TETRALOGY OF FALLOT

 Blue spells/Cyanotic
- 4 abnormalities that result in insufficiently
- Short period when reduced amount of blood flow
oxygenated blood pumped to the body
into the lungs
o Less amount of blood goes to the lungs for
 Ventricular septal defect → opening between the
oxygenation because of the narrowing of
right and left ventricles
the pulmonic valve and misplaced aorta
o Blood from the right ventricle will be
- Infant becomes acutely cyanotic and hyperpneic
directed to the left ventricle
o d/t sudden infundibular spasm decreases
 Pulmonic valve stenosis
pulmonary blood flow and ↑ right to left
o Not all the blood from the right ventricle
shunting
will be able to enter the pulmonary trunk
- May occur in any child whose heart defect includes:
due to the narrowing of pulmonic valve →
o Obstruction of the pulmonary blood flow
blood will accumulate in the right ventricle
(pulmonary stenosis)
→ pressure in the right ventricle will be
o Miscommunication between the ventricles
higher than the left ventricle
(ventricular septal defect)
 Thickened right ventricular wall
- Occurs most frequently in the 1st year of life
o Due to the accumulation of the blood in the
- Often in the morning and maybe preceded by:
right ventricle → blood becomes viscous →
o Feeding
right ventricle has a hard time pushing
o Crying
viscous blood through the stenotic
o Defecation
pulmonic valve → ↑ workload of right
o Stressful procedures
ventricle → muscles on the right ventricle
- Profound hypoxemia causes cerebral hypoxemia
enlarge
o Hypercyanotic spells require prompt
 Misplaced aorta
assessment and treatment to prevent brain
o Over ventricular septal defect
damage
 Normally, aorta should be on the
left ventricle
SQUATTING POSITION
o Both unoxygenated blood (from RV) and
- Characteristic posture of older children
oxygenated blood (from LV) goes to the
o Serves to ↓ the return of poorly oxygenated
aorta
venous blood from the LE
 Mixed blood goes to the different
 Squat → flexion → limit blood
systems of the body = hypoxemia =
going back to the right side of the
“cyanotic babies”
heart
 More unoxygenated blood enters
o To ↑ systemic vascular resistance, which ↑
the aorta because the pressure on
pulmonary blood flow and eases respiratory
the RV is greater than LV
effort
SYMPTOMS:
CLINICAL MANIFESTATION:
 Change of the skin color into blue d/t the flow of
 Slow weight gain
blood with low O2 content = cyanosis
 Exertional dyspnea
 Breathing shortness or _____ breathing while
 Fainting
feeding
 Fatigue or slowness due to hypoxia
 Loss of consciousness or fainting
 Pansystolic murmur heard at the mid lower left sternal
o d/t ↓ oxygenated blood going to the brain
border
 Poor weight gain
o Just by sucking up the nipple of the mother
Clubbing
makes the baby tired
- Thickening and flattening of the tips of the fingers
and toes (concave)
o d/t chronic tissue hypoxemia and
polycythemia
CLINICAL MANIFESTATION:
 Polycythemia: bone marrow
 Cyanosis
produces ↑ RBC = sluggish
- Blue discoloration in the mucous membrane
circulation
- Results from desaturated venous blood entering the
 Less O2 → bone marrow will
systemic circulation w/o passing through the lungs
compensate by producing more
because of the displacement of aorta
RBC
- Usually apparent when arterial O2 saturation is 80-
85%
 Blalock-Taussig Shunt
- A shunt between the subclavian and pulmonary
arteries designed to ↑ pulmonary blood flow and
reverse cyanosis
PREOP CARE
 Young children should be prepared close in time to
the event. Older children and adolescents may benefit from
teaching several weeks in advance.
 Parents should be included in the preparation.
 Use information-giving techniques:
o Written information
o Hospital tour
o Picture books
o Videos
o BP cuff, stethoscope, O2 mask, IV lines,
oximeters should be described
 Young children bringing a familiar stuffed animal or
comfort objects will help relieve anxiety
 Include distraction techniques:
o Counting
o Blowing
o Singing
o Telling stories
 The child should be assured that the parents will be there
when the child wakes up
 Allow parents to accompany child as far as possible to
the operating suite
POSTOP CARE
 At least hourly, the lungs are auscultated for breath
sounds. Diminished or absent sound may indicate:
o Atelectasis
o Pleural effusion
 Chest surgery → there will be bleeding
→ possible the blood entered the
pleura between parietal and visceral
o Pneumothorax (collapsed lung)
 Occurs when air leaks into the space
between the lung and chest wall → air
pushes on the outside of the lung and
make it collapse
 Hypothermia is expected immediately after surgery from:
o Effects of anesthesia
o Loss of body heat to the cool environment
☑ The child is kept warm to prevent additional heat
loss
Effects of hypothermia:
o Vasoconstriction
 Wound will not heal because there
will be less blood going to the
wound
o ↓ immune system
 Suppress the phagocytosis of WBC
= prone to infection because the
baby’s immune system is not fully
developed
o Suppresses actions of clotting factors
 Possible complication is bleeding
 During the next 24-48 hours, the body temperature
may rise to 37.7 degrees Celsius or slightly higher as
part of the inflammation response to tissue trauma
o After the period, an ↑ temperature is most
likely a sign of infection
 All lines must be cared using strict aseptic technique
 Suctioning is performed only as needed
o Intermittent and maintain for not more
than 5 seconds
 Lungs are not well developed yet;
the infant needs the oxygen
 Rest should be provided to ↓ workload of the heart
and promote healing
o As much as possible, prevent child from
crying
 Chest tube drainage greater than 3mL/kg/hr for
more than 3 consecutive hours or 5-10mL/kg in 1
hour is excessive and may indicate postop
hemorrhage
 Chest tubes are usually removed in 1st to 3rd postop
day
o Morphine sulfate often combined with
midazolam (Verzed) given before procedure
o Tubes are quickly pulled out at the end of
full inspiration
 Inhale – hold breath – Valsalva
maneuver – pull chest tube
o A petrolatum-covered gauze dressing is
immediately applied over the wound and
securely taped on all four sides
 Fluid is restricted during the immediate postop
period to prevent hypervolemia
o Weigh daily
o NPO for the 1st 24 hours
o Fluid restriction even when oral fluids are
given