Rosa Nanini 1

Isabella Rosa Nanini

Mr. Speice

Independent Study and Mentorship- 3A

23 January 2017

A Support Group for the Pediatric Cardiothoracic Community

http://isabellananini.wixsite.com/theirheartproject

What is the Their Heart Project?

The Their Heart Project was created in hopes to support the pediatric cardiothoracic

community by creating a support group within families. By sharing your story on our forum

feature families can create a discussion or just simply share their experiences. The overall goal of

this community is that families with children undergoing or who have undergone pediatric

cardiothoracic surgery will not feel alone, and that they will connect with others for the

betterment of their heart (the child's heart).

The Their Heart Project was created by Isabella Rosa Nanini, a junior at Reedy High School

studying pediatric cardiothoracic surgery as part of a program called Independent Study and

Mentorship offered in Frisco ISD. Part of the program in to create an original idea achieved

throughout research conducted during the first semester of school. Isabella has been researching

pediatric cardiac critical care when she came upon a couple of youtube videos made by families

with children undergoing pediatric cardiothoracic surgery who chose to share their story. Isabella
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saw that there was a need for an outlet where families could share their story in one simple

location, so she decided to create that outlet. This outlet is now the Their Heart Project, and her

research is displayed on our "The Journey" page.

The Their Heart Project Mission Statement

The Their Heart Mission is to support the pediatric cardiothoracic surgery community by

providing an outlet where families with children undergoing or who have undergone pediatric

cardiothoracic surgery can share their experiences and stories. We hope to connect these families

for the overall betterment of Their Heart, and to create a community where these families will

never feel alone.

Share your Story Forum

This forum allows a family member to create an account and create a post on a page they would

like to share their story on.

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The Journey: A Research in Pediatric Cardiac Critical Care

Several factors go into the care of a child after cardiothoracic surgery, and in hopes to

better understand the effects of pediatric cardiothoracic surgery on a patient I have chosen to

research pediatric critical care. In this research you will find an overall overview of the general

process of pediatric cardiac critical care, and risk factors that come after surgery. Keep in mind

that this is just a general overview and that your own postoperative journey may be different.

All you need to know about Pediatric Cardiac Postoperative Care

The Neonatal Heart

The neonatal heart is very different from the fully mature adult heart. First the neonatal

heart has decreased myocardial contractile force, and the heart contains 50% reduction in

myofibers and a greater quantity of non connective tissue. These myofibers are also aligned in a

non linear pattern. Overall the neonatal heart is dependent of an accelerated heart rate and

catecholamines rather than preload.

Cardiopulmonary Bypass (CPB)

The CPB is essential to congenital heart disease and pediatric cardiothoracic surgery.

This was a huge advancement in postoperative care and in the betterment of recovery for

patients. Management of CPB for congenital heart disease differs from that for adults because of

the problems of aortopulmonary shunts, the immature cardiovascular system, and the eventual

use of deep hypothermic circulatory arrest. During deep hypothermic circulatory arrest, the blood

available in the systemic veins (generally the cavas vein) is drained to the oxygenator, which

provides oxygen, removes carbon dioxide, and reduces the blood temperature. In the process, the

oxygenated blood returns to the aorta by a system of pumps that generates continuous flow from
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the CPB to the patient. In general, CPB alters all physiological processes of the organism and

may lead to organic dysfunction of different magnitudes. The morbidity associated with CPB is

largely associated with damage to blood elements and proteins caused by blood gas alterations

and the prosthetic surface interface.

Postoperative Care

Adequate monitoring during the postoperative period involves a combination of clinical

or auxiliary methods for evaluating the surgical correction, myocardial function, and the

relationship between systemic and pulmonary blood flow. Standard monitoring in the

postoperative period is similar to that during anesthesia and surgery. Sometimes, depending on

the clinical evolution, more sophisticated monitoring may be added to facilitate clinical diagnosis

and treatment. Standard monitoring consists of ECG, direct arterial pressure,temperature probe,

and central venous pressure. In the first stage of recovery the patient needs intense monitoring. In

postoperative care of the pediatric patient, clinical evaluation must be complete and systematic.

Consequently, complications can be foreseen, and catastrophic situations can be avoided. Care

should be initiated while the child is still in the operating room, with special attention to

rewarming to 36.5C, control of bleeding, ventilation, and acid-base and electrolyte balance. It is

very important during this phase to stabilize cardiac function through maintaining correct

intravascular volumes, adequate heart rate, and adequacy of myocardial contractility. Another

important factor in postoperative care is a strong and effective ICU team and cardiac team.

Clinical Examination

Important clinical signals for the evaluation of cardiac output are perspiration, adequate

level of consciousness, coloring and temperature of extremities, thermal gradient between knees
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and feet, central and peripheral thermal gradient, amplitude of peripheral pulse, capillary filling,

arterial pressure, and urinary output. Accordingly, cardiac output is considered adequate when

there is no cold perspiration or psychomotor agitation, the members of extremities are warm and

colored, the feet are hotter than the knees, the central-peripheral thermal gradient is less than

4oC, the peripheral pulse is easily palpable, capillary filling is satisfactory, arterial pressure is

within the normal limits for the age group, and urinary output is greater than l mL/kg/hour. It is

important to remember that adequate peripheral vasodilatation only occurs after the fourth

postoperative hour, with normal re-establishment of tissue perfusion around the sixth

postoperative hour. Examining a patient can prevent and treat complications after surgery.

Low cardiac output

Low postoperative cardiac output is primarily caused by reduction in myocardial contractility

caused by one of the mechanisms or factors above mentioned. Severe myocardial dysfunction

can be observed, for example, in more complex congenital heart disease that demands a lengthy

CPB procedure and aortic clamping. Left anomalous coronary artery in the pulmonary trunk,

hypoplastic left heart syndrome, transposition of the great arteries, severe tetralogy of Fallot, and

severe pulmonary hypertension are all associated with significant risk of poor cardiac function

after surgery. The LCOS is a well-recognized, frequent post-operative complication with an

accepted collection of hemodynamic and physiologic aberrations. Approximately 25% of

children experience a decrease in cardiac index of less than 2 L/min/m2 within 6-18 hours after

cardiac surgery. Post-operative strategies that may be used to manage patients as risk for or in a

state of low cardiac output include the use of hemodynamic monitoring, enabling a timely and

accurate assessment of cardiovascular function and tissue oxygenation; optimization of

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ventricular loading conditions; the judicious use of inotropic agents; an appreciation of and the

utilization of positive pressure ventilation for circulatory support; and, in some circumstances,

mechanical circulatory support. All interventions and strategies should culminate in improving

the relationship between oxygen supply and demand, ensuring adequate tissue oxygenation.

Postoperative Fever

A fear in pediatric cardiac surgery for both the surgeon and the patient is postoperative fever, a

common postoperative problem in pediatric cardiac surgery. Fever after surgery is most of the

time benign and self limiting; however, fever that develops after the first 48 hours can be

dangerous. Postoperative fever is generally related to the use of cardiopulmonary bypass(CPB),

hypothermia, and post- perfusion syndrome. Noninfectious causes include, blood contact with

the CPB circuit, presence of endotoxemia, and the development of ischemia reperfusion injury

secondary to aortic cross- clamping. Trauma and the incidence of postpericardiotomy is also a

noninfectious cause of postoperative fever. The next type of cause discussed by the article were

nosocomial infections, common nosocomial infections are bloodstream infections, lower

respiratory tract infections, and surgical site infections. The approach to postoperative fever is

discussed next. A fever within the first 24 hours after surgery is an inflammatory response to

CPB, which means it will usually resolve by itself. The presence of fever 48 hours after surgery

is when an evaluation of the cause of the fever is appropriate, because it indicated a deep- seated

infection that is dangerous to the patient. This evaluation includes a careful history, targeted

physical examination, and additional tests and studies. History is also important to note when

searching for the cause of a deep-seated infection. Young infants with a fever are more likely to

have an infection. According to the article Patients with poor nutrition or/and
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immunosuppressed are more likely to develop nosocomial infections. Drug hypersensitivity is

important to look at when searching for a cause of a fever as well. Preoperative care is also

important to note since patients with a previous infection can carry several risks related to a

postoperative infection. Continuous and careful examinations are important in postoperative care

to ensure a fevers cause and if an infection is present. Several tests should also be conducted.

Work Cited

Otavio Costa Auter, Joao et al. PEDIATRIC CARDIAC POSTOPERATIVE CARE. Revista

Do Hospital Das Clnicas, vol. 57, no. 3, 18 May 2001,

doi:http://dx.doi.org/10.1590/S0041-87812002000300007 .

Gupta, Ajayk et al. Approach to Postoperative Fever in Pediatric Cardiac Patients. Annals of

Pediatric Cardiology, vol. 5, no. 1, 2012, pp. 6168. doi:10.4103/0974-2069.93714.

"Management of the Low Cardiac Output Syndrome Following Surgery for Congenital Heart

Disease." Current Cardiology Reviews. U.S. National Library of Medicine, n.d. Web. 23

Jan. 2017.

Guidelines for the General Principles of Postoperative Care: The Neonatal and Pediatric

Cardiac Surgery Patient. Guidelines for the General Principles of Postoperative Care:

The Neonatal and Pediatric Cardiac Surgery Patient.

Surgical Site Infection After Pediatric Cardiothoracic Surgery . World Journal for Pediatric

and Congenital Heart Surgery, vol. 8, no. 1, 29 Dec. 2016, pp. 712.

doi:10.1177/2150135116674467.
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Mohamed, Saleh. Implementation of Enhanced Recovery after Surgery in Pediatric Cardiac

Practice: a Synopsis. Ainh- Shams Journal of Anaesthesiology, vol. 8, Oct. 2015, p. 464.

Health and Wellness Resource Center [Gale], doi:10.4103/1687-7934.172664.