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Cardiac Surgery - admission process

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Surgical Admissions to the Paediatric and Congenital Cardiac Service

Current theatre list is available from the Surgical Booking clerk Ph 23619

All children having elective cardiac surgery should have in their notes:

  1. Cardiosurgical summary outlining conference conclusions and investigations required prior to surgery. Please check that it is relevant to the current operation.
  2. Copy of previous operation notes and catheter reports.
  3. Other relevant investigations (eg Cardiac CT/MRI reports).
  4. ECHO report within the last 3-6 months at Starship Hospital - If no ECHO in last 6 months, this needs to be arranged via the on duty cardiologist and echo technicians.
  5. Recent 12-lead ECG - (< 2 weeks)
  6. Recent CXR: (< 1 month) unless new respiratory symptoms/problems since
  7. Blood tests: (< 2 weeks old)
    1. Full blood count
    2. Renal function and Electrolytes
    3. ESR and CRP on patient with Rheumatic Heart Disease. Contact the consultant if ESR > 20
    4. Coagulation if on warfarin - check that INR <2.0 before operation day. If ≥ 2.0 notify surgeon.
    5. Cross match +/- bypass blood:
      1. On the blood request form write "for cardiac surgery" then add either; "bypass case" OR if patient is a non-bypass write "non- bypass case".
      2. Ensure current weight is documented on the request form.
      3. Complete the transfusion history so sample will be valid for 7 days rather than 72 hours (this is important if surgery is deferred).
      4. A 21 Day Hold can be done if requested clearly on the form, you must fill in transfusion history and obtain 6 ml of blood. Preferable for children > 5 years if possible.
      5. For child < 4 months age the Group and Crossmatch will be valid even if transfused as long as they have not left the hospital or had a name change.
      6. If the patient has a name change the cross match sample will need to be resent on the new name.
      7. If 22 q 11 deletion positive or immunosuppressed, discuss with surgeon and anaesthetist regarding the need for irradiated blood for surgery

Medical admission and review

All children admitted for elective cardiac surgery require full examination.

  1. Unwell Children: Any child who is unwell on admission (fevers/diarrhoea/respiratory illnesses/skin infection) discuss with the on-call cardiologist and anaesthetist regarding fitness for surgery and anaesthesia as soon as possible. Ensure that the surgical team are notified so that another surgical case can be arranged if necessary via the on-call surgical registrar phone 021380548. Consider ordering FBC, CXR and CRP to confirm.
  2. Medical admission note: detailing history and clinical examination. Include symptoms of heart failure, exercise tolerance, recent illness, medications. Skin integrity should be checked for any infected wounds/scabies/eczema (as may need to cancel surgery if infected skin). Developmental assessment should be done in children under 6 years of age. If this is a first admission to PCCS service child should have a "First Assessment" form completed (detailing family history). Document immunisation status.
  3. Confirm current weight is documented in notes (in nursing admission and drug chart). All chidlren < 1 year of age to have a Growth chart - plot weight, length and head circumference (at least birth and current weight plotted).
  4. Ages and Stages Questionnaire are to be completed on all children >6 weeks of age to 6 years of age.

Medications

  1. Aspirin: most cases should have Aspirin stopped about 5 days pre-op.
    1. For the high risk infant who is cyanosed with a narrow shunt, it may be best to stop aspirin a couple of days before surgery, and if surgery is deferred for a few days then consider giving aspirin for 1-2 days then stop again.
    2. Aspirin never needs to be given within a day or two before surgery.
  2. Warfarin: Usually stopped 3 days prior to surgery, should be discussed with the cardiologist on call. Pre-operative INR should be < 2.0.
  3. Clopidogrel: stop 3 days prior to surgery.
  4. Heparin: If anticoagulation is needed on the day before surgery - use IV Heparin and stop Heparin 4 hours pre-op. Consult with the on-call cardiologist and surgeon.
  5. Digoxin: stopped 48 hours prior to surgery.
  6. On day of surgery: when nil per mouth prior to surgery
    1. withhold ACE and diuretic
    2. Antiarrhythmic and betablocker should be given unless specified by cardiologist

Consents

  • Surgical consent is obtained by the surgeon and anaesthetic consent is obtained by the anaesthetist or anaesthetic registrar, before the family is allowed on overnight leave, unless otherwise arranged.

Premedication

  1. Charted by the anaesthetist.
  2. Children should have cardiorespiratory parameters monitored after administration of premedication.

Nil by mouth

as per ADHB guidelines, in addition

  1. Moderately cyanotic infants and children (sats≤ 80%), especially with Hct > 0.55 should be offered clear fluids up to 2 hours preop. IV fluids if NPM >4 hours (discuss with anaesthetist).
  2. All children should have diuretics withheld once NBM.
  3. All infants with duct-dependant systemic blood flow (eg hypoplastic left heart or coarctation and VSD) should be NBM from birth and on TPN until surgery to avoid N.E.C.

Skin preparation for cardiac surgery

  1. Ensure mupiriocin nasal ointment is prescribed on medication administration sheet (see preoperative skin preparation for cardiac surgery guideline).
  2. Chase MRSA swab results.

Newborns undergoing cardiac surgery

  1. Newborn Metabolic Screening (Guthrie card):  Needs to be sent prior to bypass; so sample should be sent even if prior to 48 hours otherwise follow the NICU protocol. Send first sample pre-op even if baby has not fed.  If missed and not done prior to bypass the first sample should be sent 48-72 hours after surgery and a repeat sample sent in 3 months.
  2. Renal Ultrasound / Head Ultrasound: Required on any neonate undergoing aortic arch surgery e.g. Norwood or Coarctation of the Aorta and any syndromic neonate  AND any neonate with preop renal impairment or neurologic abnormalities
  3. Investigations for 22q11 deletion
    1. FISH for 22q11 deletion is required for all neonates who have Conotruncal abnormalities; Tetralogy of Fallot, Truncus, Interrupted Aortic Arch and on those with dysmorphisms or concern for chromosomal anomalies.
    2. A microarray can be requested where timing allows (this is useful in detecting both typical and atypical 22q11 deletions, and particularly where the infant has extra cardiac anomalies) as this process takes longer than FISH
    3. If 22q11 deletion suspected test for lymphocyte function and number straight away so will know prior to surgery if irradiated blood needed.
    4. If 22 q 11 deletion positive or immunosuppressed discuss with surgeon and anaesthetist regarding the need for irradiated blood for surgery.
    5. T cell count and function for all infants with Interrupted Aortic arch
    6. Suspected chromosome abnormality (or dysmorphic infant):  all bypass cases will be transfused so any chromosomal testing (microarray) needs to be done pre operatively.

Rheumatic fever patients

  1. Acute Rheumatic Fever is a notifiable disease in NZ. Notification must be faxed or phoned to Auckland Regional Public Health Service (using the notification form) ASAP after the diagnosis is made. A copy of the notification form that was faxed should be included in the clinical notes and the family told of notification.
  2. Ensure documentation of the date of the last dose IM Benzathine Penicillin in notes.
  3. Contact the cardiologist on call if ESR > 20.

Nursing Care Plan/Pre-op checklist

Links to the nursing care plan for cardiac surgery patients.

Information for Families

See family information sheet on Skin Preparation for Cardiac Surgery

Link through to the Starship Directory of Services for Cardiac Services - cardiac surgery information for families

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Document Control

  • Date last published: 04 January 2016
  • Document type: Other
  • Services responsible: Paediatric Cardiology
  • Intended users: Internal ADHB staff only
  • Author(s): John Stirling, Marion Hamer, Kirsten Finucane
  • Editor: Marion Hamer
  • Review frequency: 2 years