2. Demographics
• Name: JS (female) Age: 17 years
• Admitting Diagnosis: Atrial septal defect Discharge Diagnosis: ASD status post closure
• PMH:ASD, hyperthyroidism, depression
• PSH: thyroidectomy and wisdom teeth
• Social Hx: lives at home with parents.
Just finished HS and plan to attend college in Colorado in the fall.
• Family Hx: no family history of congenital heart disease
• Allergies: NKDA
• Medications: (prior to admission): levothyroxine thyroid
supplement, Celexa, Wellbutrin, Yasmin birth control.
3. History
• HPI as of 5/31: 17 year old female who was found to have a
murmur in the fall of 2012 after a workup for thyroid dysfunction.
Her echocardiogram showed a large secundum ASD.
• Concurrently being evaluated for increased work of breathing
during exercise and abnormal pulmonary function testing.
• Multidisciplinary team Review
• Options for closure:
• 0 percutaneous device
• surgical closure
• Families choice was surgery
4. The murmur
• Grade 2/6 systolic ejection murmur
• with a Fixed split S2
• Left upper sternal border
5. Pre-Operative Testing
• ECHO REPORTS:
• 9/19/12= THE STUDY WAS TECHNICALLY DIFFICULT.
• Echo images compromised by body habitus.
• Mild-moderate right ventricular enlargement.
• Moderate secundum ASD.
• Moderate left to right atrial shunt.
• Mild tricuspid regurgitation.
• 11/21/12= TEE;
• Moderate sized ASD.
• Defect measures 11 mm
9. In the operating room
• Intubated
• Right IJ was placed
• Left Radial Arterial Line was placed
• Urinary Catheter was placed
• Preoperative TEE was consistent with ASD
• Right mammary incision is made
10. Intraoperative
• (6/3) surgery-
• Right Heart enlargement is noted
• Once on bypass the heart was open, inspection of the intra-atrial septum
did not reveal the typical findings of ASD.
• The fossa ovalis membrane was redundant and thin-walled.
• Postoperative TEE did not reveal any intra-atrial level shunting.
• cardiopulmonary bypass was 80 minutes.
• aortic cross clamp time was 52 minutes.
11. Intraoperative Continued
• Right pleural catheter was placed for pain
management
• Right pleural and medistinal chest tube
• OR transfer to PICU, stable condition.
12. Post-Operative
Out of OR 1645
Remains stable, intubated, lines in place, no
inotropes
Cefazolin
Labs:
PT:11
INR:1.1
PTT:25
Fibrinogen: 358
16. Vitals and P.E.
Physical Exam:
General: awake and appropriate for age
CV: Normal S1S2, no murmur, clicks or rubs, radial & pedal
pulses +2, no edema, cap refill less than 2 sec.
Resp: CTAB, CTx2 in place
GI: Soft NT/ND, hypoactive bowel sounds, no
organomegally
MSK: moves all extremities, 4/5 strength
Skin: Incision sites are clean, dry, approximated without
redness or drainage.
Neuro: no focal deficits
HR RR BP SpO2 Temp
94 17 120/71 art. 94% RA 37.8 oral
17. POD #1
• (6/4) Extubated at 0255
• chest tube out-pulled at 1600, D/C art line, D/C
foley, D/C CVL
• Cefazolin day 2 Tmax 38.2 oral
• Fluid restriction 1500ml/day-clears were began
after extubation
• Fentanyl drip-0.5 mcq/kg/hr.
• Ropivacaine(on Qpain pump) 6ml/hr. to 8ml.hr
18. POD #2 Medications:
• Lasix 20 mg PO daily
• Cefazolin 2,000 mg IV every 8 hours
• HOME MEDICATIONS RESTARTED:
wellbutrin 100mg PO daily
Celexa 20mg PO hs
Synthroid 0.137 mg PO daily
• PRN MEDICATIONS:
Lortab 325mg-5mg, 2 tabs PO every 6 hr.
moderate pain
20. POD #2: Vitals and P.E.
Physical Exam:
General: awake and appropriate for age
CV: Normal S1S2, no murmur, clicks or rubs, radial & pedal
pulses +2, no edema, cap refill less than 2 sec.
Resp: CTAB, no retractions or difficulty breathing, on and
off hiccups
GI: Soft NT/ND, active bowel sounds, flatulent, no
stools, no organomegally
MSK: moves all extremities, 5/5 strength
Skin: Incision sites are clean, dry, approximated without
redness or drainage.
Neuro: no focal deficits
HR RR BP SpO2 Temp
93 27 134/83 RA 95% RA 37 oral
21. POD #2
• Day 3:(6/5)able to go home, hiccups, not sure
pain meds will hold
• Full fluids-tolerating general diet
• Last dose of Cefazolin
22. POD #3 Vitals and P.E.
Physical Exam:
General: alert and oriented. Calm and interactive.
HEENT: normocephalic, PEERLA, Nares patent bilaterally, mucus membranes
moist and intact. No jugular vein distention.
CV: Normal S1S2, no murmur, clicks or rubs, radial & pedal pulses +2, no
edema, cap refill less than 2 sec.
Resp: CTAB, no wheezing, no retractions or difficulty breathing, on and off
hiccups
GI: Soft NT/ND, active bowel sounds, flatulent, no stools, no organomegally
MSK: moves all extremities, 5/5 strength
Skin: right submammary Incision sites are clean, dry, well approximated
without tenderness, redness or drainage. Chest tube sites are clean, dry, well
approximated without tenderness, redness or drainage.
Neuro: no focal deficits
HR RR BP SpO2 Temp
98 15 142/79 RA 99% RA 35.6 oral
23. POD #3
• (6/6) Discharge home
• Discharge ECHO= small pericardial effusion,
good biventricular function
• No stool
• Chest x-ray: continued improvement with
bilateral lung aeration.
24. Things that were learned
• J snores
• “likes the hospital for 2 things, Morphine and
Oxygen”
• Wore oxygen for a brief time after her chest
tube were removed.
25. Discharge Medications
• Continue with home medications
• Lasix 20 mg PO daily
• Miralax 17grams PO daily
• Motrin 600mg po take q 6 hours for mild pain
• Lortab 325mg-5mg tab, 2 tab q6 hours for
moderate to severe pain
26. Discharge Instructions
• Follow up June 13, 2013 with surgeon
• Activity restriction: nothing that will force her arms to be pushed
or have her arms above her head.
• Showering restrictions: 1 week post-op okay to shower and to
wipe wounds clean and dried off with towel. Wait 4 weeks prior
to submersion.
• Incision sites: watch for redness, swelling, discharge.
• Watch for signs of infection
• Bowel regimen: Use Miralax until regular bowel regimen has
returned
28. Discussion
• What were the main complications?
• There was NO ASD
• Who was involved in the complication?
• The entire Cardiac team
29. Discussion
• What steps were missed that lead to
complication?
• How could it have been prevented?
• Interventions for the APN
30. A different choice
A different scenario
• Had JS chosen to have a 0 percutaneous
procedure(cath lab)
• Longest hospital stay would have been 1 day
• Shortest hospital stay would have been 6
hours from when the sheath was removed
• No additional medications
Editor's Notes
the pt reports that she does not have any chest pain or palpation. she said that over the past couple of months she has felt more breathless with activity. she denies any dizziness or syncope. Immunizations UTDHer findings were reviewed at the multidisciplinary team meeting there was agreement by all 6 cardiologist and 2 surgeons that there was an ASD, they also discussed best method of intervention. this defect could be closed using a 0 percutaneous device or surgical closure. there was discussion with the family regarding either method of closure and the family chose to proceed with surgical closure of the defect. Congenital cardiovascular surgery was consulted for surgical repair. After a thorough discussion about the repair, her family wished to proceed with surgery.
The murmur that she presented with that continue to be heard was:
subcostal imaging of the atrial septum was difficult despite multiple attempts. Sagittal imaging was not possible and imaging of the ASD was not adequate enough to measure the defect or to be certain there was only 1 ASD. Mild tricuspid regurgitation. Mild right ventricular enlargement. which is centrally located in the secundum septum. the defect measures 11 mm and there are probably multiple fenestrations.
Positive for right heart hypertrophyNegative for the rSr prime which is INDICATIVE of a ASDNormal axis deviation
red is flow toward, and blue is flow away from the transducer.
Now fast forward from November to June:at this time she presents for surgical closure of atrial septal defect through a limited anterior submammary thoracotomy.
Right mammary incision and placed on cardiopulmonary bypassthere did not appear to be a single jet of blood flow from the left atrium to the right atrium. the fossa ovalis was entered and it was confirmed that all the pulmonary veins returned to the left atrium. the transeptal incision was closed with prolene suture. postoperative TEE did not reveal any intra-atrial level shunting.
Required noinotropesPost op coags stable!
R wave is still bigger than the s in V1Still shows Right ventricular hypertrophy with a normal axis deviation
Late morning has right sided hiccups that become painful at the chest tube site
Minimal chest tube output, Great urine output-1.5ml/hr, leading to a negative 1162 balance over the past 16 hoursResume home medsTransition to oral pain medication:Lortab 650mg PRN wean fent gttAdvance fluids as toleratedChange lasix to PO dailyD/C bedrest, activity as tolerated up to chair 3x today, IS q1 while awake
PT/OT to see, child life assist with activityContinue IS while awakeD/C on Qpain pump-leakingAdd 600mg Motrin PRN painAble to go home tonight depending on pain tolerance.
Continues to tolerate general diet, ambulating well, pain was well managed with oral pain medications. Stable for discharge. Chest tube stiches were removed and replaced with steri strips
Didn’t need to O2 but said that it made her feel better
Activity: jumping jacks, pushups, riding bikes, rough housing, jumping on trampoline or climbing
Steps missed:Prevention: possible bubble test? All ASD’s get a cath before surgery? Interventions: Child Life for while in the hospitalletter to PCP about procedure, Right side enlargement with no ASD is not , consider a sleep study in the future r/t llikeing Oxygen but not needing it
