Pre- and Postoperative Management

I. Preoperative Management

Good preoperative preparation, including complete delineation of cardiac anatomy and assessment of hemodynamics, is mandatory for a smooth operative and postoperative course. Some infants require preoperative stabilization with prostaglandin E ₁ (continuous intravenous [IV] drip at 0.01–0.1 μg/kg/min) to maintain ductus arteriosus patency, whereas others may need inotropic and lusitropic support. Patients with TGA and restrictive PFO may require balloon atrial septostomy.

• 1.

  All children should have a careful history and physical examination within a few days before the procedure. This is to gain full understanding of chronic medical problems (e.g., renal dysfunction, asthma) and to uncover acute medical problems (e.g., upper and lower respiratory, and urinary tract infections) that would mandate rescheduling of elective surgeries.

• 2.

  Laboratory evaluation

  • a.

    Complete blood cell count, urinalysis, and comprehensive metabolic panel, including serum electrolytes and glucose, liver enzymes, blood urea nitrogen (BUN), and serum creatinine, of all cardiac patients are routinely obtained.

  • b.

    Chest radiography and electrocardiogram (ECG) of all patients are obtained.

  • c.

    Cardiac computed tomography angiography (CTA) or magnetic resonance imaging (MRI) if needed to complete the anatomic assessment.

  • d.

    Head and renal ultrasound is performed in most neonates with congenital heart defects. Preoperative brain MRI for patients with complex congenital heart defects is recommended.

  • e.

    For open heart procedures, blood coagulation studies—prothrombin time (PT), activated partial thromboplastin time (aPTT), and platelet count—are obtained.

  • f.

    If necessary, blood should be collected for chromosome studies (karyotyping, fluorescence in situ hybridization [e.g., FISH for chromosome 22q11.2 deletion syndrome—DiGeorge syndrome], and DNA microarray) preoperatively.

  • g.

    Check for chromosome 22q11.2 deletion syndrome (DiGeorge syndrome, and DNA microarray) preoperatively.

• 3.

  Patients undergoing CPB whose weight is more than 3.5 kg are cross-matched for four units of packed red blood cells (PRBCs) and those weighing less for two units of whole blood. One to two units of PRBCs are cross-matched for those undergoing closed procedures. One to four units of platelets are needed for the procedure additionally. Irradiated blood products will be required for immunocompromised patients (e.g., patients with suspected or confirmed chromosome 22q11.2 deletion).

• 4.

  Medications

  • a.

    Angiotensin-converting enzyme (ACE) inhibitors are withheld 24 hours prior to the planned surgery in an effort to minimize anesthesia-induced refractory hypotension during anesthesia induction.

  • b.

    Diuretics are discontinued 8 to 12 hours preoperatively (or this may be individualized).

  • c.

    Digoxin is discontinued after the evening dose.

  • d.

    Antiarrhythmic agents are continued at the same dosage until immediately before the surgery.

  • e.

    Nonsteroidal antiinflammatory drugs (e.g., aspirin, ibuprofen) and antiplatelet drugs (e.g., dipyridamole) are discontinued 7 to 10 days prior to surgery.

  • f.

    Warfarin is discontinued 4 days prior to the planned operation. If the patient is at high risk for thromboembolism, continuous heparin drip is started 2 days prior to the operation and the infusion rate is adjusted to maintain an aPTT of 60 to 85 sec.

• 5.

  Prevention of infection . Broad-spectrum antibiotics are used to decrease the risk of perioperative infection. Duration of antibiotic regimen is institution dependent but can be individualized based on the patient’s age, condition, and comorbidities.

  • a.

    Vancomycin, 10–15 mg/kg/dose IV every 6 to 8 hours (maximum dose 4 g/day).

  • b.

    Clindamycin, 10 mg/kg/dose (adolescents/adults: 600 mg/dose) IV every 6 to 8 hours, starting immediately prior to surgery, is the recommended regimen at some institutions.

  • c.

    Neonates who already receiving ampicillin and gentamicin continue to take these drugs.

  • d.

    Thin layer of mupirocin 2% ointment is applied to both nostrils to prevent methicillin-resistant Staphylococcus aureus (MRSA) colonization.

• 6.

  For older children, the emotional preparation for surgery is as important as the physical preparation.