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Taking Care of a Newborn

Taking care of an infant with a diseased heart is challenging. Congenital cardiovascular defect is the most common cause of an infant’s death from birth defects, since over 24 percent of infants who die from a birth defect have a heart disease (National Vital Statistics Reports). The critical congenital cardiovascular malformation is a lesion requiring intervention within the first month of life. With early diagnosis, however, most infants with heart defects can benefit from successful surgical repair or palliation. Adequate and experienced approach to such conditions is required. Caring for a critically ill newborn requires a specialized skill set that needs to be developed with thorough education. Education for all members of the neonatal cardiac service is obviously a vital part of an intensive care program and demands constant attention.

Congenital heart diseases show prevalence of four to nine cases per 1,000 newborn children. This number does not include minor heart lesions that do not require imperative interventions. Moreover, the most widespread congenital heart defects usually do not carry urgency and can be managed electively. For example, ventricular septal defect may be corrected either surgically or by endovascular approach within the first year of life or even later. In this paper, I regard to those inborn heart diseases which demand special attention starting from the first cries of the newborn child. This means that if not properly treated, the baby will surely decease soon. For example, transposition of the great arteries is a critical lesion that must be operated on within the first two or three weeks of life. If so, the expected prognosis for this individual is perfect. Babies caring this lesion never have chromosomal anomalies, so their social expectations are encouraging. This is typically a one-stage correction, and it means that no other interventions will be needed. The expected life time after successful arterial switch operation performed is particularly promising. Thus, when properly treated, a newborn child with a bad heart condition may become a full personality.

Because the total prevalence of congenital heart diseases is not very common, and some diagnoses are rare, educational process to become adequate to them may take a long time. Furthermore, infants, especially with an unwell hearts, can show extreme fragility, and to take care of them demands that all medical staff is entirely dedicated and properly trained. Nursing personnel is probably in the center of critical cardiac conditions management. A nurse is a life saving colleague who lives with the newborn, and as long as she lives with the infant, the baby is alive.

“Nurses spend more time with ICU patients than anyone else, and their long hours at the bedside can give them valuable information and insights, especially regarding areas such as family dynamics and the range of the patient's alertness or discomfort over the course of the day”.

Here, I would like to demonstrate how life saving the nurse can be. No other field of medicine can probably be more evidential to rescue than intensive neonatal cardiology. To achieve this goal, I organize the paper into three parts. First, I discuss in short what a congenital heart defect is and why it may make the baby pass away rapidly. In the second part of the manuscript, it is shown what happened in the past, when many medical patterns were unavailable. This is done to emphasize the importance of the current proceeding. In the third part, I discuss what needs to be done to save an infant’s life, concerning medical measures. Finally, the last part is devoted to the discussions and conclusions concerning nursing challenges.

CONGENITAL HEART DEFECTS

A congenital heart defect is an inborn disorder of the heart and/or the great vessels that typically lead to early mortality and high morbidity. This kind of heart lesion is an embryological error that results in anatomical disorders. The latter leads to numerous pathophysiological violations and, eventually, negative impact on life. For example, a common arterial trunk is a lesion that increases pulmonary blood flow enormously. If the lungs are over circulated, they become susceptible to infections (pneumonia), which results in vascular spasm (pulmonary hypertension) and demands excess energy (at the expense of child’s growth). Thus, the baby will retard in development and may decease from congestive heart failure or lung compromise.

Congenital heart diseases can be classified by a number of different criteria. Here, only the most common grading is mentioned:

1) shunting lesions: left-to-right shunts (also known as ‘pale’ lesions) – ventricular septal defect, and right-to-left shunt (also known as ‘blue’ lesions) – tetralogy of Fallot, transposition of great arteries

2) obstructive lesions: aortic stenosis, coarctation of the aorta

3) hypoplasia lesions: left heart hypoplastic syndrome

4) duct-dependent lesions: interrupted aortic arch, pulmonary artery atresia, et al.

Infants with critical heart lesions may present with cardiac associated borderline conditions. They include congestive heart failure, cardiac shock, arrhythmias, severe cyanosis/cyanotic spell, and pericardial effusion. Since many cardiac defects today are no more surgical emergencies, prostaglandin invention duct dependent conditions must be discussed. During fetal circulation, the patent arterial duct provides the hemodynamics. Normally, it will close after breathing starts, but if there is a heart disease, the only chance to survive is to keep the duct patent. These complex lesions are called duct-dependent. Prostaglandin E, a natural occurring chemical compound, is infused to keep the duct patent. Duct dependent lesions are numerous: tetralogy of Fallot, transposition of great arteries, tricuspid or pulmonary atresia, aortic coarctation, and hypoplastic left heart. Luckily, babies suffering from these lesions today can be saved or at least adequately stabilized.

HISTORICAL NOTE

In the past, neonatal mortality had been unacceptably high. Bains (1862) reports "Of the deaths in England in 1859, no less than 184,264 - two in every five of the deaths of the year - were of children under five years of age; and above half of these - 105,629 - had scarcely seen the light, and never saw one return of their birthday". Neonatal cardiology adds more drama to this history. For example, Taussig (1947) stated “The majority of cyanotic infants do not survive for more than a year and a half”. It was not until antibiotic invention in the 1940’s, mechanical ventilation advent in the 1950’s, and prostaglandin therapeutic approach development in the 1970’s, that survival of critical infants improved. Surgical techniques evolved too. The first attempt to palliate transposition of the great arteries dates back to the 1950’s and the first successful arterial switch operation was reported in 1983 (Freedom). This is the last half of the 20th century that made pediatric cardiology a wonderfully exciting and rewarding specialty. Today, many of these fragile conditions can be adequately managed, thus giving a chance to  bring up wonderful individuals to admire.

INTENSIVE CARE

Neonatal cardiac intensive care is a challenging and a relatively new concept. Trained nurses must be able to initiate resuscitation attempts in the absence of immediate physician. Jeremias emphasizes the bedside nurse’s importance in cardiac care: “nurse is arguably the most influential component of the multidisciplinary team from an operational perspective”. No matter how trivial it may seem, providing an infant with simple requirements is no less important than surgery or intervention itself.

The nurse is ought to monitor the baby's condition, administer necessary medications to the newborn, record the newborn’s progress and recovery, and hold and comfort the babies in distress. Nevertheless, this cardiac care demands the nurse to be fairly acquainted with resuscitation protocols, mechanical ventilation patterns, inotropic support strategies, intravenous infusion, parenteral nutrition calculations, and prostaglandin management. The cardiac neonate needs its acidosis to be properly corrected. As for any newborn, prompt temperature control is mandatory. Glucose control is of no doubt essential to consider. Central venous pressure must be measured, trachea suctioned, urine output measured, intravenous infusions changed, monitor patterns controlled, respirators checked, etc.

Typically neonatal resuscitation starts with airway, after that intravenous access is provided and monitoring started, followed by respiratory support and volume challenge (unless heart failure stated). Should duct-dependent heart disease be evident, prostaglandin is to be started. Unlike typical neonatal resuscitation, inotropic support (like dopamine) is often needed. Arrhythmia is another specific concern. They are classified into tachyarrhythmias (more than 200 beats per minute) and bradyarrhytmias (less than 100 beats per minute). The former will need an antiarrhythmic drug to be infused or vagal probes (i.e. carotis glomus massage) tried. The latter usually needs a cardiac pacemaker to be placed.

DISCUSSION AND CONCLUSIONS

Clinical and scientific advantages of the last decades made the practice of the care of children with cardiac disease a neonatal specialty (Fanaroff). Today, fetal diagnosis of cardiovascular malformations is a routine. Either palliative or reparative surgery within the first weeks of life is a commonplace today, which results in improving long-term prognosis.

The care of a neonate with a cardiac disease must be a team work. It is a collaborative process shared by many physicians as well as nurses. There needs to be a free exchange of ideas and expertise on a daily basis. A non-interrupted educational process experienced by the neonatal team, no matter how difficult it may seem, is an extremely thankful operation. It is the nurse who assists in contributing to the recovery of the diseased. The work load and its demands for a nurse are exceptional. She finishes one task on an infant just in time to start the next, and when finished, she is ready behind to do the same task again on the first. In pediatric cardiology, mistakes may be inevitable, but every procedure is potentially life-saving.

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