Cardiac - management of balloon atrial septostomy for congenital heart defects in NICU
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The Paediatric Cardiology team from Starship Hospital will determine the need for a balloon atrial septostomy in neonates with congenital heart disease. A paediatric cardiology consultant or fellow will carry out the procedure in the NICU.
SMO/Registrar / NS-ANP to ensure
- Cardiologist has obtained written consent from parents.
- The Neonatologist on-call is informed and shall be present at the bedside.
- Alternative IV access is present for the prostaglandin infusion if the infant is receiving this via an umbilical line and this route is likely to be used for catheterisation. A second PIV will be required to give other medications during the procedure.
- Infant is intubated and ventilated prior to procedure. Intubation shall be performed by senior registrar/fellow/NS-ANP or SMO.
- Fentanyl bolus (10 -20 micrograms/kg) is given prior to procedure; consider second bolus if procedure is more than 30 minutes.
- Muscle relaxant should be considered in discussion with the cardiologist. Use Rocuronium (1mg/kg) IV push.
- Skin disinfectant appropriate to gestation
- Blood gas, FBC, group & cross-match, and U&Es are taken as ordered. Coagulation profile is not routinely required unless bleeding tendencies are suspected.
- NBM >4 hours (breast milk or formula) and commence intravenous fluids as prescribed.
- The baby is nursed on a heat table.
- Fentanyl and Rocuronium (1mg/kg) should be prepared.
- Two nurses need to be in attendance to manage ventilation and drug administration throughout procedure.
- Ensure continuous monitoring including pre and post ductal saturations and blood pressure.
- Monitor sedation levels
Usual care is to extubate as soon as respiratory status allows. Liaise with Cardiology team regarding PGE1 management.
- Ensure continuous monitoring is maintained and observations
recorded half hourly for the first 2 hours, then hourly
• Cardio-respiratory status
• Blood pressure
• Saturations (pre and post ductal)
• Skin temperature
- Keep saturations within acceptable limits (as per cardiology team). Report immediately any changes in baseline levels to registrar/NS-ANP/NP.
- Maintain ventilation as per orders.
- Discontinue sedation and aim to extubate as soon as clinically appropriate.
- Review prostin infusion (as per cardiology team).
- Observe for signs of bleeding from access sites (umbilical or femoral). Report excess bleeding. Apply pressure as required.
- Neurovascular observations of lower limbs. Inform registrar / NS-ANP of discolouration, coolness, and / or decreased pulses
- If umbilical lines are to be used post procedure, secure in situ. Confirm position with an X-ray prior to commencing fluids.
- Arterial / Capillary blood gas as ordered by registrar/ NS-ANP / cardiology team
Note: The infant should not be in pain once the catheter is removed. Ongoing sedation is not required unless for other purposes.
Potential Complications of a Balloon Atrial Septostomy
- Sinus bradycardia (transient - common at time of procedure, usually self-limiting)
- Bleeding from access sites
- Reduced perfusion to lower limbs
- Embolism of clot
- Cardiac tamponade (rare)
Did you find this information helpful?
- Date last published: 17 December 2018
- Document type: Clinical Guideline
- Services responsible: Neonatology, Paediatric Cardiology
- Owner: Newborn Services Clinical Practice Committee
- Editor: Sarah Bellhouse
- Review frequency: 2 years
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