CARDIAC EMERGENCIES AND POSTPROCEDURAL CARE IN THE NICU

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CARDIAC EMERGENCIES AND POST-PROCEDURAL CARE IN
THE NICU

• NICU Cardiac Series - November, 2005 Jade
  Forlidas, MSN Jackie Smith, RN

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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.

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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.

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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.

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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.

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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.

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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.

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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 !

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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.

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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.

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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.

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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.

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CARDIAC EMERGENCIES -My Ductus is Closing !

• 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

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Ductal-Dependant Lesions
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Cardiac Emergencies -My Ductus is Closing !

• Signs in ductal-dependent PBF
• Decreased SpO2
• Hypoxemia
• Increased cyanosis

• Signs in ductal-dependant SBF
• Decreased color, warmth, pulses, perfusion, blood
  pressure, urine output

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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.

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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

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Cardiac Emergencies -Hypercyanotic Spells

• Pathophysiology
• Lowering of SVR or increase in RVOT resistance
  increases R-gtL shunting.
• Increased shunting stimulates respiratory center
  to produce hyperpnea.
• Hyperpnea results in increased systemic venous
  return.
• Increased systemic venous return increases R-gtL
  shunt creating a vicious cycle.

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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.

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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!

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CARDIAC EMERGENCIES

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

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CARDIAC EMERGENCIES

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

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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.

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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.

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HLHS - The Balancing ACT

• Normal Circulation has QPQS 11
• In HLHS, QPQS depends on resistances in the
  pulmonary and systemic circuits.
• We have to try to keep the balance!

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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.

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• 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.

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CARDIAC EMERGENCIES - Pulseless Arrest Algorithm
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CARDIAC EMERGENCIESBradycardia Algorithm
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CARDIAC EMERGENCIESTachycardia with Adequate
Perfusion Algorithm
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CARDIAC EMERGENCIESTachycardia with Poor
Perfusion Algorithm
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NURSING ISSUES - Drips

• Use Guardrails but always calculate your own
  drips - dont 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 .
• Dont give intermittent meds or boluses through
  drip infusions.

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DRIP CALCULATIONS -MCG/KG/MIN.

• DOSE
• ( ( MG/CC X 1000 ) X RATE ) /KG/60
• RATE
• ( DOSE X KG X 60 ) / (MCG/CC)

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DRUG COMPATABILITIES TABLE
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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.

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NURSING ISSUES - ARTERIAL LINES

• Umbilical artery lines
• UAC fluids should have heparin added.
• No vasoactive infusions go through the UAC.
• No phenobarbitol, dilantin,valium...

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NURSING ISSUES - VENOUS LINES

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

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Thank You