- Email: [email protected]
Patent Ductus Arteriosus Ligation: Performing Surgery Outside the Operating Room
JANUARY 1991, VOL. 53, NO 1
AORN JOURNAL
Patent Ductus Arteriosus Ligation PERFORMING SURGERY OUTSIDE THE OPERATING ROOM
Kathryn R. Huddleston, RN
E
ven though surgical procedures are best performed in the operating room, critically ill neonates requiring assisted ventilation often cannot be safely or easily transported to and from the OR. In this situation, the surgical team at The Children’s Hospital, Denver, performs surgery in the neonatal intensive care unit, which is known as the newborn center.
Patient profile
T
he Children’s Hospital is a 225-bed regional pediatric hospital, which has a 30-bed newborn center. As a referral center for high-risk infants from approximately 200 hospitals in portions of eight states, approximately 700 high-
risk infants are admitted to the newborn center each year. Of those admitted, 30% have a birth weight of less than 1,500 g (about 3 lbs), 75% require ventilator support, and 27% have congenital malformations requiring specialized medical and surgical care.’ During 1989, 6,975 surgical procedures were performed at The Children’s Hospital. Ninety-five procedures were performed in the newborn center. (See “Procedures Performed in the Newborn Center in 1989.”) Ligation of patent ductus arteriosus (PDA) is the most frequently performed surgical procedure in the newborn center. The neonatologist and surgeon make the decision to perform surgery in the newborn center based on whether the infant requires extracorporeal membrane oxygenation (ECMO), requires high-frequency ventilation (ie, up to 450 oscillating breaths per minute), and is a critically unstable, ventilated, small infant (eg, as premature as 24 to 30 weeks gestation, weighing 500 to 1,000 g).
Special Nursing Considerations
Kathryn R. Huddleston, BSN, CNOR, is a clinical level IVstaffnurse in the operating room at The Children’s Hospital, Denver. She earned her associate of science degree in nursing and her bachelor of science degree in nursing from Metropolitan State College, Denver.
P
racticing perioperative nursing outside the OR requires careful planning. The primary concern and the most obvious drawback is sterility. Every step must be taken to minimize the risk of infection to the infant. The infant’s primary nurse plays a vital role in collaborating with the perioperative nurses to ensure a successful, infection-free, surgical outcome. Second, every item needed for the procedure 69
JANUARY 1991, VOL. 53, NO 1
must be taken to the newborn center from the OR. Third, it is difficult for the newborn nurses to care for patients in the vicinity of the patient having surgery. Surgical equipment and personnel are distracting and inconvenient to work around. Despite the drawbacks, there are advantages to operating on these particular patients in the newborn center instead of the OR. By performing surgery in the newborn center the surgical team can prevent patient hypothermia, inadvertent extubation, and interruption of vascular access and monitoring. Radiant warmers are used for critically unstable neonates because they prevent heat loss through radiation and because they provide quick and easy access to the infant (Fig 1). When surgery is performed in the newborn center, the neonate's thermoregulatory needs are not compromised because he or she is never moved from the radiant warmer where the procedure takes place (Fig 2). Complications that might occur because of monitoring interruptions are avoided by performing surgery in the newborn center. Infants do not have to be switched from newborn center monitors and equipment to portable monitors, and then have the process repeated before the infant is returned to the newborn center.
Etiology, Treatment Patent Ductus Arteriosus
I
n the fetus, the patent ductus arteriosus is an important communication that shunts blood from the pulmonary artery into the aorta. During fetal life, the lungs are inactive and blood is oxygenated in the placenta? The patent ductus closes soon after birth. Closure of patent ductus in the newborn is caused by a rise in arterial oxygen tension, which occurs when respiration begins. Failure to close may be due to immaturity of the ductus, hypoxia in the infant, or primary structural abnormalities of the ductal wall. Structural abnormalities are often the cause in the term or mature infant, while in the premature baby, hypoxia (usually due to respiratory distress syndrome), and immaturity of the ductus are the caw? Epidemiological studies show patency of the ductus arteriosus is the second most frequent
AORN JOURNAL
Procedures Performed in the Newborn Center in 1989 Ligation of patent ductus arteriosus 39 *ECMO cannulation 22 *ECMO decannulation 20 Broviac catheter insertion 5 Reposition of ECMO cannula 1 Direct laryngoscopy and bronchoscopy 1 Diaphragmatic hernia repair 1 Anoplasty 1 Cauterize subcapsular (liver) hematoma 1 Colostomy and circumcision 1 Insertion chest tube 1 Exploratory laparotomy 1 Revision ileostomy 1 *EMCO cannulation and decannulation are performed only in the newborn center.
cardiac defect accounting for 9% to 12% of all children with congenital heart disease! The incidence of PDA in neonates is between 15% and 35% of all premature or low birth weight infants and 35% in neonates below 1,500 g birth weight.5 The incidence is dramatically high in the very low birth weight infant (less than 1,000 g) where it may exceed 50%: Studies show that persistent PDA is almost always present in neonates below 32 weeks gestation? The incidence of PDA is closely associated with hyaline membrane disease (HMD). Dyspnea, tachypnea, and respiratory failure with cyanosis are features of both PDA and HMD. Management of an infant with patent ductus arteriosus includes fluid restriction, conventional medical treatment of cardiac failure, and use of indomethacin, which is a prostaglandin synthetase inhibitor, to promote closure of the ductus. Surgery is indicated when medical treatment fails to control cardiac failure or the infant fails to gain weight steadily. Within the first seven to 10 days of life, initial problems of hyaline membrane disease often resolve. Infants with respiratory failure who require continued ventilation after this period are prime candidates for surgical closure of PDA.8
d) 71
AORN JOURNAL
JANUARY 1991, VOL. 53,NO 1
Fig 1. Radiant warmers provide provide easy access to premature infants and prevent heat loss through radiation. Very low birth weight infants of less than 1,500 g or with gestational ages of 24 to 30 weeks fit the criteria for surgery in the newborn center because they cannot be transported safely. Because of their prematurity and low body weights, these infants have severe temperature instability and must be intubated and ventilated. Surgical closure of PDA decreases the need for mechanical ventilation because the fetal shunt created by the PDA has been closed. In infants with PDA when pulmonary pressures decrease after birth, shunting of blood through the PDA reverses and allows blood to flow from the aorta to the pulmonary artery causing left heart failure and pulmonary edema (Fig 3). After surgical closure of the PDA, the neonate may be able to be weaned rapidly from the respirator as left heart failure and pulmonary edema is corrected.
Preoperative Teaching
T
he decision to operate in the newborn center is made by the surgeon and neonatologist. The surgeon discusses the
74
benefits and risks of PDA with the neonate’s parents, and the surgical consent is obtained. Preoperative teaching by the perioperative nurse often is not possible when surgery takes place in the newborn center. If the procedure is an emergency, time may not allow the perioperative nurse to visit with the parents. In these instances, the neonatologist and surgeon prepare the family while obtaining consent for the surgical procedure. Often the neonate’s mother is hospitalized in another facility, and the surgeon must contact her and the father by phone. In a nonemergency situation, the perioperative nurse introduces himself or herself to the parents at the infant’s bedside. The nurse assesses the parent’s knowledge of what is to happen to their infant, answers questions, and reassures them. The infant’s primary nurse plays a critical role in preoperative teaching because he or she is at the bedside when the decision to operate is made as well as throughout the surgical procedure. The primary nurse also cares for the patient postoperatively. Both the infant’s primary nurse and the perioperative nurse collaborate during the infant’s surgical experience.
JANUARY 1991. VOL. 53, NO 1
AORN JOURNAL
Fig 2. Infants remain in their radiant warmers when surgery is performed in the newborn center.
Preoperative Assessment, Planning
T
he perioperative nurses pull the surgeon’s preference card and gather supplies and instruments. The newborn center stores an electrosurgical unit, spotlight, head lamps, and privacy screens for surgical procedures. Surgical hats, masks, sterile gowns, and surgical hand scrub brushes also are available. Sinks for handwashing are located conveniently throughout the newborn center, and the water supply is foot controlled, making surgical scrubs possible. After speaking with the infant’s primary nurse and parents (if possible), the perioperative nurse reviews the patient chart to assess the status of surgical consent, patient’s weight, gestational age, and birth date, NPOstatus, laboratory results, availability of blood, and vital signs.
Generally, these infants are so critically ill that they have been NPO for at least the past 24 hours. For surgery to be performed, infants must be NPO for at least 4 hours preoperatively. Because of the location of patent ductus arteriosus to the aorta and pulmonary artery, blood for transfusion must be at the patient’s bedside and available for rapid infusion before the incision is made. A 500 g (or approximately 1 Ib ) infant has a blood volume of approximately 40 to 50 mL and, therefore, a 10% blood loss would be a mere 4 to 5 mL of blood. Blood loss is determined intraoperatively by visual estimation and assessment of the infant’s pulse and blood pressure. Transfusions are based on blood loss and the infant’s preoperative hematocrit. Anesthesia personnel may give 5%albumin, 10 to 20 mL/kg, if the infant reacts adversely (eg, significant drop in blood pressure or pulse) to factors other than blood loss. For example, pavulon and fentanyl administered before the procedure may cause significant vasodilatation 15
JANUARY 1991, VOL. 53, NO 1
AORN JOURNAL
suprior vena cava
aorta
right pulmonary artery
pulmonary veins
inferior vena cava
Fig 3. A patent ductus arteriosus in the neonate allows blood from the aorta to backflow into the pulmonary artery causing left heart failure and pulmonary edema. with resultant drop in blood pressure and pulse. The perioperative and newborn nurses prepare the area surrounding the infant for the surgical procedure by removing unnecessary equipment from the area. Parents of other infants in the area are asked to leave. The space around the patient’s radiant warmer is screened off, and those within this area must wear hats and masks. Newborn center personnel normally wear scrub clothes and do not change clothing before the procedure. Traffic within the immediate area is limited to the surgical team, newborn center primary nurse, neonatologist, and respiratory therapist. If the parents are present, the anesthesiologist discusses his or her role with them. Because the infant is already intubated and on a ventilator, the anesthesiologistis present to monitor the infant, 16
administer doses of intravenous (IV) narcotics (eg, fentanyl10 to 50 microgramdkg) for pain control, and muscle relaxants (eg, pancuronium 0.1 mg/ kg) to prevent movement of the infant. These infants already have IV lines in place such as percutaneously placed Silastic catheters as small as 1.2 Fr, for total parenteral nutrition infusion. The anesthesiologist may start an additional IV line for rapid infusion of blood, albumin, or medications, thus reducing the risk of contaminating indwelling central line catheters. The perioperative nurse assists as needed in starting IV lines. The anesthesiologistcan choose to ventilate the infant by hand using a Mapleson circuit, or leave the infant on the ventilator for the surgical procedure. Inhalational anesthetic agents (eg,
AORN JOURNAL
JANUARY 1991. VOL. 53, NO 1
Table 1
Patent Ductus A rteriosus Instruments 2 #3 knife handles 2 6” Debakey tissue forceps 2 Adson tissue forceps with teeth 2 8“ fine Debakey tissue forceps 1 Metzenbaum scissors 1 suture scissors 1 tenotomy scissors 4 towel clips 4 mosquito clamps 2 Kelly clamps 3 Peon clamp 1 6” small fine right angle clamps 1 8” small fine right angle clamps 1 right angle clamp
halothane, nitrous oxide) are not used for procedures in the newborn center, and thus, anesthesia machines are not brought to the unit.
Intraoperative Care
T
he perioperative nurse assists the surgeon in positioning the infant for a left posterolateral thoracotomy. The surgeon places the infant on his or her right side and places a rolled cloth diaper or washcloth under the patient’s right axilla, taking care not to dislodge the endotracheal tube. The perioperative nurse places an infant dispersive electrode pad around the patient’s buttocks and pads possible pressure areas with cloth diapers or sheepskin. The surgeon uses adhesive tape to maintain the infant’s position. He or she places the tape from one side of the radiant warmer to the other across the patient’s left hip. The infant’s skin is protected beneath the tape with a gauze pad. Routine monitoring of the patient includes electrocardiogram (ECG), pulse oximeter, blood pressure, arterial blood pressure, skin temperature, use of an esophageal stethoscope, and end-tidal carbon dioxide monitoring, if possible. The nurse repositions ECG pads if they have been placed too close to the proposed incision
1 small hemoclip applier 1 medium hemoclip applier 2 needle holders 1 spoon vascular clamp 1 Statinsky vascular clamp 2 angled Debakey vascular clamps 1 Yankauer suction tip 1 sponge stick 2 eyelid retractors 2 small vein retractors 1 small Finocchetto rib spreader 1 Senn retractor 1 Army-Navy retractor site. Because the premature infant’s skin is extremely fragile, an adhesive solvent is used to remove ECG pads with less damage to the skin. The pulse oximeter probe is attached securely to a hand or foot on the palm or midfoot, as the fingers and toes of these patient’s often are too tiny to use. Intravenous tubings are positioned so that the infant is not lying on them and so that fluid boluses, medications, and blood products can be easily and quickly administered. The anesthesiologist inserts an esophageal stethoscope to monitor heart and respiratory sounds and tapes the infant’s eyes closed with plastic tape to prevent corneal injury. The infant’s thermoregulatory needs are not compromised because he or she is not removed from the radiant warmer. A skin temperature probe normally taped to the infant’s abdomen, gives a continuous monitor readout of the infant’s temperature. The perioperative nurse checks the wall suction and positions it for proper functioning and easy accessibility. In the newborn center as in the OR, monitor screens must be placed in appropriate locations before surgery begins. Monitor probes and IV lines must be positioned to prevent patient injury and protected so they are not disconnected or obstructed during the procedure. 77
JANUARY 1991, VOL. 53,NO I
AORN JOURNAL
Fig 4. Closure of patent ductus arteriosus is accomplished with vascular clips. (Reprinted from The American Journal of Surgery 152 (December 1986) with permksion from Cahner’s Publkhing Co, New York, NY) After a fmal check of the patient, the circulating nurse preps the operativesite with povidone-iodine soap and paint. A dry prep (ie, sponges squeezed so they do not drip) is done to prevent heat loss through evaporation and to prevent chemical burns from solution pooled under the patient. The prep must be done very gently to preserve the premature infant’s skin integrity. During the positioning and preparation of the infant, the scrub nurse opens sterile supplies, completes his or her hand scrub, and sets up the back table and Mayo stand with the PDA instruments (Table 1). The surgical team relies on the newborn center personnel to keep the area surrounding the infant clear of traffic and unnecessary personnel. The anesthesiologist is responsible for documenting the infant’s vital signs during the procedure, but the circulating nurse and primary newborn nurse also constantly monitor the infant. The neonatologist and respiratory therapist normally are in attendance as well. It is only through these 78
collaborative efforts that a positive outcome is obtained.
Surgical Procedure
A
fter the prep, the surgical team drapes the infant. The anesthesiologist may don a sterile gown and gloves if he or she needs to be close to the surgical field. Because overhead lights are stationary, the surgeon wears a headlight for better visualization. The surgeon makes a thoracotomy incision for PDA closure at the third or fourth intercostal space. It averages 3.75 cm (1.5 in) long in a 500 g infant. The surgeon takes an extrapleural approach using small vein retractors to pull the ribs apart. He or she protects the wound edges with sponges and uses a Finochetto rib spreader to keep the ribs apart. The surgeon pushes the pleura down and retracts the lung with micropeanuts. He or she
AORN JOURNAL
JANUARY 1991, VOL.53, NO 1
identifies and protects the recurrent laryngeal nerve and dissects the aortic arch and pulmonary artery. The surgeon uses fine vascular forceps and scissors to dissect the parietal pleura overlying the ductus, the adventitid layer of the ductus, and a small portion of the obscure posterior ductus to admit a right-angle clamp. Without dissecting behind the ductus, the surgeon applies a medium to medium-large vascular clip across the ductus (Fig 4). If the ductus cannot be clipped, the surgeon can place a #1 silk tie around it. The anesthesiologist reexpands the lung after the PDA has been closed. The surgeon checks to ensure that the pleura has not been opened. He or she inserts a chest tube if the pleura demonstrates a leak. The surgeon irrigates the wound with warm antibiotic irrigation and closes the chest wall in layers. The scrub nurse applies a dressing when the skin has been closed. Surgical time for PDA closure averages 25 minutes.
Postoperative Care
P
ostoperatively, the primary nurse who was present during the surgical procedure recovers the infant. The infant remains intubated and ventilated, and the neonatologist and respiratory therapist make ventilator changes as needed. The perioperative nurses return to the OR with their supplies and instruments. The surgeon and neonatologist inform the parents of the surgical outcome and the patient’s condition. Postoperatively, the perioperative nurses visit the newborn center to check on the status of the infant, to assess the outcome of the surgical procedure, and to promote positive rapport with the family and the newborn center staff. During the days following the procedure, the patient’s gastrointestinal function often improves allowing the infant to gain weight. Hospital costs decrease because the hospital stay is shortened.
Conclusion
S
urgery outside the OR is advantageous for a select group of neonates. They can receive high quality care and have positive surgical
outcomes without a trip to the OR. Complications of PDA closure which are infrequent, include recurrent laryngeal nerve paralysis and chylothorax? Complications in ventilator-dependent neonates include bronchopulmonary dysplasia, retrolental fibroplasia, and a higher incidence of necrotizing enterocolitis.lo Deaths related directly to PDA closure are generally less than 1%” Mortality in this group of patients is most often a result of concomitant disease. The surgical infection rate at The Children’s Hospital for procedures during 1989-1990 (including those performed outside the OR) averaged less than 1% per month. The consensus of the surgical team is that the infection risk is low compared to the risks that transport to the OR presents for these tiny, fragile infants. 0 Notes 1. L Sigier, D L Holliday, “The newborn center,” Impact (Spring 1987) 3. 2. B J Gruendemann,M H Meeker, eds,Alexander’s Care of the Patient In Surgery, eighth ed (St Louis: The C V Mosby Co, 1987) 923. 3. N R C Roberton, ed,Textbook of Neonatology (New York City: Churchill Livingstone, 1986) 354. 4. C E Mullins, “Patent ductus arteriosus,” in m e Science and Practice of Pediatric Cardiology, ed A Garson et a1 (Philadelphia: Lea and Febiger, 1990) 1055-1068;R D Rowe et al, “Patent ductus arteriosus,” in The Neonate with Congenital Heart Disease, second ed (Philadelphia: W B Saunders, 1981) 273. 5. S R Mayfield, R Uauy, J B Warshaw, “The premature newborn,” in Principles and practice of Pedbtnks, ed F A Oski et a1 (Philadelphia: J B Lippincott, 1990) 297-302; Rowe et al, “Patent ductus arteriosus,” 273. 6. &id. 7. M L Rigby, D Pickering, A Wilkerson, “Cross sectional electrocardiography in determining persistant patency of the ductus arteriosus in preterm infants,” Archives of Disease in Childhood 59 (April 1984) 341345. 8. Roberton, Textbook of Neonatology, 355. 9. Mullins, “Patent ductus arteriosus,” 1055-1068. 10. Roberton, Textbook of Neonatology, 357. 11. Campbell, M D, conversation with author, Denver, August 1990, J K Kirklin, “Neonatal patent ductus surgery,” in Fetal and Neonatal Cardiology, W A Long, ed, (Philadelphia: W B Saunders, 1990) 756758.
AORN JOURNAL
Patent Ductus Arteriosus Ligation PERFORMING SURGERY OUTSIDE THE OPERATING ROOM
Kathryn R. Huddleston, RN
E
ven though surgical procedures are best performed in the operating room, critically ill neonates requiring assisted ventilation often cannot be safely or easily transported to and from the OR. In this situation, the surgical team at The Children’s Hospital, Denver, performs surgery in the neonatal intensive care unit, which is known as the newborn center.
Patient profile
T
he Children’s Hospital is a 225-bed regional pediatric hospital, which has a 30-bed newborn center. As a referral center for high-risk infants from approximately 200 hospitals in portions of eight states, approximately 700 high-
risk infants are admitted to the newborn center each year. Of those admitted, 30% have a birth weight of less than 1,500 g (about 3 lbs), 75% require ventilator support, and 27% have congenital malformations requiring specialized medical and surgical care.’ During 1989, 6,975 surgical procedures were performed at The Children’s Hospital. Ninety-five procedures were performed in the newborn center. (See “Procedures Performed in the Newborn Center in 1989.”) Ligation of patent ductus arteriosus (PDA) is the most frequently performed surgical procedure in the newborn center. The neonatologist and surgeon make the decision to perform surgery in the newborn center based on whether the infant requires extracorporeal membrane oxygenation (ECMO), requires high-frequency ventilation (ie, up to 450 oscillating breaths per minute), and is a critically unstable, ventilated, small infant (eg, as premature as 24 to 30 weeks gestation, weighing 500 to 1,000 g).
Special Nursing Considerations
Kathryn R. Huddleston, BSN, CNOR, is a clinical level IVstaffnurse in the operating room at The Children’s Hospital, Denver. She earned her associate of science degree in nursing and her bachelor of science degree in nursing from Metropolitan State College, Denver.
P
racticing perioperative nursing outside the OR requires careful planning. The primary concern and the most obvious drawback is sterility. Every step must be taken to minimize the risk of infection to the infant. The infant’s primary nurse plays a vital role in collaborating with the perioperative nurses to ensure a successful, infection-free, surgical outcome. Second, every item needed for the procedure 69
JANUARY 1991, VOL. 53, NO 1
must be taken to the newborn center from the OR. Third, it is difficult for the newborn nurses to care for patients in the vicinity of the patient having surgery. Surgical equipment and personnel are distracting and inconvenient to work around. Despite the drawbacks, there are advantages to operating on these particular patients in the newborn center instead of the OR. By performing surgery in the newborn center the surgical team can prevent patient hypothermia, inadvertent extubation, and interruption of vascular access and monitoring. Radiant warmers are used for critically unstable neonates because they prevent heat loss through radiation and because they provide quick and easy access to the infant (Fig 1). When surgery is performed in the newborn center, the neonate's thermoregulatory needs are not compromised because he or she is never moved from the radiant warmer where the procedure takes place (Fig 2). Complications that might occur because of monitoring interruptions are avoided by performing surgery in the newborn center. Infants do not have to be switched from newborn center monitors and equipment to portable monitors, and then have the process repeated before the infant is returned to the newborn center.
Etiology, Treatment Patent Ductus Arteriosus
I
n the fetus, the patent ductus arteriosus is an important communication that shunts blood from the pulmonary artery into the aorta. During fetal life, the lungs are inactive and blood is oxygenated in the placenta? The patent ductus closes soon after birth. Closure of patent ductus in the newborn is caused by a rise in arterial oxygen tension, which occurs when respiration begins. Failure to close may be due to immaturity of the ductus, hypoxia in the infant, or primary structural abnormalities of the ductal wall. Structural abnormalities are often the cause in the term or mature infant, while in the premature baby, hypoxia (usually due to respiratory distress syndrome), and immaturity of the ductus are the caw? Epidemiological studies show patency of the ductus arteriosus is the second most frequent
AORN JOURNAL
Procedures Performed in the Newborn Center in 1989 Ligation of patent ductus arteriosus 39 *ECMO cannulation 22 *ECMO decannulation 20 Broviac catheter insertion 5 Reposition of ECMO cannula 1 Direct laryngoscopy and bronchoscopy 1 Diaphragmatic hernia repair 1 Anoplasty 1 Cauterize subcapsular (liver) hematoma 1 Colostomy and circumcision 1 Insertion chest tube 1 Exploratory laparotomy 1 Revision ileostomy 1 *EMCO cannulation and decannulation are performed only in the newborn center.
cardiac defect accounting for 9% to 12% of all children with congenital heart disease! The incidence of PDA in neonates is between 15% and 35% of all premature or low birth weight infants and 35% in neonates below 1,500 g birth weight.5 The incidence is dramatically high in the very low birth weight infant (less than 1,000 g) where it may exceed 50%: Studies show that persistent PDA is almost always present in neonates below 32 weeks gestation? The incidence of PDA is closely associated with hyaline membrane disease (HMD). Dyspnea, tachypnea, and respiratory failure with cyanosis are features of both PDA and HMD. Management of an infant with patent ductus arteriosus includes fluid restriction, conventional medical treatment of cardiac failure, and use of indomethacin, which is a prostaglandin synthetase inhibitor, to promote closure of the ductus. Surgery is indicated when medical treatment fails to control cardiac failure or the infant fails to gain weight steadily. Within the first seven to 10 days of life, initial problems of hyaline membrane disease often resolve. Infants with respiratory failure who require continued ventilation after this period are prime candidates for surgical closure of PDA.8
d) 71
AORN JOURNAL
JANUARY 1991, VOL. 53,NO 1
Fig 1. Radiant warmers provide provide easy access to premature infants and prevent heat loss through radiation. Very low birth weight infants of less than 1,500 g or with gestational ages of 24 to 30 weeks fit the criteria for surgery in the newborn center because they cannot be transported safely. Because of their prematurity and low body weights, these infants have severe temperature instability and must be intubated and ventilated. Surgical closure of PDA decreases the need for mechanical ventilation because the fetal shunt created by the PDA has been closed. In infants with PDA when pulmonary pressures decrease after birth, shunting of blood through the PDA reverses and allows blood to flow from the aorta to the pulmonary artery causing left heart failure and pulmonary edema (Fig 3). After surgical closure of the PDA, the neonate may be able to be weaned rapidly from the respirator as left heart failure and pulmonary edema is corrected.
Preoperative Teaching
T
he decision to operate in the newborn center is made by the surgeon and neonatologist. The surgeon discusses the
74
benefits and risks of PDA with the neonate’s parents, and the surgical consent is obtained. Preoperative teaching by the perioperative nurse often is not possible when surgery takes place in the newborn center. If the procedure is an emergency, time may not allow the perioperative nurse to visit with the parents. In these instances, the neonatologist and surgeon prepare the family while obtaining consent for the surgical procedure. Often the neonate’s mother is hospitalized in another facility, and the surgeon must contact her and the father by phone. In a nonemergency situation, the perioperative nurse introduces himself or herself to the parents at the infant’s bedside. The nurse assesses the parent’s knowledge of what is to happen to their infant, answers questions, and reassures them. The infant’s primary nurse plays a critical role in preoperative teaching because he or she is at the bedside when the decision to operate is made as well as throughout the surgical procedure. The primary nurse also cares for the patient postoperatively. Both the infant’s primary nurse and the perioperative nurse collaborate during the infant’s surgical experience.
JANUARY 1991. VOL. 53, NO 1
AORN JOURNAL
Fig 2. Infants remain in their radiant warmers when surgery is performed in the newborn center.
Preoperative Assessment, Planning
T
he perioperative nurses pull the surgeon’s preference card and gather supplies and instruments. The newborn center stores an electrosurgical unit, spotlight, head lamps, and privacy screens for surgical procedures. Surgical hats, masks, sterile gowns, and surgical hand scrub brushes also are available. Sinks for handwashing are located conveniently throughout the newborn center, and the water supply is foot controlled, making surgical scrubs possible. After speaking with the infant’s primary nurse and parents (if possible), the perioperative nurse reviews the patient chart to assess the status of surgical consent, patient’s weight, gestational age, and birth date, NPOstatus, laboratory results, availability of blood, and vital signs.
Generally, these infants are so critically ill that they have been NPO for at least the past 24 hours. For surgery to be performed, infants must be NPO for at least 4 hours preoperatively. Because of the location of patent ductus arteriosus to the aorta and pulmonary artery, blood for transfusion must be at the patient’s bedside and available for rapid infusion before the incision is made. A 500 g (or approximately 1 Ib ) infant has a blood volume of approximately 40 to 50 mL and, therefore, a 10% blood loss would be a mere 4 to 5 mL of blood. Blood loss is determined intraoperatively by visual estimation and assessment of the infant’s pulse and blood pressure. Transfusions are based on blood loss and the infant’s preoperative hematocrit. Anesthesia personnel may give 5%albumin, 10 to 20 mL/kg, if the infant reacts adversely (eg, significant drop in blood pressure or pulse) to factors other than blood loss. For example, pavulon and fentanyl administered before the procedure may cause significant vasodilatation 15
JANUARY 1991, VOL. 53, NO 1
AORN JOURNAL
suprior vena cava
aorta
right pulmonary artery
pulmonary veins
inferior vena cava
Fig 3. A patent ductus arteriosus in the neonate allows blood from the aorta to backflow into the pulmonary artery causing left heart failure and pulmonary edema. with resultant drop in blood pressure and pulse. The perioperative and newborn nurses prepare the area surrounding the infant for the surgical procedure by removing unnecessary equipment from the area. Parents of other infants in the area are asked to leave. The space around the patient’s radiant warmer is screened off, and those within this area must wear hats and masks. Newborn center personnel normally wear scrub clothes and do not change clothing before the procedure. Traffic within the immediate area is limited to the surgical team, newborn center primary nurse, neonatologist, and respiratory therapist. If the parents are present, the anesthesiologist discusses his or her role with them. Because the infant is already intubated and on a ventilator, the anesthesiologistis present to monitor the infant, 16
administer doses of intravenous (IV) narcotics (eg, fentanyl10 to 50 microgramdkg) for pain control, and muscle relaxants (eg, pancuronium 0.1 mg/ kg) to prevent movement of the infant. These infants already have IV lines in place such as percutaneously placed Silastic catheters as small as 1.2 Fr, for total parenteral nutrition infusion. The anesthesiologist may start an additional IV line for rapid infusion of blood, albumin, or medications, thus reducing the risk of contaminating indwelling central line catheters. The perioperative nurse assists as needed in starting IV lines. The anesthesiologistcan choose to ventilate the infant by hand using a Mapleson circuit, or leave the infant on the ventilator for the surgical procedure. Inhalational anesthetic agents (eg,
AORN JOURNAL
JANUARY 1991. VOL. 53, NO 1
Table 1
Patent Ductus A rteriosus Instruments 2 #3 knife handles 2 6” Debakey tissue forceps 2 Adson tissue forceps with teeth 2 8“ fine Debakey tissue forceps 1 Metzenbaum scissors 1 suture scissors 1 tenotomy scissors 4 towel clips 4 mosquito clamps 2 Kelly clamps 3 Peon clamp 1 6” small fine right angle clamps 1 8” small fine right angle clamps 1 right angle clamp
halothane, nitrous oxide) are not used for procedures in the newborn center, and thus, anesthesia machines are not brought to the unit.
Intraoperative Care
T
he perioperative nurse assists the surgeon in positioning the infant for a left posterolateral thoracotomy. The surgeon places the infant on his or her right side and places a rolled cloth diaper or washcloth under the patient’s right axilla, taking care not to dislodge the endotracheal tube. The perioperative nurse places an infant dispersive electrode pad around the patient’s buttocks and pads possible pressure areas with cloth diapers or sheepskin. The surgeon uses adhesive tape to maintain the infant’s position. He or she places the tape from one side of the radiant warmer to the other across the patient’s left hip. The infant’s skin is protected beneath the tape with a gauze pad. Routine monitoring of the patient includes electrocardiogram (ECG), pulse oximeter, blood pressure, arterial blood pressure, skin temperature, use of an esophageal stethoscope, and end-tidal carbon dioxide monitoring, if possible. The nurse repositions ECG pads if they have been placed too close to the proposed incision
1 small hemoclip applier 1 medium hemoclip applier 2 needle holders 1 spoon vascular clamp 1 Statinsky vascular clamp 2 angled Debakey vascular clamps 1 Yankauer suction tip 1 sponge stick 2 eyelid retractors 2 small vein retractors 1 small Finocchetto rib spreader 1 Senn retractor 1 Army-Navy retractor site. Because the premature infant’s skin is extremely fragile, an adhesive solvent is used to remove ECG pads with less damage to the skin. The pulse oximeter probe is attached securely to a hand or foot on the palm or midfoot, as the fingers and toes of these patient’s often are too tiny to use. Intravenous tubings are positioned so that the infant is not lying on them and so that fluid boluses, medications, and blood products can be easily and quickly administered. The anesthesiologist inserts an esophageal stethoscope to monitor heart and respiratory sounds and tapes the infant’s eyes closed with plastic tape to prevent corneal injury. The infant’s thermoregulatory needs are not compromised because he or she is not removed from the radiant warmer. A skin temperature probe normally taped to the infant’s abdomen, gives a continuous monitor readout of the infant’s temperature. The perioperative nurse checks the wall suction and positions it for proper functioning and easy accessibility. In the newborn center as in the OR, monitor screens must be placed in appropriate locations before surgery begins. Monitor probes and IV lines must be positioned to prevent patient injury and protected so they are not disconnected or obstructed during the procedure. 77
JANUARY 1991, VOL. 53,NO I
AORN JOURNAL
Fig 4. Closure of patent ductus arteriosus is accomplished with vascular clips. (Reprinted from The American Journal of Surgery 152 (December 1986) with permksion from Cahner’s Publkhing Co, New York, NY) After a fmal check of the patient, the circulating nurse preps the operativesite with povidone-iodine soap and paint. A dry prep (ie, sponges squeezed so they do not drip) is done to prevent heat loss through evaporation and to prevent chemical burns from solution pooled under the patient. The prep must be done very gently to preserve the premature infant’s skin integrity. During the positioning and preparation of the infant, the scrub nurse opens sterile supplies, completes his or her hand scrub, and sets up the back table and Mayo stand with the PDA instruments (Table 1). The surgical team relies on the newborn center personnel to keep the area surrounding the infant clear of traffic and unnecessary personnel. The anesthesiologist is responsible for documenting the infant’s vital signs during the procedure, but the circulating nurse and primary newborn nurse also constantly monitor the infant. The neonatologist and respiratory therapist normally are in attendance as well. It is only through these 78
collaborative efforts that a positive outcome is obtained.
Surgical Procedure
A
fter the prep, the surgical team drapes the infant. The anesthesiologist may don a sterile gown and gloves if he or she needs to be close to the surgical field. Because overhead lights are stationary, the surgeon wears a headlight for better visualization. The surgeon makes a thoracotomy incision for PDA closure at the third or fourth intercostal space. It averages 3.75 cm (1.5 in) long in a 500 g infant. The surgeon takes an extrapleural approach using small vein retractors to pull the ribs apart. He or she protects the wound edges with sponges and uses a Finochetto rib spreader to keep the ribs apart. The surgeon pushes the pleura down and retracts the lung with micropeanuts. He or she
AORN JOURNAL
JANUARY 1991, VOL.53, NO 1
identifies and protects the recurrent laryngeal nerve and dissects the aortic arch and pulmonary artery. The surgeon uses fine vascular forceps and scissors to dissect the parietal pleura overlying the ductus, the adventitid layer of the ductus, and a small portion of the obscure posterior ductus to admit a right-angle clamp. Without dissecting behind the ductus, the surgeon applies a medium to medium-large vascular clip across the ductus (Fig 4). If the ductus cannot be clipped, the surgeon can place a #1 silk tie around it. The anesthesiologist reexpands the lung after the PDA has been closed. The surgeon checks to ensure that the pleura has not been opened. He or she inserts a chest tube if the pleura demonstrates a leak. The surgeon irrigates the wound with warm antibiotic irrigation and closes the chest wall in layers. The scrub nurse applies a dressing when the skin has been closed. Surgical time for PDA closure averages 25 minutes.
Postoperative Care
P
ostoperatively, the primary nurse who was present during the surgical procedure recovers the infant. The infant remains intubated and ventilated, and the neonatologist and respiratory therapist make ventilator changes as needed. The perioperative nurses return to the OR with their supplies and instruments. The surgeon and neonatologist inform the parents of the surgical outcome and the patient’s condition. Postoperatively, the perioperative nurses visit the newborn center to check on the status of the infant, to assess the outcome of the surgical procedure, and to promote positive rapport with the family and the newborn center staff. During the days following the procedure, the patient’s gastrointestinal function often improves allowing the infant to gain weight. Hospital costs decrease because the hospital stay is shortened.
Conclusion
S
urgery outside the OR is advantageous for a select group of neonates. They can receive high quality care and have positive surgical
outcomes without a trip to the OR. Complications of PDA closure which are infrequent, include recurrent laryngeal nerve paralysis and chylothorax? Complications in ventilator-dependent neonates include bronchopulmonary dysplasia, retrolental fibroplasia, and a higher incidence of necrotizing enterocolitis.lo Deaths related directly to PDA closure are generally less than 1%” Mortality in this group of patients is most often a result of concomitant disease. The surgical infection rate at The Children’s Hospital for procedures during 1989-1990 (including those performed outside the OR) averaged less than 1% per month. The consensus of the surgical team is that the infection risk is low compared to the risks that transport to the OR presents for these tiny, fragile infants. 0 Notes 1. L Sigier, D L Holliday, “The newborn center,” Impact (Spring 1987) 3. 2. B J Gruendemann,M H Meeker, eds,Alexander’s Care of the Patient In Surgery, eighth ed (St Louis: The C V Mosby Co, 1987) 923. 3. N R C Roberton, ed,Textbook of Neonatology (New York City: Churchill Livingstone, 1986) 354. 4. C E Mullins, “Patent ductus arteriosus,” in m e Science and Practice of Pediatric Cardiology, ed A Garson et a1 (Philadelphia: Lea and Febiger, 1990) 1055-1068;R D Rowe et al, “Patent ductus arteriosus,” in The Neonate with Congenital Heart Disease, second ed (Philadelphia: W B Saunders, 1981) 273. 5. S R Mayfield, R Uauy, J B Warshaw, “The premature newborn,” in Principles and practice of Pedbtnks, ed F A Oski et a1 (Philadelphia: J B Lippincott, 1990) 297-302; Rowe et al, “Patent ductus arteriosus,” 273. 6. &id. 7. M L Rigby, D Pickering, A Wilkerson, “Cross sectional electrocardiography in determining persistant patency of the ductus arteriosus in preterm infants,” Archives of Disease in Childhood 59 (April 1984) 341345. 8. Roberton, Textbook of Neonatology, 355. 9. Mullins, “Patent ductus arteriosus,” 1055-1068. 10. Roberton, Textbook of Neonatology, 357. 11. Campbell, M D, conversation with author, Denver, August 1990, J K Kirklin, “Neonatal patent ductus surgery,” in Fetal and Neonatal Cardiology, W A Long, ed, (Philadelphia: W B Saunders, 1990) 756758.