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
PRINCIPAL CONTRIBUTORS
Current and Former Members of the Pediatric Heart Program of the Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Medical Campus, Kochi
- 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
- Praveen Reddy Bayya MS MCh (CVTS) FPCS
- Assistant Professor
- Department of Cardiovascular and
- Thoracic Surgery
- (Division of Pediatric Cardiac Surgery)
- 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
- Jessin P Jayashankar MD (Anesthesia) FCA (Cardiac Anesthesia)
- Associate Professor
- Department of Cardiac Anesthesia
- Amrita Institute of Medical Sciences and Research Centre
- Amrita Vishwa Vidyapeetham
- Kochi, Kerala, India
- Mahesh Kappanayil DCH DNB (Pediatrics) FNB (Pediatric Cardiology)
- Professor
- Department of Pediatric Cardiology
- Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham
- Kochi, Kerala, India
- Balaganesh Karmegaraj MD (Pediatrics) DM (Pediatric Cardiology)
- Assistant Professor
- Department of Pediatric Cardiology
- Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham
- Kochi, Kerala, India
- Pragnatha Komaravolu MBBS MRCPH
- Assistant Professor
- Department of Rheumatology
- Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham
- Kochi, Kerala, India
- Brijesh P Kottayil MS MCh (CVTS)
- Associate Professor
- Department of Cardiovascular and Thoracic Surgery
- Head (Division of Pediatric Cardiac Surgery)
- Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham
- Kochi, Kerala, India
- Mani Ram Krishna DNB (Pediatrics) FNB (Pediatric Cardiology)
- Assistant Professor
- Department of Pediatric Cardiology
- 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
- Sreelakshmi P Leeladharan MD (Anesthesia) DM (Cardiac Anesthesia)
- Assistant Professor
- Department of Cardiac Anesthesia
- Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham
- Kochi, Kerala, India
- Thushara Madathil MD (Anesthesia) DM (Cardiac Anesthesia)
- Assistant Professor
- Department of Cardiac Anesthesia
- Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham
- Kochi, Kerala, India
- Suresh G Nair MD DA (Anesthesia) FIACTA (Hon) FTEE (Hon)
- Lead Consultant
- Anesthesia and Critical Care
- Aster Medcity
- Kochi, Kerala, India
- Amitabh C Sen DNB (Anesthesia) PDCC (Cardiac Anesthesia)
- Consultant Anesthesiologist
- Sultan Qaboos University Hospital
- Muscat, Oman
- Balaji Srimurugan MS MCh (CVTS) FPCS
- Assistant Professor
- Department of Cardiovascular and Thoracic Surgery (Division of Pediatric Cardiac Surgery)
- Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham
- Kochi, Kerala, India
- Balu Vaidyanathan MD (Pediatrics) DM (Cardiology)
- Professor
- Department of Pediatric Cardiology
- Head (Fetal Cardiology Division)
- Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham
- Kochi, Kerala, India
- Sudheer Babu Vanga MD (Anesthesia) FCA DM (Cardiac Anesthesia) Testamur in American Society of Echocardiography
- Assistant Professor
- Department of Cardiac Anesthesia
- Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham
- Kochi, Kerala, India
Additional Contributors
Co-Authors of reproduced manuscript
- Andrew C Argent MBBCh MMed MD (Pediatrics) FRCPCH FCPaeds (SA)
- Professor Emeritus
- Department of Pediatrics and Child Health
- University of Cape Town
- Cape Town, South Africa
- Amina Khan RN RM BSCN NCLEX RN
- Critical Care Nurse
- Intensive Care Unit
- El Campo Memorial Hospital
- Texas, USA
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.