Be judicious with fluids and oxygen. Consider 5–10 mL/kg normal saline boluses rather than the usual 20 mL/kg boluses in the hemodynamically unstable infant to improve preload and encourage further opening of the PDA and pulmonary blood flow through the duct.⁸ Although the pulse oximetry goal in non-CHD patients is greater than 92 percent, in some CHD patients, aiming for this high of an oxygenation can prove deleterious to pulmonary blood flow, and it can worsen hypoxemia. Some CHD patients require a pulse oximetry of only 75 to 85 percent. Inotropes and/or vasopressors may be necessary to maintain adequate systemic perfusion and encourage pulmonary perfusion—consider them in consultation with a pediatric intensivist.

Avoid ketamine in patients suspected of CHD because it increases systemic vascular resistance (SVR), which worsens left-to-right shunting and can lead to cardiovascular collapse. Etomidate is preferred to minimize changes in hemodynamics.⁹

Be judicious with positive-pressure ventilation. Start with a very low positive end-expiratory pressure (PEEP). Positive-pressure ventilation can increase PVR and decrease SVR as well as preload, which can adversely affect shunt flow.¹⁰

Summary

The next time you’re faced with a crashing infant, rather than racking your brain for the details of every congenital heart lesion, simply consider CHD in your differential diagnosis, whether the infant is younger than 1 month of age or not, and whether they appear pink, gray, or blue. Look for silent tachypnea and assess limb differentials. Complete a hyperoxia test. Look for signs of ventricular hypertrophy on ECG. Use bedside ultrasound to determine global cardiac function, the presence of a septal defect, and the chamber count. Be judicious with fluids, oxygen, and positive-pressure ventilation. Consider prostaglandins for all blue and gray neonates, and avoid ketamine.

If you remember these simple principles, you could save an infant’s life.

Special thanks to Dr. Gary Joubert and Dr. Ashley Strobel for their contributions to the podcast from which this article was inspired.

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References

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10. Shekerdemian L, Bohn D. Cardiovascular effects of mechanical ventilation. Arch Dis Child. 1999;80(5):475-480.