POSTOPERATIVE CARE AFTER THE NORWOOD OPERATION

Transcription

1 POSTOPERATIVE CARE AFTER THE NORWOOD OPERATION Congenital Skills and Decision Making Jennifer C. Hirsch-Romano, MD, MS University of Michigan C.S. Mott Children s Hospital AATS Annual Meeting Toronto, Ontario April 26, 2014

2 NO DISCLOSURES OR OFF LABEL USAGE

3 PHYSIOLOGIC CHALLENGES

4 NORWOOD PHYSIOLOGY Circulation in parallel Goal Qp/Qs < 1 Variable systemic and pulmonary vascular resistance Impact of surgical timing Recent CPB General anesthesia and post operative sedation BT shunt physiology Diastolic run off RV-PA conduit physiology Impact of early myocardial dysfunction

5 PATIENT SPECIFIC FACTORS Small for gestational age and premature Genetic syndromes and non-cardiac anomalies Anatomic risk factors Coronary sinusoids (AA, MS)? Small ascending aorta Restrictive atrial septum Non-HLHS single ventricle anatomy Pre-operative factors Hemodynamic instability/arrest Overcirculation Renal dysfunction

6 SURGICAL DECISION MAKING Hybrid Norwood Reserved for neonates with >2 risk factors Perfusion strategy DHCA exclusively Shunt type Primarily surgeon preference Anatomic variants (aberrant right subclavian)

7 PRACTICE PATTERN VARIATION

8 MORE RELIGION THAN SCIENCE Minimal evidence to support best practices Significant variation in almost all components of post operative care SVR Trial (Pasquali et al. JTCVS 2012;144:915-21) 4 fold difference in mechanical ventilation time 5 fold variation in ICU stay Delayed sternal closure % ECMO 7-35% Feeding modality and medications at discharge Striking consistency within centers over time Don t fix it if it is not broken

9 DELAYED STERNAL CLOSURE Johnson et al. JTCVS 2010;139(5):

10 UNIVERSITY OF MICHIGAN MANAGEMENT STRATEGY

11 ICU MODEL Dedicated pediatric cardiac ICU 24/7 in house coverage Attendings: Pediatric Cardiology Intensivists and pediatric cardiac surgeon (1) Fellows: Pediatric cardiology always primary Nurse practitioners No in house surgical residents/fellows Dedicated nursing pool 24/7 ECMO availability

12 STANDARD MONITORING Oral intubation, standard pulse oximetry Almost 100% delayed sternal closure UAC/UVC preferred, peripheral arterial line and CVL (all lower extremity) as needed Common atrial monitoring line Variable use of intracardiac broviacs Intermittent ABG and lactates to monitor and direct care Rate of change more predictive than absolute value (Charpie et al. JTCVS 2000;120(1):73-80)

13 ALTERNATIVES SvO 2 monitoring Intermittent or continuous Low predictability from SaO 2 (Hoffman JTCVS 2004;127(3):738-45) More sensitive for systemic perfusion Issue of access and availability NIRS Continuous Has been shown to correlate with SvO 2 Prolonged ScO 2 <45% associated with poor outcomes Poor correlation between cerebral and somatic High inter and intra patient variability

14 SURVIVING THE FIRST 48 HOURS

15 HEMOSTASIS/ANTICOAGULATION Fractionated blood products used in the OR and ICU ACT driven management in the OR Standard coags (Ptls, PT, PTT, Fibrinogen) used in the ICU Tranaxemic acid used exclusively in the OR Rare use of Factor 7 Individual center reports of improved hemostasis with fresh whole blood (CHOP) and priming of CPB with platelets and FFP (Milwaukee) ASA started when taking enteral feeds for shunt prophylaxis Role of aspirin resistance testing, affects up to 60% of neonates Heparin bridge to aspirin if shunt concern No routine indwelling line prophylaxis

16 VASOACTIVE SUPPORT Standard across surgeons Low dose dopamine, epinephrine, and vasopressin to maintain MAP > 45 mmhg Afterload reduction with milrinone (phentolamine on CPB) Titrated for increasing lactates or hypertension Transitioned to ACE-I for poor function or AVVR Eliminates systemic hypoperfusion associated with high SaO2 (Hoffman JTCVS 2004;127(3):738-45) Use of vasopressin remains controversial at many centers Increased recent interest in norepinephrine in pediatric intensive care literature

17 DIURESIS DRIPS TO DRAINS Historical use of intermittent lasix and diuril starting within 24 hours of OR to encourage diuresis Increasing use of low dose lasix/bumex infusion with intermittent diuril Less hemodynamic variability with fluid shifts Easier to titrate Peritoneal dialysis (PD) Reserved for AKI with inadequate diuresis with maximal medical therapy Improved time to negative fluid balance, earlier extubation, and improved inotrope score with routine PD (Kwiatkowski JTCVS 2013;epub) Hemodialysis Rare use do to hemodynamic instability in neonates Only in patients who have contraindication to PD

18 VENTILATION MANAGEMENT Standard mechanical ventilation management via oral intubation Minimize FiO2 to maintain PaO2 > 30 Subambient not used in the post operative setting ph strategy of normal to mild alkalosis to minimize PVR Infrequent use of ino Patients with predisposing risk for pulmonary hypertension such as restrictive atrial septum Increasing use of JET ventilation with severe volume overload

19 MECHANICAL CIRCULATORY SUPPORT (MCS) Failure to wean from CPB, declining hemodynamics with rising lactates, or cardiac arrest STS database study demonstrated the Norwood operation to have the highest rate of MCS (17%) (Mascio JTCVS 2014 epub) Risk factors for needing ECMO: < 2.5 kg, longer CPB time, high vasoactive inotrope score (27) in first 48 hours, and peak serum lactate (Friedland-Little JTCVS 2013;epub) Survival through staged palliation (Friedland-Little Ann Thorac Surg 2014;epub) Hospital discharge, 43.8% Stage II palliation, 35.9% Stage III palliation, 25.4%

20 SEDATION/PAIN MANAGEMENT No longer use fentanyl infusion in first 24 hours Morphine drip with early addition of ativan Increased use of dexmedetomidine Rare issues with bradyarrhythmias Patients transitioned to oxycodone when taking enteral feeds Increased awareness of withdrawal in patients with prolonged intubation Aggressive use of methadone and valium weans

21 RESIDUAL LESIONS Need for reintervention associated with prolonged hospital stay and increased mortality (Nathan, JTCVS in press) Most common is shunt reintervention (mbt>rv-pa) Rare arch obstruction Should be considered in any patient with unanticipated clinical trajectory ECHO performed on an as needed basis and at the time of discharge

22 NEUROLOGIC ISSUES

23 NEUROMONITORING Baseline cranial ultrasound and post op as needed Routine neuromonitoring not performed Continuous EEG monitoring for any clinical concern of seizure activity No protocol driven therapeutic hypothermia for low cardiac output states or post cardiac arrest All patients enrolled in long term neurodevelopmental follow up program

24 SVR TRIAL NEURODEVELOPMENTAL OUTCOMES ND impairment is more highly associated with: Innate patient factors Demographic Socioeconomic Maternal education Genetic Weight < 2.5 kg Preoperative intubation Overall morbidity in the first year of life CPR Longer hospital stay Longer mechanical ventilation More complications Additional surgical procedures Not associate with: Shunt type Perfusion type Cardiac anatomy Newburger Circulation 2012 Mahle Pediatr Cardiol 2013

25 GETTING TO THE POINT OF DISCHARGE

26 FEEDING Preoperative parental nutrition only Dietician driven postoperative enteral feeding protocol and caloric evaluation Enteral feeds started at 24 hours unless hemodynamically unstable Low clinical threshold for NEC evaluation and treatment Nasogastric (NG) feeds advanced to oral as tolerated Majority of patients discharged on at least partial NG feeds G-tube placement deferred until post Stage 2 if needed Interstage growth does not depend on feeding modality (Hill JTCVS 2014;epub) Swallow evaluation as needed 48% of patients have swallowing dysfunction despite only 9% having recurrent laryngeal nerve dysfunction (Skinner JTCVS 2005;130(5): )

27 PARENTAL EDUCATION Improved interstage mortality with the introduction of our home monitoring program in collaboration with JCCHD (Hehir Curr Opin Cardiol 2013;28(2):97-102) Ongoing efforts to incorporate social media into education efforts CPR training pre discharge Angled car seat testing while on cardiorespiratory monitors

28 CONCLUSIONS

29 CONCLUSIONS Significant improvements in post operative care especially with increased use of clinical practice guidelines to minimize variation Significant practice pattern variation exists between centers Collaborative efforts currently underway to identify best practices at high performing centers with dissemination and education to other centers Ongoing research into improved monitoring strategies to allow for identification of hemodynamic derangements early with effective interventional strategies

30 Q41. The sternum in patients following the Norwood procedure at our institution is: a. Always left open until the patient achieves dry weight b. Always left open for the first hours only c. Always closed d. Selectively left open for hemodynamic concerns/bleeding

31 Q42. Afterload reduction in the postoperative setting: a. Milrinone for all patients that is transitioned to ACE inhibitor b. Milrinone for all patients, select patients transitioned to ACE inhibitor c. Milrinone +/ ACE inhibitor for select patients d. Rarely/never use milrinone

32 Q43. Our institutional approach to neuromonitoring: a. Multimodality continuous monitoring (NIRS, EEG.) b. Continuous NIRS monitoring c. Select monitoring for clinical concerns