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NEWBORN WITH TRANSPOSITION OF THE GREAT ARTERIES

Preparing for an Emergent Balloon Atrial Septostomy (BAS)



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Debrief


OVERVIEW

SIMULATION TYPESimulator based
SIMULATION TIME15 - 20 minutes
LevelComplex
PATIENT AGE GROUPNewborn
DEBRIEFING TIME30 minutes
TARGET GROUPSNurses, Advanced Practice Providers, Physicians, Physician
Assistants, Respiratory Therapists


WHY USE THIS SCENARIO?

This scenario presents a term newborn with prenatally diagnosed transposition of
the great arteries (TGA) and uncertain atrial mixing.
The priority is for the team to recognize inadequate atrial mixing after birth,
understand that starting Prostaglandin E1 (alprostadil) alone is not sufficient,
recognize the emergent need for a balloon septostomy, and implement the plan to
stabilize and transfer the newborn for this procedure.

This scenario is intended for use by advanced teams in medical centers that
stabilize newborns with cyanotic congenital heart disease in the delivery room.
Multiple steps, including sedation, paralysis, and intubation of the newborn and
initiation of a Prostaglandin E1 drip are required. This scenario offers
advanced teams the opportunity to practice teamwork skills to rapidly stabilize
and transport a critically ill newborn for an emergent procedure in the cardiac
catheterization laboratory.
The instructor may need to modify the script in accordance with local practice.
It may be helpful to review this scenario with local pediatric cardiology
resources.

The instructor may also determine if the team would benefit from simulating
transport of the baby with IV pumps, central lines, ventilatory support, etc.
from the stabilization area to the transport vehicle or to the cardiac
catheterization laboratory.




SUMMARY

This scenario presents vaginal birth and delivery room resuscitation of a term
newborn with prenatally diagnosed transposition of the great arteries (TGA).

Before birth, flow through the atrial septum was uncertain but was not believed
to be restrictive. The baby is breathing at birth and has an initial heart rate
of 120 bpm but is persistently cyanotic. Supplemental oxygen does not improve
pre-ductal saturation levels above 50%.
The highest priorities are to recognize the baby with TGA and inadequate atrial
mixing (restrictive atrial septum), improve pulmonary venous oxygen saturation,
decrease oxygen demand through sedation, paralysis, and intubation, initiate an
infusion of Prostaglandin E1 (alprostadil) through a centrally placed umbilical
venous catheter, place an umbilical arterial catheter for blood gas analysis and
lab work (optional) and quickly prepare/transport the newborn for an emergent
balloon atrial septostomy.

Without intubation this baby will experience apnea as a side effect of
prostaglandin E1 administration.




SCENARIO LEARNING OBJECTIVES


SPECIFIC LEARNING OBJECTIVES

 * Describe stabilization interventions and possible complications associated
   with the management of a newborn with prenatally diagnosed transposition of
   the great arteries (TGA)
 * Identify the clinical signs of TGA with inadequateatrial mixing
 * Demonstrate the correct procedure for ordering, preparing, and administering
   IV Prostaglandin E1(alprostadil)
 * Demonstrate procedures that decrease a newborn’s oxygen demand, including
   sedation, paralysis, and intubation.
 * Identify possible risk factors associated with IV Prostaglandin E1
 * Demonstrate effective communication and teamwork in the rapid stabilization
   and preparation for an emergent cardiac procedure


GENERAL LEARNING OBJECTIVES

 * Identify risk factors that can help predict which babies will require
   resuscitation
 * Perform a pre-resuscitation team briefing to review the clinical situation
   and any management plan developed during antenatal counseling
 * Demonstrate effective and supportive communication with the parent(s)
   regarding the anticipated plan of care
 * Perform an equipment check to ensure availability and function of supplies
   and equipment needed for this complex resuscitation
 * Ask the 3 rapid evaluation questions to determine if cord clamping can be
   delayed for at least 30 seconds
 * Demonstrate the initial steps of newborn care, thermoregulation, oxygen
   administration, and positive-pressure ventilation
 * Evaluate respirations, heart rate, and oxygen saturation at appropriate
   intervals
 * Debrief the resuscitation
 * Apply teamwork and communication behavior skills




EDUCATIONAL INFORMATION

Learner Requirements

The scenario is designed to teach neonatal resuscitation complicated by the
presence of a congenital anomaly and is based on principles from the Textbook of
Neonatal Resuscitation, 8th edition.

Before entering the simulation, learners are expected to be familiar with the
cognitive components of neonatal resuscitation, and be able to demonstrate all
relevant resuscitation skills, using proper technique, in the NRP algorithm
sequence.

Scenarios that include a congenital anomaly require that learners prepare for
simulation by reviewing cognitive materials about the anomaly, how the anomaly
may impact resuscitation interventions, and practice technical skills specific
to resuscitating the newborn with a specified congenital anomaly. This allows
the learners and the instructor to focus on improving communication and teamwork
during simulation training.

Resuscitation responsibilities of team members vary among hospitals. Depending
on the team members’ differing levels of clinical responsibility, you may need
to assist with team composition to ensure that the team comprises learners who
can perform the needed interventions (such as intubation) and that learners are
performing in roles that fit their professional scope of practice.

It is important that instructors clarify any differences in roles and
responsibilities between the simulation exercise and actual clinical
responsibility, especially if learners are occasionally expected to act outside
their usual role during a scenario. Acting in a role different from their
everyday role does not authorize the learners to perform interventions outside
their scope of practice in their real-life professional setting.

Learner’s Guide

See below for general information about participating in neonatal simulation
training.

 * This scenario requires resuscitation of a newborn in the hospital. Prenatal
   care revealed the presence of a congenital anomaly that will impact
   resuscitation interventions. This vaginal birth takes place in the delivery
   room.
 * The simulation training requires you to integrate cognitive, technical, and
   behavioral skills within the NRP algorithm sequence.
 * Before starting the simulation, you will be oriented to the setting, the
   simulator features, if necessary, any additional devices or moulage used to
   simulate specific clinical conditions, and the possible participation of
   standardized patients. This will allow you to prepare and ask questions.
 * The “props” of a simulated birth may vary. In some scenarios, a standardized
   patient may play the role of the laboring mother and the baby will be born
   from under a blanket on the mother’s lap. If the mother does not convey or
   ask for information in the scenario, a person need not play the role of the
   mother and the baby may simply be born from under a blanket.
 * Because the SimNewB Classic must be connected by cables during simulation, it
   is difficult to move the simulator from the delivering mother to the radiant
   warmer. Therefore, in scenarios using SimNewB Classic, a “stand-in” baby (a
   toy doll), can be used for the birth sequence, and SimNewB Classic is covered
   with a blanket on the radiant warmer. If the newborn must be cared for on the
   radiant warmer, the “stand-in” doll is carried toward the radiant warmer and
   set aside, SimNewB Classic is uncovered, and the resuscitation proceeds with
   the simulator.
 * Before starting the simulation, your instructor will ask you to identify a
   team leader. The team leader will start the simulation by discussing plan of
   care with the obstetric provider and confirming the baby’s anticipated plan
   of care with the mother (parents). Afterwards you will all enter the
   simulation for a pre-resuscitation team briefing. This should be performed
   quickly and efficiently.
 * Approach the care of the simulated newborn and the birthing mother / family
   member in the same serious, thoughtful manner, that you care for real
   patients. To optimize the learning situation, be aware of following aspects:
   * Say your thoughts and actions aloud, to let your team and faculty know what
     you are thinking and doing.
   * Please do the actions; do not pretend them.Note the exception to this
     rule:no liquid may be infused into the airway of the human simulator. If
     you need to administer endotracheal epinephrine, surfactant, or other
     medication, do it without using any liquid.
 * The post-resuscitation debriefing provides the opportunity to discuss the
   events of the scenario and analyze both individual and team behaviors that
   worked well to optimize teamwork and communication, and those that need
   improvement.

A detailed description of the human simulator´s features can be found in the
attachment.
(See Attachment: “The Neonatal Simulator Features – SimNewB”)

View attachment

Separate attachment to download and print: The Neonatal Simulator Features –
SimNewB


WHY USE THIS SCENARIO?

This scenario presents a term newborn with prenatally diagnosed transposition of
the great arteries (TGA) and uncertain atrial mixing.
The priority is for the team to recognize inadequate atrial mixing after birth,
understand that starting Prostaglandin E1 (alprostadil) alone is not sufficient,
recognize the emergent need for a balloon septostomy, and implement the plan to
stabilize and transfer the newborn for this procedure.

This scenario is intended for use by advanced teams in medical centers that
stabilize newborns with cyanotic congenital heart disease in the delivery room.
Multiple steps, including sedation, paralysis, and intubation of the newborn and
initiation of a Prostaglandin E1 drip are required. This scenario offers
advanced teams the opportunity to practice teamwork skills to rapidly stabilize
and transport a critically ill newborn for an emergent procedure in the cardiac
catheterization laboratory.
The instructor may need to modify the script in accordance with local practice.
It may be helpful to review this scenario with local pediatric cardiology
resources.

The instructor may also determine if the team would benefit from simulating
transport of the baby with IV pumps, central lines, ventilatory support, etc.
from the stabilization area to the transport vehicle or to the cardiac
catheterization laboratory.


RELATED SCENARIOS

This scenario is part of a set of 7 scenarios focusing on congenital anomalies
and birth trauma

Resuscitation of 24-hr old Newborn with Seizures - Guideline Update 2020

Delivery Room Resuscitation of Newborn with Omphalocele - Guideline Update 2020

Delivery Room Resuscitation of Newborn with Myelomeningocele - Guideline Update
2020

Show more



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