CYNOTIC HEART DEFECTS

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CYNOTIC HEART DEFECTS:

CYNOTIC HEART DEFECTS Monika Williams Clinical Instructor Army College of nursing ,jal cantt

Introduction:

Introduction A cyanotic heart defect is a group-type of CHDs. The patient appears blue, due to deoxygenated blood bypassing the lungs and entering the systemic circulation. This can be caused by right to left or bi-directional shunting, or malposition of the great arteries.

Definition:

Definition Cyanotic heart disease is a defect or group of defects in the structure or function of the heart or the great vessels, present at birth, consisting of abnormal blood flow from the right to the left part of the circulatory system (either at the level of the atria, the ventricles, or the great vessels). This abnormal communication (called right-to-left shunt) results in poor oxygenation of the body and therefore cyanosis (bluish coloration of the body).

Types:

Types CHDs that cause cyanosis are following TOF Dextro - Transposition of great arteries. Ebstein's Anomaly Tricuspid Atresia Total Anomalous Pulmo.Venous Drainage. Persistent Truncus Arteriosus Hypo Plastic Left Heart Syndrome

TOF:

TOF Tetralogy of Fallot is a common syndrome of congenital heart defects. Characterized by occurring at once. A large membranous VSD Over riding Aorta (placed at VSD) Pulmonary Valve stenosis or atresia. Right Ventricle Hypertrophy. 4 Classical Anatomical Defects

TOF Cont…:

TOF Cont… The degree of RV outflow tract obstruction may range from slight pulmonary stenosis to complete atresia. Infundibular stenosis is most commonly present.

TOF:

TOF The problem starts very early in the uterus with a narrowed pulmonary valve and a hole between the ventricles. It is only after birth that the defects pose a problem. The low oxygen causes the blood to get thicker and clot more easily. The lining of the heart become more susceptible to infection (endocarditis), septicemia.

Incidence and Etiology:

Incidence and Etiology Occurs in approximately 3 to 6 per 10,000 births and represents 5-7% of congenital heart defects. More often in males than in females. Embryology- Anterior mal-alignment of the conal septum, resulting in the clinical combination of a VSD, pulmonary stenosis, and an overriding aorta.

Embryological anatomy:

Embryological anatomy Asymmetric septation of the truncus arteriosus results in inequality in size of the two great vessels. It creates unavailability of that portion of membranous septum that would normally close the Atrioventricular area resulting in large VSD. Infundibular stenosis develop because of excessive amount of tissue in this area.

Embryological anatomy:

Embryological anatomy There is a consistent hypertrophy of the crista supraventricularis, hypoplasia of pulmonary valve annulus with stenosis, and a subcristal defect that equal the size of aortic lumen.

Symptoms:

Symptoms Babies are blue at birth, Sometimes only when they cry. Have loud precordial systolic murmur. Attacks of worsened cyanosis---- turn very blue, have shortness of breath, and can faint, unconscious. (tet spell- dangerous event). Difficulty in feeding, retarded growth and physical development, dyspnea on exertion, Clubbing of the fingers and toes, polycythemia.

Symptoms:

Symptoms Child prefer to squat, thereby increasing peripheral resistence and favorably influencing pulmonary blood flow.

Patho-physiology:

Patho-physiology Mixing of oxygenated and deoxygenated blood in the left ventricle and preferential flow of blood from the ventricles to the aorta. This is known as a right-to-left shunt. It is often evidenced by a bluish tint to the baby's skin.

Patho-physiology:

Patho-physiology Compensatory mechanism to these changes may develop- Delayed closure of PDA. Collateral circulation between systemic and pulmonary arterial system.

Diagnosis:

Diagnosis A complete evaluation of the circulation is required, including testing the blood for its oxygen content. Ultrasound and x rays of the heart accompanied by a contrast agent to determine the amount of blood flowing in the wrong direction.

CXR:

CXR

Diagnosis :

Diagnosis ECG- reflects RV hypertrophy, RA hypertrophy. Echo- demonstrate overriding of aorta, reflects the size of pulmonary artery. Cardiac catheterization- anatomy of RV outflow tract, pulmo artery size, VSD.

Treatment:

Treatment Two levels Immediate emergency care for “Tet Spells" Surgery for its long term progressive effects . “Total” Repair

Emergency manage. of “tet” spell:

Emergency manage. of “tet” spell Beta Blockers- Propranolol. Oxygen Morphine to reduce ventilatory drive. Phenylephrine to increase blood pressure. knee-chest position-reduces systemic venous return, increases systemic vascular resistance.

Palliative Surgery:

Palliative Surgery Blalock Taussig Shunt surgery. Joining the left subclavian artery leaving the heart to the left pulmonary artery leading to the lungs. This gave a large portion of the partially oxygenated blood leaving the heart a second chance at oxygenation, and greatly relieved symptoms in patients.

Surgical Repair:

Surgical Repair Surgery (OHS) carefully timed, attention to the progression of the disease process, the size of the infant, and the size of the various defects. Temporary surgical procedures can prolong the time before corrective surgery while the baby grows larger and stronger. “Total Repair”

Total Repair:

Total Repair The surgery generally involves making incisions into the heart muscle, relieving the right ventricular outflow tract stenosis by careful resection of muscle, And repairing the VSD using a Gore-Tex or Dacron patch or a homograft. Additional reparative or reconstructive work is done on some patients, since the anatomy varies.

Total Repair:

Total Repair The infundibular resection is accomplished with excision of any parietal or septal band The pulmonary valve is opened through an incision in pulmonary artery. The annulus is calibrated with hegar dilators after completion of pul.valvotomy. Entire outflow tract, infundibulum, annulus and pul artery is enlarged by closing it with a pericardial patch.

Prognosis:

Prognosis Surgical correction has a high rate of success, returning the child to near-normal health. Does not completely correct the defect. Patients often have a leaky pulmonary valve, some degree of residual right outflow tract stenosis, and damage to the electrical system of the heart from the surgical incisions. Risk for sudden cardiac death and heart failure.

D-TGA:

D-TGA Sometimes also referred to as complete transposition of the great arteries , is a CHD in which the primary arteries (the aorta and the pulmonary artery) are transposed. With d-TGA, blue blood from the right heart is pumped immediately through the aorta and circulated to the body and the heart itself, while the left heart pumps red blood continuously back into the lungs through the pulmonary artery. In effect, two separate “circular" (parallel) circulatory systems are created, rather than the “figure 8" (in series) circulation of a normal cardio-pulmonary system.

Embryology :

Embryology Between 3-4 weeks of gestation the truncus arteriosus is divided by spiral down growth of truncoconal ridges. So normally LV empties ----aorta, RV---pulmo. Artery. If disruption of this normal septation the septum may grow straight downwards so aorta arises from the RV & PA from LV.

D-TGA:

D-TGA

Simple and Complex d-TGA:

Simple and Complex d-TGA d-TGA is often accompanied by other heart defects, the most common type being intracardiac shunts such as ASD including patent FO, VSD, and PDA. Stenosis of valves or vessels may also be present.

Simple and Complex d-TGA:

Simple and Complex d-TGA When no other heart defects are present it is called 'simple' d-TGA. Complex d-TGA presents better chance of survival and less developmental risks than simple d-TGA, as well as usually requiring fewer invasive procedures.

Symptoms :

Symptoms Cyanosis in peripheral areas: around the mouth and lips, fingertips, and toes; since the circulated blood is not fully oxygenated to begin with, very little oxygen reaches the peripheral arteries. Baby will exhibit in drawing beneath the ribcage and "comfortable tachypnoea" due to homeostatic reflex of the ANS in response to hypoxic hypoxia.

Symptoms:

Symptoms The infant will be easily fatigued. Weakness, particularly during feeding or playing. Failure to thrive. Syncopic episodes Clubbing of the fingers and toes.

Diagnosis :

Diagnosis In Utero with an ultrasound after 18 weeks gestation. Echocardiogram. Chest x-rays and electrocardiograms. Systolic murmur may be present. CC & angiography.

Surgical treatment :

Surgical treatment Palliative Rashkind Procedure- balloon atrial septostomy The balloon passed through the patent FO in to LA, inflated & pushed back in to RA rupturing the membrane of foramen & permitting intracardiac mixing of blood. Lifesaving for having intact ventricular septum

Palliative Conti….. :

Palliative Conti….. Blalock –Hanlon procedure. Performed through a right thoracotomy. It is an atrial septostomy, preformed when balloon septostomy is inadequate. 3. Bending of pulmonary artery– done in presence of large VSD to prevent excessive pulmo. Blood flow. 4. Blalock Taussing Shunt: done in presence of associated VSD & Pulmo. Stenosis.

Definitive Procedures:

Definitive Procedures Carried out via midline sternotomy, using by pass machine, hypothermia & cardioplegia. Atrial switch procedures:- The mustard operation Large patch of pericardium harvested & shaped. Atrial septum excised through right atriotomy.

Atrial Switch:

Atrial Switch There are two types of atrial switch operations - the MUSTARD operation, and the SENNING operation. Both are similar in principle, but differ in technique. The atrial switch operation is an open heart procedure and is carried out with the assistance of a heart-lung machine. The right atrium is opened, and the wall between the atria is fully removed.

Atrial Switch:

Atrial Switch Using pericardium (Mustard) or flaps created from the atrial septum and wall (Senning), a "baffle" is constructed directing blood from the veins in the right atrium towards the left ventricle. The same baffle also directs blood from pulmonary veins to the right ventricle. The circulation is therefore restored to normal in a functional sense.

Definitive Procedures:

Definitive Procedures Rastelli procedure. Pulmo artery transected distal to its valve and proximal end is oversewn. Rt. Ventricle incised high along its outflow tract. Intraventricular dacron prosthetic tunnel is created between the edge of septal defect and aortic orifice.

Definitive Procedures:

Definitive Procedures A conduit of appropriate size is sutured distally to transected pulmo. Artery and, after being trimmed is anastomosed proximally to the edges of the ventriculotomy. 3. Jatene procedure:- Anatomy of coronary artery origins defined The site of their transfer to pulmo. Artery is marked with fine sutures.

Definitive Procedures:

Definitive Procedures Aorta is transected beyond its sinuses, coronary arteries with rim of aortic wall excised, & pulmo. Artery is transected. Pulmo. Arteries incised at perviously marked sites and cuffed coronary arteries are sutured in to place. Distal aorta is anastomosed to proximal pulmonary artery.

Definitive Procedures:

Definitive Procedures Distal pulmo. Artery anastomosed to root of aorta. Defect created by excision of coronary ostia are repaired with patches of bovine pericardium. (The aorta and pulmonary artery are detached from their native roots and reattached to the opposite root; thus, the pulmonary root becomes the neo-aorta, and the aortic root becomes the neo-pulmonary artery. The coronary arteries are transplanted from the aorta/neo-pulmonary artery to the pulmonary artery/neo-aorta.)

Corrected (L-)TGA:

Corrected (L-)TGA EMBRYOLOGIC ANATOMY. Due to abnormal looping of primitive embryonic heart tube the Rt. Atrium is connected to Lt. ventri. From which courses the pulmo. Artery. Lt. atrium– Rt. Ventri.– aorta. Associated intracardiac defects e.g.VSD, pulmo. Stenosis, insufficiency of Atrio-Ventricular valve.

Diagnosis :

Diagnosis CXR--- Cardiomegaly ECG--- AV block, Lt. Ventri. Hypertrophy. 2-D Echo- confirms L-TGA. Cardiac catheterization, Angiography. Ventriculography – to confirm AV valve incompetence.

Surgical treatment:

Surgical treatment Pulmonary banding- large VSD +nt Blalock Shunt-pulmonary stenosis. Valve reconstruction or repair- AV valve. Permanent pacemaker for spontaneous heart block. VSD closure & relief of pulmo. outlet obs. Using external conduit B/W LV & pulmo artery.

Tricuspid Atresia:

Tricuspid Atresia No vestige of valvular tissue, the small thickened non perforated membrane prevent any communication B/w RA & RV. Associated ASD or patent foramen +nt. Rt. Ventri. Small, rudimentary, blood filled.

Embryology :

Embryology Tricuspid valve normally formed by a blending of – Anterior and posterior endocardial cushion With a segment of interventricular septum. And ventricular muscle. Process completed by 5 th week gestation at which time the associated papillary muscles and chordae tendinae develop from sculpturing of ventricular muscle.

Embryology:

Embryology Disruption in balance between proliferation and resorbtion adversely affects the valve leaflet formation, with atresia as the end result.

Clinical Features:

Clinical Features Cyanosis- central, finger clubbing, polycythaemia. SOB on exertion, failure to thrive, poor physical development, CHF. On auscultation single first, single second sound & absence of murmur. If murmur present- associated VSD, or pulmonary stenosis.

Haemodynamics:

Haemodynamics RA RV LA LV ASD AORTA SYS TEM IC CIR CUL ATIO N

Diagnosis :

Diagnosis Radiology – Cardiomegaly, large RA & LV ECG- LV hypertrophy & strain, tall P wave reflect RA hypertrophy. Echo- absence of tricuspid valve, hypoplasia of RV. Cardiac catheterization & angiography.

Surgical Treatment:

Surgical Treatment Palliative Surgery-appropriate in first 2 years of life. Blalock systemic- pulmonary type shunt Glenn shunt- an anstomosis between the superior vena cava and pulmonary artery.

Fontan Procedure:

Fontan Procedure If the RV is present even if small and there is adequate pulmonary annulus then RA to RV connection is created. If there is no RV then the RA must be connected to pulmonary artery, either with or without a conduit.

Fontan Procedure:

Fontan Procedure Currently, 2 forms of procedure are performed- An intracardiac RA baffle, directing blood from the infe. vena cava to the pulmonary arteries. An extra-cardiac conduit, taking blood from the inferior vena cava directly to the pulmonary arteries.

Ebstein’s anomaly:

Ebstein’s anomaly The normal development of tricuspid valve may be disrupted with downwards displacement in to RV. RA is large, RV is small and TV potentially or actually deformed & incompetent. RBBB due to disruption of Rt. Sided bundle of His. Anomalous conduction pathways results in Wolff-Parkinson-White syndrome.

Haemodynamics :

Haemodynamics The course of the circulation is normal, but as the pressure in the right atrium is increased blood is shunted through the ASD from right to left.

Clinical Features:

Clinical Features Heart failure due to impaired filling of RV. With distended neck veins, hepatomegaly, and ascites. Central cynosis- progressive. Arrhythmias- paroxysmal Tachy episodes Heart sounds- holosystolic murmur at the lower end of sternum, widely split second sound.

Diagnosis :

Diagnosis CXR- gross cardiomegaly due to enlarged Rt. Atrium, diminished vascularity of lungs ECG- tall P wave, RBBB, features of WPW syndrome Echo- position of abnormal TV & ASD. Cardiac catheterization, angiography.

Surgical Treatment:

Surgical Treatment RA is opened & the large billowy anterior leaflet is reattached in its normal position at the annulus with interrupted pledgeted mattress sutures which imbricate the artrialized portion of RV.

Surgical Treatment:

Surgical Treatment ASD is closed with pericardial patch. An ellipse of RA is excised to make it smaller and the atrium is closed. If TV can’nt be reconstructed than prosthetic valve is used to replace it. WPW syndrome- accessory conduction fibers are interrupted to eliminate tachyarrhythmias. Fontan procedure- if RV grossly deformed.

Persistent Truncus Arteriosus:

Persistent Truncus Arteriosus Persistent truncus arteriosus is a rare form of CHD that presents at birth. It derives its name from the embryological structure also known as the truncus arteriosus. In the condition, the vessel never properly divides into the pulmonary artery and aorta.

Causes:

Causes Genetic disorders, and teratogens (viruses, metabolic imbalance, and industrial or pharmacological agents) have been associated as possible causes. Up to 50% of cases are associated with chromosome 22q11 deletions.

Causes:

Causes The cardiac neural crest, directly contributes to the aortic pulmonary septum. Micro ablation of the cardiac neural crest in developing chick embryos and genetic anomalies affecting this population of cells in rodents results in persistent truncus arteriosus.

Anatomical Varieties:

Anatomical Varieties Type 1- a common trunk arises from the heart. Pulmonary artery comes off the aorta as a result of partial septation and then branches off in to Rt. & Lt. arteries. Type 2- Right and left pulmonary artery arises separately from the posterior wall of the common aortic trunk.

Anatomical Varieties:

Anatomical Varieties Type 3 – the right and left pulmonary artery arises separately from the lateral walls of the common trunk. Type 4 – no pulmonary artery arises from the common trunk. Right and left bronchial arteries arises directly from the descending aorta.

Clinical Features:

Clinical Features Cyanosis presents at birth. Heart failure occurs within weeks Systolic ejection murmur is heard at the left sternal border. Murmur often associated with a palpable thrill, second heart sound is unsplit as there is a single set of 3-4 leaflets.

Clinical Features:

Clinical Features Dyspnoea, tachypnoea, sweating and failure to thrive are associated with cardiomegaly. Pulmonary blood flow is usually increased.

Diagnosis :

Diagnosis CXR- gross biventricular cardiomegaly with absence of pulmonary arch, hyperaemic lungs fields. ECG- biventricular hypertrophy & strain. Echo- reveals single major vessel arising from the heart and associated VSD. CC- demonstrate equal pressure in both ventricles.

Primary repair:

Primary repair Pulmonary artery is occluded, the LV is vented. The pulmonary trunk is dissected and separated from the aorta after appropriate clamp control. The aortic opening is sutured. Alternatively vertical aortotomy is done through which the pulmonary artery ostium is patched & the aortic incision sutured.

Primary repair:

Primary repair The RV is incised just below the truncus and the VSD closed with a Dacron patch. A large valve conduit (14-16 mm) is sutured to the pulmonary artery with 5-0 prolene, keeping the valve as close as possible to the pulmonary artery. The proximal prosthesis is then tailored for a 3-0 prolene anastomosis to the ventriculotomy.

Total anomalous pulmonary venous drainage :

Total anomalous pulmonary venous drainage TAPVD is rare, comprising around 1% of all congenital heart abnormalities. Pulmonary vein development- The primitive lungs are drained by a venous plexus, which normally loses its connections with the cardinal, umbilical and vitelline veins. The pulmonary venous plexus anastomoses with the two bilateral branches of the common pulmonary vein, which is absorbed into the body of LA.

Pulmonary vein development:

Pulmonary vein development This provides the final normal relationship of four pulmonary veins draining into the left atrium. Any disruption of these changes will result in the common pulmonary vein draining to the heart via several circuitous pathways, with blood returning from the lungs to the right atrium.

Types :

Types Type I: Supracardiac The common pulmonary vein courses through a vertical venous communication into the left innominate vein and through the superior vena cava to the right atrium. Type II: Cardiac The common pulmonary vein drains in to the coronary sinus and thus to the right atrium.

Types:

Types Type III Infracardiac The common pulmonary vein drains inferiorly through a descending vein that communicates with the portal vein via the ductus venosus and inferior vena cava to reach the RA.

Types:

Types Type 4 Components of any of the other 3 types lead the pulmonary venous drainage directly in to the RA. Patent foramen:- in anomalous pulmonary venous drainage some connection between rt. And lt. heart is necessary to sustain life and this is usually mediated by a patent foramen ovale.

Clinical features:

Clinical features Two clinical patterns may manifest The restricted pattern There is obstruction to the pulmonary venous return to the right atrium, leading to cyanosis which presents early, pulmonary edema and congestive cardiac failure. The cyanosis is responsive to oxygen administration.

Clinical features:

Clinical features 2. The non-restricted pattern The symptoms are delayed, with failure to thrive, growth retardation and recurrent respiratory infections. Tachycardia, tachypnoea and hepatomegaly are common. Cyanosis is usually mild in the unrestricted type but is severe and appears early in the neonatal period in restricted form.

Clinical features:

Clinical features Without operative intervention, death ensues within 3 months or birth in the restricted group. In the unrestricted group, cardiac failure will cause death within a year in 70% of cases.

Surgical treatment:

Surgical treatment Supracardiac type The apex of the heart is elevated and the ascending common venous channel exposed. After creating a 2 cm incision in the pulmonary venous trunk, the ascending communicating vein is ligated at its origin.

Surgical treatment:

Surgical treatment An incision in the left atrium extend from the atrial septum to the base of the left atrial appendage. The anastomosis is fashioned between the left atrium and the pulmonary venous trunk. The patent foramen ovale is then closed through a right atriotomy.

Surgical treatment:

Surgical treatment Intracardiac type:- A right atriotomy permits excision of the intervening septal wall between the atrial septal defect and the coronary sinus, into which the pericardial patch is sutured into place. The atrial septal defect is closed so that the coronary sinus and its pulmonary venous blood empties into the left atrium.

Surgical treatment:

Surgical treatment Infracardiac type In this uncommon type of anomalous pulmonary venous drainage, the descending vein is ligated before it reaches the diaphragm and an anastomosis is created between the left atrium and the common pulmonary venous trunk. A right atriotomy then permits closure of the atrial septal defect.

Hypo plastic left heart syndrome :

Hypo plastic left heart syndrome This condition is the most common cause of death due to CHD in the first month of life. There is atresia or stenosis of the aortic and Mitral valves and hypoplasia of the left ventricle. Life is sustained by patency of the ductus arteriosus. There is usually an associated coarctation of the aorta.

Clinical features:

Clinical features Cyanosis becomes evident within few hours of birth. Inadequate coronary blood flow leads to shock with tachycardia, tachypnoea and signs of cardiac failure.

Clinical features:

Clinical features Peripheral pulses are thready and the child has cold clammy extremities. No murmurs are audible, the first heart sound is normal but there will only be a single sound, representing closure of pulmonary valve.

Diagnosis :

Diagnosis CXR- cardiomegaly and pulmonary venous congestion are apparent. ECG- right axis deviation keeping with right ventricular hypertrophy. ECHO- demonstrates the hypo plastic LV. An hypo plastic ascending aorta and absent aortic valve. A small Mitral valve.

Treatment:

Treatment Immediate control of acidosis and renal failure is essential. PGE1 IV as soon as the diagnosis is established in order that patency of the ductus arteriosus is maintained.

The Norwood Procedure:

The Norwood Procedure The PDA is divided. Pulmonary artery is transected and the distal end is oversewn. The hypo plastic aorta is enlarged with a tubular prosthetic patch and the proximal pulmonary artery is incorporated in to the aortic anastomosis. A Blalock subclavian to pulmonary 4 mm Gore- tex shunt is created to provide pulmonary blood flow.

Fontan procedure:

Fontan procedure At a later reparative stage a right atrial to distal pulmonary artery anastomosis directs blood flow to the lungs. The systemic circulation is sustained by the RV. Cardiac transplantation- if an appropriate donor become available.

Nursing management :

Nursing management Preoperative management Postoperative management

Preoperative management:

Preoperative management Preoperative assessment includes- Admission history and physical exam. Preoperative studies- - CXR - EKG - Lab. Tests- CBC, Hb, coagulation profile, electrolytes level, and urine exam - Blood typing & cross matching.

Preoperative management…:

Preoperative management… Baseline vital signs- - Apical pulse rate. - BP in all extremities. - Respiratory status and temperature. Height and Weight measurement- - Basis for calculating fluid replacement volumes and medication doses.

Preoperative management…:

Preoperative management… Additional nursing observations- - Child’s normal cycle of activity and rest is determined. - Child’s like and dislikes Preoperative teaching- - Goals:- - helping the parents and child deal with an unfamiliar situation.

Preoperative management…:

Preoperative management… Reducing the trauma of the experience. Promoting growth and coping abilities. Areas of teaching- - Introduction to the enviornment, tour of the recovery room, ICU. - Introduction to the equipments. - Introduction to postoperative procedure.

Preoperative management…:

Preoperative management… - Turning, Position changing. - Deep breathing, Coughing. - Postural drainage and percussion. - Intermittent positive pressure. NBM for 12 hours before surgery. Skin preparation. Cleansing enema.

Preoperative management…:

Preoperative management… Preoperative medication. Procedures that are likely to provoke anxiety, such as IV infusions, injections or other invasive procedures, should be discussed at the end of entire preparation and should be followed by play periods.

Postoperative care:

Postoperative care The child is transferred to the ICU or recovery room for 24-48 hrs. The goals of nursing management are to assist in restoring optimal functioning of the cardiopulmonary, GIT, renal and CNS, and to maintain them at this level. Postoperatively, prophylactic antibiotics may be administered for several days to prevent infection.

Postop…:

Postop… Electrolyte therapy, such as calcium and potassium, may be given to promote optimal cardiac functioning. Digoxin is given when indicated. If there is hemodynamic instability, vasopressor may be given for restlessness and presumed pain.

Nursing Diagnoses:

Nursing Diagnoses Impaired gas exchange R/T altered pulmonary blood flow Altered cardiac output R/T specific anatomic defect Activity intolerance R/T  O2 in blood & tissues Fluid volume excess with CHF Altered nutrition : Less than body requirement R/T excessive energy demands Increased potential for infection R/TCHF Anxiety related to procedures & hospitalization Developmental delay R/T  energy , inadequate nutrition Alterations in parenting

Postop…:

Postop… Cardiopulmonary Functioning- Immediately postoperatively the nurse assesses the child’s general condition. The vital signs are taken every 15 minutes for the first 12 to 24 hours. The temperature is monitored carefully on neonates and infants, who may have a low temperature.

Postop…:

Postop… The heart rate is auscultated apically for a full minute. The nurse observes the respiratory rate and auscultates the lungs for breath sounds. The nurse continues to evaluate the child’s cardiac status or the effectiveness of cardiac output.

Postop…:

Postop… Serial readings of blood pressure, heart rate, central venous pressure, and arterial pressure from modules are observed and recorded. Lowered CVP indicates that the child is hypovolemic. The use of a CVP catheter can cause atrial arrhythmias and infusion overload

Postop…:

Postop… lips, buccal mucosa, and nail beds are observed for cyanosis. The peripheral pulses (radial, tibial, and pedal) are palpated on the right and left sides at the same time. Mechanical ventilation is accomplished through the use of an oral or nasal ET tube.

Postop…:

Postop… Postural drainage is done at least every 3 to 4 hours. Deep suctioning must be done very carefully in order to avoid vagal stimulation with resulting cardiac arrhythmias. Blood is replaced as necessary.

Postop…:

Postop… Gastrointestinal and Renal Functioning- Fluid intake by mouth is usually restricted during the first 24 hours of the postoperative period . Mouth care and frequent rising with water will alleviate some of the thirst the child may experience. The patient may be placed in a humidified environment in order to liquefy secretions and to make expectoration easier.

Postop…:

Postop… The child gradually progresses from clear liquids to solid foods as tolerated. All intake and output of fluids are measured accurately. The specific gravity of the urine is determined to assess the ability of the kidneys to concentrate urine. For metabolic acidosis urinary pH. Central Nervous System Functioning :- the pupils are checked for size, position, equality, reaction to light, and accommodation. The muscle strength and reflexes are checked for equality in both the arms and the legs.

Post op …:

Post op … Reducing the workload of heart Organize nursing care to provide periods of rest Avoid unnecessary activities Prevent excessive crying Explain the child need for rest Provide diversional therapy requiring limited expenditure of energy

Postop..:

Postop.. Preventing infection Prevent exposure to communicable disease Know immunization status Report temperature elevation, diarrhea,vomiting, URI symptoms Pophylactic medicines for IE

Postoperative Complications:

Postoperative Complications Cardiovascular complications- arrhythmias, hypotension, hypovolemia, cardiac temponade, cardiac failure, the formation of emboli. Respiratory complications- accumulations of mucus in the respiratory tract, atelectasis, pneumonia, and pneumothorax. CNS complications include decreased cerebral blood flow and the possibility of embolus. Infections and Renal failure

Discharge teaching:

Discharge teaching the child will need medical follow-up care postoperatively. Such care may involve further treatment for congestive heart failure or routine medical supervision during growth and development. The symptoms of post perfusion and postpericardiotomy syndrome, such as lethargy, unexplained temperature elevation, difficult respirations, and chest pain, should also be explained so that the parents can report them

Discharge teaching:

Discharge teaching Children need close supervision, especially if they wish to pursue active or competitive sports. Risk for developing infective endocarditis, they should receive good dental care and prophylactic dentistry in order to prevent caries and gingival infection. Informed about the need for antibiotic prophylaxis during and for a few days after any minor dental or surgical procedure.

Research inputs:

Research inputs Surgery Insight: late complications following repair of TOF and related surgical strategies for management. Nature Clinical Practice Cardiovascular Medicine (2006) The potential for late complications is, however, an important concern for the growing number of postrepair survivors. Progressive pulmonary valve regurgitation leading to right heart failure and arrhythmia are centrally important problems faced by these patients. New techniques are, however, likely to change the future outcomes for postrepair survivors. These techniques include percutaneous valve replacement, arrhythmia ablation surgery, and strategies that emphasize preservation of the pulmonary valve even at the cost of leaving some residual valvular stenosis.

Research inputs:

Research inputs Classic shunting operations for congenital cyanotic heart defects. E Arciniegas, ZQ Farooki, The Journal of Thoracic and Cardiovascular Surgery, Both the Blalock-Taussig and Waterston shunts demonstrated a higher mortality (p less than 0.02) among patients in Group II (complex defects) than in patients in Group I (tetralogy of Fallot and pulmonary atresia with ventricular septal defect [VSD]).

Research inputs:

Research inputs However, the Blalock-Taussig shunt had a significantly lower (p less than 0.04) probability of early postoperative death than the Waterston shunt among patients with complex lesions. The Blalock-Taussig shunt also revealed a lower incidence of important late postoperative complications and did not affect adversely the hemodynamic result after intracardiac correction, as evidenced by late postoperative cardiac catheterization.

Summary :

Summary Definition of CHDs. Types TOF TA TPAVD HLHS D-TGA Surgical and nursing management.

Bibliography :

Bibliography Marlow , Barbara, Pediatric nursing, Elsevier publication, 6 th edition, 480-492. Ghai OP, Essential Pediatrics, CBS publication, 6 th edition, 402-415. Charles Marks, Fundamentals of cardiac surgery, Champan and Hall Medical publication, 1 st edition, 280-290. Whaley and Wong, nursing care of infants and children, 5 th edition. www.answer.com www.wikipedia.com

Thank you:

Thank you

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