Hybrids and Norwoods

Pediatric Critical Care Columnist · Feb 8, 2009

Are you referring to the Norwood-Sano? Most of our seem to do okay. But then, we get kids from all over western Canada and once they've gone home, we might not hear about them suddenly dying. And we see so many of them that if they don't return at 5 or 6 months for their Glenns, no one would notice.

Post-op care. Hmm. They are in the NICU until surgery then come to PICU from the OR; they usually have open sternums, they have sump chest tubes for the first couple of days and are all on milrinone plus whatever other vasoactive drugs are needed. We run their sats in the 70s and monitor mixed venous gases q6h, looking for venous sats of at least 50. Once their sternums are closed, the intracardiac lines are out and they're on minimal inotropic support we send them back to NICU to finish their recovery. Average PICU stay is about 6 days for the uncomplicated ones. Most of them seems to be with us for the short stay. I don't get those kids too often. I usually get them post-Fontan when they're leaking and freaking.

Sari2009 · Feb 12, 2009

I have cared for many, many norwoods over the years but have just begun working in a PICU that has a very sucsessfull hybrid approach to many congential heart defects. For HLHS babies they stent open the PDA to mantain flow and place bilat PA bands to limit overflow to the lungs. This is sometimes combined with a septostomy depending on the size of the septal defect. The goal is to allow the infant to gain and grow and gain strength prior to proceeding with the Glenn. I find it facinating. I have seen one done in the short time I have been there and am anxious to see how these kids progress.

Pediatric Critical Care Columnist · Feb 12, 2009

I admitted a Norwood today; she was undiagnosed prenatally and was already 3 days old before she presented. She was deathly ill on her admission to our NICU and we all expected her to be at least as sick after her Norwood. Amazingly enough, other than a ton of bleeding and 0.12 of epi, she looked pretty good. Of course it's early days...

PICURNROCKS · Feb 12, 2009

I hope she does really well. Thank you for sharing your insight and experience with me.

Pediatric Critical Care Columnist · Feb 12, 2009

People kept walking by the bed and saying, "THAT'S the Norwood?" Not like I had anything to do with her condition, mind you. Nor can I say that my helper made any great contribution, since it was the first time she'd been in the second nurse role and couldn't quite keep track of everything. Baby came late in the shift, and I spent most of the remaining time charting!

PICNICRN, BSN, RN · Feb 13, 2009

Ya know, I came from a place where these babes did REALLY well. I mean they are always really sick but for the most part did great all things considered. Can't say I saw more than a handful in 10 years not make it to their Glenn.

HOWEVER... I have moved to another part of the country, different surgeons, different post op management, and a whole lot more "issues" with these babies! They do not do nearly as well IMHO.

Pediatric Critical Care Columnist · Feb 13, 2009

My baby isn't quite as good as she was when I left her Wednesday evening. She went back to the OR with a tamponnade... Looking a bit better now, but paced, cooled, sedated and on amiodarone.

HRM672 · Feb 25, 2009

We do tons of Norwood-Sanos, and still some BT shunts. Most return for the Glenn, although the BT shunts are more fragile. I would like to hear more about this Hybrid procedure? I'm not familiar with it.

Our hospital has a CICU, a cardiac stepdown, and we are the only pediatric cardiac in our state and we draw from a few adjoining states so we have a large pool of HLHS patients.

PICURNROCKS · Feb 26, 2009

The Hybrid procedure, named hybrid becomes it combines interventional cath lab with surgical procedures, is an alternative to the Norwood. The reason for the hybrid is because it is less invasive, takes approximately 5hr less and can generally be done without cardiopulmonary bypass. It can also reduce the number of pump runs, which generally has a better outcome. This procedure then allows the infant to grow older, stronger and develop a better immune system before proceding to the next stage (Glenn Shunt) for major reconstruction. They implant a stent in the ductus arteriosus, which connects the pulmonary artery to the aorta. Then band the branch PA to restrict some pulmonary blood flow.

I think the problem we have been having is, for whatever reason, when they are doing the banding it is too big. My last patient that had this procedure passed away. I was told the band was too big. I am not sure if it is because she was so small and there wasn't a way to get the band tight enough to restrict enough of the pulm blood flow. I guess typing this has made me think of some things I'd like to speak to our CV docs about. So Jan I hope your little baby is doing better!! And I hope the above info was informative enough. Bless you all!

Pediatric Critical Care Columnist · Feb 27, 2009

Thanks for remembering her. She's much better and has been back in NICU for more than a week. We'll see her in the fall for her Glenn...

PCICURN · Apr 29, 2009

I have taken care of many HLHS kids. Almost all of them have had the Norwood with either the BT or Sano shunt. We have performed the hybrid procedure here at our facility twice. The first passed away at about 3 months and the other was successful but has not yet returned for their Glenn. From the reading that I have done on the procedure the majority of kids undergoing the hybrid do wonderfully for their first stage of repair and then have a harder time with their Glenn since they are also doing a whole arch reconstruction at that time.