Clinical Pathway: Ventricular Septal Defect (VSD) or
Atrial Septal Defect (ASD) Repair
Notes: (1) This pathway is a general guideline and does not represent a professional care standard governing providers’ obligations to patients. Care is
revised to meet the individual patient needs. (2) This is a quality improvement document and should not be a part of the patient’s medical record.
Eligibility Criteria
 No significant co-morbidities
 Expected length of stay 3-5 days
Circumstances when a patient should come off pathway (examples, not an exhaustive list):
 Expected length of stay is longer than 5 days (e.g., patient has cardiogenic shock, infection, sepsis, JET, or other clinical
problem)
Pathway Process
Pre-op
Operative
CT surgery
identifies
pathway
patients
CT surgery &
Peds
Anesthesia
report on
surgery and
hand off
patient to ICU
Post-op
ICU
Transfer
MD team
follows
pathway
(packet stays
in patient’s
door)
Pathway
packet travels
with patient
Post-op
intermediate
care unit
MD team
follows
pathway
(packet stays
in patient’s
door)
Note to ICU physician team: The daily goals pathway sheets should be fully completed each day, including the quality
measures and family communication sections located on the back of sheets for post-op days 1 and 2. The pathway sheets
take the place of the standard daily goals communication sheets and should stay in the patient doors when not being filled
out.
Instructions for HUCs

Obtain most recent version of pathway packet here:
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When making copies of the packets, copy post-op days 1 and 2 double-sided
Entire pathway packet should be stapled together
Copies of packets are kept in the file drawer of secretary desk at high end
When pulling packet for a patient, include a date stamp on the Day of Surgery
sheet
Make note of each pathway patient on the daily census assignment sheet
Make sure the pathway packet accompanies patient through transfer to
intermediate care unit
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Quality Improvement Document ---- Do NOT place in patient’s chart
Clinic al Pathway: Ventricular Septal Defect (VSD) Repair
Notes:
(1) This pathway is a general guideline and variations can occur based on professional judgment to meet
individual patient needs.
(2) This pathway is for VSD pre-ICUstay. If ASD patient skip to ASD/VSD Daily Goals Sheet
(3) This is a quality improvement document and should not be a part of the patient’s medical record.
Pathway Process
Surgery
Scheduled
Pre-op
Clinic
Day of
Surgery
Intraoperative
PICU
Transition
Instructions for Providers
 All patients should have a paper copy of this pathway in their chart from
preoperative clinic thru OR to PICU transition of care.
 Please obtain most recent version of pathway packet here:
https://www.med.unc.edu/ticker
 Please fill out Y/N and comments for each step of the pathway.
 After transition of care to the PICU, a PICU team member should put the
pathway in the box outside of the patient room for collection by the
pathway team.
 Contact information for questions:
o Meg Kihlstrom: [email protected]
o Nicole Conrad: [email protected]
o Karla Brown: [email protected]
o
o
Quality Improvement Document ---- Do NOT place in patient’s chart
Patient Barcode Label
Clinic al Pathway: Ventricular Septal Defect (VSD) Repair
Suggested Guidelines
PREOPERATIVE
Y - check; comments
LABS
 Type and Screen
 Abo/Rh
 CBC
 Patient specific considerations: CMP, UA, thyroid, albumin/total protein, RVP
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IMAGING
 ECHO within 1 month of case
 CXR
 ECG
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ORDERS
 CARDIAC SURGERY TEAM
o Prepare pRBC: < 10kg: 1 full unit; 2 split packs; > 10kg: 2 units
o Prepare FFP: 1 full unit
 ANESTHESIA TEAM
o Antibiotics: Cefuroxine 50mg/kg x2 doses; alternate - Vancomycin
o Vasoactive: Epinephrine, Vasopressin, Calcium (< 6mo); Patient specific (Milrinone - no
loading dose, start infusion at 0.5mcg/kg/min)
INSTRUCTIONS
 Medications
o Respiratory: continue
o Cardiac: Lasix - continue; ACE/ARB - discontinue
o Neuro: continue
 NPO guidelines
 Chlorhexidine wash
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DAY OF SURGERY
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ANESTHESIA TEAM
o ECHO order
o Blood verification (call blood bank and anesthesia tech to bring blood to room)
o Premedication +/PICU TEAM: pre-admission orders (CXR/labs)
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INTRAOPERATIVE
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Intubation: < 10kg: nasal; >10kg: oral
Lines
o 2 PIVs
o Central line: first attempt RIJ (<5kg: 5F 5cm; >5kg: 5F 8cm; >100cm: 5F 12cm)
o Arterial line
ECHO
o Probe size (< 3kg: micro; 3-29kg: pediatric; >29kg: adult)
o Report in EPIC as a procedure note (pre/post bypass; written by anesthesia with
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assistance of cardiology)
Quality Improvement Document ---- Do NOT place in patient’s chart
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Infusions
o Aminocaproic acid
 Neonate: 50mg/kg load, 40mg/kg/hr infusion
 Child: 75mg/kg load, 75mg/kg/hr infusion
o Vasoactive (listed above in preoperative section)
Neuraxial anesthesia: immediately after intubation (lengthen time till heparinization)
o <5yo: caudal (morphine 50mcg/kg; clonidine 1-2 mcg/kg)
o >5yo: spinal (morphine 5mcg/kg; clonidine 1-2 mcg/kg)
Monitors
o NIRS - cerebral and somatic (neonatal < 45 weeks gestation)
Labs
o ABG - q30min
Blood
o If more pRBC is needed; anesthesia to order split packs if <10kg
o If more FFP is needed; anesthesia to order full unit
PERFUSION
o Prime
 Neonate circuit: 150mL pRBC, 100mL FFP
 Pediatric circiut: blood prime if Hgb <10
 Adult circuit: blood prime if Hgb <10
o Aminocaproic acid:
 Neonate circuit: 10mg/100mL prime
 Child circuit: 25mg/100mL prime
o MUF: neonate circuit; available with pediatric circuit
o Cell saver >20kg
CBP
o MAP goals
 Neonate 35-45
 Infant 40-50
 Toddler 45-55
 Older child/teenager 20% of baseline
o PaO2: Not greater than 150
o PaCO2: 35-45
Other medications
o Optional (Magnesium, furosemide)
Extubation: Plan to extubate unless patient specific considerations
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OR to PICU TRANSITION
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Transport/transition
o See anesthesia transfer notes and handoff form attached
o Infusions: all that are not in use should be dismantled from pumps, capped and
transported to PICU
o Airway adjuvant: small nasal cannula with CO2 (PICU to send nasal cannula with bed and
monitor AND anesthesia will stock in OR)
o Monitor (NIRS cable sent with monitor)
o Blood
 MUF blood labeled with patient sticker and expiration (<4 hours post opening)
 Any opened blood products labeled with patient sticker and expiration (<4 hours
post opening)
 Unopened blood products transported to PICU in cooler
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Quality Improvement Document ---- Do NOT place in patient’s chart
Patient Barcode Label
Clinic al Pathway: Ventricular Septal Defect (VSD)
Repair
Pediatric Cardiac Transfer Note
Patient Name:
Weight:
kg
Age:
Notable PMHx & PSHx:
Home Meds:
Allergies:
Procedure:
Pre-op cath/TTE:
Type of Anesthesia:
General
Mask ventilation:
Easy
ETT: Size:
Induction:
Two-hand
Nasal
Mask
Intravenous
Oral airway used --- size:
Oral
Blade & # of attempts:
Depth:
Access:
PIV:
Caudal:
PIV:
Yes
No
CVC:
A-line:
Morphine PF:
mcg
Clonidine:
Medications:
Fentanyl:
mcg
Antibiotic:
mg @
Neuromuscular blockade:
Yes
Acetaminophen:
mg @
CPB start time:
No
Reversed:
Yes
No
Other meds:
CPB: Pump Time
Circulatory arrest:
minutes
Cross clamp Time:
minutes
minutes
Low Flow Time:
minutes
Fluids:
Crystalloid:
Colloid:
PRBC’s:
FFP:
Cell Saver:
Cryoprecipitate:
Platelets:
Urine Output:
Pacer Capture:
A-wires:
V-wires:
Echocardiogram: (EPIC report)
Pre-CPB TEE:
Post-CPB TEE:
mcg
Quality Improvement Document ---- Do NOT place in patient’s chart
Suggested Guidelines
Time of Arrival to ICU
PM Rounds
System
PULM:
Plan/Goals
Plan/Goals
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▪Wean off mechanical vent support
▪Complete Post Op Orders
▪Review CXR and Labs
CV:
▪Assess risk of Low Cardiac Output Syndrome. Increased risk includes
long CPB times and complicated repairs.
▪Review ECG
▪Echo completed at 48 hrs post op (unless clinically indicated sooner)
RENAL: +
▪Diuretic plan POD #1 = furosemide IV Q6-Q12h depending on prior
exposure and fluid balance - can write order on pm rounds for next day.
Follow UOP for goal of 1 ml/kg/h
FEN/GI:
▪Goal 75% maintenance Total Fluids (standard maint IVF = D5 1/2NS +/KCL pending labs results)
▪Complete Post Op Orders
▪Famotidine
▪Discuss plan for clears tonight or tomorrow and advance as tolerated
HEME:
▪verify transfusion goals with surgical team at handoff
ID: Antibiotics/ day ____ of ____
▪Complete Post Op Orders; empiric cefuroxime
NEURO/SEDATION:
▪Verify regional anesthesia use with surgical team at handoff (if yes,
then see separate sheet for regional anesthesia plan)
▪If extubated or weaning for extubation AVOID BENZODIAZEPINES due
to respiratory depression risk
▪Verify indications for Toradol with surgical team at time of handoff, if
approved start Toradol 6 hours after admission to PICU only with
normal renal function and no significant bleeding. 72h max course
▪PRN Fentanyl or Morphine for breakthrough pain.
▪Scheduled Tylenol (IV or PO/PR) Timing of last dose in OR ______
LINES/TUBES/MONITORING:
□ Foley
□ tubes
□ art-line □ central line □ wires
□ CT
SCHEDULED LABS:
▪Complete Post Op Orders
Update family with current status and expectations overnight
Does the patient require care deviating from this pathway?
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Yes
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No
Describe reason here and document in medical record:
Goal Parameters: SBP______ pH_________ Net -/+
Day Shift
ICU MD/DO ___RN ___
RT ___
Night Shift
ICU MD/DO ___RN ___
RT ___
MAP_______ O2 Sats_________
Peds Cardiology ___
CT Surgery___
Quality Improvement Document ---- Do NOT place in patient’s chart
Goals for
CICC Transfer
Suggested Guidelines
System
AM Rounds
Plan/Goals
PM Rounds
Plan/Goals
PULM:
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Desirable to
have tubes and
lines out if no
longer
necessary. May
go to
intermediate
care unit with
CVL or CT if
needed.
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Family aware of
transfer and
received caregiver
booklet
▪CXR Review
▪Pulmonary Toilet
CV:
▪Plan for post op ECHO tomorrow (POD #2) or sooner if
clinically indicated
RENAL:
FEN/GI:
▪Nutrition: advance as tolerated – discuss “goal” (volume
and calories for feeds) on rounds and time to get to full
feeds
HEME:
▪Review current indications for transfusion with team
ID: Antibiotics/ day ____ of ____
▪Most commonly 6 doses cefuroxime (48 hours post op)
NEURO/SEDATION:
▪Continue Scheduled Tylenol (and Toradol if normal renal
function and no signif bleeding)
▪Transition from IV to PO narcotic PRN
▪Wean off precedex if started
▪Transition Tylenol to PO if previously IV
LINES/TUBES/MONITORING:
□ Foley
□ tubes
□ art-line
□ central line □ wires □ CT
Can anything be removed?
Foley removal on POD #1 unless otherwise
contraindicated
SCHEDULED LABS:
Only requiring
NC O2 or less
pulmonary
support.
Cardiology team
accepts patient
for transfer
Turn page to complete other side
▪Uncomplicated VSD repair = furosemide IV Q6h-q12h
starting today (POD #1) with goal of UOP of > 1 ml/kg/hr
and diuresis
Discuss with
cardiology
Decreasing
requirements for
IV narcotics for
pain
Quality Improvement Document ---- Do NOT place in patient’s chart
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Does the patient require care deviating from this pathway?
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Yes
No
Describe reason here and document in medical record:
Goal Parameters: SBP______ pH_________ Net -/+
Day Shift
ICU MD/DO ___RN ___
RT ___
Night Shift
ICU MD/DO ___RN ___
RT ___
MAP_______ O2 Sats_________
Peds Cardiology ___
CT Surgery___
Quality Control Measures (mandatory)
ICU MD – please complete for family
At the end of rounds – include the main goals
to be communicated with the family for the
day – even if they are already on rounds.
Events or deviations?
Y
N
HOB elevated 30 deg, OOB, inc spirom?
Y
N
Examples:
Pharmacist on rounds?
Y
N
Up and walking, turning down the ventilator,
taking out chest tubes, tolerate feeds.
Over 30kg requiring adult doses?
Y
N
RN PLEASE TRANSCRIBE TO WHITE BOARD
Antibiotic levels due?
Y
N
Respiratory weaning goals?
Y
N
n/a
Ulcer prophylaxis?
Y
N
n/a
Glucose control?
Y
N
n/a
DVT prophylaxis?
Y
N
n/a
Isolation? Reason: ___________________
Y
N
Sedation/paralytic holiday?
Y
N
Can anything be removed?
Y
N
PT/OT/Speech/Rehab consulted?
Y
N
DNR
Y
N
Y
N
Y
N
Y
N
Incident Report? □ Yes □ No
(Ex.unplanned extubation; medication error; near miss)
Staff concerns addressed?
Nursing, Respiratory Therapy
Pressure ulcers?
Medication reconciliation? CPOE vs. MAR
Time: _____
n/a
1
2
3
n/a
4
5
Quality Improvement Document ---- Do NOT place in patient’s chart
Quality Improvement Document ---- Do NOT place in patient’s chart
Notes: (1) This pathway is a general guideline and does not represent a professional care standard governing providers’ obligations to patients. Care
is revised to meet the individual patient needs. (2) This is a quality improvement document and should not be a part of the patient’s medical record.
Suggested Guidelines
System
PULM:
▪CXR Review
▪Pulmonary Toilet
CV:
▪Plan for post op ECHO today (POD
#2) if not already complete
RENAL:
▪Uncomplicated VSD repair =
FEN/GI:
▪Full enteral feeds
▪Continue famotidine while on
Toradol
HEME:
▪ Review indications for transfusion
and decrease phlebotomy as possible
ID: Antibiotics/ day ____ of ____
▪Completed periop antibiotics
▪Decrease risk of healthcare acquired
infections – assess needs for
tubes/lines
NEURO/SEDATION:
▪Continue PO acetaminophen
scheduled /PO narcotic PRN/Toradol
as long as stable renal function and no
bleeding
LINES/TUBES/MONITORING:
□ Foley
□ tubes
□ art-line
□ central line □ wires □ CT
Can anything be removed today?
Foley should already be discontinued
SCHEDULED LABS:
Minimize as possible
PM Rounds
Goals for transfer to
intermediate care unit
Plan/Goals
Plan/Goals
Discuss with cardiology
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Only requiring NC O2 or
less pulmonary support.
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Does the patient require care deviating from this pathway?
Describe reason here and document in medical record:
Goal Parameters: SBP______ pH_________ Net -/+
Day Shift
ICU MD/DO _____
RN_____
Night Shift
ICU MD/DO _____
RN_____
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Yes
Cardiology team accepts
patient for transfer
Turn page to complete other side
furosemide IV Q6-Q12h, consider
transition to PO furosemide and dose
based on fluid status and UOP
AM Rounds
Decreasing requirements
for IV narcotics for pain
Desirable to have tubes
and lines out if not longer
necessary. May go to
intermediate care unit
with CVL or CT if needed.
Family aware of transfer
and received caregiver
booklet
□
No
MAP_______ O2 Sats_________
RT______
Peds Cardiology_____ CT Surgery______
RT______
Quality Improvement Document ---- Do NOT place in patient’s chart
Quality Control Measures (mandatory)
PICU MD – please complete for family
At the end of rounds – include the main goals
to be communicated with the family for the
day – even if they are already on rounds.
Events or deviations?
Y
N
HOB elevated 30 deg, OOB, inc spirom?
Y
N
Examples:
Pharmacist on rounds?
Y
N
Transfer to intermediate care unit, Up and
walking, taking out chest tubes, taking feeds
without using feeding tube
Over 30kg requiring adult doses?
Y
N
RN PLEASE TRANSCRIBE TO WHITE BOARD
Antibiotic levels due?
Y
N
Respiratory weaning goals?
Y
N
n/a
Ulcer prophylaxis?
Y
N
n/a
Glucose control?
Y
N
n/a
DVT prophylaxis?
Y
N
n/a
Isolation? Reason: ___________________
Y
N
Sedation/paralytic holiday?
Y
N
Can anything be removed?
Y
N
PT/OT/Speech/Rehab consulted?
Y
N
DNR
Y
N
Y
N
Y
N
Y
N
Incident Report? □ Yes □ No
(Ex.unplanned extubation; medication error; near miss)
Staff concerns addressed?
Nursing, Respiratory Therapy
Pressure ulcers?
Medication reconciliation? CPOE vs. MAR
Time: _____
n/a
1
2
3
n/a
4
5
Quality Improvement Document ---- Do NOT place in patient’s chart
Quality Improvement Document ---- Do NOT place in patient’s chart
Notes: (1) This pathway is a general guideline and does not represent a professional care standard governing providers’ obligations to patients. Care
is revised to meet the individual patient needs. (2) This is a quality improvement document and should not be a part of the patient’s medical record.
Goals (please indicate if patient has met goals (y/n)
FEN/GI:
▪ On defined full feeds and tolerating (define with nutrition support)
▪ No need for IV fluids or nutrition
CV:
▪ On all enteral medications
▪ No complex arrhythmias
▪ Normal BP for age
▪ Pre-discharge echocardiogram and ECG completed if indicated
PULM:
▪ Off oxygen 24 hours or on home therapy
Date:
Date:
Date:
RENAL:
▪ Voiding well
HEME:
▪ stable clinically appropriate hemoglobin
ID:
▪ afebrile with no evidence of wound infection
NEURO/SEDATION:
▪ appropriate exam for age or at baseline
▪ need for PO medications only for pain
LINES/TUBES:
▪No lines or tubes in place with exception of peripheral IV or if going home
with central access all services in place with case management coordination
Psychosocial:
▪ (define with case management support)
Family Education:
▪ Start Teaching Packet on day of arrival (or if stays in ICU with transfer
orders and no bed available in intermediate care unit)
▪ Housestaff to contact primary care MD and arrange for appointment to
see primary care MD in 48 after discharge
▪Complete Discharge Instructions
Family Communication (daily):
At the end of rounds – include the main goals to be communicated with the
family for the day – even if they are already on rounds.
Examples: tolerating goal calories, get rid of NG tube, taking all feeds by
mouth, family teaching
RN PLEASE TRANSCRIBE TO WHITE BOARD
Day Shift
Night Shift
MD ___RN ___
MD ___RN ___
MD ___RN ___
MD ___RN ___
MD ___RN ___
MD ___RN ___
Quality Improvement Document ---- Do NOT place in patient’s chart