Cardiac Intensive Care and Mechanical Support
Postoperative intensive care
After cardiopulmonary bypass, children are at risk for low cardiac output, bleeding, tamponade, arrhythmia, and capillary leak. Management prioritizes oxygenation, ventilation, sedation, and judicious fluid resuscitation. Junctional ectopic tachycardia is common after congenital heart surgery and may require cooling, magnesium, or amiodarone. Chylothorax after arch surgery requires drainage and nutrition modification. Mechanical circulatory support with ECMO or ventricular assist devices is used for refractory failure; anticoagulation and infection prevention are critical.
Traps
Do not treat hypotension with fluid alone; assess ventricular function, tamponade, and vascular resistance. A chest tube that suddenly stops draining may signal clot obstruction and tamponade. Postoperative cyanosis may reflect residual shunt, pulmonary hypertension, or pleural effusion. Sedation must balance comfort against hemodynamic instability.
Worked example
A 1-day postoperative arterial switch patient has rising lactate, oliguria, and hypotension despite adequate filling pressures. Echocardiography shows poor ventricular function without tamponade. Optimize ventilation and sedation, start inotropic support, and evaluate for ECMO if perfusion does not improve. Rule of thumb: after bypass, look for the reversible causes-bleeding, tamponade, arrhythmia, residual lesion, and sepsis-before escalating support.