In Brief

Article Outline

• Copyright

Caring for a child with congenital heart disease or acquired heart failure is challenging and requires thorough understanding of normal cardiovascular dynamics, development, anatomy, and physiology. From this, the practitioner can have an understanding of the pathophysiology and natural history of different congenital and acquired cardiac abnormalities. That extensive knowledge is used by multiple team members comprising the care team to optimize the outcome of those children. A team of cardiologists, cardiac surgeons, cardiac anesthesiologists, perfusionists, cardiac intensivists, nurses, and respiratory therapists is necessary to work in concert with the family to care for the child. The journey of a child with complex congenital heart disease starts in utero and continues into adulthood. It is important for the team to realize that the work done in infancy establishes a lifelong relationship with these patients.

This lifelong commitment has led to the surgical repair and palliation of complex congenital heart defects and advances in heart transplantation, which have evolved exponentially over the last 60 years and led to significant technical and conceptual developments in cardiac anesthesia, perioperative intensive care, and diagnostic and interventional cardiology. The special needs of these children led to separation of the cardiac intensive care unit from the medical and surgical unit and to development of specific protocols and pathways to facilitate and expedite coordinated medical and interventional/surgical management. This practice is based mainly on clinical experience and expertise because randomized, controlled clinical trials in children are limited.

Optimal perioperative care for newborns with congenital heart disease is delivered by expert and experienced teams with access to adequate facilities and state-of-the art equipment. Decision-making in the intensive care unit is dynamic and depends on the availability of modern neurologic and hemodynamic monitoring capabilities and the ability of the team to interpret the data derived from these devices, such as the pulmonary artery catheter, the continuous central venous saturation monitor, the PiCCO thermodilution and pulse contour analysis system (Pulsion Medical Systems, Munich, Germany), and near-infrared spectroscopy. Data regarding these devices in the pediatric age group are accumulating.

Interfaces between different teams caring for the patient are a major source of morbidity and mortality and require careful and methodical consideration and control. The main interfaces are the referring hospital and the admitting hospital transport team, the transport team and the admitting cardiac intensive care unit, and the intensive care unit and operating room. Open communication channels between key staff members are paramount. Details regarding the patient's history and course in the referring hospital should be discussed between the referring and admitting intensive care attending physicians. Briefing of the transport team and medical control of the team's actions must be assumed by the attending intensivist and require ready availability for consultation throughout the transport and during the patient's arrival to the intensive care unit. Hand over of the patient from the intensive care unit to the operating room team, and from the operating room to the intensive care unit, is critical.

The subsystem approach to these critically ill children has worldwide acceptance in the pediatric intensive care arena. This approach allows the team to form a broad clinical picture based on details derived from careful analysis of each organ system. We chose to use this approach to discuss the postoperative management of the pediatric cardiac surgery patient in our hospital, while citing the most current literature related to each clinical problem.