Management of Balloon Atrial Septostomy for Congenital Heart Defects in the NICU


Approved by Clinical Practice Committee in collaboration with John Wright & Julie Stubbs (Cardiology)
June 2013
 
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Registrar Responsibilities Nursing Responsibilities Postoperative Care
  Potential Complications  

The Paediatric Cardiology team from Starship Children’s Hospital will determine the need for a balloon atrial septostomy in neonates with congenital heart disease. A paediatric cardiology consultant or fellow will carry out the procedure in the NICU.

Registrar / NS-ANP to ensure:

  1. Cardiologist has obtained written consent from parents.

  2. The Neonatologist on-call is informed and shall attend

  3. Alternative IV access is present for the prostaglandin infusion if the infant is receiving this via an umbilical line and this route is likely to be used for catheterisation

  4. Infant is intubated and ventilated prior to procedure

  5. Fentanyl bolus (10 -20 micrograms/kg) is given prior to procedure; consider second bolus or Fentanyl infusion (1-5 micrograms/kg/hour) if procedure is more than 30 minutes

  6. Skin disinfectant appropriate to gestation

Nursing Responsibilities:

  1. Blood gas, FBC, group & cross-match, and U&Es are taken as ordered. Coagulation profile is not routinely required unless bleeding tendencies are suspected

  2. NBM >4 hours (breast milk) or >6 hrs (formula) and commence intra venous fluids as prescribed

  3. The baby is nursed on a heat table

  4. Fentanyl and Pancuronium should be prepared

  5. Two nurses need to be in attendance to manage ventilation and drug administration throughout procedure

  6. Ensure continuous monitoring including pre and post ductal saturations

  7. Monitor sedation levels

Postoperative Care:

  1. Ensure continuous monitoring is maintained and observations recorded half hourly for the first 2 hours, then hourly of:
    • Cardio-respiratory status
    • Blood pressure
    • Saturations (pre and post ductal)
    • Skin temperature

  2. Keep saturations within acceptable limits (as per cardiology team). Report immediately any changes in baseline levels to registrar/NS-ANP

  3. Maintain ventilation as per orders.

  4. Aim to discontinue sedation and extubate if clinically appropriate.

  5. Review prostin infusion (as per cardiology team).

  6. Observe for signs of bleeding from access sites (umbilical or femoral). Report excess bleeding. Apply pressure as required.

  7. Neurovascular observations of lower limbs. Inform registrar / NS-ANP of discolouration, coolness, and / or decreased pulses

  8. If umbilical lines are to be used post procedure, secure in situ.
    Confirm position with an X-ray prior to commencing fluids.

  9. Arterial / Capillary blood gas as ordered by registrar/ NS-ANP / cardiology team

  10. Ensure adequate analgesia

Note: The infant should not be in pain once the catheter is removed. Ongoing sedation is not required unless for other purposes.
 

Potential Complications of a Balloon Atrial Septostomy

  1. Sinus bradycardia (transient – common at time of procedure, usually self limiting)

  2. Bleeding from access sites

  3. Reduced perfusion to lower limbs

  4. Embolism of clot

  5. Cardiac tamponade (rare)