Biventricular Pathway for infants 6 weeks to 1 year

Transcription

1 Biventricular Pathway fr infants 6 weeks t 1 year Pre-perative care Pre-perative preparatin Pre-perative admissin and Dcumentatin dcumentatin Pre admissin screening Prepare Family/whānau fr theatre and Medicatin management prvide educatin Nutritin Early extubatin Mnitr fr lw cardiac utput Mbilise pre chest drain remval Ensure adequate analgesia Remval f chest drains and invasive lines Ensure adequate analgesia Prepare Family/whānau fr PICU discharge Transfer t 23B IOA Immediate Pst-perative PICU care Day 0 Pst-perative Day 1 EXACT prtcl Pst-perative antibitics Fluid and diuresis Pain management Nutritin Family/whānau supprt Interventins Pain management Fluid and diuresis Nutritin Diagnstic tests Patient handver and discharge dcumentatin Transfer t 23b IOA pst-perative Day 1 Cntinued IOA admissin Daily needs bundle f care Transitin t ral medicatin Fluid and diuresis Initiate Family/whānau discharge educatin Nutritin Pain management Pst-perative Day 2 t Discharge Discntinue telemetry after 24hrs f cntinuus mnitring frm IOA admissin Liberalise ral fluids and cmmence diet as age apprpriate Ensure adequate analgesia Prepare t discharge Expected length f hspital stay 5-6 days Pst Discharge Management Interventins Fluid and diuresis / Nutritin Pain management Daily needs bundle f care Diagnstic tests Family/whānau supprt and discharge educatin 2-4 weeks pst discharge Discharge frm Service 1

2 Biventricular Clinical Pathway Inclusin/exclusin criteria Inclusin Criteria >6 weeks -1 year f age Islated VSD s (inlet, utlet, muscular) AVSD Tetralgy f Fallt with preservatin f pulmnary valve ASD + VSD VSD/AR Simple pulmnary valvtmy N Exclusin Criteria Infants < 6 weeks TGA +/- VSD Arch bstructin Single Ventricle Physilgy Tetralgy f Fallt requiring a transannular patch Yes Patient eligible fr clinical pathway Dcument patient is t fllw pathway in the clinical ntes Patient is nt eligible t cmmence the clinical pathway The purpse f the variance recrd is t track and dcument variatins frm the clinical pathway Variatins and actins need t be recrded n the pathway by either nursing r medical team 2

3 Pre-perative care 23B Cmplete pre-perative admissin and dcumentatin Prepare Family/whānau fr theatre and prvide educatin Pre perative preparatin Date Medical admissin (see cardiac surgery admissin guideline) Ages and Stages questinnaire Resus chart Shwer and chlrhexidine wipe the night prir t surgery and the mrning f surgery Organise interpreter fr cnsent if required Ward leave frm t be cmpleted if patient is suitable fr Rnald McDnald huse vernight Dcumentatin Admissin t discharge planner Pre-p checklist (see cardiac surgery admissin checklist) Cnsent - If nt cmpleted by 5pm, Clinical Charge Nurse r shift crdinatr t fllw up Preadmissin screening Medicatin management AVSD Chrmsmal screening fr T21 perfrmed Tetralgy f Fallt 22q deletin screen with further testing if psitive Overseas patients MRSA + MSSA screening (nasal and grin swab) MRO screening (rectal/faeces swab) Patients frm ther hspitals MRSA + MSSA screening Ptassium sparing diuretics - withhld fr 24 hurs prir t surgery Lp diuretics - withhld mrning dse ACE inhibitrs - withhld mrning dse Beta blckers - mrning dse can be given with small sip f water Anti-staph bundle mupircin treatment Pre-medicatin charted Nutritin Establish NBM times (see anaesthetic fasting guideline and cardiac surgery admissin prcess guideline) Des patient have any f the fllwing Temp > 37.5 Signs f chest infectin Infected skin lesins Vmiting /Diarrhea fr the last 24 hurs Infectius cntact. i.e. Chicken px, measles Actin Cntact surgical Fellw/Registrar t review patient Theatre delayed r cancelled Recmmence pathway nce theatre date is cnfirmed Dcument variance belw 3

4 Immediate pst-perative care Day 0 PICU Early extubatin Mnitr fr lw cardiac utput Adequate analgesia Date: EXACT prtcl EXACT as per 2 r 6 hur prtcl Administer supplemental O2 t maintain Sp02 >93-98% Identify patients suitable fr early chest drain remval prtcl n 2000hrs ward rund Mbilise pre chest drain remval CLAB and Glamrgan Pst-perative Cephazlin - 2 dses pst-perative antibitics Fluid and diuresis Discntinue IV maintenance fluids pst extubatin Accurate fluid balance Nutritin Encurage ral fluids pst extubatin nce cardirespiratry status stable Liberalise ral fluids if(?) n fluid restrictin is required Pain management Fllw PICU unintubated 0-12 mnths analgesia and sedatin algrithm Family/whānau supprt Q6 hrly paracetaml Q8 hrly ibuprfen (can be administered n an empty stmach) unless: Patient is < 3mth ld Evidence f bleeding Renal impairment is present Patient is receiving captpril Antiemetic if child has pstperative nausea r vmiting (first line ndansetrn) Orientate Family/whānau t PICU Surgical educatin pst PICU admissin Actin Diversin frm the EXACT prtcl, child n lnger fllws the pathway and care is managed as per care f the cardiac child PICU guideline Fllw care as per care f the cardiac child PICU guideline Pain and sedatin management as per PICU intubated 0-12mnths analgesia and sedatin algrithm Recmmence pathway nce patient is extubated Dcument variance belw 4

5 Pst-perative Day 1 PICU Remval f chest drains and invasive lines Ensure adequate analgesia Transfer t 23b IOA Date: Interventins Wean O2 t maintain SpO2 >93-98% Remve chest drains at 0600 if patient meets early chest drain remval criteria r pst-surgical ward rund Mbilise pre chest drain remval Pst ward rund remve Central line Arterial Line Fley catheter Ensure 1x functining IV cannula remains insitu Cmplete CLAB and Glamrgan Diagnstic tests Chest x-ray pst chest drain remval Pst-perative ECG prir t surgical ward rund Pain management Fllw PICU unintubated 0-12 mnths analgesia and sedatin algrithm Q6 hrly paracetaml Q8 hrly ibuprfen unless Patient is < 3mth ld Evidence f bleeding Renal impairment is present Patient is receiving captpril Antiemetic if child has pstperative nausea and vmiting (first line ndansetrn) Nutritin Encurage breast/ral feeding Child is able t upgrade t nrmal daily intake as tlerated, n fluid restrictin is required Remve nasgastric tube if child is tlerating medicatin and feeding rally Fluid and diuresis Administer BD IV frusemide 1mg/kg and ptassium sparing diuretic at 06:00hrs if PICU discharge dcumentatin and patient handver Family/whānau supprt K+, Urea and Creatinine are nrmal Accurate fluid balance Medical team review chest x-ray pst drain remval, prir t transfer t 23b Discharge dcumentatin cmpleted including PEWS scre, Pain team and PaR team referral if required. Medical staff t call 23b admissin phne and verbally handver t Registrar/NP prir t transfer Prepare Family/whānau fr PICU discharge Family/whānau educatin Actin Failure t discharge frm PICU due t a change in clinical status Recmmence pathway nce child s clinical status is stable and ready fr transfer t 23b Dcument variance belw 5

6 Pst-perative Day 1 cntinued Ward 23B IOA admissin Transfer t 23b IOA Cnsider transitining t ral medicatin Initiate family/whānau discharge educatin Date: IOA admissin Medical admissin, review diagnstics tests Cntinuus mnitring as per Starship bservatins and mnitring guideline fr 24hrs pst IOA admissin Wean O2 t maintain SpO2 >93-98% Daily needs bundle f care Hygiene needs/ral care Glamrgan Mbilise as develpmentally apprpriate ut f bed, sitting up, ut fr cuddles with Family/whānau Pain Management Q6 hrly paracetaml Q8 hrly ibuprfen unless Patient is < 3mth ld Evidence f bleeding Renal impairment is present Patient is receiving captpril PRN Oral Mrphine Antiemetic if child has pstperative nausea and vmiting (first line ndansetrn) Nutritin Encurage nrmal daily intake as tlerated Encurage breast/ral feeding Remve nasgastric tube if patient is tlerating medicatin and feeding rally Fluid Diuresis Cntinue BD frusemide 1mg/kg and ptassium sparing diuretic Family/whānau supprt Cnsider transitining t ral diuretics Accurate fluid balance Family/whānau educatin Supprt family/whānau t participate in child s care Actin Failure t discharge frm PICU due t ward capacity Patient cntinues n pathway in PHDU and can bypass the IOA if pst-p day 1 gals have been achieved Dcument variance belw 6

7 Pst-perative Day 2 t pst-perative Day 4 Ward 23B Aim fr discharge pstperative day 3 r 4 Ensure adequate analgesia Liberalise ral fluids and encurage nrmal daily intake as tlerated Prepare t discharge Fluid and Diuresis Pst p day 2 Date: Day 3 pst p Date: Day 4 pst p Date: Transitin t ral diuretics BD r daily if Absrbing feeds N evidence f CHF Weight is tracking back twards pre-p weight N clinical signs f dehydratin Daily weight Accurate fluid balance Nutritin Encurage breast/ral feeding Encurage nrmal daily intake as tlerated Cntinue with ral diuretics BD r daily Daily weight Encurage breast/ral feeding Encurage hme diet as age apprpriate If ral intake is less that 70ml/kg/day discuss with medical team Cnsider reducing r stpping diuretics Daily weight Encurage breast/ral feeding Encurage hme diet as age apprpriate Interventins Check diagnstic tests are cmpleted fr remval f pacing wires n day 3 pstp Transfer ut f IOA if child is clinically stable and prgressing as expected Discntinue telemetry if patient meets the belw criteria Alert Electrlytes within nrmal levels Sinus rhythm fr the last 24 hurs Child is clinically stable and prgressing as expected Cmmence lactulse daily if BNO Surgical wund review Remve pacing wires as per pacing wire remval prtcl and Discntinue mnitring as per pacing wire remval prtcl Remve all dressings n dry wunds Remve peripheral IV 6 hurs pst pacing wire remval if child is clinically stable Cnsider discharging in the afternn if child has prgressed well and meets the discharge criteria Discharge if child has prgressed well and meets the discharge criteria Care cntinues n the next page 7

8 Pain Management Diagnstic tests Daily needs bundle f care Infectin surveillance Parental discharge educatin Discharge criteria Discharge referrals Pst p day 2 Date: Day 3 pst p Date: Day 4 pst p Date: Q6 hrly paracetaml Cntinue with regular Q6 Q8 hrly ibuprfen unless hrly paracetaml Patient is < 3mth ld PRN ibuprfen Evidence f bleeding PRN Oral Mrphine Renal impairment is present Antiemetic if required Patient is receiving captpril PRN Oral Mrphine Antiemetic if required U and E s Echcardigram is required prir t discharge Cntinue with regular paracetaml PRN ibuprfen Antiemetic if required Bath/ral hygiene Supprt family/whānau t care fr child Mbilise as apprpriate sitting up, ut f bed, cuddles with Family/whānau Encurage nrmal develpmental play activities as tlerated Glamrgan Pyrexia f < 38.5 within 48 hurs can cmmnly be assciated with a SIRS respnse Ensure patient is hydrated and manage with paracetaml See variance recmmendatins fr temperature >38.5 Cmmence discharge educatin Wund educatin Medicatin educatin Signs f when t seek medical advice Oral feeding has been sufficiently established Patients still requiring diuretics n day f discharge can cntinue with daily frusemide and ptassium sparing diuretic fr ne week Patients receiving diuretics pre-p can cntinue with daily frusemide and ptassium sparing diuretic fr tw weeks Discharge t lcal hspital n day 4 if child is cardivascularly stable but requires n-ging feeding supprt Review medicatin prir t discharge Family/whānau discharge educatin cmpleted Wund review and remval f sutures by the GP n day 7-10 pst p If the wund has interrupted sutures, remval f sutures is rganised by the surgical team fr 14 days pst-p Hme care nursing referral Neurdevelpment referral (see neurdevelpment fllw up f cardiac patients guideline) Rutine check by GP within the first week f discharge Arrhythmias On-ging xygen requirement frm day 3 pst p Temperature > 38.5 C Actins Arrhythmia Oxygen Cnsult with Cardilgist Clinical examinatin Delay pacing wire remval Review last chest x-ray Cntinue ECG mnitring Cnsider fluid verlad as cause Check electrlytes Dcument variance belw Temperature Clinical examinatin Check wund Review last CXR FBC/bld cultures MSU sample 8

9 Pst-discharge management 1 week pst discharge Rutine check by GP within the first week f discharge Diuretics t be stpped by GP after 1 week Children receiving diuretics pre-p, cntinue n daily diuretic management fr 2 weeks 9