Surgical Management Of Vsd

Nutrition & VSD A case study on a term infant Presented By: Dong Mei Quah Su Chin Lu Han Goh Choon Hua

Case Study • Baby Johan was born at term to a 35year-old woman. During breast feeding on the postnatal ward, Johan’s mother noticed that he became blue. Investigation revealed that Johan had a ventricular septal defect. He was scheduled for surgery. On his 3rd POD, his mother asked if she could continue breast feeding Johan or switch to formula

Objectives • Discuss the pathophysiology and types of

VSDs • Discuss how VSD affects the nutritional needs of Baby Johan Discuss nutritional needs of a term infant • Identify causes of malnutrition and its consequences • Identify types of surgery for VSD • Discuss Feeding methods • Discuss how to feed Baby Johan postoperatively

Ventricular Septal Defect • a communication between the right

and left ventricles, which is the most common congenital heart disease • can occur anywhere in the muscular or membranous ventricular septum • The size of the defect is important in determining the severity of the condition or haemodynamic consequences

(RuizVentricular Septal Defect, 2006)

Types of VSD • Inlet VSD: usually part of an AV canal defect; 5% to 7% of all VSDs.

• Perimembranous (Conoventricular, or infracristal) VSDs: 80% of all VSDs.

• Muscular VSD: can be single or multiple and of variable size in any given patient; 5% to 20% of all VSDs.

• Conal septal malalignment VSD: the conal septum is not properly aligned with the rest of the ventricular septum, resulting in a defect; it’s always large and unrestrictive. –

Anterior malalignment is associated with obstruction of the right ventricular (RV) outflow tract (e.g., tetralogy of Fallot)

–

Posterior malalignment is associated with obstruction of the left ventricular (LV) outflow tract and aorta (e.g., posterior malalignment VSD with coarctation).

• Conal septal hypoplasia VSD • There also may be multiple VSDs of different types in a single

Atrioventricular Canal Defect

Perimembranous VSD

Muscular VSD

Pathophysiology of VSD • The defect causes shunting of blood between ventricles

• The direction of blood shunting depends on the relative PVR and SVR

• Amount of shunting depends on the size of the defect

• Small VSD: small left to right shunt; the

workload of two ventricles is normal. ECG and CXR are normal.

• Moderate-sized VSD: amount of shunting can be large and is affected by the relative of PVR and SVR. RV pressure is normal or only mildly increased.

Pathophysiology of VSD • Large (unrestrictive) VSD: RV and LV pressures are equal. Direction and amount of shunting is purely determined by PVR and SVR.

• A large left-to-right shunt leads to increased

pulmonary blood flow, left atrial and left ventricular dilation, tachypnea, and congestive heart failure (CHF). Typical onset of CHF is at 2 to 8 weeks of age as the PVR falls post-natally.

• If a large VSD is left untreated, pulmonary vascular

disease (irreversible increase in PVR) may develop, leading to reversal of the shunt, cyanosis, and right ventricular failure (Eisenmenger syndrome).

VSD & Nutritonal Needs • Feeding difficulties – – –

Tiring easily from the effort to suck Poor eater Poor oral intake

• Fail to grow to thrive normally

Nutritional Needs • Infants’ diet must contain adequate

nutrients, such as protein, carbohydrate, fat, mineral, and vitamins. • Protein is needed for rapid cellular growth and maintenance . • Carbohydrate provides energy. • Fat is necessary for the normal development of the neonatal brain and neurologic system. • Mineral and vitamins are needed to

Energy Requirement Age

kcal/kg/day

Neonate

100-120

< 10kg

100

10kg – 20kg

1000 + 50 kcal/kg over 10kg

> 20kg

1000 + 20 kcal/kg over 20kg

(Hendricks & Duggan, 2000)

Daily Reference Intake for Normal Infants Nutrient

0-6 months (6kg)

7-12 months (9kg)

Protein (g)

9.3

11

Carbohydrate (g)

60

95

Fat (g)

31

30

Fluid (mL)

700

800

(Hendricks & Duggan, 2000)

Nutrition • Oral feeding – –

Breast Milk Formulas

• Oro-gastric tube feeding – Expressed breast milk – Formulas

• Total parental nutrition

Causes of Malnutrition • Inadequate intake • Illness • Lack of access to food, e.g. Poverty • Inappropriate feeding and caring • Insufficient healthcare services

Consequences of Malnutrition • Catabolism Catabolism

– Impaired physical and cognitive development

• Depressed immunity

– Most commonly, infectious diarrhea, which causes anorexia, decreased nutrient absorption, increased metabolic needs, and direct nutrient loss

• Impaired organ function – – –

• • •

Fatty degeneration of the liver and heart Atrophy of small bowel Decreased intravascular volume leading to secondary hyperaldosteronism

Delayed wound healing Prolonged morbidity Increased mortality

(Grigsby, 2006)

Surgical and Nutritional Management

Surgical Management of VSD • Indicated when infants: – –

Fail to thrive Develop complications despite medical management – When VSD is severe or >5mm in size and not responding to medical management

Surgical Management of VSD • Types of surgery depends on: – – –

Location of VSD Size of VSD Number of VSDs • Isolated • Multiple – Presence of other medical conditions e.g. co-existing with TOF, CoA – Severity

Surgical Management of VSD • Types of Surgery – Transcatheter closure of VSD for certain anatomic VSDs – Patch repair with CPB/open heart surgery – Palliative repair • For infants with complicated anatomical access and co-morbidities • To improve life expectancy

– Usually can live up to 15-20 years of age.

Impact of Critical Illness on Nutritional Needs • Why is nutrition important? – Critical illness coupled with poor nutrition leads to: • Prolonged ventilator dependency • Prolonged ICU stay • Heightened susceptibility to nosocomial

infections • Increased mortality with mild/moderate or severe malnutrition

Impact of Critical Illness on Nutritional Needs • Goals of Nutritional Support – – –

support basic body function promote healing support normal immune function to prevent infection and other complications – prevent catabolism – promote growth

Post Surgery: Feeding • Feeding routes: – Transpyloric feeding (Drip feeding) • Usually in premies and infants with respiratory distress who cannot tolerate enteral feeding

– Enteral feeding • Orogastric / Nasogastric • Offers several advantages over TPN/PPN – Maintaining gut motility, improving mesenteric flow, support gut-associated lymphoid tissue

– Parenteral Feeding • Requires central venous access

Feeding Guidelines Maintenance Fluid Requirements Weight

Volume /kg/day

1 - 10 kg

100 ml/kg/day

10 - 20kg

1000 ml + 50 ml for each kg > 10 kg

20 kg

1500 ml + 20ml for each kg > 20 kg

Enteral Feeding Advancement Guide Weight

Initial volume/kg/day

Incremental advance per day

< 1250g

10 cc/kg/day

10 cc/kg/d*

1250 - 1500g

10 - 15 cc/kg/d

10 - 15 cc/kg/d*

> 1500g

20 cc/kg/d

20 cc/kg/d (Hendricks & Duggan, 2000)

Feeding Baby Johan • Term Baby – Fluid Management in the initial post-op period

• 50% of calculated needs • Balance with fluid losses, diuresis, cardiac output needs

– Initiate enteral feeding with EBM (assuming his gut function is adequate) once constant diuresis is reached with adequate circulatory support

• Assuming Baby Johan is ~3kg – Initiate feeding at 50-60cc/kg/day. If well tolerated, advance by another 20cc/kg/day . Allow a pacifier for non-nutritive sucking during feeding to enhance oromotor skills. – If no signs of feeding intolerance and has good oromotor skills: may progress to breastfeeding.

Post-Surgery Factors That May Delay Baby Johan’s Progression to Oral Feeds

Factors that can complicate Johan’s progression to oral feeds • Late return of bowel sound • Infection • Difficulty in extubation • Intolerance to oral feeds

Factors that can complicate Johan’s progression to oral feeds • Post-op Complications – – – – –

Arrhythmias Bleeding Gastrointestinal Complications Postoperative Pulmonary Hypertension Postoperative infection

Signs of Feeding Intolerance • • • • • • • • •

Excessive gastric residuals > 2x the hourly rate on COG feeds > ½ the feeding volume on bolus gavage feeds Bilious or bloody gastric aspirates Vomiting Visible or palpable loops of bowel on abdominal exam A firm or distended abdomen Stools Diarrhea

Assessing adequacy of oral feeding • Adequacy of milk intake • Assessed by voiding and stooling patterns • And by aspirating

• Fluids, Electrolytes, and Nutrition • Fluid retention • Fluid management :Diuretic therapy is typically started within 24 to 48 hours

• Total body weight

Post Surgery Preparing Mother and Baby Johan for home

Providing Advise: Feeding of Baby Johan    

Benefits of breast feeding “How to” of breast feeding Infection issues Psychological aspects: Allaying Breastfeeding Anxiety

Benefits of breast feeding Human milk • Contains anti-inflammatory factors and other factors that regulate the response of the immune system against infection.

• Contains immunologic agents and other compounds, such

as secretory antibodies, leukocytes, and carbohydrates that acts against viruses, bacteria, and parasites. The transfer of these factors from human milk provides a distinct advantage that infants fed formula do not experience.

• Contains a balance of nutrients that closely matches human infant requirements for growth and development than does the milk of any other species. Eg. compared to cow’s milk, human milk is low in total protein and low in casein, making it more readily digestible and less stressful on immature infant kidneys. The lipids and enzymes in human milk

Benefits of breast feeding For infants

• Better gastrointestinal function and protection

from gastrointestinal infections, such as vomiting and diarrhea.

• A reduced risk of respiratory infections, ear infections, and wheezing.

• Some studies suggest that breastfeeding reduces the risk of obesity, cardiovascular disease, and autoimmune diseases, such as type 1 diabetes mellitus.

Benefits of breast feeding For women • Reduced blood loss after childbirth as a result of a

hormone, oxytocin, which is released into the mother’s bloodstream while breastfeeding. Oxytocin helps the uterus to contract, which reduces uterine bleeding

• Reduced levels of stress in the mother as a result of several hormones released during breastfeeding

• Increased weight loss after pregnancy (if breastfeeding continues for at least six months).

• Reduced risk of ovarian and premenopausal breast cancers, and possibly a reduced risk of osteoporosis.

Benefits of breast feeding For Family

• Reduced infant feeding costs. Infant formula and

associated supplies are estimated to cost at least $1000 during the first 12 months.

• Reduced costs related to healthcare, including

doctor’s visits, hospital costs, and lost time from work. Infants who are breastfed are less likely to become ill and less likely to be hospitalized, reducing the potential costs and anxieties of caring for an ill child.

Providing Advise: Feeding of Baby Johan    

Benefits of breast feeding “How to” of breast feeding Infection issues Psychological aspects: Allaying Breastfeeding Anxiety

“How to” of breast feeding Correct latch-on • Mother should be comfortable and the infant positioned so that nothing interferes with mouth-to-breast contact.

• Nipple is stroke against the infant’s cheek nearest the nipple. Entire nipple and most of the areola should be placed in the infant’s mouth.

• Infant latch-on by compressing the lips. Normal sucking

include suction of 4-6 cm of the areola, compression of the nipple against the palate, stimulation of milk ejection by initial rapid non-nutritive sucking, and extraction of milk from the lactiferous sinuses by a slower suck-swallow rhythm of approximately one per second.

• Infant may be removed from the breast by placing a clean finger between the infant’s and the areola to release

“How to” of breast feeding Positioning • • • •

Cradle hold Cross-cradle hold Football hold (Clutch Position) Side-lying position

Cradle hold • Support the baby with

• •

•

the arm on the same side as the nursing breast Sit up straight — preferably in a chair with armrests. Cradle the baby and rest his or her head in the crook of your elbow while he or she the nursing breast. For extra support, place a pillow on your

Cross-cradle hold • Ideal for early breast-feeding, • •

•

•

when you and your newborn are getting used to the process. Sit up straight in a comfortable chair with armrests. Hold your baby crosswise in the crook of the arm opposite the breast you're feeding from — left arm for right breast, right arm for left. Support the baby's trunk and head with your forearm and palm. Place your other hand beneath your breast in a Ushaped hold (this guides the baby's mouth to your breast and make it easier for the baby to latch on) Don't bend over or lean forward to bring your breast

Football hold • This position is especially popular among mothers who:

– Are recovering from Caesarean births – Have large breasts – Nursing a premature baby or two babies at once – Need to encourage a baby to take more of the nipple into his or her mouth

• Hold your baby at your

•

side, with your elbow bent. With your open hand, support your baby's head and face him or her toward your breast. Your baby's back will rest on your forearm. For comfort, put a pillow at your side and use a chair

Side-lying hold • A lying position may help

your baby latch on to your breast correctly in the early days of breast-feeding.

– It's also a good choice when you're tired. – If you're recuperating from a Caesarean birth, reclining may be your only option for the first few days.

• Lie on your side and face

• •

your baby toward your breast, supporting baby with the hand of the arm you're resting on. With your other arm and hand, grasp your breast and then touch your nipple to your baby's lips. Once your baby latches on, use the bottom arm to

“How to” of breast feeding

Advice for Mum: Determining effectiveness of breast-feeding • • • • • • •

Steady weight gain is often the most reliable sign Most newborns breast-feed eight to 12 times a day If you listen carefully, you’ll be able to hear your baby swallowing Your breasts may feel firm or full before the feeding, and softer or emptier afterward. Expect your baby to have six to eight wet diapers a day A well-nourished baby also will have one to three or even more bowel movements a day A baby who seems satisfied after a feeding and is alert and active at other times is likely getting enough to eat

“How to” of breast feeding

Advice for Mum: Milk production and expression • Ideally, infants who are medically stable and able to breastfed should be put to breast for all feedings.

• If infant is unable to breastfeed effectively, the mother

should express her milk approximately 8 to 12 times / day to initiate, maintain or increase her milk supply.

• You should save any milk that is expressed. • A mother who is expressing milk for an ill or hospitalized

infant requires education concerning milk production, use of an electric breast pump. She should be able to demonstrate how to assemble the pump, use it, and clean it before she leaves the hospital.

Providing Advise: Feeding of Baby Johan    

Benefits of breast feeding “How to” of breast feeding Infection control Psychological aspects: Allaying Breastfeeding Anxiety

Infection Issues Infection through Breast feeding • Many maternal illnesses associated with fever do not require

separation of the mother and infant or additional precautions to protect the infant. (eg. Breasts engorgement, atelectasis, UTI, etc)

• Most anti-microbial agents used to treat infection can be

used in infants and children. Additional amounts that are ingested by the infant in breast milk are usually insignificant.

• Standard precaution include, avoiding direct contact with

blood and body fluids, broken skin and mucous membranes, careful hand washing before and after breastfeeding, and washing the breast before and after breastfeeding.

Infection Issues Healthy lifestyle choices

Your lifestyle choices are just as important when you’re breastfeeding as they were when you were pregnant. • Eat plenty of fruits, vegetables and whole grains. • Drink lots of fluids. • Rest as much as possible. • Only take medication with your doctor’s consent. • Don’t smoke. • Beware of caffeine and alcohol.

VSD management

• Because infection can occur up to 3 weeks after surgery, •

parents need to be educated about signs of bacterial endocarditis, wound infection, including purulent drainage, fever, and a foul-smelling odor. Prophylactic antibiotics therapy is usually continued for up to 6 months post VSD closure to prevent bacterial endocarditis. – Teach Mum how to administer medications to Baby Johan

• With early diagnosis and repair of a VSD, the outcome is generally excellent, and minimal follow-up is necessary. Activity levels, appetite, and growth will return in most

Providing Advise: Feeding of Baby Johan    

Benefits of breast feeding “How to” of breast feeding Infection issues Psychological aspects: Allaying Breastfeeding Anxiety

Psychological Issues: Allaying Breast-feeding anxiety

• Explain to the mother, the infant’s heart • • • •

condition, sign and symptoms and why it affect the feeding so that it will not affect the mother psychologically. Allay the fear and anxiety of breastfeeding for the infant after surgical intervention. Provide educational resources and demonstrate correct breastfeeding techniques for a surgical infant to ensure that their feeding decision is a fully informed one. Support and encouragement by the father can greatly assist the mother when problem arises. Encourage breastfeeding post operatively. Eg. Provide private room, avoid procedure that interfere with breastfeeding, teach infant feeding cues, the needs to establish and maintain an

Summary • Most baby born with a congenital heart defect may be

• •

• •

medically managed or may require surgical intervention. Surgery can be accomplished in the immediate newborn period or planned for when the infant reaches a specific age or weight. Family support, education and participation in the infant’s care is essential in assisting the family to cope with the diagnosis and to ensure optimal outcomes for the infant. Ongoing maternal support, education, and assistance with breastfeeding or expressing milk for the infant unable to nurse is essential to ensure positive outcomes for the mother and her infant. Once discharged home, infants require follow-up to provide appropriate health care and monitor of growth and nutrition. Breastfeeding provides numerous benefits to infants and

References Abdulla, R. (2007). Atrioventricular canal defect [on-line]. Available: http://pediatriccardiology.uchicago.edu/PP/chd%20for%20parents%20avc.h tm (26 Jan, 2008). Carole, K., Judy W.L. & Ann, A.F. (1998). Comprehensive neonatal nursing: a physiologic perspective. Philadelphia: W. B. Sauders Company. Gomella, T.L., Cunningham, M.D., Eyal, F.G. & Zenk, K.E. (2004). Management, procedures, on-call problems, diseases, and drugs (5th ed.). New York: Lange Medical Books/McGraw-Hill Medical Pub. Grigsby, D.G. (2006). Malnutrition. Emedicine from WebMD [on-line]. Available: http://www.emedicine.com/ped/topic1360.htm (20 January, 2008). Hendricks, K.M. & Duggan, C. (2000). Manual of pediatric nutrrtion (3rd ed.). Hamilton: B.C.Decker. Hockenberry, M.J. & Wilson, D. (2007). Wong’s nursing care of infants and children (8th ed.). St. Louis: Mosby.

References Klossner, N.J. & Hatfield, N.T. (2006). Introductory maternal and pediatric nursing. Philadelphia: Lippincott Williams & Wilkins. Lawrence, R. M., Lawrence, R. A. (2004). Clin Perinatol: Breast milk and infection. New York: Elsevier Inc. Merenstein, G.B. & Gardner, S. L. (2006). Hand Book of Neonatal Intensive Care (6th ed.). St. Louis: Mosby. Olds, S.B., London, M.L., Ladewig, P.A.W. & Davidson, M.R. (2004). MaternalNewborn nursing and women’s health care (7th ed.). New Jersey: Prentice & Hall. Ruiz, M. (2006). Image:Ventricular septal defect.svg [on-line]. Available: http://commons.wikimedia.org/wiki/Image:Ventricular_septal_defect.svg (26 January, 2008). Ramaswamy, P., Anbumani, P., Srinivasan, K., Srinivasan, A., Natesan, V. & Srinivasan, S. (2006). Ventricular Septal Defect, General Concepts. Emedicine from WebMD [On-line]. Available: http://www.emedicine.com/ped/topic2402.htm (20 January, 2008).

References Slonim, A.D. & Pollack, M.M. (2006). Pediatric critical care medicine (1st ed.). Philadelphia: Lippincott Williams & Wilkins. Spitzer, A. R. (1996). Intensive Care of the Fetus and Neonate. St Louis: Mosby-Year Book US Department of Health and Human Services.(2000). HHS Blueprint for Action on Breastfeeding. [On-line]. Available: www.cdc.gov/breastfeeding/pdf/bluprntbk2.pdf (31 January 2008) Wilkinson, J. (2007). Ventricular septal defects (VSD) – large [on-line]. Available: http://www.rch.org.au/cardiology/health-info.cfm?doc_id=3579 (26 Jan, 2008). Yale University. (2001) Perimembranous ventricular septal defects [on-line]. Available: http://www.med.yale.edu/intmed/cardio/chd/e_vsd_memb/index.html (26 Jan, 2008).