The Arterial Switch Procedure for Transposition of the Great Arteries

The Arterial Switch Procedure for Transposition of the Great Arteries STARLA DEBORD, RN, BSN; CECILE CHERRY, RN, MSN, CNOR; CAROL HICKEY, RN, MSN

T

ransposition of the great arteries (TGA) is a congenital heart defect in which the normal anatomic positions of the aorta and pulmonary artery are transposed (ie, the aorta originates from the right ventricle and the pulmonary artery arises from the left ventricle). In babies with TGA, deoxygenated blood from the right ventricle exits the aorta and enters the systemic circulation; oxygenated blood from the left ventricle returns to the lungs via the pulmonary artery. The majority of babies born with TGA will not survive to their first birthday without a surgical correction. The arterial switch procedure is a corrective surgical procedure that restores the aorta and pulmonary artery to their normal anatomic positions. This is accomplished by completely detaching the aorta and the pulmonary artery above the level of the valves and “switching” them to the anatomically normal positions, with the aorta exiting from the left ventricle and the pulmonary artery exiting from the right ventricle. The coronary arteries are detached and reimplanted into the aorta in its corrected position, now referred to as the “neo-aorta.” This surgical procedure is performed through a median sternotomy incision with the infant on cardiopulmonary bypass (CPB). The arterial switch procedure should be performed within the infant’s first two weeks of life;

indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article and taking the examination on pages 227–228 and then completing the answer sheet and learner evaluation on pages 229–230. You also may access this article online at http://www.aornjournal.org.

© AORN, Inc, 2007

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otherwise, the muscular strength of the left ventricle will deteriorate because pumping blood to the pulmonary circulation requires less force than pumping blood to the systemic circulation.1,2

ANATOMY AND FUNCTION OF THE HEART AND GREAT VESSELS The heart is a muscular pump with four chambers—the right atrium and ventricle and left atrium and ventricle. The heart is located slightly to the left of the midline of the mediastinum and directly behind the sternum. The heart provides the power to move blood through the circulatory system’s two circuits— pulmonary circulation and systemic circulation. PULMONARY CIRCULATION. The right side of the heart provides blood flow to the pulmonary circulation. Deoxygenated blood from the body’s venous system returns via the superior and inferior vena cavae to the right side of the heart and enters the right atrium. From the right atrium,

ABSTRACT TRANSPOSITION OF THE GREAT ARTERIES is the most common congenital heart defect among the birth defects that present with cyanosis during the early neonatal period. INFANTS WITH THIS CARDIAC BIRTH DEFECT, in which the aorta originates from the right ventricle and the pulmonary artery originates from the left ventricle, usually do not survive without surgical intervention in the first few days of life. THE ARTERIAL SWITCH PROCEDURE, performed via a median sternotomy incision during cardiopulmonary bypass, restores the aorta and pulmonary artery to their normal anatomic positions. AORN J 86 (August 2007) 211-226. © AORN, Inc, 2007.

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blood flows through the tricuspid valve into the right ventricle. The right ventricle pumps the deoxygenated blood to the lungs via the main pulmonary artery where carbon dioxide in the blood is exchanged for oxygen. SYSTEMIC CIRCULATION. The left side of the heart provides the blood supply to the systemic circulation. The newly oxygenation blood flows through the pulmonary veins into the left atrium and through the mitral valve to the left ventricle. Contraction of the left ventricle ejects blood into the aorta where it enters the systemic circulation. PRESSURE GRADIENTS. Blood flow is determined by pressure gradients—blood flows from areas of higher pressure to areas of lower pressure. Higher pressures are found in the left side of the heart and systemic circulation; lower pressures are found in the right side of the heart and pulmonic circulation.3

EMBRYONIC CARDIAC DEVELOPMENT Development of the human heart is a complex process that begins in the third week of fetal life and is complete with a fully developed, fourchambered heart by the end of the eighth week after conception. During week three, the cardiac tube forms in the thoracic cavity, It begins to contract rhythmically around day 23 of fetal life. The primitive heart tube grows, elongates, and folds on itself, looping to the right to form a single atrium, single ventricle, and outflow tract. The fetal heart develops further with a single outflow tract (ie, truncus arteriosus ) exiting both ventricles. During the fifth week of fetal life, the truncus lengthens and spirals, then divides and separates into the aorta and the pulmonary artery. Transposition of the great arteries occurs as a result of a developmental abnormality during this stage of cardiac growth. During weeks five through eight, the atrial and ventricular septa and the atrioventricular valves form. The four-chambered heart is fully functional by the end of the eighth week of intrauterine life.4

FETAL CIRCULATION The developing fetus receives all of its oxygen and nutrients via placental circulation. The lungs receive just enough blood to perfuse the developing lung tissues as a result of high pulmonaryvascular resistance in the uninflated fetal lungs

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and fetal vascular shunts that direct blood away from the lungs (Table 1 and Figure 1). The three fetal vascular shunts include the • ductus venosus, a conduit that carries arterial blood from the umbilical vein to the inferior vena cava; • foramen ovale, an opening between the right and left atria that allows oxygenated blood from the right atrium to bypass the right ventricle and pulmonary circulation; and • ductus arteriosus, a conduit from the main pulmonary artery to the descending aorta that allows the majority of blood from the

TABLE 1

Fetal Circulation1,2 Fetal arterial blood circulation

•

Oxygenated blood enters the fetal circulation via the umbilical vein. Approximately half of this blood perfuses the liver, the rest passes through the ductus venosus to enter the inferior vena cava.

•

Blood from the inferior and superior vena cavae flows into the right atrium. Most of the blood in the right atrium passes through the foramen ovale into the left atrium of the heart. Blood from the left atrium passes through the mitral valve into the right ventricle, where it exits through the aorta to enter the systemic circulation.

•

The remainder of the blood in the right atrium flows through the tricuspid valve into the right ventricle. The blood then flows into the pulmonary artery, where most of it is diverted through the ductus arteriosus to the aorta, bypassing the left side of the heart. The small amount of blood that does not exit through the ductus arteriosus flows though the main pulmonary artery into the left and right pulmonary arteries to perfuse developing lung tissue.

Fetal venous blood circulation

•

Deoxygenated blood from the fetus returns to the placenta via the two umbilical arteries.

1. Westmoreland D. Critical congenital cardiac defects in the newborn. J Perinat Neonatal Nurs. 1999;12(4):68-69. 2. Hazinski MF. Congenital heart disease in the neonate. Neonatal Network. 2002;21(3):34-35.

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right side of the heart to bypass the lungs.5

TRANSITION TO EXTRA-UTERINE LIFE The transition from fetal to neonatal circulation begins at birth and continues for the first few hours of life. Beginning with the first breath, the newborn’s lungs expand with air. Increased oxygen levels in the lungs lead to a rapid decrease in pulmonary vascular resistance, which increases blood flow through the pulmonary vascular bed. As the blood flow to the left atrium increases, the pressure in the left atrium becomes greater than the pressure in the right atrium, leading to functional closure of the foramen ovale. Increased arterial oxygen levels and reduced pulmonary vascular resistance stimulate changes in the wall of the ductus arteriosus, causing closure of this conduit. The foramen ovale and the ductus arteriosus may open and close intermittently in the days after birth. Final closure of these conduits usually is complete by three months of age, and all three of the three fetal circulation conduits become nonfunctioning ligaments.6,7

Figure 1 • Normal fetal circulation. Illustration courtesy of Steven P. Goldberg, MD.

FIGURE 2

Distribution of Congenital Heart Defects1 All other congenital heart defects

44%

Atrioventricular septal defect 9%

CONGENITAL HEART DEFECTS Congenital heart defects are structural abnormalities of the heart, great vessels, or both that are caused by abnormal heart development during the first eight weeks of fetal development. Congenital heart defects are one of the most common birth defects (Figure 2); in the United States, more than 32,000 babies are born every

Coarctation of the aorta Tetralogy of Fallot

15%

10%

Transposition of the great arteries Ventricular septal defects

10%

12%

1. American Heart Association. Congenital cardiovascular defects: statistics. http://www.americanheart.org/presenter.jhtml?identifier=4576. Accessed June 14, 2007.

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year with a congenital heart defect (ie, approximately eight per every 1,000 live births).8 Congenital heart defects vary greatly in severity, from very minor to life-threatening, and can occur in an affected child as an isolated birth defect or in combination with other birth defects, including other cardiac defects.8 Congenital heart defects are the leading cause of death for children who die from birth defects during the first year of life.9 It usually is not possible to determine why a child is born with heart abnormalities (Table 2).10 Congenital heart defects generally are believed to occur as the result of multiple factors, including genetic and environmental influences. The incidence of congenital heart disease is slightly increased in children who have a parent or sibling with a congenital heart defect.10 Male and female babies are born with congenital heart defects in equal numbers, but some congenital heart defects occur more often in one gender than the other.11 For example, TGA and coarctation of the aorta occur more commonly in male babies, whereas atrial septal defects occur more commonly in female babies.11 Maternal illness and medications12 and environmental factors10 including chemical agents are implicated in some congenital heart anomalies. Other congenital heart defects are caused by chromosomal abnormalities; estimates indicate that 5% to 8% of congenital heart defects have genetic causes.13 It is not possible to prevent congenital heart defects, but some researchers believe there are actions a woman can take to minimize her risk of having a child with birth defects, including congenital heart defects. Recommendations include abstaining from alcohol during pregnancy and receiving immunization against rubella before attempting to conceive a child. Taking a daily vitamin supplement containing 400 mcg of folic acid is recommended for all women of childbearing age. Research evidence shows a reduced risk of neural tube defects in babies whose mothers took daily folic acid before conception and during the early stages of pregnancy.14 At least one study demonstrated a reduced incidence of congenital heart defects in babies of women who took a daily multivitamin supplement containing folic acid during the periconceptional period.12 Women with diabetes can reduce their risk of

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TABLE 2

Maternal and Environmental Factors Implicated in the Development of Congenital Heart Defects1,2 Maternal diabetes

• • •

Transposition of the great arteries (TGA) Pulmonary stenosis Ventricular septal defects (VSDs)

Rubella

• •

Atrial septal defects (ASDs) and VSDs Coarctation of the aorta

Medications

•

• •

Trimethadione increases risk of • TGA • Tetralogy of Fallot • Hypoplastic left heart syndrome • VSD Phenytoin increases the risk of • Aortic stenosis • Coarctation of the aorta • ASD and VSD Lithium increases the risk of • Ebstein’s Anomaly • VSD

Maternal alcohol use

• • •

Pulmonary stenosis Coarctation of the aorta VSD

Maternal exposure to pesticides and herbicides during the periconceptional period

•

TGA

Chromosomal abnormalities

• •

Trisomy 21 (ie, Down’s syndrome) increases the risk of • ASD • VSD XO (ie, Turner’s syndrome) increases the risk of • Coarctation of the aorta

1. Althaus F. Maternal exposure to weed, rodent killers raises risk of congenital heart defect. Fam Plann Perspect. May/June 2001;33:137. 2. Coleman K. Genetic counseling in congenital heart disease. Crit Care Nurs Q. 2002;25(3):8-10.

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having a child with birth defects by maintaining good control of blood glucose levels before conception and during the first trimester of pregnancy. Women who are taking medication for any chronic health condition should talk with their health care providers to ensure that the medications they are taking are safe to take during pregnancy. Some women may need to switch to other medications for the duration of their pregnancy.13

CLASSIFICATION

OF

CONGENITAL HEART DEFECTS

Traditionally, congenital heart defects have been classified as either cyanotic (ie, the most obvious presenting sign is a baby blue with cyanosis) or acyanotic (ie, the baby is pink with no apparent cyanosis) (Table 3). Cyanosis in babies with cardiac defects is caused by intracardiac vascular shunts, obstructions to pulmonic or systemic blood flow, or both. Vascular shunts in congenital heart defects are classified as either left-to-right or right-to-left. In left-to-right shunts, oxygenated blood is shunted from the left side of the heart to the right side of the heart; right-to-left shunts result in deoxygenated blood being shunted from the right side of the heart to the left side (Table 4). Congenital heart defects can be classified further as either ductal-dependent or nonductal-dependent. The presence of a ductal-dependent lesion means that the baby depends on a patent ductus arteriosus (PDA) to provide a major portion of the blood flow to the pulmonary or systemic circulation. Transposition of the great arteries is one example of a congenital defect in which the baby’s systemic blood flow is dependent on a PDA.15

PATHOPHYSIOLOGY

OF

TGA

In a neonate with TGA, pulmonary and systemic circulation are separate and parallel without the normal anatomic communications between these two circuits (Figure 3). Deoxygenated systemic blood returns to the right atrium, flows through the tricuspid valve into the right ventricle, and returns to the systemic circulation via the aorta without passing through the lungs. Oxygenated blood from the lungs flows into the left atrium and passes through the mitral valve into the left ventricle where it is returned to the lungs via the pulmonary artery without ever passing into the

TABLE 3

Classification of Common Congenital Heart Defects (CHDs)1 Cyanotic CHDs (ie, right-to-left shunts or obstruction to either systemic or pulmonary blood flow)

• • • • • •

Hypoplastic left heart Pulmonary atresia Pulmonary stenosis Tetralogy of Fallot Transposition of the great arteries Truncus arteriosus

Acyanotic CHDs (ie, left-to-right shunts)

• • • •

Atrial septal defect Coarctation of the aorta Patent ductus arteriosus Ventricular septal defect

1. Jacobs J. Nomenclature and classification for congenital cardiac surgery. In: Mavroudis C, Backer C, eds. Pediatric Cardiac Surgery. 3rd ed. St Louis, MO: Mosby; 2003.

TABLE 4

Right-to-Left versus Left-to-Right Vascular Shunting in Congenital Heart Defects (CHD)1 Right-to-left shunts (ie, cyanotic CHD)

• • •

Unoxygenated blood is shunted from the right side of the heart to the left side of the heart without traveling through the pulmonary circulation. Unoxygenated or partially oxygenated blood enters the systemic circulation. Oxygen saturation typically is less than 95%.

Left-to-right shunts (ie, acyanotic heart disease)

• •

A portion of the oxygenated blood from the left side of the heart is shunted to the right side of the heart. Oxygenated blood enters the pulmonary circulation, increasing the workload for the right side of the heart.

1. Jacobs J. Nomenclature and classification for congenital cardiac surgery. In: Mavroudis C, Backer C, eds. Pediatric Cardiac Surgery. 3rd ed. St Louis, MO: Mosby; 2003.

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Figure 3 • Fetal heart with transposition of the great arteries. Illustration courtesy of Steven P. Goldberg, MD.

systemic circulation. After birth, the initial survival of the neonate with TGA is dependent on vascular shunts to allow communication between the left and right sides of the heart. A ventricular septal defect, a patent foramen ovale, or an atrial septal defect allows oxygenated and unoxygenated blood to mix in the heart so that the blood flowing into the systemic circulation is at least partially oxygenated. A PDA allows further mixing between the pulmonary and systemic circulations by serving as a conduit between the pulmonary artery and aorta. A PDA is essential for systemic oxygenation in neonates with TGA who do not have an accompanying ventricular septal defect.5

CLINICAL PRESENTATION

AND

DIAGNOSIS

OF

TGA

Prenatal diagnosis is optimal for a child with TGA, allowing both the parents and health care professionals the opportunity to plan care before the child’s birth. Prenatal diagnosis gives parents time to prepare themselves and other family members, including any other children, for the birth of a child with a serious cardiac defect. Prenatal diagnosis also allows time to plan for the baby’s birth to occur at a facility with a neonatal intensive care unit (NICU) and pediatric cardiologists and cardiac surgeons on staff.16

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At University Hospital, Birmingham, Alabama, the parents of a child diagnosed prenatally with a congenital heart defect are offered the opportunity to meet with a multidisciplinary team comprised of a neonatologist, pediatric cardiologist, cardiovascular nurse practitioner, and cardiac surgeon to discuss diagnosis, prognosis, and treatment options. Parents also have the option of touring the NICU where their baby will be admitted immediately after birth. Even with the prevalence of routine prenatal screening via maternal transabdominal ultrasound examinations in this country, many babies with TGA are not diagnosed prenatally. The quality of most routine ultrasounds in early pregnancy is good enough to verify that the fetus has a structurally normal, fourchambered heart, but it usually cannot provide a detailed view of the great vessels, in part due to the small size of the developing fetus. Pregnant women considered to be atrisk for having a child with a congenital heart defect as a result of maternal or fetal indications can be referred to a center that offers fetal echocardiography. Fetal echocardiography, which is performed via an abdominal ultrasound, is available at centers that provide high-risk maternal-fetal medical care. This examination provides a more-detailed view of the heart and great vessels and can be performed as early as 18 weeks gestation.17,18 The major presenting sign of TGA is cyanosis, which usually develops during the first day of life, often as early as the first hour of life. The degree of cyanosis is determined by the presence, size, and location of shunts that allow mixing of oxygenated and unoxygenated blood in the heart.19 Many babies with TGA will not have a heart murmur, particularly if TGA is the only defect. In the period shortly after birth, the majority of neonates will have a normal electrocardiogram and chest x-ray.20 Transposition of the great arteries is diagnosed most often by a transthoracic echocardiographic examination, which demonstrates that the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle. Echocardiography also can be used to determine the presence of other cardiac defects.

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PREOPERATIVE STABILIZATION OF THE NEWBORN WITH TGA Babies with TGA are admitted to the NICU for stabilization before surgery. Preoperative stabilization consists of supportive treatment that includes continuously monitoring oxygen saturation and providing supplemental oxygen via nasal cannula or an oxygen hood to maintain the baby’s oxygen (O2) saturation percentage between 92% to 98%. The neonatologist places an umbilical artery catheter, or the NICU nurse places a peripheral IV for vascular access. The pediatric cardiologist or surgeon commonly prescribes prostaglandin E1 (ie, PGE1 or alprostadil) to medically stabilize babies with ductaldependent cardiac defects until surgery can be performed. The PGE1 maintains ductal patency by causing vasodilatation of the vascular smooth muscle in the wall of the ductus arteriosus. When the NICU nurse administers PGE1, he or she begins the infusion at 0.05 mcg/kg/minute to 0.1 mcg/kg/minute; the nurse then titrates the medication to the lowest effective dose according to the neonate’s response. This medication can be administered through a peripheral IV line or an umbilical artery catheter. Signs of a positive response to the infusion include improved • peripheral pulses, • capillary refill, • blood pressure, and • arterial blood PO2 and pH. It is extremely important that the PGE1 infusion not be interrupted because the medication is metabolized quickly; sudden ductal closure can be catastrophic in babies with ductal-dependent heart lesions.21,22 The most common side effect of PGE1 is apnea, which may be severe enough to require that the baby be intubated and mechanically ventilated. When transporting a baby with cardiac disease who is on a PGE1 infusion, the transport team may elect to intubate and ventilate the baby as an elective procedure in the referring facility before transport to the treating facility rather than take the risk that the neonate will need to be intubated mid-transport. Other possible side effects of PGE1 infusion may include fever, flushing, jitteriness, and an increased Moro reflex (ie, a normal reflex to a sudden loud noise in which the infant flexes his or her legs, demonstrates an embracing pos-

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ture of the arms, and usually emits a brief cry). The PGE1 infusion is continued until the baby has surgery, and it may be continued in the early postoperative period to reduce cardiac afterload by promoting systemic vasodilatation.21,22 Balloon atrial septostomy (ie, surgical creation of an opening in a septum) can be performed in the cardiac catheterization laboratory to stabilize babies with TGA who are hypoxic before the arterial switch procedure. The interventional cardiologist uses a balloon catheter to enlarge and maintain patency of the foramen ovale. This procedure allows mixing of blood between the left and right sides of the heart and can improve oxygenation in babies with TGA.23

PREPARATION

OF THE

OR

AND INFANT

The circulating nurse and scrub person gather all equipment, supplies, instruments, and medications for the procedure (Table 5). A

TABLE 5

Equipment and Supplies for the Arterial Switch Procedure Equipment

• • • • •

Cardiopulmonary bypass machine Forced-air temperature-regulating blanket Defibrillator Electrosurgical unit Transesophageal echocardiography if patient’s weight is less than 4.4 kg

Supplies

• • • • •

Chest tubes Closed chest drainage system Temporary pacing wires Pacemaker cable Bovine pericardium (have available)

Medications

•

Heparin

Instruments

• • •

Basic instruments for pediatric cardiac procedures Electric reciprocating sternal saw Pediatric internal defibrillator paddles

Positioning aids

• •

Small gel pads Foam padding

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NICU nurse and a respiratory therapist transfer the baby to the OR in an infant transport incubator. The parents of the child, if present, may accompany their baby to the OR. The circulating nurse and anesthesia care provider meet the transport team and receive a handoff report from the NICU team members. In preparation for formulating appropriate nursing diagnoses and developing an intraoperative plan of care specific for that baby (Table 6), the circulating nurse introduces himself or herself to the infant’s parents, if they are present, and verifies the infant’s identity verbally with the NICU nurse, the parents, and by using the infant’s medical record and hospital identification bracelet. The circulating nurse then verifies that the scheduled surgical procedure is consistent between the OR schedule, the infant’s signed consent form, and the parents’ verbal confirmation. After reviewing the surgeon’s preoperative progress notes, the circulating nurse performs a preoperative assessment during which he or she confirms that the surgeon and parents cooperatively identified and marked the surgical site according to the correct site surgery policy. The circulating nurse also reviews the infant’s medical record for relevant laboratory test results and the presence of a consent form for the administration of blood products. The circulating nurse speaks with the parents, offering support and answering any questions that arise. It is important that perioperative nursing care of the infant with TGA includes the family members, who are a crucial part of the health care team for any seriously ill baby. Parents of an infant with a cardiac defect may experience a range of emotions, such as shock, fear, guilt, anger, and denial. Parents may feel a sense of grief for the loss of the healthy baby for which they had been planning. Many parents have difficulty understanding the baby’s diagnosis and treatment and will need simplified explanations provided in layman’s terms. At University Hospital, parents are offered a social service referral for assistance with financial arrangements, and certified child life specialists are available to provide support and education for parents and siblings to assist them in coping with the infant’s medical condition.

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INTRAOPERATIVE CARE The circulating nurse and anesthesia care provider place a warming unit on the OR bed during the setup time to ensure that the bed is warm before transferring the infant from the transport incubator onto the OR bed. The circulating nurse places additional warm blankets on the infant for comfort and heat retention then remains close to the infant during induction of anesthesia to restrain the infant and offer assistance to the anesthesia care provider. After anesthesia induction, the RN first assistant (RNFA) inserts an indwelling urinary catheter with a temperature probe to monitor the infant’s core temperature during surgery. The surgeon and anesthesia care provider place pressure monitoring lines (eg, radial arterial line, central line) for hemodynamic monitoring during the intraoperative and immediate postoperative periods. The circulating nurse places the infant’s wrist with the arterial line on a padded disposable arm board to help maintain the correct position of the arterial catheter. The circulating nurse, surgeon, anesthesia care provider, and RNFA place the infant in the supine position for the procedure with towels behind the shoulders to ensure that correct body alignment is maintained. The anesthesia care provider places the infant’s head on a padded headrest. He or she then places cerebral oxygen sensors on the infant’s forehead and over the infant’s right kidney to monitor cerebral oxygenation. The circulating nurse places an electrosurgical unit (ESU) dispersive pad under the infant’s buttocks. The circulating nurse tapes the monitoring lines, oxygen saturation lines, and urinary catheter to the bed to prevent any movement.

THE ARTERIAL SWITCH PROCEDURE After the infant has been positioned, the circulating nurse initiates a surgical time out in which all the members of the surgical team participate. At this time, the team members verify the infant’s identity, scheduled surgical procedure, and proper completion of the informed consent; appropriate marking of the surgical site; correct patient position; and availability of implants, special equipment, and radiologic examinations, if applicable.

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TABLE 6

Nursing Care Plan for Infants Undergoing the Arterial Switch Procedure for Transposition of the Great Arteries Diagnosis Risk for alteration in cardiac output or tissue perfusion related to congenital heart defect and undergoing cardiopulmonary bypass

•

Risk for injury related to congenital heart defect and surgery

•

• • • •

• •

• Risk for hypothermia related to perioperative environment, patient age, exposed body surfaces, and undergoing cardiopulmonary bypass

Interim outcome criteria

Outcome statement

Assesses for pre-existing conditions that predispose to inadequate tissue perfusion. Identifies baseline cardiac function and tissue perfusion. Collaborates in fluid management. Monitors physiological parameters (eg, peripheral pulses, urinary output, blood pressure, filling pressures). Evaluates postoperative cardiac function and tissue perfusion.

Infant maintains adequate tissue perfusion and cardiac output throughout the procedure as demonstrated by • blood pressure, oxygen saturation, and filling pressures remaining within normal limits; • peripheral pulses equal to or greater than perioperative baseline; and • adequate urinary output.

Infant’s cardiac function and wound and tissue perfusion are consistent with or improved from identified preoperative baseline levels.

Confirms identity using at least two identifiers, operative procedure, and surgical site before the surgical procedure. Assesses infant for physical alterations and sensory impairments that may affect procedure-specific positioning. Implements protective measures to prevent injury caused by electrical, thermal, chemical, or physical sources, including • verifying allergies, • applying safety devices, • ensuring prep solution does not run under electrosurgical grounding pad, • performing required counts, and • using supplies and equipment within safe parameters. Evaluates for signs and symptoms of injury.

Infant’s skin and tissue remain intact and no sensory or motor deficits are noted through out the perioperative period.

Infant is free of signs and symptoms of injury.

Monitors infant’s body temperature throughout the perioperative period. Implements thermoregulatory measures, such as • applying temperature-regulating blanket or other warming devices, when applicable; • using IV and irrigation solution warmers, when applicable; and • adjusting room temperature appropriately. Evaluates response to thermoregulatory measures.

Infant’s temperature remains within expected range throughout the perioperative period.

Infant is at or returning to normothermia at the conclusion of the perioperative period.

Nursing interventions

• •

•

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TABLE 6

Nursing Care Plan for Infants Undergoing the Arterial Switch Procedure for Transposition of the Great Arteries (continued) Diagnosis Risk for compromised family coping related to knowledge deficit and the stress of surgery

• • • • • •

Risk for acute or chronic pain related to surgical procedure

• •

• • Risk for fluid volume imbalance

• • • • • •

Risk for infection related to immature immune system and neonatal age

Interim outcome criteria

Outcome statement

Determines knowledge level, readiness to learn, and barriers to communication. Elicits family members’ perceptions of anesthesia and surgery. Explains sequence of events and reinforces teaching about treatment options. Provides verbal and written instructions and educational materials for surgical procedure and discharge based on identified need. Communicates family members’ concerns to appropriate surgical team members. Evaluates response to instruction.

Family members •verbalize understanding of the procedure and expected outcomes and •demonstrate the ability to cope throughout the perioperative period. Parents and infant demonstrate appropriate bonding.

Family members demonstrate knowledge of the expected responses to the procedure and required discharge care.

Assesses infant’s pain preoperatively using the FLACC (ie, face, legs, activity, cry, consolability) pain assessment tool. Provides pain management instruction and explains the FLACC pain assessment tool to family members to allow them to participate in assessment of their infant’s pain management. Implements pain management guidelines. Evaluates infant’s response to pain management interventions.

Infant demonstrates adequate pain management, and vital signs are equal to or improved from preoperative values.

Infant demonstrates and family members report perceived pain control throughout the perioperative period.

Verifies NPO status. Monitors physiologic parameters for fluid deficit and signs of hypervolemia and hypovolemia. Identifies factors associated with an increased risk for hemorrhage or fluid and electrolyte loss. Recognizes and reports deviation in diagnostic study results. Collaborates in fluid management and administers blood products and electrolyte therapy as prescribed. Observes characteristics of any drainage.

Infant maintains adequate intake and output and laboratory values remain within normal limits.

Infant’s fluid, acid-base, and electrolyte balances are consistent with or improved from preoperative values.

Assesses infant’s skin integrity, sensory impairments, and immune status. Observes sterile field and perioperative team members to ensure that asepsis is maintained. Validates that preoperative antibiotic was administered according to facility policy. Allows sufficient time for surgical prep solution to dry before infant is draped.

Infant’s wound and all invasive sites remain dry and not reddened or warm, with no excessive drainage during the perioperative period.

Nursing interventions

• • • •

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No excessive drainage is noted from chest tubes or incision.

Infant is free of signs and symptoms of infection upon discharge from the facility.

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They also identify any special requirements before the incision is made. The circulating nurse preps the infant’s skin with an iodine/alcohol solution from the chin to the groin, taking care to avoid pooling of the prep solution. After the prep solution dries completely, the scrub person, RNFA, and surgeon drape the infant using surgical towels; a split surgical drape; and finally, an iodine-impregnated adhesive plastic drape over the infant’s exposed skin. The scrub person and the RNFA pass the CPB pump lines off the sterile Figure 4 • Precorrection anatomy showing the aorta exiting from the right ventricle and the pulmonary artery exiting from the left ventricle. field before the skin incision is made. The surgeon uses a #15 knife blade to make a sutures in the ascending aorta as aortic pursestrings. The RNFA and scrub person thread the midline incision extending from the supraclavsuture through a disposable tourniquet and seicular notch to just beyond the xiphoid process. cure it with a hemostat on which rubber shods The surgeon places a small army/navy retrachave been placed. The surgeon places a single tor in the upper end of the incision to expose 5-0 polypropylene purse-string suture in the the sternal notch. He or she uses a small right angle clamp to separate the transverse ligament right atrial appendage for the venous purseand uses a bipolar ESU pencil to transect it. The string suture and secures it in the same manner as the aortic purse-string suture. The pursesurgeon uses the ESU pencil to cut the subcutastring sutures will be used for cannulation of neous tissue and pectoralis muscle down to the the heart to initiate CPB. The surgeon adminissternum. He or she then marks the sternum for sawing with the ESU pencil. Using an electrical- ters the appropriate dose of heparin, which is weight-dependent, directly into the infant’s right ly powered sternal saw, the surgeon performs a atrium. Before cannulation, the surgeon clamps median sternotomy. He or she then uses the the pump tubing on both the arterial and venous ESU to obtain hemostasis of the sternal edges sides and inserts the appropriate connectors into and soft tissue. the pump lines to fit the cannulas. The surgeon and RNFA place a two-bladed, The surgeon cannulates the ascending aorta self-retaining sternal retractor between the sternal edges. The surgeon uses the ESU to open the with a #11 knife blade and the appropriate size cannula. The surgeon tightens each tournpericardial sac. If necessary, the surgeon removes the lobes of the thymus gland to improve iquet and secures them with a hemostat with rubber shods. The surgeon ties a 0-silk suture exposure. The surgeon then excises the anterior pericardium for later use as a patch. To make the around the cannula and the tourniquets to maintain proper cannula placement. He or she autologous pericardial patch stiffer and ultiuses a 2-0 silk suture to secure the aortic canmately easier to use, the scrub person fixates it nula to the skin. according to current technique.14 The surgeon The surgeon cannulates the right atrial apthen places five 3-0 silk stay-stitches in the rependage in the same manner. If necessary, the maining pericardium, tacking into the sternal surgeon uses a fine hemostat to dilate the openedges for exposure (Figure 4). ing in the appendage. He or she then secures The surgeon places two 5-0 polypropylene AORN JOURNAL •

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the cannula with a 0-silk suture for proper cannula placement (Figure 5). After CPB has been initiated, the perfusionist cools the infant to a 15° C (59° F) core temperature. The surgeon administers a cold cardioplegic solution into the ascending aorta via a 16-gauge needle. As the infant is being cooled, the surgeon dissects around the ductus arteriosus. When the ductus arteriosus has been isolated, the surgeon divides the ductus with a 5-0 polypropylene suture. Figure 5 • Cardiopulmonary bypass cannulas in place. The surgeon mobilizes the branched pulmonary arteries biback to normal. During this rewarming phase laterally. He or she also mobilizes the aorta and main pulmonary artery using the ESU pencil. The of the surgery, the surgeon removes the aortic cross clamp and prepares the pulmonary artery surgeon places the aortic cross clamp when the for reconstruction. The scrub person ensures infant’s core temperature reaches 15° C (59° F), at that the previously fixated pericardial patch has which point, the perfusionist institutes low-flow been thoroughly rinsed in 0.9% sodium chloCPB of 50 mL/kg. The surgeon makes a transverse incision in the mid position of the aorta to ride solution.14 The surgeon then cuts the patch divide the ascending aorta and then performs a of pericardium into the shape of a pantaloon to LeCompte maneuver (ie, a procedure in which construct the new pulmonary artery from the pulmonary artery bifurcation is translocated which the coronary artery buttons were excised. anterior to the distal ascending aorta). The surThe surgeon uses a continuous, double-armed, geon makes a medial incision in the anterior 6-0 polypropylene suture to sew the pericardial mid aorta and, using dissecting scissors, detach- patch to the pulmonary artery. After this anases the coronary ostia from the aorta with rims of tomosis, the surgeon sews the reconstructed aortic tissue. The surgeon completes the pulmonary artery to the primary pulmonary artranslocation of each coronary ostia into the tery confluence using a 6-0 polypropylene connew aorta using a continuous, double-armed, tinuous suture. 7-0 polypropylene suture (Figure 6). When rewarming of the infant is complete, When coronary circulation has been reestabthe perfusionist gradually discontinues CPB, and lished, the surgeon attaches the distal end of the the surgeon removes the atrial cannula. The aordivided aorta to the new proximal aorta using a tic cannula remains in place to allow for the continuous, double-armed, 6-0 polypropylene residual volume in the CPB system to be infused. suture. The surgeon institutes a period of circuThe surgeon places temporary pacing wires on latory arrest and opens the right atrium. If an the heart if necessary. When the blood volume atrial septal defect is present, the surgeon closes from the pump has been infused into the infant, it with a 5-0 polypropylene continuous suture. the surgeon removes the aortic cannula. The surThe surgeon closes the right atrium in two laygeon inspects the surgical sites for bleeding, and ers using a 5-0 polypropylene continuous suthe anesthesia care provider administers a heture. The perfusionist recommences CPB, and parin antagonist to reverse the anticoagulant efthe surgeon instructs the perfusionist to begin fect of the heparin administered for the CPB bringing the infant’s temperature gradually phase of the procedure.

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Edema sometimes occurs during repair of transposition of the great arteries. If this occurs, the sternum may remain open to allow the edema to decrease. The surgeon places a 15-Fr Blake drain into the pericardium, and the scrub person connects it to a closed chestdrainage system to monitor postoperative bleeding. A bovine pericardial patch is cut to size by the surgeon for placement over the open sternum. This patch provides a nonporous barrier to protect against contamination until the infant’s chest is closed on postoperative day one. The surgeon attaches the pericardiFigure 6 • The procedure is completed by detaching and transferring the coronary um to the skin using a continarteries to the neo-aorta. Illustration courtesy of Steven P. Goldberg, MD. uous 5-0 polypropylene suture. Several layers of iodineimpregnated surgical drape are placed over the nurse begins to wean the infant from the ventiwound for protection. The anesthesia care lator as tolerated. After extubation, the infant reprovider, circulating nurse, and RNFA transfer ceives supplementary oxygen via a nasal cannuthe infant to the cardiac intensive care unit la, if needed, to maintain the oxygen saturation (CICU). During transfer, the anesthesia care percentage in the upper 90s. The CICU nurse provider continues to monitor the infant’s elecadministers IV morphine or oral acetaminophen trocardiogram, arterial pressure, and oxygen as needed for pain control. The surgeon usually saturation with a portable monitoring unit and removes the infant’s chest tubes on the third ventilates the infant using a bag/mask device postoperative day, provided the drainage from the chest tubes is not greater than 1 mL/kg/hour. and a portable oxygen tank. The parents are allowed to start oral feedings after the infant has been weaned successfully POSTOPERATIVE CARE from the ventilator if the infant’s vital signs On arrival in CICU, the circulating nurse and and oxygen saturation remain stable. If the inanesthesia care provider give a hand-off report to fant tolerates the oral feedings well and his or the CICU nurse who will be caring for the infant. her respiratory and hemodynamic status reA respiratory therapist connects the infant to the mains stable, the CICU nurse may transfer the ventilator. The CICU nurse connects the infant to infant to the NICU for the remainder of his or the monitors for continuous monitoring of the inher hospitalization. fant’s physiological parameters, such as the electrocardiogram, oxygen saturation, and arterial MANAGING POSTOPERATIVE PAIN pressure. The CICU nurse also monitors the inProviding effective pain management for bafant’s arterial blood gas results, chest tube bies is very challenging for nurses because infants drainage, and urinary output according to the are unable to verbalize and quantify their pain. It surgeon’s orders and unit policy. The infant will is essential to provide adequate pain relief for inhave a continuous infusion of fentanyl for pain fants postoperatively, not only to provide for management on the day of surgery. comfort needs after surgery, but also to support On the first postoperative day, the CICU AORN JOURNAL •

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TABLE 7

FLACC (ie, Face, Legs, Activity, Cry, Consolability) Pain Assessment Tool Categories

Score 0

Score 1

Score 2

Face

• No particular

• Occasional grimace

• Frequent to constant frown • Clenched jaw • Quivering chin

expression or smile

Legs

• Normal position or relaxed

Activity

Cry

• Lying quietly • Normal position • Moves easily • No cry when awake or asleep

Consolability

• Content and relaxed

or frown

• Withdrawn • Disinterested • Uneasy • Kicking or legs drawn up • Restless • Tense • Squirming • Arched, rigid, or jerking Shifting back and forth • • Tense • Moans or whimpers • Crying steadily • Screams or sobs • Reassured by • Difficult to console •

occasional touching, hugging, or being talked to Distractable

or comfort

Assessment of FLACC behavioral score: 0 = Relaxed and comfortable 1 to 3 = Mild discomfort 4 to 6 = Moderate pain 7 to 10 = Severe discomfort or pain Reprinted with permission from Sandra Merkel, MS, RN, clinical nurse specialist, University of Michigan Medical Center, Ann Arbor, MI.

the development of the infant’s central nervous system. Long-term studies indicated that there may be long-term consequences to unrelieved pain in infants; repeated painful stimuli have the potential to affect the developing brain, causing altered pain sensitivity and emotional problems. There also is evidence that unrelieved, repetitive pain can increase intracranial pressure and contribute to intracranial hemorrhage.24 Several pain scales have been developed that use observable behavioral and physical signs to assess the analgesic needs of infants. The pain assessment tool used at University Hospital to assess the pain of infants and young children is the FLACC scale (Table 7). This scale was developed by clinicians at the University of Michigan Health Systems, Ann Arbor, and uses a health care provider’s observations of five behavioral categories to determine the presence and severity of pain.

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The observer rates facial expression, leg position and/or movement, activity, cry, and consolability on a 0 to 2 scale, with a possible overall score of 0 (ie, the child does not display any pain behavior) to 10 (ie, the child displays significant pain behavior). Nurses caring for infants postoperatively in the CICU and NICU use this scale to determine the baby’s need for pain medication.25 The CICU and NICU nurses also use nonmedication interventions, including offering the baby a pacifier, controlling noise levels around the baby, lowering room lights, and planning care to allow uninterrupted rest periods in order to keep the infant as comfortable as possible.

OUTCOMES Potential complications of the arterial switch procedure include those commonly seen in cardiac procedures with CPB—bleeding, pneumonia,

DeBord — Cherry — Hickey

and wound infections. Complications specific to the arterial switch procedure include the potential for • coronary artery obstruction or kinking, • bleeding from the great vessels or coronary anastomosis suture lines, and • aortic and/or pulmonary stenosis. Cardiac arrhythmias are uncommon after this procedure because the suture lines do not cross the heart’s conductive tissues.2 The long-term survival of children who have undergone the arterial switch procedure and whose only cardiac abnormality is TGA is similar to that of children who are born without cardiac anomalies. One eight-year study of 125 infants who underwent the arterial switch procedure demonstrated that the majority of the infants had normal cardiac function on echocardiographic examination. The majority of these infants’ long-term health status was similar to that of children with no cardiac history.26 The infants in this study had a lowerthan-average overall performance on standard intelligence tests at four years of age, but by eight years of age, their test scores mirrored those of the general population.27 There is one published report of a young woman who became pregnant 19 years after having an arterial switch procedure in infancy. As an adult, this young woman had a successful pregnancy and delivery with no cardiac complications and gave birth to a healthy baby boy.28 The arterial switch procedure is an effective treatment for infants with TGA, contributing to excellent long-term survival rates and long-term health and neurocognitive status comparable to that of babies who are born without a congenital heart defect. Acknowledgement: The authors thank James K. Kirklin, MD, division director of cardiovascular/ thoracic surgery, and Christopher J. Knott-Craig, MD, chief of pediatric cardiovascular surgery, University of Alabama at Birmingham, for their assistance with the preparation of this manuscript, and Steven P. Goldberg, MD, resident physician in cardiothoracic surgery at the University of Alabama at Birmingham, for the use of his original illustrations.

AUGUST 2007, VOL 86, NO 2

REFERENCES 1. Jones K, Willis M, Uzark K. The blues of congenital heart disease. Newborn Infant Nurs Rev. 2006;6 (3):123. 2. May L. Pediatric Heart Surgery: A Ready Reference for Professionals. 2nd ed. Milwaukee, WI: Maxishare; 2005:23-24. 3. Klabunde RE. Cardiovascular Physiology Concepts. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:2-6. 4. Hazinski MF. Congenital heart disease in the neonate. Neonatal Network. 2002;21(3):34-35. 5. Westmoreland D. Critical congenital cardiac defects in the newborn. J Perinat Neonatal Nurs. 1999; 12(4):67-87. 6. Verklan M. Physiologic variability during transition to extrauterine life. Crit Care Nurs Q. 2002;24 (4):41-56. 7. Seifert P. Cardiac Surgery: Perioperative Patient Care. St Louis, MO: CV Mosby; 2002:209-212. 8. Congenital cardiovascular defects: statistics. American Heart Association. http://www.ameri canheart.org/presenter.jhtml?identifier=4576. Accessed June 14, 2007. 9. Quick reference and fact sheets: congenital heart defects. March of Dimes. http://www.marchof dimes.com/professionals/14332_1212.asp. Accessed June 14, 2007. 10. Information on heart defects: how congenital defects develop. American Heart Association. http:// www.americanheart.org/presenter.jhtml?identifier= 150. Accessed June 14, 2007. 11. Miller-Hance WC, Tacy TA. Gender differences in pediatric cardiac surgery: the cardiologist’s perspective. J Thorac Cardiovasc Surg. 2004;128(1):7-10. 12. Botto L, Mulinare J, Erikson JD. Occurrence of congenital heart defects in relation to maternal multivitamin use. Am J Epidemiol. 2000;151(9):878-884. 13. Coleman K. Genetic counseling in congenital heart disease. Crit Care Nurs Q. 2002;25(3):8-16. 14. D’Andrilli A, Ibrahim M, Venuta F, De Giacomo T, Coloni GF, Rendina EA. Glutaraldehyde preserved autologous pericardium for patch reconstruction of the pulmonary artery and superior vena cava. Ann Thorac Surg. 2005;80(1):357-358. 15. McConnell M, Elixson E. The neonate with suspected congenital heart disease. Crit Care Nurs Q. 2002;25(3):18. 16. Creaden J, Kohr L. The nurse practitioner’s role in patient management. In: Mavroudis C, Backer C, eds. Pediatric Cardiac Surgery. 3rd ed. St Louis, MO: Mosby; 2003:143-144. 17. Huhta J. Evaluating the fetus with transposition. Cardiol Young. February 2005;15(Suppl 1):88-92. 18. Rychik J. Frontiers in fetal cardiovascular disease. Pediatr Clin North Am. 2004;51(6):1489-1502. 19. Kouchoukos NT, Blackstone EH, Doty DB, Hanley FL, Karp RB. Complete transposition of the great arteries. In: Kirklin/Barratt-Boyes Cardiac AORN JOURNAL •

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Surgery: Morphology, Diagnostic Criteria, Natural History, Techniques, Results, and Indications. 3rd ed. Philadelphia, PA: Churchill Livingstone; 2003: 1438-1508. 20. Lodge A, Spray T. Transposition of the great arteries. In: Sabiston & Spencer Surgery of the Chest. Vol 1. 7th ed. Philadelphia, PA: Elsevier Saunders; 2005:2137. 21. Fleiner S. Recognition and stabilization of neonates with congenital heart disease. Newborn Infant Nurs Rev. 2006;6(3):137-150. 22. Buck M. Alprostadil (PGE1) for maintaining ductal patency. Medscape. http://www.medscape.com/view article/410907_print. Accessed June 14, 2007. 23. Wernovsky G. Transposition of the great arteries. In: Allen HD, Gutgesell HP, Clark EB, Driscoll DJ, eds. Moss and Adams’ Heart Disease in Infants, Children, and Adolescents Including the Fetus and Young Adult. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:1066-1067. 24. Reyes S. Nursing assessment of infant pain. J Perinat Neonatal Nurs. 2003;17(4):291-302. 25. Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs. 1997;23(3):293-297. 26. Dibardino DJ, Allison AE, Vaughn WK, McKenzie ED, Fraser CD. Current expectations for newborns undergoing the arterial switch operation. Annals of Surgery. 2004;239(5):588-596. 27. Mussatto K, Wernovsky G. Challenges facing the child, adolescent, and young adult after the

arterial switch operation. Cardiol Young. 2005;15 (Suppl 1):114-115. 28. Ploeg M, Drenthem W, van Dijk A, Pieper P. Successful pregnancy after an arterial switch procedure for complete transposition of the great arteries. BJOG. 2006;113(2):243-244.

Starla DeBord, RN, BSN, is a CVOR nurse clinician at University of Alabama at Birmingham. Ms DeBord has no declared affiliation that could be perceived as posing a potential conflict of interest in publishing this article. Cecile Cherry, RN, MSN, CNOR, is a CVOR nurse clinician at the University of Alabama at Birmingham. Ms Cherry has no declared affiliation that could be perceived as posing a potential conflict of interest in publishing this article. Carol Hickey, RN, MSN, is a CVOR advanced nursing coordinator at the University of Alabama at Birmingham. Ms Hickey has no declared affiliation that could be perceived as posing a potential conflict of interest in publishing this article.

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he AORN Journal publishes articles that appeal to professional perioperative nurses at all skill levels. The Journal currently is looking for manuscripts on the following topics: • total joint replacement in the older adult patient, • minimally invasive surgery/natural orifice surgery, • designing student learning experiences for the perioperative setting, and

• competency assessment of nurses in ambulatory surgery settings. Inexperienced authors are encouraged to contact Linda DeLia, manuscript solicitation editor, for writing tips and expert assistance; contact her by e-mail at [email protected] or by telephone at (800) 755-2676 x 249. To view the author guidelines or submit a manuscript online, visit http://www.aornjournal.org/authorinfo.

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ORN is now accepting submissions of poster presentations for display at the 2008 AORN Congress, which will take place March 30 to April 3, 2008, in Anaheim, California. In addition to the Clinical Improvement/Innovation and Research/Evidence-Based Practice Poster categories from previous years, a new Informational Poster category has been added for Congress 2008. Informational posters describe a chapter or hospital activity that is performed with or for the community or facility staff members but that does not have

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a direct relationship to patient outcomes. Submissions for poster presentations should be in the form of an abstract of 200 to 250 words on a clinical improvement/innovation, research/evidence-based practice, or informational topic. For more information or to submit an abstract, visit http://www.aorn.org /Education/EducationEvents/CallForAbstractsPosters/. The deadline for poster abstract submissions for Congress 2008 is October 1, 2007. Submissions received after the deadline will be considered for Congress 2009.

Examination

3.7

The Arterial Switch Procedure for Transposition of the Great Arteries PURPOSE/GOAL To educate perioperative nurses about the arterial switch procedure for transposition of the great arteries.

BEHAVIORAL OBJECTIVES After reading and studying the article on the arterial switch procedure, nurses will be able to

1. compare fetal circulation with neonatal circulation, 2. describe transposition of the great arteries (TGA), 3. identify the clinical signs of TGA, 4. discuss perioperative care of the infant undergoing the arterial switch procedure for treatment of TGA, and

5. identify complications of the arterial switch procedure for treatment of TGA. QUESTIONS 1.

With transposition of the great arteries (TGA), the aorta originates from the ________________ and the pulmonary artery arises from the ______________. a. right atrium/left atrium b. right ventricle/left ventricle c. left atrium/right atrium d. left ventricle/right ventricle

2.

The arterial switch procedure should be performed within the infant’s first two weeks of life because otherwise a. decreased cranial blood flow increases the risk of retardation beyond a reasonable level. b. the muscular strength of the left ventricle will deteriorate. c. the risk for myocardial infarction is too great.

3.

The four-chambered heart is fully functional by the end of the ______________ week of intrauterine life. a. second b. fourth c. sixth d. eighth

© AORN, Inc, 2007

4.

In fetal circulation, most of the blood in the right atrium passes through the _________________ into the left atrium, bypassing pulmonary circulation. a. ductus arteriosus b. ductus venosus c. foramen ovale

5.

When transition from fetal to neonatal circulation is complete, the fetal circulatory conduits become nonfunctioning ligaments. a. true b. false

6.

A patent ductus arteriosus is essential for systemic oxygenation in neonates with TGA who do not have an accompanying ventricular septal defect. a. true b. false

7.

The major presenting sign of TGA is a. a heart murmur. b. an abnormal chest x-ray. c. an abnormal electrocardiogram. d. cyanosis. AUGUST 2007, VOL 86, NO 2 • AORN JOURNAL • 227

Examination

AUGUST 2007, VOL 86, NO 2

8.

When caring for an infant who has TGA, perioperative nurses should be aware that the infant’s parents may 1. experience a range of emotions, such as shock, fear, guilt, anger, denial, and grief. 2. have difficulty understanding the baby’s diagnosis and treatment and need simplified explanations provided in layman’s terms. 3. need a social service referral for assistance with financial arrangements. 4. need a referral to a certified child life specialist to provide support and education to assist them in coping with the infant’s medical condition. a. 1 and 3 b. 2 and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4

The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education.

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9.

The most appropriate method for determining an infant’s pain after the infant has undergone surgery to repair TGA is a. a numeric pain assessment scale. b. parental observation and opinion. c. the FLACC pain assessment tool.

10. Complications specific to the arterial switch procedure include the potential for 1. aortic and/or pulmonary stenosis. 2. bleeding from the great vessels or coronary anastomosis suture lines. 3. frequent and varied cardiac arrhythmias. 4. coronary artery obstruction or kinking. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

Answer Sheet

3.7

The Arterial Switch Procedure for Transposition of the Great Arteries

Event #07038 Session #8394

lease fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photocopies and mail with appropriate fee to:

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AORN Customer Service c/o AORN Journal Continuing Education 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711 or fax with credit card information to (303) 750-3212. Additionally, please verify by signature that you have reviewed the objectives and read the article, or you will not receive credit.

Signature ______________________________________ 1. Record your AORN member identification number in the appropriate section below. (See your member card.) 2. Completely darken the spaces that indicate your answers to examination questions one through 10. Use blue or black ink only. 3. Our accrediting body requires that we verify the time you needed to complete this 3.7 continuing education contact hour (222-minute) program. ______ 4. Enclose fee if information is mailed. AORN (ID) #____________________________________________ Name__________________________________________________ Address ________________________________________________ City ___________________________________________________

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Signature _________________________________________________ Fee: Members $18.50 Nonmembers $37 Program offered August 2007 The deadline for this program is August 31, 2010 © AORN, Inc, 2007

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A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program will receive a certificate of completion. AUGUST 2007, VOL 86, NO 2 • AORN JOURNAL • 229

3.7

Learner Evaluation The Arterial Switch Procedure for Transposition of the Great Arteries

his evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.

T

PURPOSE/GOAL To educate perioperative nurses about the arterial switch procedure for transposition of the great arteries.

OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Compare fetal circulation with neonatal circulation. 2. Describe transposition of the great arteries (TGA). 3. Identify the clinical signs of TGA. 4. Discuss perioperative care of the infant undergoing the arterial switch procedure for treatment of TGA. 5. Identify complications of the arterial switch procedure for treatment of TGA.

CONTENT To what extent 6. did this article increase your knowledge of the subject matter? 7. was the content clear and organized? 8. did this article facilitate learning? 9. were your individual objectives met? 10. did the objectives relate to the overall purpose/goal?

TEST QUESTIONS/ANSWERS To what extent 11. were they reflective of the content? 12. were they easy to understand? 13. did they address important points?

LEARNER INPUT 14. Will you be able to use the information from this article in your work setting? a. yes b. no 15. I learned of this article via a. the Journal I receive as an AORN member.

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b. a Journal I obtained elsewhere. c. the AORN Journal web site. 16. What factor most affects whether you take an AORN Journal continuing education examination? a. need for continuing education contact hours b. price c. subject matter relevant to current position d. number of continuing education contact hours offered What other topics would you like to see addressed in future continuing education articles? Would you be interested or do you know someone who would be interested in writing an article on this topic? Topic(s): __________________________________ __________________________________________ Author names and addresses: _______________ __________________________________________ __________________________________________ © AORN, Inc, 2007