Post-Op Norwood pathway

Post-op Norwood v.2.0: Criteria and Overview

Executive Summary Explanation of Evidence Ratings

Test Your KnowledgeSummary of Version Changes

Inclusion Criteria

· Post-operative Norwood patient

Exclusion Criteria· Patient receiving Extracorporeal

Membrane Oxygenation (ECMO)

· Norwood procedure with BT Shunt

Phase I: Day of Surgery to Chest Closure

Phase II: Chest Closure to Extubation

Phase III: Extubation to Transfer to Ward

Shock

Hemostasis

Feeding Assessment

Feeding Ordering

Feeding Contraction

Last Updated: 08/15/2012

Valid until: 08/15/2015

For questions concerning this pathway,

contact: [email protected]© 2012, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

Pathway Overview

http://www.seattlechildrens.org/terms-of-use/

Interventions by System

Cardiovascular· Milrinone infusion (0.5 mcg/kg/min)

· Dopamine infusion (5 mcg/kg/min):

Once hemodynamics have

stabilized (typically POD #2-3),

titrate dopamine to maintain a MAP

(typically > 45 mmHg) that

promotes diuresis

· For signs and symptoms of Low

Cardiac Output, see Shock

algorithm

Post-op Norwood Phase I: Day of Surgery to Chest Closure v.2.0

Monitoring and Assessments

Monitoring· Cardiorespiratory monitor

· SaO2

· End-tidal CO2

· Cerebral/Renal NIRS

· Core/toe temperatures

· Consider continuous SvO2

Assessments· Vitals per CICU routine, Interval

physical exam

· Hourly urine output

· Hourly chest tube output

· 4 extremity blood pressure every

AM

· Daily assessment of possibility for

chest closure

· Chest X-ray-admission and daily

· ECG-admission: Atrial wire study

as necessary

· Vascular US as needed if:

1. Platelet count decreasing

2. High volume chest tube output

3. Signs of CVL malfunction

Lines and Tubes· Central venous catheter

· Arterial line

· PICC line

· Foley catheter

· Chest tubes

· NG tube to LIWS

· Atrial and ventricular pacing

wires

Laboratory· Admission: Lytes, Mg, Phos, BUN,

creatinine, CBC, PT/INR, aPTT,

fibrinogen, SVO2 POC: ABG,

lactate, iCa, glucose,

· Every 2 hours for 8 hours: SVO2

POC: ABG, lactate, iCa, glucose.

Then consider increasing interval,

but not less frequently than every 6

hours

· Daily at 0400: Lytes, Mg, Phos,

BUN, creatinine, CBC/diff, albumin,

POC: ABG, lactate, iCa, glucose

Respiratory· Mechanical ventilation-SIMV/PC

· Target: PaCo2 35-50 mmHg/pH

7.3-7.4, SaO2 > 75%

· If SaO2 < 75%: CXR, +/- ↑PEEP,

↑FiO2, +/- initiate iNO, consider

ECHO to r/o anatomic obstruction

to pulmonary bloodflow, consider

Shock

Hematologic· Monitor chest tube output. If

sanguinous output > 3 mL/kg/hr

(see hemostasis algorithm).

· Target: see hemostasis algorithm

*Hematocrit ≥ 40%

*Normal coagulation parameters

INR < 1.5

PTT < 40

Fibrinogen > 200

Platelet count > 200

· Day 2: if hemostasis achieved,

begin heparin infusion for central

line prophylaxis (target range 0.2-

0.3 International Units/mL)

1. Hold heparin 4 hours prior to

chest closure

Infectious Disease· Antibiotic prophylaxis (assure

timing related to most recent dose

in operating room)

· Routine: cefazolin-standard IV

dosing

· If MRSA or PCN allergy-

Vancomycin standard IV dosing

Neurologic· Morphine infusion-start at

20 mcg/kg/hr, and titrate per ICU

comfort protocol

· Target: ICU comfort score of 2





Interventions

Chest Closure

To Phase II: Chest Closure to Extubation

Admit from OR

Fluids, Electrolytes and Nutrition· NPO

· Day of surgery: IVF fluids- D10 ½ NS

@ total fluid limit of 50 ml/kg/day

· Post op day 1:

1. AM rounds: order TPN with TFL of

100 mL/kg/day, and begin

furosemide infusion of 0.05 mg/kg/hr

2. Continue IVF (50 mL/kg/d) until

new TPN arrives (e.g. 1600)

3. increase furosemide throughout

the day as indicated

4. If by 1600 I/O well balanced then

begin TPN (100 mL/kg/d), if I>>O

then begin TPN at fluid restricted rate

(e.g., 50-80 mL/kg/d) and/or continue

to increase furosemide to target even

fluid balance

· Post op day 2 → chest closure

Advance TPN and TFL (range:80-

120 mL/kg/day) to optimize nutrition

while minimizing fluid administration

to target negative fluid balance.

· Ranitidine- standard IV dosing; add

to TPN when possible

· Consider chlorothiazide IV 4-8 mg/kg/

day ÷ BID for synergy

· Post op day 1:

1. AM rounds: order TPN with TFL of

100 mL/kg/day, and begin furosemide

infusion of 0.05 mg/kg/hr

· Day of surgery: IVF fluids- D10 ½ NS

@ total fluid limit of 50 mL/kg/day


Post-op Norwood Phase II: Chest Closure to Extubation

(Goal duration 1-2 days), v.2.0








· SaO2

· ETCO2

· Cerebral/Renal NIRS


Assessments· Vitals per CICU routine; Interval

physical exam, including

assessment of surgical wound

· Hourly urine output

· Hourly chest tube output

· 4 extremity blood pressure every

AM

· Chest X-ray daily while intubated

and/or chest drains present

· Vascular US as needed if:




Lines and Tubes· Central venous catheter

· Arterial line

· PICC line

· Foley catheter

· Chest tubes

· NG tube to LIWS

· Atrial and ventricular pacing

wires

Laboratory· Immediately after chest closure:

every 2 hours for 6 hours: POC

lactate, ABG. Then adjust interval

as indicated

· Daily: Lytes, Mg, Phos, BUN, creat,

CBC/diff, POC: ABG, lactate, iCa,

glucose

Fluids, Electrolytes and

Nutrition· NPO

· Once hemodynamically stable,

initiate post-op cardiac surgery

feeding protocol

· Continue TPN/ TFL to optimize

nutrition

· Continue furosemide infusion

Respiratory· Mechanical ventilation-SIMV/PC

· Daily extubation readiness testing

Cardiovascular· Continue milrinone infusion

· Wean dopamine infusion

· Wean epinephrine infusion

Hematologic· Maintain hematocrit > 40%

· Heparin infusion for central line/RV

to PA conduit prophylaxis

· Discontinue heparin infusion and

begin standard dosing of ASA when:

1. CVC has been removed (PICC

does not need to have been

removed) AND

2. Tolerating enteral feeds

· Enoxaparin if vascular thrombus

present: If using, do not start ASA

· Remove chest drains (if ≤ 1 mL/kg/

hr after discussion with CV surgeon)

Infectious Disease· Antibiotic prophylaxis for 48 hours

following chest closure

Neurologic· Wean morphine infusion to facilitate

extubation

Interventions

Extubation

To Phase III: Extubation to Transfer to Ward

Lines and Tubes· If PICC line present and

clinical status allows, remove

ASAP after chest closure

· +/- Remove chest tubes

· +/- DC foley

· Consider removing pacer

wires: Either at the time of

chest closure, or when patient

has been arrhythmia-free for

48 hours

Note: · Patients commonly have a mild-moderate form of

low cardiac output syndrome for 12-24 hours

following chest closure. This is usually managed

with fluid bolus administration and limited

escalation of inotropes.

· If low cardiac output syndrome persists or

worsens despite these interventions, consider re-

opening the patient’s sternum.


Post-op Norwood Phase III: Extubation to Transfer to Ward, v.2.0








· SaO2


Assessments· Vitals per CICU routine; Interval

physical exam

· Urine output

· Chest tube output

· Chest X-ray daily until chest drains

removed:

1. Assure that patient has had chest

X-ray following most recent chest

tube removal to r/o pneumothorax

2. Otherwise as indicated by clinical

status

· Vascular US if:




Laboratory· Following extubation: POC ABG

· Daily: Lytes, Mg, Phos, BUN, Cr, glu,

POC iCa; consider POC ABG, lactate

· Weekly: CBC

· Consider trending CRP if concern for

infection

Fluids, Electrolytes and Nutrition· Begin feeding: Initiate post-op

cardiac surgery feeding protocol

· Wean TPN/IL

· Discontinue ranitidine when at 50%

goal feeding rate, and if no concern

for GERD

· OT swallow evaluation prior to

attempting PO

· Consider otolaryngology consultation

if specific concern for vocal cord

dysfunction

· Transition furosemide from drip to

enteral (dosing guideline: 1 mg/kg

every 8 hours)

Respiratory· Wean from non-invasive ventilation

· Wean from oxygen

Cardiovascular· Wean milrinone off

· Consider maintenance afterload

reduction with ACE inhibitor if:

1. Hypertension

2. Decreased myocardial function

3. AV valve regurgitation

Hematologic· Discontinue heparin infusion and

begin standard dosing of ASA when

1. CVC has been removed (PICC

does not need to have been

removed) AND

2. Tolerating enteral feeds

· Enoxaparin if vascular thrombus

present: If using, do not start ASA

Neurologic· Wean sedatives/analgesics

· Transition sedatives/analgesics to

enteral if has been on infusion

for > 7 days

Interventions

Evaluate readiness to transfer to ward

Transfer Criteria Met? (all must be met)

· SaO2 > 75% with NC O2 flow < 1 LPM for over 24 hours

· Tolerated 24 hours of feeding protocol

· Stable hemodynamics without need for vasoactive infusions

· Tolerating intermittent diuretics

· Invasive monitoring discontinued

· Chest X-ray stable following most recent chest tube removal

No: Continue

ICU careYes

Transfer to

Ward

Infectious Disease· Antibiotic prophylaxis for 48 hours

following chest closure

Lines and Tubes· Discontinue NIRS monitors

· Remove central venous catheter

· Remove arterial line

· PICC line-leave in place for

transfer to ward


Evaluate Central Venous

Pressure (CVP)

Post-op Norwood v.2.0: Shock

HR < 130

· Evaluate for dysrhythmia

· Consider atrial or

atrioventricular sequential

pacing

CVP ≤ 8 mmHg

· Consider fluid administration

(10 mL/kg NS). Repeat up to

2 times (e.g. total 30 mL/kg)

as needed, then consider

increasing dopamine infusion

· Reassessment of CVP

CVP > 8 mmHg

· Consider an initial fluid bolus

(10 mL/kg NS), and reassess

hemodynamics. If no

improvement and CVP

remains > 8 mmHg, consider

increasing dopamine infusion

Signs of shock in patients status-post Norwood procedureNote: all signs may not be present in all patients; numeric values are guidelines and must be considered in the clinical context.

· Serum lactate > 2 mmol/L

· SaO2-SvO2 > 30

· Cerebral or renal oximetry by NIRS < 40%

If shock is present, evaluate the following clinical parameters to determine appropriate intervention

No improvement Despite Dopamine

Dose of 10 mcg/kg/min

1. Initiate epinephrine infusion @ 0.05 mcg/kg/min, and titrate as

necessary

2. Consider muscle relaxation

3. Check serum cortisol level, and consider initiating

hydrocortisone 1 mg/kg/dose IV every 6 hours

4. Transfuse pRBC's to maintain Hct > 40%

5. Consider additional fluid boluses especially if CVP remains

< 8 mmHg

6. Consider echocardiogram to assess:

a. Pericardial effusion

b. Ventricular function

c. AV valve regurgitation

d. RV-PA conduit/ PA stenosis

e. Residual systemic outflow/arch obstruction

CVP ≤ 8mmHg CVP > 8mmHg

Evaluate Heartrate (HR)

HR > 180

· Primary fever: Antipyretics,

consider cooling to low-normal

temperature.

Note: Elevated core temperature due

to peripheral vasoconstriction is a

sign of shock. Therefore, specific

therapies to treat fever will often be

ineffective. Rather, efforts should be

focused on improving cardiac output.

· Evaluate and treat for dysrhythmia

· If SBP > 60 mmHg

(MAP > 45mmHg) consider

weaning chronotropic infusions

· Consider chest X-ray and ECHO to

rule out intrathoracic air/ fluid

collection

HR < 130 HR > 180

If no improvement despite

dopamine of 10 mcg/kg/min:

SBP > 75 mmHg

(MAP > 60 mmHg)

1. Consider weaning

vasoconstrictors

2. Assure sedation and analgesia

are adequate

3. Consider increasing vasodilation

a. increase milrinone to a maximum

dose of 1 mcg/kg/min

b. consider starting nitroprusside at

0.5 mcg/kg/min, and titrate up to

target goal BP

SaO2 > 85%: try to optimize

balance of Qp:Qs by:

1. Decreasing FiO2 as tolerated to

0.21

2. Increasing milrinone to maximum

dose of 1 mcg/kg/min

3. Consider echocardiogram to

assess:

a. Pericardial effusion

b. Ventricular function

c. AV valve regurgitation

d. RV-PA conduit/ PA stenosis

e. Residual systemic outflow/arch

obstruction

4. If elevated BP, consider initiating

nitroprusside infusion @ 0.5 mcg/kg/

min and titrate to forged goal BP

Evaluate Systolic Blood

Pressure (SBP)

Evaluate Arterial Oxygen

Saturation (SaO2)

!Frequent

reassessment

to determine the

adequacy of the

intervention is essential

Return to Phase I

· Cool or mottling of extremities (Toe temp < 28 degrees)

· Urine output < 1mL/kg/hr





Common Causes of Shock

· Low cardiac output syndrome

· Pericardial tamponade

· Pneumothorax

· Arrhythmia

· Residual cardiac lesion

· Infection

· Bleeding/anemia

· Ventricular dysfunction

· Tachycardia (HR > 180 bpm)

· Hypotension (SBP < 55 mmHg, MAP < 40 mmHg)

· Desaturation (SaO2 < 75%)


Post-op Norwood v.2.0: Hemostasis





Monitor Chest Tube Output (hourly)

General Approach

Initial management of post-operative bleeding is focused on normalizing the patient's coagulation profile using

the appropriate blood products. If bleeding is minimal or seems to be decreasing, one may take a more

conservative approach to blood product replacement. However, the general parameters to maintain are:

1. INR < 1.5

2. PTT ≥ 40

3. Fibrinogen > 200

4. Platelet count > 200

5. Hematocrit ≥ 40%

Maintain

1. INR < 1.5

2. PTT < 40

3. Fibrinogen > 200


Monitor

· Coagulation profile

· Hematocrit

· Consider

Thromboelastography

· Continue to monitor chest

tube output

Transition from sanguinous to serous

over first several post-operative hours

Sanguinous

Output > 3 mL/kg/hr

Continue to monitor

chest tube output

Continued serous output

Maintain

1. INR < 1.3

2. PTT < 40

3. Fibrinogen > 200


Continued sanguinous

output past several post-

operative hours

!Notify surgeon for

bleeding > 10mL/kg/hr

or 5mL/kg/hr for 2

consecutive hours

Bloody Output

> 10 mL/kg/hr or

> 5 mL/kg/hr

for 2 consecutive hours

Bloody Output

> 10 cc/kg/hr or > 5 mL/kg/hr

for 2 consecutive hours

Return to Phase I



Post-op Norwood v.2.0: Enteral Feeding: Assessment

Inclusion Criteria· Term Neonate (< 30 days)

· Cardiac Surgery Service

Exclusion Criteria· Small for gestational age

!

Chest closed

Soft Abdomen

Well Perfused

Functional GI Tract

Feed via Total

Parenteral Nutrition

(TPN)

Place Nasoduodenal

(ND) Tube

Feed ND + TPN

Place Nasogastric (NG)

Tube

Feed NG + TPN

Ready for Enteral

Feeds?

Gastric Feeding OK?

Intubated?

Place Nasogastric

(NG)Tube

Feed PO/NG + TPN

No

No

No

Yes

Yes

Yes





To Feeding Ordering

Return to Phase III


Post-op Norwood v.2.0: Enteral Feeding: Ordering

90mL/kg/day: to

24 kcal/oz

120mL/kg/day: to

27 kcal/oz; stop

intralipids

Increase

concentration per

above table

Advance feeds 0.5mL/

kg/hr(12 mL/kg/day)

Provide additional

TPN as needed while

advancing feeds

Check Residuals

Start with 0.5 mL/kg/hr

(12mL/kg/day)

Tolerated Feeds for 6

hours?

At Full Feeds?

(120mL/kg/day

Off

Pathway

!

22 kcal/oz

1. Breast milk fortified

with Alimentum OR

2. Alimentum

!

Diarrhea

Bloody Stools

Incr. abd girth

Emesis/lg. residuals

Bloody/bilious residuals

Yes

Yes, contract feeds

No

No





To Feeding

Contraction

Return to Phase III


Post-op Norwood v.2.0: Enteral Feeding: Contraction

!

Tachycardia

Irritable with feeds

Prior NEC or ECMO

Prior feeding intolerance

!

Normal perfusion

Tolerates 110-140

mL/kg/day

Ready for Bolus

Feeds?

High Risk?

Contract to 2 hour

bolus for 1 feed

Contract to 1.5 hour

bolus for 1 feed

Contract to 1 hour

bolus for 1 feed

Contract to 30 minute

bolus feeds

Contract to 2 hour

bolus for 3 feeds


bolus for 3 feeds

Contract to 1 hour

bolus for 3 feeds

Contract to 45 minute

bolus for 3 feeds


bolus for 3 feeds

Continual

Reassessment

Yes

No

No

Yes





Return to Phase III


Return to Home

Post-Op Norwood pathway: Inclusion Criteria

Neonates admitted to the

Cardiac ICU following the

Norwood operation

Return to Home To Pg 2

Ductal Dependent Systemic Blood Flow

Infants with ductal dependent systemic blood flow have left

ventricular outflow obstruction

• Hypoplastic left heart syndrome (HLHS)

• Interrupted aortic arch

• Critical aortic stenosis

HLHS

• HLHS and related functional single ventricle conditions remain

the highest risk and costliest group of lesions among the

commonly occurring congenital heart defects

• No congenital heart defect has undergone a more dramatic

change in diagnostic approach, management, and outcomes

than hypoplastic left heart syndrome (HLHS)

• Outcome data is highly regarded and often synonymous with

overall programmatic success

• Tend to have long lengths of stay

o Provides scope to make measurable improvements that are significant

(days not hours)

o Potential for increased risk of iatrogenic harm

Return to Home To Pg 3Return to Pg 1

Norwood Procedure

In HLHS the single ventricle must be

connected to both the systemic and

pulmonary circulations

Systemic circulation

• The main pulmonary artery is separated from

the pulmonary artery branches and connected to

the ascending aorta. The remainder of the aorta

is reconstructed using homograft material. Blood

is now pumped from the single right ventricle out

the “neo-aorta” to the systemic circulation.

Pulmonary circulation

• Since the pulmonary artery is now committed to

the systemic circulation there needs to be a

source pulmonary blood flow. The Sano shunt is

a Gore-Tex conduit that connects the lungs to

the single ventricle via an incision made in the

anterior wall of the right ventricle.

Image source:

http://radiology.rsna.org/content/247/3/617/F7.expansion

Post-Operative Management Strategies

Optimizing oxygen delivery

• Goal: to achieve normal systemic oxygen delivery. This requires

that the Pulmonary to systemic blood flow ratio (Qp:Qs) is close

to 1

o SvO2 to SaO2 difference of ~25% suggests adequate O2 delivery

Balancing the pulmonary and systemic circulations

• Univentricular output is apportioned by the balance of systemic

and pulmonary resistances

This image has been

removed

Return to Home Return to Pg 2

Post-Operative Norwood Algorithm

The algorithm is divided into three phases with each phase

having specific targets:

• Phase I: Day of surgery to chest closure

• Phase II: Chest closure to extubation

• Phase III: Extubation to ward transfer

• Ward transfer is based on achieving specific transfer criteria

Post-Operative Norwood Algorithm (Cont’d)

Each phase is presented in a system based fashion. There

are two additional sub phases of the algorithm:

• Shock

• Hemostasis

Return to Home Return to Phase 1


Utility of Continuous SvO2 Monitoring in Post-op

CQ: What is the utility of continuous SvO2 monitoring in

post-op Norwood/cardiac surgery patients?

Continuous Sv02 monitoring should be considered in the management

of postoperative Norwood patients.

[ Low quality] (Hoffman, et al., 2000; Hoffman, et al., 2004; Tweddell, et al., 2002)

Routine use of continuous SvO2 monitoring catheters is not

recommended at this time because of the limited experience with the

use of these catheters in this patient population.


Optimal Fluid Management Post-op

CQ: What is the optimal fluid management of post-op

Norwood patients?

During the first postoperative day and night, patients should receive a

½ maintenance rate of IV fluid, using additional bolus fluid

administration to optimize hemodynamics.

(No evidence/Local consensus opinion)


Optimal Diuretic Management Post-op

CQ: What is the optimal diuretic management for post-op

Norwood patients?

Diuretic therapy should be initiated the first post-operative morning

[ Low quality evidence] (Luciani et al., 1997; local consensus opinion)


Phase II: Chest Closure to Extubation

Primary objective:

• Hemodynamic stability with ongoing diuresis in preparation for

chest closure

Protocols:

• Once hemodynamically stable initiate post-op cardiac surgery

feeding protocol


Phase III: Extubation to Ward Transfer

Primary objective:

• Wean support in preparation for ward transfer

Recommendations:

• Patient should be given H2 blockers until they are at 50% of their

goal enteral feeds. The drug should be discontinued unless there

is concern for ongoing stress gastritis or evidence of

gastroesophageal reflux.

[No evidence] (Local consensus opinion)

Transfer to Ward Criteria

• O2 saturation > 75% with NC O2 flow < 1 LPM for over 24 hours

• Tolerated 24 hours of feeding protocol

• Stable hemodynamics without need for vasoactive infusions

• Tolerating intermittent diuretics

• Invasive monitoring discontinued

• Chest X ray stable following most recent chest tube removal

Return to Home Return to Shock

Subphase: Shock

• Primary objective:

o Recognize shock and intervene in a timely fashion

• Recognition:

o Includes standard clinical parameters of poor perfusion:

– Tachycardia, hypotension, desaturation, mottling, decreased urine

output and acidosis

• Intervention:

o Standardized interventions based on distortions of heart rate, central

venous pressures, arterial saturation and blood pressure

Subphase: Shock (Cont’d)

Cardiogenic shock (“Low cardiac output”)

• Common after Norwood palliation

• Definition: inadequate systemic O2 delivery

• Clinical picture: Tachycardia, hypotension, desaturation,

mottling, decreased urine output and acidosis

• Common causes:

o Low cardiac output syndrome

o Arrhythmia

o Pericardial tamponade

o Hemorrhage/anemia

o Pneumothorax

o Ventricular dysfunction

o Residual cardiac lesion

Return to Home Return to Hemostasis

Subphase: Hemostasis

• Primary objective:

o Normalize coagulation profile to reduce bleeding

• Recognition:

o High volume chest tube output or tension of the membrane covering

the open chest

– Bleeding that may require surgical exploration

– Coagulopathy

• Intervention:

o Frank bleeding > 10cc/kg in one hour or > 5cc/kg/hr for 2 consecutive

hours -> notify surgery

o Otherwise target normal parameters for:

– INR, PTT, Fibrinogen, Platelet count, and HCT

Return to Home

Executive Summary

Go to Executive Summary Page 2

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Executive Summary

Return to Executive Summary Page 1

Return to Home View Answers

Self-Assessment

· If you are taking this self-assessment as a part of required departmental training, you will need to logon to

the Learning Center (for SCH only) to receive credit. Completion also qualifies you for 1 hour of Category II

CME credit.

1. Which of the following is not part of the surgical Norwood procedure?a. Aortic reconstruction using pulmonary artery and homograft materialb. Creation of a source of pulmonary blood flowc. Enlargement of atrial communicationd. Aortic valve replacement

2. What is the standard IV fluid rate the first postoperative day and night?a. 25%b. 50% c. 75%d. 100%

3. Which of the following is considered a marker of frank bleeding and is an indication to contact surgery?a. 3 cc/kg in one hourb. 5-10 cc/kg in one hourc. > 10 cc/kg in one hour

4. Which are the following are considered findings in low cardiac output state?a. Tachycardia (HR > 180 bpm)b. Hypotension (SBP < 55 mmHg, MAP < 40 mmHg)c. Desaturation (SaO2 < 75%)d. SaO2-SvO2 > 30e. All the above

5. Infants on ECMO can be enrolled in the pathwy:a. Trueb. False

6. The post-operative Norwood patient diuretics are typically initiated:a. Upon admission to the CICU immediately after surgeryb. The first morning after surgery c. Post operative day 5d. Never

7. In an infant without evidence of gastroesophageal reflux, H2 blockers can be discontinued when:a. Feeds are startedb. Feeds achieve 25% of enteral goalc. Feeds achieve 50% of enteral goal d. Upon transfer to the ward

Return to Home

Answer Key

1. Which of the following is not part of the surgical Norwood procedure?d. Aortic valve replacement

2. What is the standard IV fluid rate the first postoperative day and night?b. 50%

3. Which of the following is considered a marker of frank bleeding and is an indication to contact surgery?c. > 10 cc/kg in one hour

4. Which are the following are considered findings in low cardiac output state?e. All the above

5. Infants on ECMO can be enrolled in the pathway:b. False

6. The post operative Norwood patient diuretics are typically initiated:b. The first morning after surgery

7. In an infant without evidence of gastroesophageal reflux, H2 blockers can be discontinued when:c. Feeds achieve 50% of enteral goal

Return to Home

Evidence Ratings

We used the GRADE method of rating evidence quality. Evidence is first assessed as to

whether it is from randomized trial, or observational studies. The rating is then adjusted in the following manner:

Quality ratings are downgraded if studies:• Have serious limitations

• Have inconsistent results• If evidence does not directly address clinical questions• If estimates are imprecise OR

• If it is felt that there is substantial publication bias

Quality ratings can be upgraded if it is felt that:• The effect size is large• If studies are designed in a way that confounding would likely underreport the magnitude

of the effect OR• If a dose-response gradient is evident

Quality of Evidence: High quality

Moderate quality

Low quality

Very low quality

Expert Opinion (E)

Reference: Guyatt G et al. J Clin Epi 2011: 383-394

To Bibliography

Return to Home

Summary of Version Changes

§ Version 1.0 (8/15/2012): Go-Live

§ Version 2.0 (11/21/2012): Added Exclusion Norwood procedure with BT Shunt

Return to Home

Medical Disclaimer

Medicine is an ever-changing science. As new research and clinical experience

broaden our knowledge, changes in treatment and drug therapy are required.

The authors have checked with sources believed to be reliable in their efforts to

provide information that is complete and generally in accord with the standards

accepted at the time of publication.

However, in view of the possibility of human error or changes in medical sciences,

neither the authors nor Seattle Children’s Healthcare System nor any other party

who has been involved in the preparation or publication of this work warrants that

the information contained herein is in every respect accurate or complete, and

they are not responsible for any errors or omissions or for the results obtained

from the use of such information.

Readers should confirm the information contained herein with other sources and

are encouraged to consult with their health care provider before making any

health care decision.

Bibliography

1084 records identified through database searching

27 additional records identified through other sources

1111 records after duplicates removed

1093 records screened 1066 records excluded

27 full-text articles assessed for eligibility8 full-text articles excluded, 8 did not answer clinical question 0 did not meet quality threshold

19 studies included in pathway

Identification

Screening

Elgibility

Included

Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535

Go to Page 2 Return to Home

Bibliography

Ando, M., Park, I.S., Wada, N. & Takahashi, Y. (2005). Steroid supplementation: a legitimate pharmacotherapy after neonatal open heart surgery. Annals of Thoracic Surgery, 80(5), 1672-1678. doi:10.1016/j.athoracsur.2005.04.035

Bronicki, R.A. (2010). Is cardiac surgery sufficient to create insufficiency?. Pediatric Critical Care Medicine, 11(1), 150-151. doi: 10.1097/PCC.0b013e3181ae4cc4

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Hoffman, G.M., Mussatto, K.A., Brosig, C.L., Ghanayem, N.S., Musa, N., Fedderly,R.T., Jaquiss,R.D. & Tweddell, J.S. (2005). Systemic venous oxygen saturation after the Norwood procedure and childhood neurodevelopmental outcome. Journal of Thoracic & Cardiovascular Surgery, 130(4), 1094-1100. doi:10.1016/j.jtcvs.2005.06.029

Hoffman, G.M., Tweddell, J.S., Ghanayem, N.S., Mussatto, K.A., Stuth, E.A., Jaquis, R.D. & Berger, S. (2004). Alteration of the critical arteriovenous oxygen saturation relationship by sustained afterload reduction after the Norwood procedure. Journal of Thoracic & Cardiovascular Surgery, 127(3), 738-745. doi:10.1016/S0022-5223(03)01315-1

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Naito, Y., Aoki, M., Watanabe, M., Ishibashi, N., Agematsu, K., Sughimoto, K. & Fujiwara, T. (2010). Factors Affecting Systemic Oxygen Delivery After Norwood Procedure With Sano Modification. Annals of Thoracic Surgery, 89(1), 168-173. doi:10.1016/j.athoracsur.2009.09.032

Pasquali, S.K., Hall, M., Li, J.S., Peterson, E.D., Jaggers, J., Lodge, A.J., Marino, B.S., Goodman, D.M. & Shah, S.S. (2010). Corticosteroids and outcome in children undergoing congenital heart surgery: analysis of the Pediatric Health Information Systems database. Circulation, 122(21) 2123-2130. doi: 10.1161/CIRCULATIONAHA.110.948737

Pasquali, S.K., Li, J.S., He, X., Jacobs, M.L., O'Brien, S.M., Hall, M., Jaquiss, R.D., Welke, K.F., Peterson, E.D., Shah, S.S., Gaynor, J.W. & Jacobs, J.P. (2012). Perioperative methylprednisolone and outcome in neonates undergoing heart surgery. Pediatrics, 129(2), e385-91. doi: 10.1542/peds.2011-2034

Photiadis, J., Sinzobahamvya, N., Fink, C., Schneider, M., Schindler, E., Brecher, A.M., Urban, A.E. & Asfour, B. (2006). Optimal pulmonary to systemic blood flow ratio for best hemodynamic status and outcome early after Norwood operation. European Journal of Cardio-Thoracic Surgery, 29(4), 551-556. doi:10.1016/

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Post-Op Norwood pathway

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