Norwood Part 2: Procedure & Immediate Post-Op Management with Dr. Greg Yurasek
May 29, 2023
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Dr. Greg Yurasek discusses the step-by-step process of the Norwood procedure, options for blood delivery to the PA bifurcation, surgeon's decision-making process for cardiac procedures in children, immediate post-op care strategies, and managing urine output in children after surgery.
The Norwood procedure involves complex surgical steps and the choice of shunt depends on the surgeon's preference and experience.
After the Norwood procedure, maintaining optimal cardiac output and oxygen delivery is crucial, requiring strategies such as fluid replacement, vasoactive medications, and close monitoring of ventilation parameters.
Deep dives
Overview of the Norwood Procedure
The Norwood procedure is a complex surgery that aims to establish unobstructed systemic outflow for infants with hypoplastic left heart syndrome. The procedure involves several surgical steps, including the creation of a neo aorta, augmentation of the hypoplastic ascending aorta and transverse arch, and coarctectomy. The surgery requires great precision due to the small size of the vessels involved and the challenges of connecting them. Surgeons typically choose between two shunt options, the Sano shunt or the BTT shunt, depending on the specific anatomy of the patient. While the Sano shunt offers short-term benefits, including improved survival, it may be associated with a higher risk of additional procedures in the long run. The choice of shunt is typically based on the surgeon's preference and experience.
Postoperative Considerations and Strategies
After the Norwood procedure, ensuring optimal cardiac output and oxygen delivery is crucial for the patient's recovery. Anesthesiologists adopt specific strategies to achieve these goals. They focus on maintaining good hemostasis and adequate lung function while carefully monitoring the patient's access, chest condition, and urinary output. An initial fluid replacement strategy is implemented, with close attention to fluid balance, as capillary leak is common. Adequate volume must be maintained to support cardiac function. Additionally, vasoactive medications, such as Milrinone and Epinephrine, may be utilized to enhance contractility while considering the balance between systemic vascular resistance and diastolic blood pressure. Manipulating these variables can help achieve the desired cardiac output and systemic perfusion. Close monitoring and adjustment of medications are essential, and in some cases, systemic steroids may be administered to reduce capillary leak and optimize blood pressure response to treatment.
Physiological Goals and Considerations
In the postoperative period, the focus shifts to optimizing oxygen delivery and addressing physiological challenges for the patient. Anesthesia providers aim to maintain a normal pH and Paco2 while considering patient comfort. Ventilation parameters are adjusted accordingly, with a target pH of 7.4 and Paco2 of 40. Monitoring and maintaining adequate oxygenation with a PO2 of 35-43, depending on the type of shunt utilized, is crucial. The sedation level and neuromuscular blockade are adjusted to ensure patient comfort and minimize agitation. Overall, a comprehensive approach is employed to promote optimal physiological function and support the patient's recovery after the Norwood procedure.
Dr. Yurasek is a graduate of the Columbia University College of Physicians and Surgeons. He completed his pediatric residency at Children’s Hospital of Boston followed by a pediatric cardiology fellowship also at Boston Children’s and a PICU fellowship at Massachusetts General Hospital. He is now a CICU attending and the director of critical care simulation at Children’s National Hospital in Washington, DC.
Objectives for this series: 1. Understand the physiologic considerations that influence preoperative care in the cardiac intensive care unit (CICU). 2. Recall the goals and general steps of operative repair. 3. Recognize the key information provided in post-op handoff that will affect management. 4. Recognize important postoperative complications and develop an approach to their management. 5. Develop a mental framework of the expected postoperative CICU course with a focus on barriers to ICU discharge. Support the show
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Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.comfor detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.
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