A Practical Manual of Pediatric Cardiac Intensive Care R Krishna Kumar, Aveek Jayant, Rakhi Balachandran
INDEX
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table.
A
Accidental air embolism 172
Acetaminophen 68
Acetazolamide 398
Acid base 276
Acidosis 88, 199
hyperchloremic 47
metabolic 53, 187, 219, 273, 316
Activated partial thromboplastin time 216, 406
Acute kidney injury 313, 314t, 315t
network 313, 314
Acute respiratory distress syndrome 112, 194, 337
Adenosine 398
Adrenaline 39, 95, 379, 398
doses of 193
Adrenergic agents, tapering of 180
Air
bubbles 19
embolism 24, 29, 41
oxygen mixture 103
trapping 99
Airway
dysfunction 194
edema 77, 100
evaluation 110
issues 109
Albumin 117
Allergic reactions 48
Allergy 145
Ambu bags 397
American Heart Association Guidelines 322, 328
Amikacin 149
Aminophylline 398
Amiodarone 398
use of 290fc
Amplitude 365
Analgesia 64, 359, 381
controlled 71
epidural 173
Analgesic therapy 65
Anesthesia, induction of 145
Angiotensin-converting enzyme 174, 288
Anorectal malformations 182
Antegrade pulmonary blood flow 185
Antiarrhythmics 398
Antibiotic 113, 381
administration, timing of 140
choice of 143
for prophylaxis, choice of 140
guidelines 139
policy 142
practices 139
prophylactic 134, 135, 141, 147
regimes 140
therapy
preoperative 145
second-line 142
Anticoagulants 11
Antifungal prophylaxis 147
Antifungal therapy 148
duration of 148
Antimicrobial spectrum 140
Antimicrobial therapy 144t
Antiplatelet therapy 220
Anuria 316
Aorta 214, 223, 230, 235, 241, 243, 244, 253, 262, 263
coarctation of 46t, 171, 203
descending 171
juxtaductal coarctation of 172f
repair of coarctation of 171
Aortic arch, interruption of 256
Aortic regurgitation 273
Aortic stenosis, severe 5
Aortic suture lines 172
Aortic valve 229
regurgitation, Severe 326
Aortopulmonary collateral arteries 192f
Arginine vasopressin 44
Arrhythmia 29, 179, 180, 187, 201, 207, 211, 247, 281
diagnose 205
identification of 283
incidence of 281
postoperative 155
supraventricular 201
ventricular 205
Arterial blood gas 16, 18, 193, 273, 406t
analysis 159
sampling 85
procedure for 22
Arterial blood pressure 18, 100, 154, 176, 193, 397
Arterial duct 214
Arterial line
care of 18
maintenance of 20
removal of 24
Arterial oxygen
saturation 216
tension 88, 230
Arterial pressure 215
monitoring setup 19
Arterial switch 206
operation 109, 203
Arterial waveform 20, 273
Arteriovenous malformations, pulmonary 234
Artery
pulmonary 35, 37, 97, 153f, 159, 164, 166f, 167, 183, 192, 203, 210, 219, 230, 243, 244, 252, 253f, 262, 263, 257f, 294, 303, 324, 352
subclavian 171
Aspiration 119
pneumonia 144
Aspirin 156, 220, 398
Asymmetric pulmonary blood flow 217
Atelectasis 245
development of 77
Atracurium 75, 398
Atresia 225
pulmonary 191, 214, 215
Atrial communication 184
Atrial ectopics 284f
Atrial electrogram 283f, 364
study 284f
Atrial fibrillation 291
Atrial flutter 291
Atrial pressure 273
Atrial septal defect 153, 153f, 176, 177, 263, 285f, 351, 352
closure 154f
Atrial septectomy 225
Atrioventricular block, high degree 364
Atrioventricular dissociation 285f, 288f
Atrioventricular septal defect 176, 177f, 182, 295
repair of 176
Atrioventricular synchrony, loss of 184
Atrioventricular valve 227
regurgitation 101, 109, 273, 327
Atropine 39, 398
Axillary artery 19
Azotemia 316
B
Baclofen 310
Baffle obstruction 212
Balloon atrial septostomy 203
Band, type of 226
Barbiturates 310
Barotrauma 86
Benzodiazepine 72, 310
Bernheim effect, reverse 264
Beta-lactam antibiotics 140
Bicarbonate 30, 53
Bidirectional Glenn shunt 84, 234, 235f, 239
Bi-level noninvasive ventilation 397
Bi-level positive airway pressure 103, 180, 189
Bipolar atrial electrogram 283f
Bipolar pacing wires 362
Biventricular pathway 264
Blalock-Taussig shunt 46t, 96, 214, 234
modified 214, 214f, 230f, 328
Blood 146, 315, 386, 388
cardioplegia 385, 386, 392
components 145
culture 380
drawing 33
exiting left ventricle 272
flow 378
pulmonary 192f, 196, 214, 222, 223f, 224, 234, 241, 295, 321, 324, 327
glucose 60
management 57, 59
management 193, 254, 259, 265
pressure
diastolic 327
noninvasive 397
systolic 172
product transfusion 381
pulmonary venous 196
transfusion sets 397
urea
elevated 273
nitrogen 110, 124
Bloodstream infection 29, 333, 334
catheter related 30
central line associated 143, 335, 336
Body
surface area 271
water, total 43
Borderline blood sugar levels 146
Bosentan 299
Brachial artery 19
Brachial plexus 306, 310
injury 311
Brachiocephalic vein 25
Bradyarrhythmia 211, 283, 364
Bradycardia 69, 71, 219, 225227, 273
Brain
abscess 309
damage, etiology of 305
Breathing
circuit 79, 397
spontaneous 186
work of 320
Bretschneider's solution 389
Bretylium 398
British Society of Pacing and Electrophysiology 366
Bronchiolitis 77, 103
Bronchopulmonary dysplasia 167, 168
Budesonide respirator suspension 398
Butyrophenones 310
C
Caffeine 398
Calcium 30, 387
administration, guidelines for 54
channel blockers 174
chloride 398
gluconate 39, 398
management 54
overload 384
Caloric expenditure method 46t
Caloric supplementation 119
Candida
albicans 148
glabrata 148
krusei 148
parapsilosis 148
Capillary blood, pulmonary 230
Capillary leak syndrome 44
Carbamazepine 310
Cardiac advanced life support 321
Cardiac arrest 147, 319, 330
management of 319, 323f
Cardiac catheterization 208, 351
access for 354
Cardiac compression 132
Cardiac damage 384
Cardiac disease 110
Cardiac dysfunction 44
severe 379
Cardiac failure, congestive 45
Cardiac index 271
Cardiac magnetic resonance data 262
Cardiac output 183, 271, 272
determinants of 272f
monitor 397
Cardiac physiology, types of 107
Cardiac rhythm, abnormalities of 274
Cardiac status 135
Cardiac surgery 43, 107, 109, 272, 282f, 305
Cardiac tamponade 132, 247, 274, 379
Cardiac-children's hospital early warning score 319, 320t
Cardiomyopathy 103
Cardioplegia 385, 386
delivery 390
periodic infusion of 391
types of 385
Cardiopulmonary bypass 18, 43, 46, 57, 76, 123, 159, 168, 178, 185, 196, 205, 210, 215, 225, 235, 258, 271, 281, 296, 305, 313, 347, 399
Cardiovascular collapse 217, 226, 232
Cardiovascular system 111
Catheter 9
interventions 352t, 356
leak 350
maintenance 31
manipulations 353
nonfunction 40
rehabilitation 195
removal 350
residence of 40
retention 41
tip 41
Caudal opiates 168
Cefazolin 135, 141
Cefoperazone-sulbactum 149
Ceftazidime 149
Cefuroxime 135, 140, 149
Center for Disease Control and Prevention 335
Central lymphatic
flow disorder 301
system 304
Central nervous system 61, 68, 279, 382
Central systemic veins 242
Central thoracic duct 300
Central venous catheter 25, 335, 397
Central venous pressure 37, 154, 183, 197, 223, 242, 244, 247, 265, 273, 301f, 302, 378, 397
diagnostic role of 379t
monitoring 172
Cerebral
circulation 167
dysgenesis 307
hypoperfusion, diffuse 307
hypoxic-ischemic injury 305
injury 305
predictors of 305
near infrared spectroscopy 258
perfusion 321
Cerebrospinal fluid 143, 144, 146
Cerebrovascular accidents 110
Chest
closure 132
compression, site for 327
physiotherapy and incentive spirometry 246
tube 16
output 48
X-rays 357
Chloral hydrate 310
Chlorhexidine
gluconate 26
sanitizer 11
tincture 26, 358
Choreoathetosis 305, 309
Chyle through thoracic duct 302
Chylothorax 239, 240, 249, 303fc
conservative management of 304
mechanism of 300
medical management of 302
postoperative 300
resolution of 303
Circulation
pulmonary 215, 234
spontaneous 329
systemic 210
Cisterna chyli 301f
Clinical pulmonary infection score 337t
Clonidine 70
Clostridium difficile infections 139
Coarctation repair 18
Colistin 149
Common antibiotic 149t
dosages 149
Complete atrioventricular septal defect 177f, 178
Complete blood count 145, 406
Complete heart block 161, 207, 281, 284, 286f
Complex biventricular conversions 50
Complex coronary transfer 209
Complex open heart procedures 305
Computed tomography scan 303, 328, 355, 358
Congenital cardiac repairs, complexity of 35
Congenital heart disease 4, 76, 104, 116, 117, 132, 153, 158, 168, 187, 191, 209, 241, 281, 294, 300, 305, 313, 322, 333, 351, 377, 394
diagnosis of 3
malnutrition in 116
Consciousness, delayed recovery of 306
Continuous electrocardiography 265
Continuous flush system 20f
Continuous oxygen analyzers and alarms 397
Continuous positive airway pressure 103, 160, 194, 206, 254, 260
Continuous renal replacement therapy 51, 316
Coronary artery 184, 203
blood flow 207
evaluation 208
Coronary sinus 197
defect 153
orifice 263
Corticosteroids, role of 114
C-reactive protein 58, 142, 143, 239, 248, 336
Critical aortic valve stenosis 326
Critical coarctation 5, 171
Critical illness myopathy 306, 311
Crystalloid cardioplegia 386, 392
Custodial cardioplegia 386, 389
Cyanosis 248
after fontan operation, causes of 248t
Cyclic adenosine monophosphate 277
Cyclic guanosine monophosphate 371
D
Data collection system 401
Deep hypothermic circulatory arrest 305, 309
Deep vein thrombosis 112
Defibrillator 397
internal paddles for 397
Dehydration, severe 145
Deintensification 156, 181, 189, 201, 220, 250
del Nido cardioplegia 388
components of 389t
Delayed sternal closure 133
timing of 136
Delhi Neonatal Infection Study 334
Depression, respiratory 69
Descending thoracic aorta 171
Dexamethasone 114, 398
Dexmedetomidine 67, 69, 75, 398
effects of 186
infusion 186
Dextrocardia 25
Dextrose-added balanced crystalloid solution 48
Diaphragm
evaluation 110
palsy 110
Diarrhea 73
osmotic 120
Diarrheal diseases 220
DiGeorge syndrome 54, 79, 142, 256
Digoxin 398
Diphenhydramine 310
Disposable pediatric breathing circuit 79
Diuretic 11, 211
therapy 52, 155, 160, 173, 179, 186, 199, 206, 219, 226, 237, 245
Dizziness 374
Dobutamine 198, 272, 277, 379, 398
Dopamine 198, 272, 276, 398
agonists 310
depleting agents 310
receptor blockers 310
Dorsalis pedis 19
Down syndrome 79, 300
Drugs 39, 145
Dual-chamber pacemaker 365
Ductal patency 167
Ductus arteriosus 166, 230
Dyspnea 374
E
Ebstein anomaly 76, 263f
Carpentier subtypes of 263t
repair of 109, 262
Ebstein malformation 262, 262f
Echocardiogram 163
Echocardiography 185, 239, 273, 296
Edema 77
pulmonary 198, 374
Electrocardiogram 281, 364, 397, 406
machine 397
Electroencephalogram 306
Electroencephalography 329
Electrolyte 276
imbalances 180, 187
management 52
Emergency sternotomy set 397
Emphysema, subcutaneous 28
Enalapril 255, 398
Encephalopathy 316
End-diastolic pressure 98, 185
Endothelial dysfunction 57, 198
Endotracheal tube 7, 9, 77, 94, 188, 397
End-tidal carbon dioxide 397
Energy
requirements 123t
supply, diversification of 124
Enteral nutrition 59, 116, 338
Enzyme
activity 385
cyclooxygenase 68
Epilepsy, secondary 61
Epinephrine 136, 216, 272, 276
Escherichia coli 30
Estimated glomerular filtration rate 314
calculation of 313
Ethacrynic acid 51
European Society of Paediatric Gastroenterology 123, 124
Extracellular cardioplegia 386
Extracellular fluid volume, regulation of 44fc
Extracorporeal cardiopulmonary resuscitation 321, 328, 377
Extracorporeal life support 327, 328
organization 377
Extracorporeal membrane oxygenation 147, 229, 278, 306, 328, 355, 377379, 379t, 380, 396
circuit 378f
complications 382
support, assessing adequacy of 380
Extubation 101, 173, 260, 265
early 405
failure 101, 108110, 114, 163, 194
incidence of 108
managing 92
potential causes of 109
readiness, assessment of 113
Eye care 87, 113
F
Fatigue, diaphragmatic 103
Fatty acids, essential 302
Feeding
and nutrition 155, 161, 173, 179, 200, 206, 219, 226, 246
postoperative 120
Femoral artery 18
Femoral vein 235
pressure 244
Fentanyl 39, 67, 68, 72, 398
Fever 73, 110, 330
Fibrinolytic mechanisms 187
Flexible fiberoptic bronchoscope 397
Fluid 315
and electrolyte management 43
balance 378
bolus 51
imbalance 304
management 136, 155, 159, 172, 179, 185, 193, 206, 211, 218, 225, 231, 236, 245, 254, 259, 265, 379
overload 313, 316, 357
calculation of 51
prevention of 51
removal 51
responsiveness, assessment of 50
restriction 136
strategy 198
Fluorescent in-situ hybridization 192
Fontan circuit 244, 244f, 245
Fontan failure, early 250
Fontan operation, extracardiac 241
Fontan pathway, anatomic obstruction in 247
Fontan procedure 105, 241f
Fontan surgeries 300
Fossa ovalis 154
Fresh frozen plasma 245, 379
Functional residual capacity 78, 187, 199, 237, 381
Fungal growth 148
Fungal infections
postoperative 148
prophylaxis for 148
Furosemide, continuous infusion of 211
G
Gamma-aminobutyric acid 69
Gas exchange 215
Gastric residual volumes 219
Gastritis 68
Gastroesophageal contents 112
Gastroesophageal reflux 110
Gastrointestinal complications 110, 219, 220
Gastrointestinal dysfunction 279
Gastrointestinal intolerance 303
Gastrostomy 122
tube feedings 310
Gatzoulis phenomenon 185
Genetic syndromes 79, 158
congenital 300
Gestational age 61, 167
Glenn anastomosis 357
Glenn circulation 88
Glenn shunt 234, 236, 238, 241
Glenn surgeries 300
Glomerular filtration rate 44, 68
Gluconeogenesis 57
Glucose
disturbance 276
ranges 58
transporter 384
uptake and enhanced recovery 384
Glycopyrrolate 39, 72
Great arteries
dextro transposition of 203
transposition of 203, 204f
Great Ormond street echocardiography score 263, 263t
Guanosine triphosphate 371
H
Hallucinations 73
Headache 374
Hearing impairment 61
Heart
block 161, 180
congenital 285f
defect, congenital 182, 321
disease 3, 329fc
congenital 4, 76, 104, 116, 117, 132, 153, 158, 168, 187, 191, 209, 241, 281, 294, 300, 305, 313, 322, 333, 351, 377, 394
left-sided 326
major 4
right-sided 325
failure 158
congestive 5
lesions, cyanotic 305
rate 271, 272, 320, 378, 397
Rhythm Society 366
surgery, congenital 9, 94, 108
Hematocrit
low 305
postoperative 216
Hematuria 374
Hemodynamic management 135, 154, 159, 172, 178, 184, 193, 198, 205, 210, 216, 224, 231, 236, 242
Hemodynamic monitoring 252, 257, 265
Hemodynamic status 198
Hemofiltration 381
Hemoglobin 49, 371
Hemorrhage 309
cannula site 382
intracranial 305, 382
intraventricular 167
pulmonary 382
surgical site 382
Hemostatic blood products 193
Hemothorax 29
Heparin 398
Hepatic dysfunction 68
Hering-Breuer reflex 77
High-flow nasal cannula oxygen therapy 103, 106
Hinge point 263
Histidine 390
tryptophan-ketoglutarate solution 389
Hormone
antidiuretic 45
counterregulatory 57
Human albumin 48
Human insulin 60
Humidification 99
Hydrocortisone 398
Hydroxyethyl starches 48
Hyperbilirubinemia 374, 382
Hypercapnea 330
Hypercarbia 88, 199
Hypercyanotic spells 183
Hyperglycemia 57, 60, 62, 305, 374
adverse effects of 57
risk of 124
Hyperinflation 99
Hyperkalemia 53, 273, 316
management 315
treatment of 53
Hypernatremia 47, 52
Hyperoxia 265, 330
test 4
Hyperpyrexia, unexplained 147
Hypertension 73, 171, 174, 238
control postoperative 172
mild pulmonary 294
paradoxical 173
persistent pulmonary 372
postoperative pulmonary 199
preoperative pulmonary 198
pulmonary 79, 100, 158, 161, 178, 179, 196, 198, 200, 212, 216, 276, 294
arterial 258, 326
Hypertensive crisis, management of 297
Hyperthermia 162, 273, 276, 305
aggressive management of 279
Hypertonia 305
Hyperventilation 298
Hypervolemia 43, 379
Hypoalbuminemia 357
Hypocalcemia 307
Hypoglycemia 48, 59, 61, 307
diagnosis of 61
management of 61
risk of 124
severe 59
Hypokalemia 52, 374
Hypomagnesemia 307
perioperative 54
Hyponatremia 47, 304
Hypoperfusion, systemic 219
Hypoplasia 182
Hypoplastic left heart syndrome 229, 230f, 257
Hypotension 219, 273, 374
systemic 277
Hypothermia 13, 271, 273, 276, 382
mild 171
prevention of 87
Hypotonia 305
Hypotonic fluids 47
Hypovolemia 43, 78, 245, 246, 273, 379
Hypoxemia 88
Hypoxia 199, 238, 384
catastrophic 217
correct 161
intraoperative 305
perinatal 305
severe 67
Hypoxic-ischemic injury 307
I
Iliac vein 25
Indomethacin 398
Indwelling pulmonary arterial lines 296
Infections 23, 374
after pediatric cardiac surgery 333
catheter associated 40
control 350
Infective endocarditis, neurologic manifestations of 309
Inferior vena cava 5, 25, 50, 154, 197, 198, 214, 223, 241f, 248, 263, 303, 324
Infracardiac variant 196
Infrared spectroscopy 230
Infusion 145
pumps 15
Inhaled nitric oxide 259, 298, 327, 373, 374
uses of 372
Inhaled steroids 189
Injury 271
Inotrope 276
and hemoglobin target 216
infusion orders 11
management 244
Inspiratory nasopharyngeal resistance 104
Inspired oxygen
fraction of 83
tension, reduction of 231
Insulin
solution 60
therapy 57, 60
side effects of 61
Intense pulmonary vasoconstriction, substrate for 296
Intensive care unit 3, 9, 58, 64, 105, 159, 183, 215, 256, 266, 281, 294, 313, 321, 334, 347, 353, 357, 363f, 364, 378, 395
Intensive insulin therapy 59
Interatrial septum 153
Intercostal drain 39, 357, 397
care of 359
insertion 358
management of 357
removal 361
system 359f
Intermittent hemodialysis 316
Intermittent positive pressure ventilation 45
Internal jugular vein 25, 242
International Nosocomial Infection Control Consortium 339
International Quality Improvement Collaborative 402
Interstitial compartments 43
Intestinal mucosal atrophy 126
Intra-aortic balloon pump 278, 323
Intracardiac catheters 35, 38f
Intracardiac transthoracic lines 38
Intracellular type crystalloid cardioplegia 386
Intraoperative cerebral injury, mechanism of 305
Intrathoracic pressure 50, 244
Intravascular volume 49
management of 43
Intravenous magnesium therapy
dose of 54
guidelines 54
Intravenous potassium, administration of 52
Intrinsic rhythm 365
Invasive arterial blood pressure 197, 265
monitoring 18, 183
Invasive hemodynamic monitoring 135
Irrigation fluid 358
Ischemia 305
coronary 232, 258
distal 23
postoperative 207
Isoprenaline 398
Isotonic fluid 47
Ivabradine 194, 398
dosage 291
J
Jugular vein catheters 236, 238
Junctional ectopic tachycardia 184, 193, 194, 207, 208, 281, 287, 288f, 289f, 290, 327, 364
Juxtaglomerular apparatus 44
K
Keratitis 113
Ketamine 39, 67, 72, 398
Ketoglutarate 390
Kidney 44
disease 314
chronic 314
improving global outcomes 313
injury, acute 313, 314t, 315t
Klebsiella pneumoniae 30
L
Labile blood pressure 146
Lactic acidosis 71
Laryngomalacia 109
Laryngoscopes 397
Laryngospasm 77
Leaving sternum open, benefits of 133
Left atrial pressure 37, 242, 244, 247
Left atrium 262, 327
Left circumflex artery 253
Left coronary artery 37, 97, 252
anomalous origin of 252
Left internal jugular vein 301f
Left posterolateral thoracotomy 171
Left pulmonary artery 234, 244
Left ventricle 257, 262, 297, 324, 327
Left ventricular
dysfunction 90, 185, 207
end diastolic
pressure 200
volume 159
outflow tract obstruction 109, 203, 273
volume 159
Leukomalacia, periventricular 307
Levodopa 310
Levosimendan 163, 193, 207, 277, 398
Lid edema 113
Lidocaine 389
Lignocaine 95, 358, 398
Lipogenesis 124
Lipoprotein 125
Liver function tests 406
Lobar pneumonia 100
Lorazepam 69
Low cardiac output 219, 246, 247t
state 111, 163, 174, 179, 187, 200, 227
causes of 37t
syndrome 271
indicators of 272
management of 271
Low molecular weight heparin 309
Low respiratory rate 381
Low right ventricular pressures 193
Lower brain maturity scores 305
Lower peak inspiratory pressure 237
Lower pressure pulmonary artery 168
Lung 275
collapse 86, 173
complications 174
development 77
disease 110
parenchymal 295
infiltrates 147
injury 194, 360
protective ventilator strategies 112
ventilation of 167
volumes 187
Lymphatic failure, modes of 301
Lymphatic injury 357
Lymphatic system 300
M
Magnesium 387, 392
intravenous administration of 54
management 54
sulphate 398
Magnetic resonance imaging 306
Main pulmonary artery 203, 241
Major aortopulmonary collateral arteries 191, 303
Malnutrition 110, 112, 116, 117f, 304
prevention of 87
Mannitol 387, 389, 390
Mean arterial pressure 306, 337, 378, 380
Mean pulmonary artery pressure 193, 373
Mechanical circulatory support device strategy 329fc
Mechanical ventilation 7, 78, 79, 85, 92, 94, 111, 145, 194, 236, 278, 305
common indications for 84
conventional 76
preoperative 163
weaning from 90
Mechanical ventilator 79
support 85, 180
Medium chain triglyceride 164, 302, 303
Meningitis 309
Meropenem 135, 141, 149
Methemoglobinemia 374
Methicillin-resistant Staphylococcus aureus 140, 144, 340
Metolazone 398
Microplegia 387
Midazolam 39, 51, 69, 72, 75, 186, 246, 398
Milrinone 163, 207, 272, 277, 398
doses of 193
Mitral regurgitation 326
Mitral valve 229
repair 97
stenosis
congenital 225
severe 326
Mixed venous oxygen saturation 273
monitoring of 36
Morphine 67, 68, 398
infusion 68, 160
Movement disorders 306, 309
Murmur 215
Muscle
relaxants 70, 75t, 398
resection 188
Mustard formula 222
Mustard procedure 209
Myasthenia 110
Myocardial dysfunction 274, 277
Myocardial function 132
depressed 135
Myocardial ischemia 207, 271
Myocardial protection 384
Myoglobinuria 72
N
Naloxone 398
Narrow pulse pressure 273
Nasal cannula 96, 114, 320, 397
oxygen therapy 160
Nasogastric
decompression 173
feeds 136, 189
Nasopharyngeal dead space 104
National Health Systems Network 337
Near infrared spectroscopy 273, 311, 317
Nebulizer 218
kit 95, 397
Necrotizing enterocolitis 146, 167, 206, 257
clinical signs of 146
Neonatal intensive care units 3
Neonatal pain agitation 66t
Neonatal respiratory distress syndrome 103
Neuroendocrine 167
Neutropenia 144
Nitric oxide 296, 371
administration 372
delivery system 397
endogenous 57
Nitroglycerine 205, 398
Nitroprusside 205, 379
Noninvasive ventilation 97, 98
devices 96
Noninvasive ventilator 99, 299, 397
therapy 106
Nonsteroidal anti-inflammatory drugs 68, 156, 173, 211, 237, 246, 254
Non-traumatic chylothorax, causes of 300
Noonan's syndrome 300, 304
Noradrenaline 219
Norepinephrine 272, 278, 379, 398
Normal central venous pressure waveform 29f
Norwood operation 229, 230
Norwood procedure 96, 229
Nosocomial infection 133, 135
Nutrition 122, 315, 381
parenteral 122, 124
postoperative 121fc
Nutritional status 119
Nutritional support 119, 126, 136
O
Obstruction
mechanical 207
pulmonary venous 5, 196, 201, 295
subaortic 227
Obstructive sleep apnea 103
Octreotide 302
Oliguria 71, 232, 316
Opioids 67
dose of 173
Optimize fluid therapy 111
Optimize nutrition 111
Optimum band 226
clinical recognition of 224
Oral angiotensin-converting enzyme inhibitors 255
Oral furosemide 208
Oral iron supplements 220
Organ functions 7
Oromotor dyskinesia 310
Ostium secundum 153
Oxidative stress, postoperative 185
Oxygen
cylinders 397
delivery, surrogates of 50
mask 96, 397
saturation, lower 139
P
Pacemaker 15, 397
implantation 247
programming 366
Packed red blood cells 48, 381
Pain
and sedation management 64, 135, 155, 160, 173, 179, 186, 199, 206, 211, 219, 226, 237, 246
assessment of 65
control 173
management 254, 260, 265
general principles of 65
modes of 65
nonpharmacological methods of 70
nursing considerations in 74
Pancuronium 75, 398
Paracetamol 68, 398
Paradoxical hypertension 173
control of 174
Paralysis 179, 279
Paralytic agents 67, 113
Paraplegia 174
Parenteral amino acid requirements 124t
Parenteral glucose infusion rates 124t
Parenteral nutrition, total 126, 220
Paroxysmal supraventricular tachycardia 291
Partial thromboplastin time 216
Patent ductus arteriosus 166, 166f, 172f, 176, 182, 183, 196, 215, 275
ligation 46t
Peak inspiratory pressure 81, 381
Pediatric
advanced life support 319, 321
basic life support 319
cardiac
arrest algorithm 322fc
critical care consortium 285
intensive care unit 9, 25, 43, 60, 64, 72t, 76, 84, 103, 119, 145, 281, 283, 314, 319, 323, 347, 357, 362, 367t, 372, 377, 394, 395, 397t, 398t, 406t
programs 3
surgery 25, 48, 57, 64, 97, 105, 108, 132, 133f, 139, 271, 305, 313, 340b, 384
crash cart 27
early warning score 319
health information system 285
heart 384
transplantation 373
intensive care unit 3, 338, 339, 394
Pericardium 230
Perimembranous ventricular septal defect 162f
Perioperative antibiotic prophylaxis 139, 140t
Peripheral arterial saturation 217
Peripheral nerve injury 306, 310
Peritoneal dialysis 316, 347
catheter 397
insertion, procedure for 347
optimal functioning of 349
fluid prescription 348
technique of 348
Peritoneal drains 48
Peritoneum 347
Periventricular white matter injury 306, 307
Phenobarbitone 398
Phenothiazines 310
Phenoxybenzamine 231, 398
infusion 205
Phentolamine 379
Phenytoin 310, 398
Phrenic nerve palsy 112
Piperazilline-tazobactam 149
Plasma 193
Plasmalyte A 388, 389
Plastic bronchitis 249
Platelets 380
concentrates 193
Pneumonia 103, 110, 112, 164
ventilator associated 139, 144, 336, 337, 339
Pneumothorax 28, 86, 99, 100, 106, 358
Polymerase chain reaction 143
Polytetrafluoroethylene 183, 214
extracardiac 241f
Polyurethane 26
Positive end expiratory pressure 80, 104, 194, 205, 237, 254, 274, 323, 337
Positive pressure ventilation 78
Post-bidirectional Glenn shunt 239t
Postcoarctectomy syndrome 174
Postextubation 103
pulmonary edema 181
stridor 100, 101
treatment 100
therapy 103
Postligation cardiac syndrome 168, 169
Postoperative cardiac critical care 315
Postoperative fluid therapy, goals of 45
Postoperative intensive care unit 271
Postoperative low cardiac output syndrome 305
Postpericardiotomy syndrome 155, 156
Potassium 387
infusion 53
levels, control of 61
management 52
prescription 53
replacement 404
Pramipexole 310
Preanesthesia 145
Pressure
control ventilation 80, 81f
extension lines 397
limited ventilation 381
monitoring lines 22
pulmonary venous 167
regulated volume control 81
support ventilation 80, 82
ulcers 87
Procalcitonin 336
Propofol 72, 398
infusion syndrome 71
Prostaglandin E1 398
Protamine 398
Protein 120
losing enteropathy 249
lower 118
supplementation 123
Prothrombin time 406
Pseudomonas aeruginosa 30
Psychosis 73
Pulmonary artery 35, 37, 97, 153f, 159, 164, 166f, 167, 183, 192, 203, 210, 219, 230, 243, 244, 252, 253f, 257f, 262, 263, 294, 303, 324, 352
banding 96, 222
blood flow 185
conduit 229
dilatation of 158f
distortion 220
growth of 214
hypertension 76, 88, 109, 111, 159, 167, 273, 373
line 35
monitoring of 193
pressure 161, 163, 167, 200, 235, 239, 248, 260
monitoring 36
shunt 192f, 215, 216
stenoses 257
univentricular heart by 223f
Pulmonary blood flow 192f, 196, 214, 222, 223f, 234, 241, 295, 321, 324, 327
decreased 217
increased 4, 5
Pulmonary circulation, duct-dependent 4
Pulmonary hypertension 79, 100, 158, 161, 178, 179, 196, 198, 200, 212, 216, 276, 294
echo assessment of 297f
management of 297
Pulmonary hypertensive crisis 101, 294, 373
management of 200
Pulmonary lymphatic perfusion syndrome 301
Pulmonary pathway obstruction, prevention of 210
Pulmonary valve 184
regurgitation 189
Pulmonary vascular disease 158f
Pulmonary vascular resistance 37, 78, 104, 167, 186, 217, 224, 239, 244, 247, 248, 264, 295, 324, 327
index 295
Pulse oximetry 223, 265
Pulseless electrical activity 322
Pupils 378
Purulent endotracheal secretions 147
R
Racemic epinephrine 100, 398
Radial artery 18
Ranitidine 11
Rastelli procedure 209
Regional oxygen saturation 311
Regurgitation, pulmonary 183, 273
Renal disease, end-stage 314
Renal failure 382
Renal function tests 406
Renal ischemia 232
Renal replacement therapy 316, 316t
renal indications for 316b
Renal ultrasound 315
Renin-angiotensin-aldosterone 174
Replacement therapy 46, 48
Reserpine 310
Respiratory distress 304
signs of 99
Respiratory failure 104
treatment for 96
Respiratory infections 117
Respiratory maneuvers 169
Respiratory medicines 398
Respiratory overdrive 104
Respiratory rate 82, 320, 397
Respiratory system 112
Respiratory tract infection, lower 143
Respiratory variation 50
Resuscitation, cardiopulmonary 319, 322, 323, 329
Retrograde coronary flow 229
Richmond agitation-sedation scale 72, 72t
Right atrial pressure 186
Right atrium 235, 262, 324
Right coronary artery 253
Right pulmonary artery 241, 241f, 244
Right ventricle 257, 257f, 263, 297, 324, 327
pulmonary artery conduit 192f
Right ventricular
dysfunction 89, 300
outflow tract 183, 184, 327
obstruction 109, 182, 273
Ringer lactate solution 155
S
Salbutamol respirator solution 398
Sano right ventricular exclusion technique 264
Schofield equation 123t
Schwartz formula 314
Secundum atrial septal defects 295
Sedation 179, 265, 279, 359, 381
assessment tools 72
management 254, 260
Sedative 67, 75t
agents 69
Seizures 73, 309
cryptogenic 307
postoperative 306
postpump 307
Selective pulmonary vasodilators 298
Selenium, loss of 304
Senning procedure 210, 210f
Sensitivity 365
Sepsis 6, 110, 275
postoperative 142, 143
preoperative 3
screening, tests for 143t
soft signs of 146
therapy for 145
Septic embolism 309
Serum calcium levels 54
Serum creatinine 273, 314
Shock
septic 78
vasodilatory 379
Shunt block 219
Shunt occlusion 219
management of 217
Sildenafil 111, 299
Single ventricle
lesions 222
physiology 88, 104, 226t
Sinus
bradycardia 238, 364
node dysfunction 364
rhythm 244
maintenance of 185
tachycardia 287
venosus atrial septal defect 154f
Skin 113
Society of Thoracic Surgeons 186
Sodium 52
bicarbonate 387, 388, 398
management 52
nitroprusside 398
Somatostatin 302
Spinal cord injury 306, 310
Spirometers 397
Spironolactone 398
Spontaneous breathing 186
trial, use of 114
Spontaneous respiration decreases 78
St Thomas cardioplegia 386, 388
solution, composition of 388t
Standard hemodynamic monitoring 159, 176, 183, 223, 242
Staphylococcus aureus 30, 140
Starnes procedure, modified 264
Stenosis
pulmonary 182, 214f
subaortic 227
tracheal 79
Sternal retractors, placement of 26
Sternal wound infections 334, 339
Sternum closure, management of 136
Streptokinase 398
Stress
hyperglycemia 59
ulcer prophylaxis 381
Stressors, minimizing patient 87
Stridor, postoperative 173, 189
Stroke 306, 308, 309
arterial ischemic 308
diagnostic challenges of 309
incidence of 308
management of 309
postoperative 307
prophylaxis 309
volume 271
Subclavian flap aortoplasty 171
Subclavian patch plasty 172
Subendocardium 232
Suboptimal myocardial protection 188, 271
Sucrose 71
Sudden cardiac death 211
Superior cavopulmonary anastomosis 242, 325, 328
Superior vena cava 5, 25, 26, 88, 197, 198, 214, 223, 234, 235f, 241, 241f, 263, 303, 324, 327, 328, 352
obstruction 357
Supplemental oxygen 100
therapy devices 96
Supracardiac total anomalous pulmonary venous connection 198f
Surgical site infection 139, 143, 144
Sutures, ability of 353
Swallowing dysfunction 110
Sympathetic nervous system 44
Systemic arterial saturation 230
Systemic blood flow 321, 324, 327
duct-dependent 4
ratio, pulmonary to 234
Systemic circulation, duct-dependent 6, 89
Systemic pulmonary artery shunt 229
Systemic vascular resistance 244, 258, 275, 324, 327
Systemic venous
oxygen saturation 231
pressure 242
Systemic ventricular dysfunction 212
Systolic dysfunction 273
T
Tachyarrhythmias 162, 185, 186, 211, 287, 291, 364
postoperative ventricular 207
Tachycardia 73, 159, 273
supraventricular 207, 247, 327, 364
Tachypnea 273
Teflon 26
Temporary cardiac pacing 362, 365
Temporary epicardial pacing 364
Temporary pacemaker 27, 366f
pulse generators 363f
Temporary pacing wires 362
care of 363
indications for 364
removal of 364
Tetrabenazine 310
Tetralogy of Fallot 36, 79, 182, 182f, 184t, 214, 214f, 274, 287, 300, 327
complete repair of 182
unifocalization for 191
Thoracic aorta 166f
Thoracic duct 239, 301f, 303
Thoracic lymphatic circulation, anatomy of 301f
Thoracotomy incisions 156
Thrombi, pulmonary 249
Thrombocytopenia 146, 374
Thromboelastography 380
Thrombosis 23, 249
Thrombus formation 40
Tidal volume 82
Tight band, clinical recognition of 224
Tight glucose control 58, 59
Torsades de pointes 291
Total anomalous pulmonary venous connection 4, 196, 295, 327
types of 197f
Toxicity
antidote for 55
flushing, signs of 54
Tracheobronchomalacia 109
Tracheoesophageal fistula 182
Tracheostomy
set 397
tubes 397
Tranexamic acid 398
Transannular patch 183, 185
Transesophageal probe 178
Transpulmonary pressure 104
Transthoracic intracardiac lines 35
types of 35
Traumatic chylothorax, cause of 300
Tricuspid atresia 235
Tricuspid regurgitation, mild-to-moderate 212
Tricuspid valve 209, 210, 263
function 212
leaflet 262
morphology 262f
regurgitation 300
Tris-hydroxymethyl aminomethane 387
Trisomy 21 161, 182
Truncus arteriosus 256, 325
repair of 256, 257f
Trusler formula 222
Tryptophan 390
Turner syndrome 300
Two-hit hypothesis 284
U
Unilateral vocal cord paralysis 174
Unipolar atrial wire study 289f
Unipolar pacing wires 362
Univentricular pathway operations 264
Upper airway obstruction 112, 295
Urinary catheterization 148
Urinary tract infection 139, 144, 148, 334
catheter associated 339, 339b
Urine 146, 315
output 378
V
Valproate 310
Valve regurgitation 219
Van Praagh classification 256
Vancomycin 135, 141, 149
Vascular thrombosis 126
Vasoactive-inotropic score 272
Vasoconstrictors 278
Vasodilation, nitric oxide induced 371f
Vasodilators 278
pulmonary 298
use of 174
Vasopressin 219, 272, 278, 379
Vasospasm 23
Vecuronium 75, 398
Vein
pulmonary 196, 198f
subclavian 25
Venoarterial extracorporeal life support 329
Ventilation 7, 13, 135, 164, 173, 223, 260, 265
goals 217, 219
management 155, 160, 178, 186, 211, 217, 237, 245
time 108
volume controlled 80
Ventilator
management 225, 381
parameters 15
settings 7
support, duration of 114, 205
waveforms 81f
Ventilatory management 169, 194, 199, 205, 226t, 232
Ventilatory strategies 88
adoption of 163
Ventricular assist device 329
Ventricular dysfunction 5, 69, 162, 163, 173, 207, 247, 379
Ventricular fibrillation 321, 323, 327
Ventricular septal defect 5, 36, 147, 158f, 163, 171, 177, 182184, 192, 203, 256, 257f, 273, 285, 295, 327, 351, 352
closure of 176
patch closure of 257f
repair 158
residual 163
Ventricular septum 203, 212
Ventricular tachycardia 54, 291, 322, 327
Verapamil 398
Visceral proteins 118
Visual disturbance, long-term 61
Vitamin
A 124
D 124
E 124
K 124, 245, 249
Vocal cord palsy 77
Volutrauma 86
Vomiting 73
W
Warm cardioplegic induction 386, 392
White blood cell 337
Wong Baker faces scale 65
World Health Organization 334
×
Chapter Notes

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A Practical Manual of PEDIATRIC CARDIAC INTENSIVE CARE
A Practical Manual of PEDIATRIC CARDIAC INTENSIVE CARE
Editors Rakhi Balachandran MD (Anesthesia) PDCC (Cardiac Anesthesia) Professor Department of Cardiac Anesthesia Amrita Institute of Medical Sciences and Research Centre Amrita Vishwa Vidyapeetham Kochi, Kerala, India Aveek Jayant MD (Anesthesia) DM (Cardiac Anesthesia) Professor and Head Department of Cardiac Anesthesia Amrita Institute of Medical Sciences and Research Centre Amrita Vishwa Vidyapeetham Kochi, Kerala, India R Krishna Kumar MD DM (Cardiology) FAHA Professor and Head Department of Pediatric Cardiology Amrita Institute of Medical Sciences and Research Centre Amrita Vishwa Vidyapeetham Kochi, Kerala, India Foreword Stephen J Roth
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A Practical Manual of Pediatric Cardiac Intensive Care
First Edition: 2022
9789390595631
Printed at
CONTRIBUTORS
PRINCIPAL CONTRIBUTORS
Current and Former Members of the Pediatric Heart Program of the Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Medical Campus, Kochi
Additional Contributors
Co-Authors of reproduced manuscript
FOREWORD
The vast majority of children with congenital heart disease (CHD) are born and live in low- and middle-income countries (LMICs). As progress in human development in LMICs proceeds over the next 20–30 years, and communicable diseases cause less childhood mortality, we can anticipate that CHD, a leading birth defect throughout the world, will become more visible and prominent as a pediatric disease. Recognizing this demographic transition, leaders in pediatric health care, governments, and private organizations in many LMICs have begun to develop the human and technical resources to establish pediatric cardiovascular programs capable of delivering high-quality surgical outcomes – centers of excellence.
In India, the pediatric cardiovascular program at the Amrita Institute of Medical Sciences (AIMS) in Kochi, Kerala, is an excellent example of this possibility. The program at AIMS was established in 1998 with Dr R Krishna Kumar as one of its founding members. The program's development has been aided by sustained partnerships with Children's HeartLink (CHL) plus several faculties and staff from Boston Children's Hospital and Lucile Packard Children's Hospital, Stanford. Dr Kumar and his surgical, anesthesia, and nursing colleagues recognized the importance of establishing excellence in the provision of cardiac intensive care for their surgical patients, and they thus focused on building both a high-performing, multidisciplinary team and a dedicated pediatric cardiac intensive care unit (PCICU) at AIMS. I had the privilege of assisting the team at AIMS with this effort, and between 2000 and 2008, I participated in five visits to Kochi that were sponsored by CHL. Physicians and nurses from the PCICU at AIMS also visited Boston and Palo Alto during this time to observe clinical practice and learn about the structure and governance of our units and programs. Today, AIMS has a 24-bed dedicated PCICU that supports the intensive care of 650–700 cardiac surgical patients per year. The team has achieved excellent clinical outcomes, and their program is now regarded as among the best in India, with patients referred from throughout India, South Asia, and Africa with it for cardiac care. In 2012, Children's HeartLink designated AIMS as the first Children's HeartLink Center of Excellence in pediatric cardiac care and training.
This manual represents the collective knowledge and clinical experience of the AIMS pediatric cardiac team, and it has been created by them to serve as a practical bedside resource for physician trainees, nurses, and other frontline care-providers in the PCICU. Unlike existing handbooks developed at programs in high-resource settings, it presents key clinical information about specific defects, problems, and clinical management approaches within the context of 20 years of practice in a resource-constrained setting. For example, one chapter is devoted to perioperative nutritional rehabilitation; in India, as in other LMICs, it is common for younger cardiac patients presenting for surgery late and to have severe failure to thrive at hospital admission. And while a chapter on the use of extracorporeal membrane oxygenation is included, there is no discussion of the clinical details of mechanical circulatory support with ventricular assist devices or cardiac transplantation for terminal heart failure, too costly and complex therapies. One chapter is also offered on the most important considerations for establishing a PCICU in a limited-resource environment.
In addition to providing key information about cardiac intensive care for CHD patients, this manual promotes the practice of critical thinking at the bedside. Successful intensive care depends in part on vigilance – the “eyes and ears” at the bedside looking and listening for signals that could represent early indications of clinical decompensation. Building critical thinking skills among care team members is the best way to expand the scope of vigilance to include “minds” as well as “eyes and ears”, and this manual will assist those who embrace it in those fundamental skills.
Stephen J Roth MD MPH
Professor of Pediatrics (Cardiology)
Stanford University School of Medicine
Attending Physician, Cardiovascular Intensive Care
Lucile Packard Children's Hospital, Stanford
Palo Alto, California, USA
PREFACE
This manual of cardiac intensive care seeks to serve as a ready reckoner to nurses and resident doctors involved in the perioperative intensive care of patients with congenital heart disease. Much of what is written here has been distilled over two decades of institutional experience in caring for children with congenital heart disease.
The essence of pediatric cardiac intensive care is coordinated multidisciplinary teamwork involving nurses, pediatric cardiologists, surgeons, anesthesiologists, pediatricians and intensivists. Much of the care is finally delivered via the bedside nurse. The role of supporting personnel that includes respiratory therapists, care assistants, clinical pharmacists, nutrition specialists, medical social workers, and biomedical technicians is equally critical.
The pediatric heart program at Amrita Institute of Medical Sciences has been established in 1998 and has evolved over the past two decades. The program performs 650–700 cases annually and has accumulated substantial expertise in providing comprehensive care for neonates, infants and children with congenital heart disease. The surgical team has achieved excellence in performing all the complex congenital heart lesions in infants and adult patients alike. We strongly believe that the results achieved is largely a reflection of the multidisciplinary team approach that we have all passionately embraced.
This manual has attempted to incorporate some of the key aspects of the general postoperative care of patients undergoing congenital heart surgery, special considerations in each type of congenital heart disease, the expected postoperative complications and their management. Though we have attempted to touch upon some of the pertinent aspects of pediatric cardiac intensive care, we are cognizant of the fact that this book is by no means complete. We also recognize that institutional protocols may vary substantially and there be more than one way to take care of specific situations. Thus, rather than serving as a comprehensive reference, it aims to provide bedside solutions to common problems encountered in postoperative cardiac critical care.
This book looks to specifically assist care-providers in pediatric heart programs encountered in low and middle-income countries. Therefore, there are chapters that are specially devoted to issues that are of particular significance in low resource environments. There are chapters devoted to nutrition, pulmonary hypertension, and healthcare-associated infections. The final chapter of the book is devoted to special considerations in establishing a pediatric cardiac intensive care unit in a limited resource environment.
We would sincerely solicit feedback on the manual from its readership and hope to make this a work in progress that improves with time.
Rakhi Balachandran
Aveek Jayant
R Krishna Kumar
ACKNOWLEDGMENTS
This book has been a collective effort of past and present members of the pediatric heart program at the Amrita Institute of Medical Sciences (AIMS), Kochi, Kerala, India. Firstly, we wish to thank all the contributors who have dedicated their valuable time and knowledge in preparing the individual chapters of this manual. We sincerely acknowledge Dr Suresh G Nair, former Professor and Head, Cardiac Anesthesia and Cardiac Intensive Care Services for laying down an administrative and training framework that stands us in good stead to this day. We also thank Dr Suresh G Rao, Dr Krishnanaik Shivaprakasha and Dr Sunil GS, former pediatric cardiac surgeons whose unparalleled surgical expertise laid the foundation of excellent surgical outcomes and many unit policies related to the care of children undergoing surgical correction of heart defects.
Excellence in nursing care is paramount in facilitating good surgical outcomes. We wish to place on record our deep gratitude to our past and present nursing staff for dedicating long and stressful hours in the passionate care of critically ill children with heart disease. We specifically acknowledge the efforts of Ms Sreeja Mohan, our former Nurse In-Charge, whose impeccable clinical acumen and leadership skills facilitated training of her junior colleagues and implementation of unit policies and protocols to perfection. We specially acknowledge Ms Saibala, Director of Nursing Services, for her leadership and wholehearted support of the pediatric heart program.
The junior doctors and postgraduate residents form the main workforce of the unit for delivering uninterrupted care for sick children before and after heart surgery. Their enthusiasm and desire to learn have enabled the senior faculty to keep abreast with the latest developments in the sub-specialty and inspired them to deliver the best possible outcomes. We sincerely thank all our past and present resident doctors and faculties for contributing to the clinical work in the intensive care unit. We also thank all the supporting clinical staff of the pediatric heart program including respiratory therapists, perfusionists, technicians, physiotherapists, nutrition specialists, pharmacists, medical social workers, care assistants, biomedical engineers, members of the electrical department, and secretarial staff.
A number of developments in our intensive care program have been specifically facilitated by our decades-long association with Children's HeartLink (www.childrensheartlink.org), a non-governmental organization based in Minneapolis, USA. They helped foster the vision of multidisciplinary postoperative care and contributed greatly to the development of a cohesive team of caregivers. They have enabled training exchanges with experts at various stages of the program development and have facilitated short-term training of our faculty at centers of excellence in the United States. Their support has greatly helped in skill development and training of our nurses, infection control and a number of quality improvement initiatives.
We must specifically acknowledge those who have, in the past, visited our program regularly to enhance the quality of care. Dr Stephen Roth, Professor of Pediatrics (Cardiology) Stanford University School of Medicine was instrumental in laying the foundations of pediatric cardiac intensive care at AIMS. Dr VM Reddy, Professor, Pediatric Cardiothoracic and Vascular Surgery, UCSF, USA has taken a special interest in training our team to perform surgery for complex heart defects and for preterm infants. Sandra Staveski, RN, PhD, Assistant Professor, Family Health Care Nursing, School of Nursing, UCSF has a long and extremely fruitful association with the AIMS pediatric heart program. She has contributed greatly to elevating the quality of our nursing in the ICU and has helped establish our nurse residency program.
Our intensive care unit has embraced a commitment to continuous quality improvement right from its inception. We joined the International Quality Improvement Collaborative (IQIC) for Congenital Heart Disease (https://iqic.chboston.org/), a global project to improve outcomes in children undergoing congenital heart surgery. The introspection of data and annual benchmarking facilitated by this project enabled us to continuously strive towards achieving better standards. Here, we specially acknowledge the efforts of Mr Abish Sudhakar, Research Assistant, Pediatric Cardiology in maintaining a robust database and facilitating the annual international audit of this data.
Sustaining a successful pediatric heart program requires the unconditional support of the administrative leadership. We sincerely thank Dr Prem Nair, Medical Director, for his wholehearted support of the pediatric heart program. We also acknowledge the efforts of Dr Sanjeev K Singh, Medical Administrator, Amrita Institute for his contributions towards spearheading continuous quality improvement and infection control initiatives in the pediatric cardiac intensive care unit.
Additionally, Dr Balaji Srimurugan and Dr Praveen Reddy have made all the illustrations in this manual despite their hectic schedule.
Above all we are also blessed by the divine persona of Her Holiness Mata Amritanandamayi for Her graceful oversight of the pediatric heart program and unconditional support.
We acknowledge the strong support of our family members who have stood by us during the thick and thin of our professional life and withstood the challenges that resulted from our long periods of absence.
Finally, we must express our deep and heartfelt gratitude to our patients and their families for giving us the opportunity to trust us with their health and the opportunity to at once, serve and learn from them.