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All consents require a witness and should ideally be obtained from a person that witnessed the consent and conversation about the procedure. Damage to surrounding structures is also a risk, depending on where the target lesion is located. There is also always a possibility that the procedure will fail to yield the diagnostic or therapeutic benefits expected. Please refer to the subsequent section for specific risks associated with each procedure. For complex cases that may require extended fluoroscopy, the patient should be made aware of the small possibility of radiation exposure complications (see appendix for cutaneous injury threshold doses). Alternatively, whoever is running the desk at either hospital can print off a specific, pre-filled consent form. If the witness is not present for signature when Informed Consent is obtained, the witness must verify the signature by having the person granting consent initial, date, and record the time of verification beside their signature. The Health Care Professional(s) that is responsible for carrying out and/or personally performing the procedure is required to ensure that informed consent is obtained and documented. Facilitation duties include providing information to the patient and assisting with form completion. However, the responsible Health Care Professional remains responsible for the consent and for ensuring the adequacy of the information conveyed in the informed consent discussions and appropriate documentation of same. The general consent form for ambulatory care in the outpatient clinics is valid for one year. The Consent for Authorization for Administration of Anesthesia and for the Performance of Operations and Other Procedure form is valid unless the patient revokes it at any time prior to the treatment being performed or if the procedure has changed. The non-surgical blood consent form is valid for the duration of treatment for a medical condition up to a maximum of one year. Copies of the original blood consent form will be accepted, and must be on the chart prior to the administration of blood or blood products. Each physician must document an opinion in the medical record regarding the cause and nature of the inability to consent, its extent, and its probable duration. Emergency Situations: Medical or surgical procedures may be undertaken without Informed Consent when the patient is unable to consent, no surrogate is available immediately, and the delay caused by attempting to locate a surrogate will create a substantial risk of death, serious disfigurement, or loss or impairment of the functions of a bodily member or organ or other serious threat to the health of the patient. Healthcare for relief of suffering may be provided without consent anytime an authorized person is unavailable. When the patient is unable to consent and reasonable efforts fail to locate an authorized surrogate to act on behalf of the patient, the physician may proceed with emergency treatment. A notation must be included in the medical record explaining the medical emergency; the note should also state that a consultation with at least one other physician has been held. Phone consent conference calls: When appropriate, a telephone call to a surrogate decision-maker may be used to obtain informed consent for treatment. The Responsible Practitioner must disclose all relevant information regarding the proposed procedure or treatment.

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Diastolic hypertension is more pronounced and spasm of the mesenteric arteries can be seen. Not all examples described will be true single ventricle lesions or refer to situations that result in true single ventricle anatomy after eventual repair. In such a scenario, an emergent atrial septostomy may be needed to establish an alternate source of Qp. The portion of total cardiac output directed Qp or Qs depends on the specific heart lesion (various degrees of obstruction) and the vascular resistance to flow in the pulmonary and systemic circuits. Qp/Qs = (SaO2 – SmvO2) / (SpvO2 – SaO2), Where SaO2 = oxygenation saturation of arterial blood, SmvO2 = oxygen saturation of mixed venous blood, SpvO2 = oxygen saturation of pulmonary venous blood Obviously, not all of these variables can be easily measured in an infant prior to cardiac surgery. However, an estimate of Qp/Qs can be obtained with a pulse oximetry measurement and a few assumptions. If the patient has healthy lungs, then one can assume that the SpvO2 on room air approaches 100%. If the patient is not severely anemic or septic, and has good cardiac function, one can also assume that the systemic arterial-venous oxygenation difference (SaO2 – SmvO2) will be about 25%. This allows for the ductus to provide blood flow to structures when the cardiovascular development creates a situation in which oxygenation or perfusion is impaired by congenital heart disease. Side effects include 475  Vasodilation and capillary leak  Hypotension  Jitteriness  Temperature elevation  Hypocalcemia  Inhibition of platelet aggregation  Apnea (one must be ready to intubate when starting Prostaglandins! Widened fontanels, pre-tibial swelling and soft tissue swelling are seen in infusions > 9days. Sign-out of these infants off shift should include the acceptable parameters for the laboratory work that will be done and who to contact (sub-specialty services) for changes in clinical status. Cold stress increases free fatty acids, which promote insulin secretion and can cause a reactive hypoglycemia. To counter these heat losses:  Pre-heat the radiant warmer  Have the transport Isolette pre-warmed  Have warm towels available  Gently dry the infant and remove wet linens quickly  Put a hat on the infant → greatest area of heat loss is through scalp  Very immature infant: Saran™ Wrap may be used to cover head (but not face) and limbs About 90% of babies are born vigorous. Bradycardia is almost always due to a suboptimal airway and failure to achieve adequate oxygenation. Occasionally difficult resuscitations require volume expansion in the delivery room. Introduction Ideally, there would be clinical evidence to use to determine which therapies should be administered to each of our patients. The most common and simplest forms of clinical research are case reports and case series or institutional experiences. These types of reports make up a large portion of the pediatric surgical literature as many of the diseases we treat are rare and not amenable to large prospective trials. These studies have inherent biases as they are retrospective and usually represent either a single surgeon or single center’s experience.

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