Sreedevi S P

Staff Nurse – B
CHICU
No Direct Connection Between Any
Pulmoary Vein And Left Atrium

All The Pulmonary Veins Connect To

Right Atrium Or One Of Its Tributaries
Key Points In Postoperative Care

Maintain adequate Cardiac Output

Keep the Left Atrial Pressure

as low as possible

Prevention and Management of

PAH Crises
The Concerns….
Diagnosis
Reception to the ICU….
 ICU Hand Over
 ICU Hand Over Chart…..
♣ Properly ventilating
♣ Connections are secured
♣ Settings according to the age,
weight and condition

► SpO2 98 – 100 %
► PaO2 > 100 mm Hg
► PaCO2 35 – 40 mm Hg
► Low airway pressure

VAP Care Bundle

Haemodynamic Monitoring
Heart Rate

Tachycardia

Bradycardia

Paced or non-paced

If paced, mode, output, and sensitivity

Rhythm issues
 Blood pressure

• Neonates – ♠ Inotropes
♥ Maintain
Milrinone -
mean BP of 40 – 45 mm Hg
adequate 0.5 mics/kg/min
• Older children –
Cardiac Noradrenaline -
mean BP of 55 – 60 mm Hg
0.05 mics/kg/min
Output ♠ Crystalloids
• PAP should be < 2/3 rd the systemic pressure
• In PAH Crisis, PAP becomes suprasystemic

PA pressure

• ♦ Phospho diesterase inhibitors

• ◊ Inj. Milrinone 0.5 mic/kg/min
• ◊ Inj. Sildenafil 0.3 mg/kg/hr
• ◊ Tab Bosentan 1mg/kg
• ◊ ACE inhibitors
Pulmonary Artery Hypertensive Crisis

 A syndrome of hyperacute rise of

systolic pulmonary pressure (>50% of
systemic pressure)

 A profound reduction in cardiac output

 An abrupt fall in saturation.

Identification Of PAH Crisis
On Ventilator???
Deranged
 High PAP ABG
values
 High airway pressure

 Tachycardia

Desaturation

 Hypotension

 Bradycardia

 High CVP
 Pulmonary
vasodilators

Sedation

Attenuate
noxious stimuli
suctioning
If PAH crisis occurs…

Correct acidosis

100% Oxygen

Hyperventilate

Sedate

Pulmonary Vasodilators & Inotropes

Use of Nitric Oxide…

Diffuse through alveolar

capillary membrane &
Pulmonary Artery muscles

Activation of
Intracellular
soluble guanylate
cGMP
cyclase

More blood flow

Relaxed
from the heart to
muscles
the lungs
Key points..

Monitor PAP, ABP, CVP, & SpO2

Sedation and additional hyperventilation

Weaning after 24 hrs

Reduced slowly from 10 to 0 – 5 ppm

Sudden weaning leads to hypoxia and rebound PAH

During weaning, ABP and PAP monitored

 Collapsed lung
Hypotension & breathing
difficulties

NO Toxicity

Methemo- Withdrawal
globinemia symptoms
Off Ventilator???

Poor feeding

Irritability and high pitched cry

Hepatomegaly

Cool extremities

Desaturation
If PAH crisis occurs……
Oxygenation

Sedation

Inotropes &
Pulmonary
Vasodilators

Fluids

Reintubation
ABG analysis

PaO2 > 100 mm Hg

PaCO2 35 – 40 mm Hg

Alkalotic pH

Induce respiratory alkalosis

Prevent metabolic acidosis

 0.5 – 1 ml/kg/hr
Urine
Output Diuretics

Ascitis

Peritoneal dialysis

Aim to keep Fluids only at

CVP 8 – 10 mm Hg
negative 2ml/kg/hr
 <5
ml/kg/hr

Anti Inter costal Check for

coagulants drainage collection

Blood
transfusion
Hb
Care of Open Sternum Use Of Standard Precautions

Infection Control

Care Bundles Use Of Antibiotics

Temperature

Nutrition
Weaning and extubation

Gradual
NPO ABG
weaning

Extubated to
Room air Oxygen
NIV
 Ward or
PA line discharge
removal
Mobilize

Build up
on feeds

Pulmonary
toileting
Prevention of complications

Early Late

Pulmonary oedema Pulmonary venous obstruction

Pulmonary hypertensive crisis Anastomotic stricture

Phrenic nerve damage Pulmonary venous stenosis

Rhythm disorders
Care of PA line

Blocked once haemodynamically stable

Removed after 5 days

Coagulation parameters

Removed along with pacing wires under sedation

ECHO & X-ray

 Infection
control
practices

Feeding Alert for…

Home care

Follow up Medicine
compliance