Download Am I Blue: Cardiac Classifications

Am I Blue:
Cardiac Classifications
Lori Erickson MSN, CPNP
The Ward Family Heart Center
Children’s Mercy Hospital
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Disclosure
 No financial disclosures
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Objectives
 Identify the Neonate with potential
cardiac v. respiratory problem
 Discuss babies prenatally diagnosed
and how to manage at delivery
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Outline
 Overview of fetal physiology
 Review of Neonatal heart disease
including
– Physiology
– Clinical presentation
 Cardiac Delivery Classification for
prenatal diagnosis
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Background
 Early Diagnosis
 Prenatal
 Postnatal
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Fetal
Physiology
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Birth Changes
 Lungs expand, 02
increased
 Pulmonary vascular
resistance drops
 Pulmonary venous
return increases
 Ductus arteriosus flow
reverses
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What fetal structure is kept open with the
medication prostaglandin (PGE)?
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s
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Du
ct
A. Patent Foramen
Ovale
B. Ductus
Arteriosus
C. Ductus Venosus
D. Ventricular
Septal Defect
Congenital Heart Disease
(CHD)
 Electrical
– Arrhythmia
 Plumbing
– Blockage with any of the 4 valves have stenosis
or atresia
– Great vessels not hooked up correctly
– Holes in heart
 Function
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CHD Overview
 Goals of CHD evaluation
– Early recognition of disease
– Knowledge of physiology
– Resuscitation and stabilization
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Delivery Classification
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 Baby
 NNP
 Mother
 Cath Doc
 Father
 Cardiac Surgeon
 Neonatologist
 3 CV nurses
 Cardiologist
 2 cath nurses
 RN1
 Fetal Cardiac APRN
 RN2
 Fetal Cardiac RN
 RT
 CV Perfusion (4)
 ECHO tech
 Cardiac Anesthesia
 Neo 2
 OB team….
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Fetal ECHO’s
 Only primary cardiac
diagnosis
 See another 100 patients
with multiple conditions
 70% delivered at CMH
 60% of Class I delivered
elsewhere
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Preparation
 High risk, low
frequency cases
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Class I
 Stable
Hemodynamics
anticipated
 Examples:
 CAVC
 Truncus
arteriosus
 Non-Ductal
dependent
 TOF
 VSD
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Class I: Behavers
 Normal NRP
assessment and
evaluation
 Monitor for adequate
pulmonary and
systemic blood flow
 Echo after birth when
able
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Tetralogy of Fallot (TOF)
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Class I Expectations
 Cardiology consult after birth
 Follow-up in outpatient clinic
 No neonatal surgery planned (first 30 days of
life- may need it later)
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Class II: Neonatal surgery
 Stable
Hemodynamics
anticipated
 Examples:
 HLHS
 Single ventricle
with atresia
 Ductal dependent
lesions
 COA
 Hypoplastic
aortic arch
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Hypoplastic Left Heart Syndrome
(HLHS)
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Class II: Expectations
 Single ventricle
hemodynamics
 Most require PGE
infusion
 Pulmonary flow
 Systemic flow
 Surgery 1st 1-2 weeks
of life if term
 Umbilical lines
 Side effects of PGE
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Class II Evaluation
 Pulse oximetry
– Sat 75-85%
– Location of desaturation
 Ventilation
 ABG
– Possible Low pO2
– No significant metabolic acidosis unless
profoundly cyanotic or low cardiac output
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Class II Misbehaving
 Not acting right?
– NRP
– Evaluate hemodynamics
– Mixing appropriately
– Output getting to systemic and pulmonary
blood flow
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Class III: Expecting badness
 Possible
Hemodynamic
instability
 Examples:
 d-TGA
 TAPVR
 Heart Block
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Class III Expectations
 Cardiology in house for
echo
HELP!
 Ready for inotropic
support, airway support
 Communication earlyTroops on stand-by
 Cardiac cath on hold
 CV surgery on hold
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Clinical Presentation
 Cyanotic right from birth- 50-60’s
 Severe respiratory distress
 Weak to normal pulses
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Class III
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What do you think this above case is most likely?
Cardiology isn’t available yet- stuck in traffic
coming to your hospital
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ia
te
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l
bi
la
Se
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re
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pn
eu
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m
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ou
s
A. Meconium
Aspiration
B. Pulmonary
Hypertension
C. Total Anomalous
Pulmonary
venous return
D. Severe bilateral
pneumonia
TAPVR
 Infradiaphragmatic
TAPVR
 Pulmonary veins
return to confluence
that drains down
below the
diaphragm and
enters inferior vena
cava
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Class IV: Calvary
 Hemodynamic
 Examples:
Instability expected
 HLHS with
at separation from
restrictive atrial
placental
septum
circulation
 d-TGA with
restrictive atrial
septum
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D-tga with RAS
 Survival depends on
mixing of blue and red
blood
 Immediate
septostomy
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Class IV Expectations
 Everything for class III PLUS delivery in
cardiac OR
 Cardiac Anesthesia in delivery
 LIFE SAVING
 Only getting them stable to get to the
first surgery
 Long road ahead
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Is it Heart?
 Extremely varied presentation
 As pulmonary vascular resistance drops
– Pulmonary blood flow will increase
– Saturations will increase
– Pulmonary over-circulation may result in heart
failure (tachypnea, grunting, retractions,
tachycardia)
 Generally not distressed until develop heart
failure (gradual)
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Likely Heart Disease
 Massive cardiomegaly with poor
cardiac output, gallop and/or murmur
 Obvious dysrhythmia
– Bradycardia
– Extreme tachycardia
– Non-perfusing rhythm
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Possible Heart Disease
 Respiratory distress and cyanosis
– Most often pulmonary/infectious etiology
– May be cardiac (or combination)
– Chest x-ray may or may not be helpful in
distinguishing between etiologies
– Support as needed and early transfer to
tertiary care center for evaluation and
management
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What cardiac delivery classification
is a HLHS with no ASD restriction?
0%
0%
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ss
ifi
...
IV
Cl
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as
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Cl
Class I
Class II
Class III
Class IV
What’s a delivery
classification?
Cl
A.
B.
C.
D.
E.
Final thoughts
 High Risk, low frequency
 Life saving interventions
 Delivery with CMH only if have to!
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