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

Post Delivery / Pre-operative Management

Goal: Optimize pre-operative systemic arterial oxygen content

Access
  • Place UV, UA catheters
  • Confirm position with radiograph
  • Arterial lines should be positioned below L2
Diagnostic Studies
  • Initial Studies
  • ABG, BMP, CBC, T&S
  • CXR
  • ECG
  • Subsequent Studies for All Patients
  • Newborn screen at 48 hours if still pre-op
  • Bilirubin as indicated
  • Subsequent Laboratory Studies for Intubated Patients
  • ABGs as needed to achieve optimal ventilator settings, then every 8 hours
  • Daily CBC, BMP, CXR
Prostaglandins Initiate PGE 0.01 mcg/kg
Respiratory Support
  • Ventilated patients
  • Normocarbia
  • Wean supplemental O2 to maintain preductal saturation > 80%.
  • Spontaneously breathing patients
  • Wean supplemental O2 to maintain preductal saturation > 80%.
ECHO Echocardiography should be obtained as soon as possible at the discretion of the Attending Cardiologist.
Post-natal ECHO Criteria for Balloon Septostomy Balloon Septostomy Required
  1. ASD by width of color Doppler jet < 3 mm with intact ventricular septum regardless of oxygen saturation
  2. ASD between 3 and 5 mm plus one of the following:
    1. Arterial co-oxemtry* < 75 on any support > 2L 100% nasal cannula
      OR
    2. Pulse oximetry measurement in the right arm < 70 on any support > 2L 100% nasal cannula
  3. VSD > 2mm plus one of the following:
    1. Arterial co-oxemtry* < 75 on any support > 2L 100% nasal cannula
      OR
    2. Pulse oximetry measurement in the right arm < 70 on any support > 2L 100% nasal cannula

Balloon Septostomy not Required
ASD > 5 mm, no balloon

Address acidosis and other causes of hypoxemia after ASD is addressed

*Arterial co-oximetry: measured arterial oxygen saturation

Nutrition

Goal:
Improve gastrointestinal structural and functional integrity, improved milk tolerance for greater postnatal growth and shorter hospital stay

  1. UA position should be low (below L2)
  2. Initiate enteral trophic feeds if:
    • No acidosis
    • No signs of NEC
    • Hemodynamic stability
    • Benign abdominal exam
  3. Trial PO feed with breast milk or formula
    • <3kg 5 mL Q 3 hr
    • >3kg 10 mL Q 3 hr
  4. If oral feeds are tolerated, continue feeds and monitor PE, stools
  5. Initiate NG Feeds if:
    • Patient does not tolerate oral feeds within 24-48 hours,
    • Patient is not a candidate for PO feeds
    • <3kg 1 mL/hr via NG
    • >3k 1-2 ml/hr via NG