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109 Cards in this Set

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What does an ECG provide?
Graphic measures of the electrical activity of the heart. Supplies HR, rhythm, indications for conduction abnormalities, muscular damage, hypertrophy, electrolyte imbalance, effects of various drugs. Non invasive
What does an Chest Radiography provide?
Provides information on heart size and pulmonary blood flow patterns (X Ray Exposure). Non invasive
What does an Echo provide? What should the child know?
Uses transducer placed in esophagus behind heart to obtain images of posterior heart structure in patients. Size, shape, position, and (systolic) function of heart how well it is functioning when it SQUEEZES! (NOT RELAX)
Requires a degree of cooperation: may need to use sedation in children TEE is invasive and requires sedation
Painless, but stressful (crying, nursing and sitting effect results)
What does a cardiac CT do compared to MRI?
Cardiac CT provides 3D computer generated detailed image of structure and function. Still X-ray exposure and may require contrast and possible sedation. MRI is expensive and takes a long time, but best. Tells how many heartbeats it take for the heart to squeeze out the contrast
How would you describe the cardiac cathertization to a patient?
A catheter will be placed inside you through femoral artery. This cath will measure pressures and oxygen levels in heart chambers and visualize heart structures and blood flow patterns. Involves injection of contract material to illuminate heart structure and blood flow patterns. As tubing is advanced child may feel pressure. Child may feel warmth, N/V, restlessness and H/A when contrast material is inserted. Significant X-Ray load.
What are the three detours in fetal circulation and what do they do?
Ductus Venousus
Formane Ovale
Ductus Aerteriosus
Divert unnecessary blood from lungs and send it preferentially to the body
What is the purpose of the ductus venousus? When does it close?
directly shunt blood from liver to heart. Bright red blood. Shortcut from umbilical vein to IVC. Few days.
What is the purpose of the ductus aerteriousus and when does it close and why?
Blood from pulmonary artery to aorta (high pressure to low pressure). Blue blood is skipping across bridge from pulmonary blood and into aorta
Few Hours: Muscles inside (smooth) tighten down when oxygen levels increase and decrease in prostaglandin and begin constricting
What is the purpose of the foramen ovale and when does it close?
Cut through hole between RA (due high pressure built from lungs RV back to RA) and LA. Easier to go away from the lungs
Few Minutes
Before blood was rushing through there, but now because pressure has fallen on the right side and greater on the left side which pushes the Foramen Ovale closed
What is the prognosis for CHD?
Few kids fit textbook picture
Most are not immediately life threatening
Most structural defects are found within first year of life
What causes CHD?
Majority unknown, 10-12% chromosomal disorders, <2% r/t maternal factors - rubella, type I diabetes, medications (anti seizure), lupus, EBV, Cytomegalovirus
How does HF in children compare to adults?
Physiology is same. Etiology is different usually due to infection or birth. Symptoms: Large liver, feed difficulties, failure to thrive, irritable, exercise intolerance, respiratory infections (>5/yr)
How to manage children with CHF?
Daily Weight***
Medication: Diuretics, ACEI, Digoxin (vomiting toxicity)
Cluster Care
High calorie, time limited feeds
Oxygen?
Complications for catheterization and how nurses can avoid them?
Bleeding: Measure height, assess and mark pulse locations. Check BP
Thrombus of leg: Hold leg straight 4-6 hours.
Arrhythmia: count HR for 1 full minute
Device Embolization: Temperature or color, pulse,
What to do if bleeding occurs?
direct continuous pressure 1 inch above percutaneous skin site.
When to hypercyanotic spells occur?
Suddenly during blood draw, IV insertion, child highly agitated or following cardiac cath insertion
Treatment for hypercyanotic spell?
Infant in knee chest position
Employ calm comforting approach
Administer 100% oxygen by face mask
Give morphine SubQ or through existing IV line
Begin IV fluid replacement
Repeat morphine administration
Define "Pump Time" What does this tell you?
Time on CPB to time off CPB - BLOODLESS
Makes heart (relatively) bloodless – how long has the blood been sucked out of the heart. Beating on bypass with no blood easier for fancy sewing
Inflammatory Response - Care Plan
Define "Cross Clamp Time"? What does it tell you?
time that aorta is clamped. Keep air from entering into aorta. Have to stop heart because heart beating again brick wall  instant heart seizure. - MOTIONLESS
Coincides with delivery of cardioplegia: high volume of potassium causes heart to arrest
Length of cardiac ischemia arrythmias, funky heart function remember for planning care
Define Circulatory Arrest Time
Time that CPB must be stopped because it’s “in the way” of surgical area – if doing construction on aorta that bypass tube is in the way and you have to remove leading - VISIBLE
Body is completely without any perfusion: cooled body to 18 degree so low demand. Thermoregulation - CarePlan
Less in adults because they have bigger vessels
Outcomes of Cardiopulmonary Bypass
Temperature Instability
Renal Dysfunction (prefer pulsatile)
Atelectasis (collapse lungs to get out of the way)
Inflammatory Response (B/P, Histamine Release, Vasodilation)
Fluid/Electrolyte Shifts (inflammatory response -- third space)
Coagulopathy and Hemolysis (exposed to artificial substances, cool temperatures slow down clotting cascade and get a huge dose of heparin)
Infection
Myocardial (Rhythm and Contractility Issues)
Nursing Interventions for child after cardiac cath
The involved extremity is carefully assessed for signs of complications. Pulses below the catheterization site are monitored for equality and symmetry. Temperature and color are also monitored.
1. The child is maintained on bed rest or in parent's lap for 4 to 6 hours after the procedure.
2. Initially, vital signs are taken every 15 minutes.
4. Pulses are checked distal to the catheterization site.
What are early and later signs of heart failure?
Tachypnea is one of the early signs that should be identified. Tachycardia at rest, dyspnea, retractions, and activity intolerance are other physical signs and symptoms. Urinary output may decrease
Which of heart defect causes hypoxemia and cyanosis because desaturated venous blood is entering the systemic circulation
Tetralogy of Fallot
How manage children at home with cardiac defects
Set limits, increase caloric intake, manage spells, discipline and appropriate limits
What is the PaO level of a fetus?
40%
What occurs when a baby takes its first breath
Lungs Open
PVR Drops Significantly
Qp Increases because of the drop in PVR Pressure
PaO2 goes really high (80-100)
What happens when you clamp the umbilical cord (low pressure system)?
Increase SVR and thus forcing more normal circulation
Cut off prostaglandin supply which kept the three detours open
What occurs over the next several weeks over birth
Becomes more like adult circulation. PVR drops and SVR rises and so transitions to more normal circulation. Qp=Qs
What does oxygen do?
Dilate pulmonary blood vessels and lower PVR. Think about which defects will make heart failure worse.??
Difference between Thorocatomy vs. Sternactomy?
Thoracatomy quicker, but more painful.
How do you increase CO for a pediatric?
Maintaining CO involves optimizing preload, contractility, and afterload
Volume
Arrhythmia management (pacing)
Inotropes and vasopressors,
Electrolytes for peds receive calcium all the time because they deplete Ca stores very rapidly and need that for their heart to contract
Description of Kids with Left to Right Shunts
Qp>Qs
PVR<SVR
Excess Pulmonary Blood Flow
Present with failure to thrive and CHF, Acyanotic "Pink"
Enlarged right side of Heart
Why are Left to Right Shunts problematic?
Pulmonary Hypertension d/ excess pulmonary blood flow and right side of heart overworking
What are the Left to Right Shunt defects?
PDA
ASD
VSD
AVC
What is the most common defect in preterm infants?
PDA (rare it is the only common problem except in premies)
What is the initial treatment for PDA?
May close spontaneously or force close with indomethacin
What is the primary issue with PDA?
Still have bright red blood going to the bodies, but some backward flow into the lungs with purple blood
What is the surgical option for PDA? When is it done?
Surgical ligation is performed via left thoracotomy. Three small incisions on the left side of the chest to place a clip on the ductus. Wait 3 months to perform this procedure. Usually for the very small/premature infant or those with large or unusual PDAs.
What is the non surgical option for PDA? When it it done?
Coils to occlude the PDA are place in the cath lab.
What is the heart defect most often missed?
ASD
What is the ASD?
Hole between RA and LA. LA Pressure > RA Pressure so it will go from LA to RA so purple blood on RA and more blood on right side.
What is the prognosis for ASD?
Most spontaneously close within the 1st year and remain asymptomatic except within a few cases
When is intervention required for ASD?
3-5 years
What is the non surgical intervention for ASD?
Deploy a device in the cath lab (Helex) epithelizes and skin grows over it. Low dose aspirin for 6 months. Preferred approach
What is the surgical repair needed for ASD?
Gortex Patch w/ fancy sewing
What is most common CHD?
VSD
What is the prognosis for VSD?
30-40% may close spontaneously
When do VSDs have to be repaired?
1-2 yo to avoid the development of HTN
Which type of VSDs are difficult to repair?
Perimembranous (by the valves) Do not shrink or close
Which VSDs shrink or close?
Muscular (in the middle of the septum, not near valves)
Which type of fix is seen more often with the VSD?
Complete repair using the Gortex patch (preferred)
Which defect is associated with chromosomal disorders?
Atrioventricular Septal Defect
What are types of Atrioventricular Septal Defect?
Partial: ASD + Mitral Valve Cleft
Complete: ASD + VSD + Mitral Valve
What are different types of Complete Atrioventricular Septal Defect? Which is the most severe?
Balanced: Equal Chambers
Unbalanced: Unequal sizes
Complete, unbalanced AVSD Canal
When is surgical repair done for AVSD?
3-6 months
How do you repair an AVSD? What are the post op complications?
Patch closure of septal defects and reconstruction of AV Valve Tissue. Complications include heart blood, HF, mitral regurgitation, dysrhythmias, and pulmonary hypertension.
What are obstructive CHD? How do these children present?
Blocked from going somewhere. Depends on where the blockage. Mild - Pink, Normal, Block blood going to the lungs - Blue, Blocked blood to body - Gray (low volume red)
Examples of obstructive CHD
Aortic Stenosis
Pulmonic Stenosis
Coarctation of Aorta
What does an infant look like with severe pulmonic stenosis? What do they need until we get to the operating room?
Blue Babies
Ductal Dependent -- Start on prostaglandin infusion
What is the prognosis for pulmonary stensosis?
Balloon angioplasty (Valvuloplasty)
What is the surgical option?
Cut PA at level of obstruction -- open it up -- surgically make the area bigger and patch it up (rarely used due to valvuloplasty)
What does an infant look like with aortic stenosis?
Gray, Ductal Dependent (Need Prostaglandin)
What happens with older children who have aortic stenosis?
Often asymptomatic, but presents itself in a situation of strain (i.e. athletes who collapse)
What is the surgical option for the aortic stenosis?
Ross procedure - Replace aortic valve with pulmonic valve and replace artificial patch on pulmonic - moving coronary arteries. Long term brings complications.
What does an infant look like with Coarctation of Aorta?
Anything pass the obstruction is getting low perfusion. Ductal Dependent, Diminished femoral responses, Gray
How can you suspect a coarctation of aorta in a teenager?
Low perfusion to kidneys. BP goes up to squeeze extra blood pass the blockageBP on right arm (hypertensive before blockage) and hypotensive after blockage.
What are the repair options for infants <6 months?
Defect outside the heart. CPB is not used and a thoracotomy is used instead. Repair is by resection of the coarcted portion with an end-to-end anastomosis (cut out area of blockage and reconnect the good spots) of the oarta or enlargement of the constricted section using a graft of porstehtic material.
What is your biggest priority post op CoArc?
Profoundly hypertensive because it takes several days for their body to readjust with the lack of obstruction (kidneys and gut prone to injury) - manage BP with Nipride
What is non surgical repair option for CoArc?
Ballon dilation or stenting/only for older children
How do children present with decreased pulmonary blood flow?
Qp<Qs, Blood not getting to lungs, Blue to Very Blue
Which 4 defects are part of the Tetralogy of Fallot? Which ones are required for diagnosis of TET?
1 - Pulmonary Stenosis or Pulmonary Atresia*
2 - Overriding aorta (coming from Right and Left Ventricle) Closer to right side of heart.
3 - Right Ventricular Hypertrophy: right ventricle is pushing against a stenotic valve
4 - Ventricular Septal Defect*
When do TET spells peak?
2-4 months of age (can't predict based on defect)
When will you have a pink Tet?
Mild stenosis, and look very similar to a VSD. Pink tet looking like a kid with a VSD
When will you have a blue tet?
Blue blood going to body.
Why do kids arrest during a Tet spell?
Severely hypoxic
Blood shunt right to left so nothing is getting to their lungs so nothing is getting to their LA so they have lost that 15-20%
What happens when kids start spelling? What effect do they have on SVR and PVR
Breathe very rapidly, deeper and decreases SVR making it easier for blood to cut across.
We need to fix them!
Calm
Increase SVR making less blood flow across the VSD - knee chest
Decreases PVR giving the oxygen
Morphine
Increase SVR fluid bolus
Vasopressors (increases SVR) – neoseneprhine
Beta Blocker
What surgical option is available for TET kids who still need to grow?
BT shunt which provides blood flow to the pulmonary arteries from the left or right subclavian artertiy via tube graft
What is the biggest risk with a BT (palliative shunt)?
Clotting so they need low dose aspirin
When can you do the total repair for Tetralogy of Fallot? What do you do?
At 4 months and you can really only fix Pulmonary Stenosis and VSD
What do kids look like with Mixed Effects?
Qp>Qs
Color Spectrum
What is an example of mixed effect defect?
Transposition of Great Arteries
What is the Transposition of Great Arteries?
Great Vessels are switched! Aorta is coming off RV and pulmonary artery off LV
What do kids need in Transposition of Great Arteries to survive at birth?
ASD & Ductus. Reason for miscarriage.
What can you do within the first few hours of life for a Transposition of Great Arteries?
Balloon Atrial Septostomy: Run catheter through Femoral Vein blow up balloon and rip out septum. Now the atria are one sloshy purple to make purple blood go everything. Temporary within first few hours of life. Done with Tricuspid atresia.
What is a more permanent surgical option for for Transposition of Great Arteries?
Jantene Arterial Switch: Cut off pulmonary artery and aorta and move and resew. Need to switch coronary arteries.
What is one of the risks associated with Jantene Arterial Switch?
Coronaries are attached to aorta which are about the width of strand of aorta move to the new aorta if you do not do it correctly you will have no blood and baby has an MI
What is single ventricle defect?
Only one part of ventricle is working and need some sort of communication for purple blood to go everywhere.
What is the goal managing single ventricle defects?
Finding a sweet spot to keep sats at 85%. Balance between PVR and SVR. If PVR increases blood cannot get to lungs so the amount going to my body increases  blue blood
If PVR decreases then the body does not receive blood.
How does blood flow through tricuspid atresia
Enters right side of heart - dead ends - across ASD out the aorta - some goes to the body - rest backflows to the lungs to the ductus - lungs saturates to 95% mixing with blue blood and becomes purple. Need ductus open! Prostaglandins
What is the point of the BT shunt?
Create Ductus (palliative measure) - child will need aspiring
What is the problem with BT shunts?
Don't grow with kid and can't keep up with oxygen demand and oxygen sats decrease
Whats the next stage after BT shunt? How old are kids?
4-6 months. Glen - take SVC passively flows directly to lung. Meanwhile everything coming from IVC travels across ASD mixes and turns purple going to rest of body. Again sats 85-90%. Not enough venous blood flow
What happens at 18 months to 2 yo
Fontan - take IVC to PA. Blue blood from top of body and passively drain to lungs and returns bright red with one giant atria and ventricle that pumps to the body that is bright red - sats 95-100! Separate figure 8
What is the biggest challenge with Tricuspid Atresia?
Keep PVR low to make the blood passively drain. Think about pneumonia.
What happens if this kid with Tricuspid Atresia after the fontan who get pneumonia?
Blood wont be able to get to the heart with PVR. Fenestration is an escape patch for blue blood to come into the heart to maintain CO.
What happens with hypoplastic left syndrome (mitral atresia)
Blood returns bright red from lungs and there is not LV and small aortic arch - crosses the ASD - purple blood going out the pulmonary artery and gets to the body through the ductus (prostaglandin)
What is the firs thing you do with one sided functioning hearts?
BT Shunt (replaces ductus)
What makes hypoplastic left ventricle trickier than right side?
Aortic reconstruction in addition to the BT shunt
Discharge Teaching
Activity Limitations
Feeding and sleeping on regular schedule
Avoiding crowds and immunizations (within first 6 weeks) trying to determine cause of fever. Immunizations would have to be redone
Wound care
Discharge medications
Endocarditis prophylaxis: Dental or GI Procedures
Signs and symptoms of infection
F/U
What is post-pericadotomy syndrome?
Inflammatory Respose: Onset is weeks (mean 4 weeks) to months after any surgery involving the pericardium
Rare in children less than 2 years
Evidence of depression post-pericardiotomy (especially in women)
What are s/s of post-pericardotomy syndrome and treatment?
Signs and symptoms: fever, irritibility, chest/neck/shoulder pain, pericardial effusion, pericardial/pleural friction rub, hepatatomegaly
Treated symptomatically—Bedrest, NSAID, steroids
What are the primary long term issues for kids with CHD?
Arrrhythmias, ventricular failure, valve issues
What is IABP?
Intra-Aortic Balloon Pump (IABP): catheter based intervention through artery to aorta. Assist device relieve workload of heart. Diastole when filling the balloon will inflate to keep blood from leaking into aorta allowing more time for the heart to fill. When the heart is squeezing the balloon will deflate which creates suction relieving afterload. Sometimes for 1-2 days.
Issues to consider for ECMO/VAD Device
Optimizing cardiac output
Bleeding (especially intracranial)
Thrombosis
Hemolysis: blood running through mechanical devices
Infection
Renal dysfunction: non pulsatile
Temperature regulation
Mechanical issues
Maintaining optimal quality of life (physical and psychosocial)***
What are complications with heart transplant?
Rejection (acute and chronic – not treatable and develop atheroscleroris,) infection (immune suppressed), renal dysfunction (anti rejection meds are renal toxic), PTLD (post translant Lymphoproliferative disorders) – lymphoma after transplant
When should septic shock be suspected in children?
Triad of fever, tachycardia, vasodilation and change in mental status manifested by irritability, inapproripate crying, drowsiness, confusion, poor ineraction with parents, lethargy
What are the clinical signs of inadequate perfusion in children with septic shock
Altered mental status
Prolonged capillary refill (cold)
diminished pulses (cold)
Mottled cool extremities (cold)
Flash capillary refill (warmth)
Decreased urine output
Initial treatment of shock in children
Management of airway
Obtaining rapid peripheral IV access
Oxygen
Fluid Boluses (if liver is not enlarged an dno prsence of rales)
If fluid overload then being peripheral iniotrope
AB ASAP
Blood sampling for glucose and Ca
New borns begin prostaglandin