CARDIAC EMERGENCIES AND POST-PROCEDURAL CARE IN THE NICU

1. CARDIAC EMERGENCIES AND POST-PROCEDURAL CARE IN THE NICU NICU Cardiac Series - November, 2005 Jade Forlidas, MSN & Jackie Smith, RN

2. CARDIAC CATHERIZATION • Cath and angiography are used as definitive diagnostic tests or therapeutic interventions. Procedures include Balloon Atrial Septostomy, Balloon Valvuloplasty and Angioplasty, Blade Atrial Septostomy, embolization, and stent placement.

3. Cardiac Catherization • Risks • R/T catheter insertion and manipulation : • arrhythmias, heart block, cardiac perforation, hypoxic spells, arterial obstruction, hemorrhage, infection, venous obstruction. • R/T contrast injection: • reaction to contrast, intramyocardial injection, renal complications (hematuria, proteinuria, oliguria, anuria) • R/T exposure and sedation : • hypothermia, acidemia, hypoglycemia, seizures, hypotension, respiratory depression.

4. Cardiac Catherization • Post Procedural Care • Monitor vital signs continuously and document Q 15 min. X 1 hour, Q 30 min.x2, Q 1 hour x3. • Check color, pulses , temperature, and perfusion in affected extremity and document Q 15 min x 1 hour and then hourly . • Signs of arterial occlusion - the pale , cold white leg. • Signs of venous occlusion - the purple leg.

5. Cardiac Catherization • Post Procedural Care • Monitor dressing for signs of bleeding - remove the dressing and apply pressure if bleeding occurs and notify H.O. • Keep patient flat and extremity straight for 4-6 hours. • Add to Flowsheet - check boxes for pulse check and capillary refill time. • Report increasing venous congestion or deteriorating arterial perfusion.

6. Cardiac Catherization • Post Procedural Care - Treatment of arterial occlusion following cath. • 2-3 hours after the procedure, if no pulse: • Heparin bolus 20-50 units/kg. • Follow with Heparin infusion 20 units/kg/hr . • No need to follow PTT. • If no improvement in 24 hours, consider TPA.

7. BALLOON ATRIAL SEPTOSTOMY • For palliation of TGA, selected patients with TAPVR, PA with IVS, MA/MS, HLHS and other conditions in which a larger atrial communication is desirable. • A special balloon-tipped catheter is introduced into the LA from the RA through the PFO or existing ASD. The balloon is inflated with contrast material and rapidly pulled back to the RA creating a larger opening in the septum.

8. BAS - Bedside Emergency Procedure • Equipment and supplies needed • Cath lab staff/Cardiology Fellow will bring the Septostomy Kit from the Cath Lab containing the catheter, sheath, introducer, wires, etc. • NICU staff should assemble betadine, heparinized flush, and enough sterile towels, gowns, masks, caps, and gloves for an army! As these babies need to be readied for the OR, sterile technique is extremely important !

10. BAS - Bedside Procedure • Post Procedural Care -Same as post- Cardiac Cath. • Monitor for signs of tamponade - tachycardia, hypotension, thready pulses, muffled heart tones, pulsus paradoxus.

11. TRANSESOPHAGEAL PACING • Provide sedation and immobilization of the patient. • Assist in securing the trans-esophageal pacing probe inserted through the nasopharynx. • Clear the bedside area for pacing and EKG machines. • Run an EKG strip at bedside recorder during the procedure. • Keep the TE probe secured for future use.

12. CARDIOVERSION (Syncronized) • Indications: Treatment of choice for patients with tachyarrhythmias such as SVT, VT, A fib, A flutter with cardiovascular compromise. • Procedure: • Stat Cart, Defibrillator in SYNC mode, CV monitoring, Cardiologist/Physician and support personnel present. • Initial energy level is 0.5 joules/kg. • Second and subsequent energy levels = 1.0 joule/kg.

13. Cardioversion (Synchronized) • Precautions: • Synchronized (SYNC) mode must be activated with EVERY attempt at cardioversion. • If shock is present, intubation and ventilation with 100% O2 and establishment of vascular access is desirable but should not delay cardioversion. • “ CLEAR” before cardioversion • Consider sedation if pt. is conscious and condition/time permit.

14. Ductal -dependant PBF: Tetralogy of Fallot Transposition of the Great Arteries Pulmonary Atresia Tricuspid Atresia Ductal-dependant SBF: Interrupted Aortic Arch Coarctation of the Aorta Hypoplastic Left Heart Syndrome Critical Aortic Stenosis CARDIAC EMERGENCIES -My Ductus is Closing !

15. Ductal-Dependant Lesions

16. Signs in ductal-dependent PBF Decreased SpO2 Hypoxemia Increased cyanosis Signs in ductal-dependant SBF Decreased color, warmth, pulses, perfusion, blood pressure, urine output Cardiac Emergencies -My Ductus is Closing !

17. Cardiac Emergencies - My Ductus is closing! • Actions • Check Prostin infusion - patency, dose/rate, expiration date/time (24 hour). • Notify MD and consider increasing Prostin dose. • Consider other causes of increased resistance to blood flow.

18. CARDIAC EMERGENCIES • Hypercyanotic Spells • Definition: Hypoxic spell occurring in infants with TOF characterized by • paroxysm of hyperpnea (rapid and deep respirations) • irritability and prolonged cry • increased cyanosis • decreased intensity of heart murmur • Severe spell can lead to limpness, seizures, CVA, and death

19. Cardiac Emergencies -Hypercyanotic Spells • Pathophysiology: • Lowering of SVR or increase in RVOT resistance increases R->L shunting. • Increased shunting stimulates respiratory center to produce hyperpnea. • Hyperpnea results in increased systemic venous return. • Increased systemic venous return increases R->L shunt creating a vicious cycle.

20. Cardiac Emergencies - Hypercyanotic Spells • Treatment • Place infant in knee-chest position. • Morphine 0.1-0.2 mg/kg SC or IM suppresses respiratory center and hyperpnea. • Treat acidosis with NaBicarb 1mEq/kg IV (reducing the acidosis-stimulating effect on the respiratory center). • Administer oxygen.

21. Cardiac Emergencies - Hypercyanotic Spells • Further Treatment • If unresponsive, administer vasoconstrictors IV (Neosynephrine) raising the SVR and forcing blood flow to the lungs. • Begin preventative treatment with propranolol 2-4 mg/kg/day PO. • Ultimate treatment - interventional cath procedure or surgery!

22. CARDIAC EMERGENCIES • Pulmonary Hypertensive Crisis • Patients at risk • Large VSD • AVSD • Truncus arteriosus • Transposition of the great arteries • TAPVR • Single ventricle without pulmonary stenosis

23. CARDIAC EMERGENCIES • Pulmonary Hypertensive Crisis • Symptoms • Increased PA pressures • Increased CVP • Decreased O2 saturation • Tachycardia • Hypotension • Acidosis • Decreased UOP

24. CARDIAC EMERGENCIES • Pulmonary Hypertensive Crisis • Prevention • Avoid hypoxia • Acidosis • Hypercarbia • Hypothermia • Hypoglycemia • Maintain pain control. • Avoid or minimize tracheal stimulation . • Premedicate with suctioning the intubated patient - have second person present.

25. CARDIAC EMERGENCIES • Pulmonary Hypertensive Crisis • Treatment • Sedation (and neuromuscular blockers if necessary) for the intubated patient. • Oxygen - Maintain adequate oxygenation, avoid hypoxia. • PCO2 25-30: pH 7.45-7.55. • Low Peep. • Nitric Oxide. • ECMO.

26. HLHS - The Balancing ACT • Normal Circulation has QP:QS = 1:1 • In HLHS, QP:QS depends on resistances in the pulmonary and systemic circuits. • We have to try to keep the balance!

27. CARDIAC EMERGENCIES • The HLHS Balancing Act • My SATs are too LOW ! • Avoid swings in PVR. Keep baby quiet and calm aiming for SpO2 75-85. If necessary, slowly increase FIO2 to achieve these SATs. • If intubated on vent, giving a few manual breaths at present FIO2 can achieve the same result as increasing the FIO2 slightly . • Use blenders on all oxygen devices minimizing O2 needed to keep SATs at desired level. • If intubated, premedicate for suctioning or noxious interventions to avoid the swings.. • Dial up the FIO2 slightly for suctioning instead of using “Oxygen Breaths”.

28. The HLHS Balancing Act • My SATs are too HIGH ! • Avoid the swings, particularly this one as increased PBF means decreased SBF and coronary perfusion. • The perfect ABG is 7.40-40-40. • Use blenders,and lowest FIO2 aiming for SPO2 no greater than 75-85% • Avoid hyperventilation. Keep the baby quiet, comfortable. • Avoid systemic vasoconstrictors and pulmonary vasodilators • Notify MD if unable to keep within range - consider subatmospheric oxygen and afterload reduction.

29. CARDIAC EMERGENCIES - Pulseless Arrest Algorithm

30. CARDIAC EMERGENCIESBradycardia Algorithm

31. CARDIAC EMERGENCIESTachycardia with Adequate Perfusion Algorithm

32. CARDIAC EMERGENCIESTachycardia with Poor Perfusion Algorithm

33. NURSING ISSUES - Drips • Use Guardrails but always calculate your own drips - don’t assume the pump is correct. • Trace your drips from the bag to the IV site first time/ every time. • Check compatabilities. • Use central access if possible . • Don’t give intermittent meds or boluses through drip infusions.

34. DRIP CALCULATIONS -MCG/KG/MIN. • DOSE = • ( ( MG/CC X 1000 ) X RATE ) /KG/60 • RATE = • ( DOSE X KG X 60 ) / (MCG/CC)

35. DRUG COMPATABILITIES TABLE

36. NURSING ISSUES -ARTERIAL LINES • Peripheral arterial lines • Infuse only normal saline solutions. • Heparin, Papaverine, and lidocaine are the only additives for infusion. • No drugs, blood, or blood products are given through peripheral arterial lines.

37. NURSING ISSUES - ARTERIAL LINES • Umbilical artery lines • UAC fluids should have heparin added. • No vasoactive infusions go through the UAC. • No phenobarbitol, dilantin,valium...

38. NURSING ISSUES - VENOUS LINES • NO AIR BUBBLES IN ANY LINES - WATCH CONNECTIONS. • No precipitations. • Prevent BSI - cause of SBE, delay in surgery or transplantation..

39. Thank You