Transposition of the Great Arteries (TGA) Clinical Pathway — CICU

Immediate Post-operative CICU Care

	Goals	Recommendations
Hemodynamics Vital Signs	HR < 160 SBP > 60 DBP > 30 MAP > 40 Urine output ≥ 0.5 mL/kg/hr Begin furosemide IV POD1 pH 7.35-7.45, minimal base deficit Normothermia 36-37.5°C	Titrate infusions: Dopamine: 3-5 mcg/kg/min Milrinone: 0.3-0.5 mcg/kg/min Epinephrine: 0.01- 0.05 mcg/kg/min Discontinue for adverse effect or when no longer needed IV fluids at maintenance rate If cardiac output inadequate, obtain echocardiogram and ECG Low-grade fever within first 24 hrs is common after bypass. For fever outside this window, refer to CICU Fever Guidelines
Respiratory	Normal work of breathing pH 7.35-7.45 CO₂ < 45 Consider extubation when: PEEP 3-6 Rate 5-10 Pressure support 5-10 Maintain SpO₂ > 92%	Initial vent settings discussed at handoff Potential barriers to extubation include Bleeding Hemodynamic instability (low cardiac output, arrhythmias) Decreased level of consciousness
Neurologic	Video EEG Within 6 hrs of CICU arrival Continue for 48 hrs	If seizures detected, discuss treatment with Neurology
Diagnostic Studies	CXR Upon CICU arrival POD 1 After removal of thoracic lines, drains ABG Upon CICU arrival Q1hr x 2 Q2hr x 2 Q4hr for remainder of first 24 hrs
Pain Management	Maintain analgesia and anxiolysis Refer to Neonatal Sedation Protocol IV acetaminophen x 24 hrs as adjunctive therapy	Pain Assessment and Management Procedure Pain Management Flowchart Job Aid
Nutrition	Follow Clinical Pathway: Nutrition in Neonates after Surgery for CHD
Hemostasis	Hemostasis commonly achieved upon CICU arrival Routine coagulation profile not routinely indicated	For ongoing bleeding: Avoid hypertension Obtain CBC, INR/PT/ PTT/fibrinogen Maintain: Hgb > 10 g/dL Fibrinogen > 150 Platelets > 100 PT < 15 PTT < 50 Notify surgeon Repeat labs as indicated

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.