Inpatient Pathway for the Evaluation/Treatment of the Newborn with TGA

Immediate Post-operative CICU Care Hand -off from OR Team

Hemodynamics Continuous hemodynamic monitoring

VS Goals:

  • HR < 160
  • SBP > 60
  • DBP > 30
  • MAP > 40
Cardiac Output Maintain infusions:
  • Dopamine0-5 mcg/kg/min
  • Milrinone0.3-0.5 mcg/kg/min

Discontinue for adverse effect or when not needed – typically early AM POD 1

  • Monitor perfusion on physical exam
  • Goal: urine output ≥ 0.5 mL/kg/hr
  • Goal: pH 7.35-7.45, minimal base deficit
  • If cardiac output inadequate,
ECHO Assess for effusion, function, regional wall motion abnormalities, outflow tract obstruction
ECG Document sinus rhythm
Respiratory Support

Initial vent settings set at handoff and goal for extubation discussed (based on full emergence, hemostasis, hemodynamic stability.)
Parameters for Weaning
  • Goal:
  • Wean ventilator frequently to maintain:
    • Normal work of breathing
    • pH 7.35-7.45
    • CO2 < 45
Parameters for Extubation Consider if:
  • PEEP 3-6
  • Rate 5-10
  • Pressure support 5-10
Barriers to Extubation
  • Bleeding
  • Hemodynamic instability including low cardiac output and arrhythmias
  • Decreased level of consciousness
Extubate to Nasal Cannula
  • Wean to maintain sats >92% and normal work of breathing
Chest X-ray
  • Upon arrival to CICU
  • POD 1
  • After removal of thoracic lines, drains
ABG
  • Upon arrival
  • q 1 hr x 2, q 2 hrs x 2
  • Then q 4 hrs for 1st 24 hours
Pain Management Assessment Baseline at handoff and followed as per Nursing protocol
Maintain analgesia and anxiolysis
  • PRN boluses of fentanyl/morphine and versed or continuous infusions
  • If requiring frequent PRN boluses, convert to infusion
  • Assess patient for etiology if increase in agitation, pain
  • Decrease or discontinue infusions if adequate analgesia
  • Consider extubation plan
Neurological Support EEG
  • Video EEG within 6 hours of CICU arrival
  • Monitor for 48 hours
  • If seizures detected, discuss treatment with neurology
Fluids Maintenance
  • Monitor physical exam, intake and outake
  • Begin IV lasix by POD#1
Nutrition Parameters
  • Initiate PO feeds within 6 hours of extubation.
  • Assess ability to PO feed on several attempts.
Hemostasis

Hemostasis
commonly achieved
by CICU arrival.
Routine coagulation
profile is not
routinely needed
Ongoing Bleeding
  • Avoid hypertension
  • CBC, INR/PT/ PTT/fibrinogen
Maintain:
  • Hgb > 10 g/dL
  • Fibrinogen > 150
  • Platelets > 100
  • PT < 15
  • PTT < 50

Notify surgeon
Repeat labs as needed

Temperature Control Parameter
  • Normothermia 36.5-37.5°C
  • Low grade fever within 1st 24 hours is common after bypass
Infectious Disease Post-op Antibiotics
  • Initiate post-op cefazolin
    • Discontinue POD 1 if chest is closed
  • If temperature > 39°C in 1st 24 hours or > 38°C after 24 hours obtain:
    • CBC, CRP, UA
    • Blood, urine cultures
    • ETT Gram stain and culture
    • RRP if respiratory symptoms present
  • Initiate ampicillin/cefotaxime based on clinical appearance and/or inflammatory markers