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PostoperativeCareinthePatientWithCongenitalHeartDiseaseUTHSCSAPediatricResidentCurriculumforthePICUPostoperativeCareinthePati1GeneralPrinciplesPatienthomeostasisEarly–decliningtrendsdonotcorrectthemselvesLate–timecanbeimportantdiagnostictool“Theenemyofgoodisbetter”GeneralPrinciplesPatienthome2SpecificApproachesCardiovascularprinciplesApproachtorespiratorymanagementPaincontrol/sedationMetabolic/electrolytesInfectionEffectsofsurgicalinterventionsontheseparametersNOPARAMETEREXISTSINISOLATIONSpecificApproachesCardiovascu3先天性心脏病患者术后护理课件4先天性心脏病患者术后护理课件5MaximizingOxygenDeliveryOXYGENDELIVERYOXYGENCONTENTCARDIACOUTPUTX=MaximizingOxygenDeliveryOXYG6O2Content= Saturation(O2Capacity)+(PaO2)0.003OxygenCapacity=Hgb(10)(1.34)So..HemoglobinandsaturationsaredeterminantsofO2deliveryMaximizingOxygenDelivery

CardiacOutputO2Content=MaximizingOxygen7GiddingSSetal1988y=-0.26(x)+38R=0.77S.E.E.=1.6MaximizingOxygenDelivery

CardiacOutputGiddingSSetal1988Maximizin8MaximizingOxygenDelivery

CardiacOutputStrokeVolumeContractilityDiastolicFillingAfterloadHeartratePhysiologicResponseNon-physiologicResponseSinusvs.junctionalvs.pacedventricularrhythmCardiacOutputStrokeVolumeHeartRate=XMaximizingOxygenDelivery

Car9MaximizingOxygenOxygenconsumptionDecreasingmetabolicdemandsSedation/paralysisThermoregulationMaximizingOxygenOxygenconsum10VentilatorStrategiesRespiratoryacidosis/hypercarbiaOxygenationPhysiologyofsingleventricle/shuntlesionsOxygendelivery!Atelectasis–15-20cc/kgtidalvolumes.PEEP,inspiratorytimesVentilatorStrategiesRespirato11VentilatorStrategies:

PulmonaryHypertensionSedation/neuromuscularblockadeHighFiO2–nolessthan60%FiO2MildrespiratoryalkalosispH7.50-7.60pCO2–30-35mmHgNitricOxideVentilatorStrategies:

Pulmona12VentilatorStrategies:

PulmonaryHypertensionThevisciouscycleofPHTNPrecipitatingEvent-Coldstress-Suctioning-AcidosisMetabolicAcidosisHypercapniaIncreasedPVRDecreasedPulmonaryBloodFlowDecreasedLVpreloadRVdysfunctionCentralVenousHypertensionHypoxemiaLowoutputIschemiaVentilatorStrategies:

Pulmon13PainControl/SedationStressresponseattenuationLimitedmyocardialreserve–decreasingmetabolicdemandsLabilepulmonaryhypertensionAnalgesia/anxiolysisPainControl/SedationStressre14PainControl/SedationOpioidsMSO4–Goldstandard:bettersedativeeffectsthansyntheticopioidsCardioactive–histaminereleaseandlimitsendogenouscatecholaminesFentanyl/sufentanylLesshistaminereleaseMorelipidsoluble–betterCNSpenetrationPainControl/SedationOpioids15PainControl/SedationSedativesChloralhydrateCanbemyocardialdepressantMetabolitesincludetrichloroethanolandtrichloroaceticacidBenzodiazepinesValium/Versed/AtivanPainControl/SedationSedatives16PainControl/SedationMusclerelaxantsDepolarizing–SuccinylcholineBradycardia(ACH)Non-depolarizingPancuronium–tachycardiaVecuronium–shorterdurationAtracurium“spontaneously”metabolizedHistaminereleasePainControl/SedationMusclere17PainControl/SedationOthers:Barbiturates–vasodilation,cardiacdepressionPropofol–myocardialdepression,metabolicacidosisKetamine–increasesSVREtomidate–NocardiovasculareffectsPainControl/SedationOthers:18FluidandElectrolytesEffectsofunderlyingcardiacdiseaseEffectsoftreatmentofthatdiseaseFluidandElectrolytesEffects19CardiopulmonaryBypass“Controlledshock”LossofpulsatilebloodflowCapillaryleakVasoconstrictionRenovasculareffectsRenin/angiotensinCytokinereleaseEndothelialdamageand“sheerinjury”CardiopulmonaryBypass“Control20CardiopulmonaryBypassStressResponseSIRSMicroembolicEventsRenalInsufficiencyFluidAdministrationHemorrhageCapillaryLeakSyndromeFeltes,1998LungFluidFiltration=[()-()]MicrovascularHydrostaticPressureMicrovascularOncoticPressureCardiopulmonaryBypassStressS21CirculatoryArrestHypothermicprotectionofbrainandothertissuesAccesstosurgicalrepairnotaccessiblebyCPBaloneFurtheractivationofSIRS/worsenedcapillaryleak.CirculatoryArrestHypothermic22FluidandElectrolytePrinciplesCrystalloidTotalbodyfluidoverloadMaintenancefluid=1500-1700cc/m2/dayFluidadvancement:POD0:50-75%ofmaintenancePOD1:75%ofmaintenanceIncreaseby10%eachdaythereafterFluidandElectrolytePrincipl23FluidandElectrolytePrinciplesFlushesandCardiotonicDripsRemember:FlushesandAntibiotics=VolumeUTHSCSAprotocoltominimizecrystalloid:StandardDripConcentration

Mixindextroseorsalinecontainingfluidtooptimizeserumglucose&electrolytesSedation:(Usedcurrentlyascarrierfordrips)MSO4 2cc/hr=0.1mg/kg/hrFentanyl 2cc/hr=3mcg(micrograms)/kg/hrCardiotonicmedications:Dopamine/Dobutamine 50mg/50ccEpi/Norepinephrine 0.5mg/50ccMilrinone 5mg/50ccNipride(Nitroprusside) 0.5mg/50ccNitroglycerin 50mg/50ccPGEI 500mcg/50cc

FluidandElectrolytePrincipl24FluidandElectrolytePrinciplesIntravascularvolumeexpansion/FluidchallengesColloid–osmoticallyactiveFFP5%albumin/25%albuminPRBC’sHCTadequate:5%albumin(HR,LAP,CVP)HCTinadequate:5-10cc/kgPRBCCoagulopathic:FFP/CryoprecipitateOngoinglosses:CTandPeritonealfrequently=5%albuminFluidandElectrolytePrincipl25MetabolicEffectsGlucoseNeonatesvs.children/adultsHyperglycemiaintheearlypost-opperiodMetabolicEffectsGlucose26MetabolicEffectsCalciumMyocardialrequirementsRhythmContractilityVascularresistanceNEVERUNDERESTIMATETHEPOWEROFCALCIUM!MetabolicEffectsCalcium27Calcium/inotropesSarcoplasmicReticulumcAMP-DependentPKCaCaCaCaCaPhosphodiesteraseAdenylateCyclaseRegulatoryGProteinNacAMPcAMPcAMPAlpha1Beta1DAGIP3MyofibrilNaKSRCalcium/inotropesSarcoplasmicc28MetabolicEffectsPotassiumMetabolicacidosisRhythmdisturbancesMetabolicEffectsPotassium29ThermalRegulationAsasigntowatch,andanitemtomanipulate…PerfusionJunctionalectopictachycardiaMetabolicdemandsOxygenconsumptionInfectionThermalRegulationAsasignto30InfectionRoutineanti-staphylococcaltreatmentInfectionRoutineanti-staphylo31EffectsofSurgicalInterventionsCardiopulmonaryBypassvs.Non-BypassFluidsandelectrolytesModifiedultrafiltrationTypesofanatomicdefectsOvercirculated–increasedbloodvolumespreoperativelyUndercirculated–reperfusionofareapreviouslyexperiencingmuchreducedflowvolumes.EffectsofSurgicalInterventi32SummaryOptimizeoxygendeliverybymanipulationofcardiacoutputandhemoglobinSedationandpaincontrolcanaidintherecoveryAppreciateeffectsofcardiopulmonarybypassandcirculatoryarrestonfluidandelectrolytemanagementTightcontrolofallparameterswithinthefirst12hours;afterthattime,patientsmaybebetterabletodeclaretrendsthatcanguideyourinterventions.SummaryOptimizeoxygendeliver33PostoperativeCareinthePatientWithCongenitalHeartDiseaseUTHSCSAPediatricResidentCurriculumforthePICUPostoperativeCareinthePati34GeneralPrinciplesPatienthomeostasisEarly–decliningtrendsdonotcorrectthemselvesLate–timecanbeimportantdiagnostictool“Theenemyofgoodisbetter”GeneralPrinciplesPatienthome35SpecificApproachesCardiovascularprinciplesApproachtorespiratorymanagementPaincontrol/sedationMetabolic/electrolytesInfectionEffectsofsurgicalinterventionsontheseparametersNOPARAMETEREXISTSINISOLATIONSpecificApproachesCardiovascu36先天性心脏病患者术后护理课件37先天性心脏病患者术后护理课件38MaximizingOxygenDeliveryOXYGENDELIVERYOXYGENCONTENTCARDIACOUTPUTX=MaximizingOxygenDeliveryOXYG39O2Content= Saturation(O2Capacity)+(PaO2)0.003OxygenCapacity=Hgb(10)(1.34)So..HemoglobinandsaturationsaredeterminantsofO2deliveryMaximizingOxygenDelivery

CardiacOutputO2Content=MaximizingOxygen40GiddingSSetal1988y=-0.26(x)+38R=0.77S.E.E.=1.6MaximizingOxygenDelivery

CardiacOutputGiddingSSetal1988Maximizin41MaximizingOxygenDelivery

CardiacOutputStrokeVolumeContractilityDiastolicFillingAfterloadHeartratePhysiologicResponseNon-physiologicResponseSinusvs.junctionalvs.pacedventricularrhythmCardiacOutputStrokeVolumeHeartRate=XMaximizingOxygenDelivery

Car42MaximizingOxygenOxygenconsumptionDecreasingmetabolicdemandsSedation/paralysisThermoregulationMaximizingOxygenOxygenconsum43VentilatorStrategiesRespiratoryacidosis/hypercarbiaOxygenationPhysiologyofsingleventricle/shuntlesionsOxygendelivery!Atelectasis–15-20cc/kgtidalvolumes.PEEP,inspiratorytimesVentilatorStrategiesRespirato44VentilatorStrategies:

PulmonaryHypertensionSedation/neuromuscularblockadeHighFiO2–nolessthan60%FiO2MildrespiratoryalkalosispH7.50-7.60pCO2–30-35mmHgNitricOxideVentilatorStrategies:

Pulmona45VentilatorStrategies:

PulmonaryHypertensionThevisciouscycleofPHTNPrecipitatingEvent-Coldstress-Suctioning-AcidosisMetabolicAcidosisHypercapniaIncreasedPVRDecreasedPulmonaryBloodFlowDecreasedLVpreloadRVdysfunctionCentralVenousHypertensionHypoxemiaLowoutputIschemiaVentilatorStrategies:

Pulmon46PainControl/SedationStressresponseattenuationLimitedmyocardialreserve–decreasingmetabolicdemandsLabilepulmonaryhypertensionAnalgesia/anxiolysisPainControl/SedationStressre47PainControl/SedationOpioidsMSO4–Goldstandard:bettersedativeeffectsthansyntheticopioidsCardioactive–histaminereleaseandlimitsendogenouscatecholaminesFentanyl/sufentanylLesshistaminereleaseMorelipidsoluble–betterCNSpenetrationPainControl/SedationOpioids48PainControl/SedationSedativesChloralhydrateCanbemyocardialdepressantMetabolitesincludetrichloroethanolandtrichloroaceticacidBenzodiazepinesValium/Versed/AtivanPainControl/SedationSedatives49PainControl/SedationMusclerelaxantsDepolarizing–SuccinylcholineBradycardia(ACH)Non-depolarizingPancuronium–tachycardiaVecuronium–shorterdurationAtracurium“spontaneously”metabolizedHistaminereleasePainControl/SedationMusclere50PainControl/SedationOthers:Barbiturates–vasodilation,cardiacdepressionPropofol–myocardialdepression,metabolicacidosisKetamine–increasesSVREtomidate–NocardiovasculareffectsPainControl/SedationOthers:51FluidandElectrolytesEffectsofunderlyingcardiacdiseaseEffectsoftreatmentofthatdiseaseFluidandElectrolytesEffects52CardiopulmonaryBypass“Controlledshock”LossofpulsatilebloodflowCapillaryleakVasoconstrictionRenovasculareffectsRenin/angiotensinCytokinereleaseEndothelialdamageand“sheerinjury”CardiopulmonaryBypass“Control53CardiopulmonaryBypassStressResponseSIRSMicroembolicEventsRenalInsufficiencyFluidAdministrationHemorrhageCapillaryLeakSyndromeFeltes,1998LungFluidFiltration=[()-()]MicrovascularHydrostaticPressureMicrovascularOncoticPressureCardiopulmonaryBypassStressS54CirculatoryArrestHypothermicprotectionofbrainandothertissuesAccesstosurgicalrepairnotaccessiblebyCPBaloneFurtheractivationofSIRS/worsenedcapillaryleak.CirculatoryArrestHypothermic55FluidandElectrolytePrinciplesCrystalloidTotalbodyfluidoverloadMaintenancefluid=1500-1700cc/m2/dayFluidadvancement:POD0:50-75%ofmaintenancePOD1:75%ofmaintenanceIncreaseby10%eachdaythereafterFluidandElectrolytePrincipl56FluidandElectrolytePrinciplesFlushesandCardiotonicDripsRemember:FlushesandAntibiotics=VolumeUTHSCSAprotocoltominimizecrystalloid:StandardDripConcentration

Mixindextroseorsalinecontainingfluidtooptimizeserumglucose&electrolytesSedation:(Usedcurrentlyascarrierfordrips)MSO4 2cc/hr=0.1mg/kg/hrFentanyl 2cc/hr=3mcg(micrograms)/kg/hrCardiotonicmedications:Dopamine/Dobutamine 50mg/50ccEpi/Norepinephrine 0.5mg/50ccMilrinone 5mg/50ccNipride(Nitroprusside) 0.5mg/50ccNitroglycerin 50mg/50ccPGEI 500mcg/50cc

FluidandElectrolytePrincipl57FluidandElectrolytePrinciplesIntravascularvolumeexpansion/FluidchallengesColloid–osmoticallyactiveFFP5%albumin/25%albuminPRBC’sHCTadequate:5%albumin(HR,LAP,CVP)HCTinadequate:5-10cc/kgPRBCCoagulopathic:FFP/CryoprecipitateOngoinglosses:CTandPeritonealfrequently=5%albuminFluidandElectrolytePrincipl58MetabolicEffectsGlucoseNeonatesvs.children/adultsHyperglycemiaintheearlypost-opperiodMetabolicEffectsGlucose59MetabolicEffectsCalciumMyocardialrequirementsRhy

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