical status.
  • Surgical procedure done.
  • Intraoperative problems, if any.
  • Bypass duration.
  • Hypothermia, circulatory arrest/low-flow perfusion rate duration.
  • Aortic cross clamp time.
  • Intraoperative medications.
Specific postoperative instructions:
Calculate fluid:
              800–1000 mL/m2 (open heart surgery).
              80–100 mL/kg/day (close heart surgery).
  • ⇒ For first day, colloidal solution is a good choice.
  • ⇒ 20% albumin—1 mL/kg/h for 5 hours.
  • ⇒ FFP—10 to 15 mL/kg over 5 hours.
  • ⇒ Whole blood or PCV—10 mL/kg over 4h to 5h.
    (For details, seeChapter 6: Fluide and Electrolyte Management).