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The care of infants, children, and adults with congenital heart disease (CHD) can be complex and challenging. In particular, the inpatient periprocedural setting can pose unique management challenges and represents one of the highest risk periods for the patient with CHD. Successful congenital heart surgery and interventional cardiac catheterization require a comprehensive, well-coordinated, team-based mode of care delivery that incorporates a solid knowledge base with sound clinical judgment. Management of the postprocedural patient should reflect a firm understanding of common congenital heart defects and surgical interventions, cardiopulmonary anatomy and physiology, advanced technical skills, pharmacology, and common complications. Patient and family-centered anticipatory guidance should be effective and confident with similarly comprehensive communication with primary care providers throughout the hospitalization and discharge process. This chapter provides an informative overview in the approach to the care of the postoperative and postcatheterization patient with CHD, specifically focusing on the immediate postprocedure and post–hospital discharge time periods.
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Preoperative Stabilization
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The goals of preoperative intensive care unit (ICU) care are focused on stabilizing the patient (often with a ductal-dependent cardiac lesion), maintaining stable hemodynamics, and accurately identifying abnormal cardiac anatomy for appropriate procedural planning. In the current era, many neonates with CHD are diagnosed prenatally. Families should be encouraged to seek obstetrical care at a tertiary center with specialized pediatric cardiac services that allow for safe delivery of the infant while avoiding potentially life-threatening complications related to transfer and delays in care. However, a significant percentage of neonates with CHD continue to present in the postnatal period1 (Table 6-1). Immediate stabilization with initiation of prostaglandins, where appropriate, and transfer to a surgical and interventional cardiac center should be initiated promptly.
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Once in the ICU setting, preoperative stabilization of the neonate consists of maintaining hemodynamic stability while avoiding preoperative morbidity that may impact the timing or effectiveness of definitive therapies such as surgery or interventional catheterization. Intravenous prostaglandin may be required for the neonate to maintain ductal patency prior to surgery. Hemodynamic support in the form of inotropes and/or mechanical ventilation may be required in the setting of severe cardiorespiratory compromise. Prostaglandin therapy and its associated side effects, including apnea, require close monitoring, although effective administration with low-dose infusions (0.01 μg/kg/min) have been successful without the need for tracheal intubation (Table 6-2...