Predictors of postoperative outcome after general surgical procedures in patients with congenital heart disease

Comparison of Apgar scores and cord blood gas parameters in fetuses with isolated congenital heart disease and healthy controls

OBJECTIVE

This retrospective study aimed to investigate how congenital heart disease (CHD) affects early neonatal outcomes by comparing Apgar scores and umbilical cord blood gas parameters between fetuses with structural cardiac anomalies and healthy controls. Additionally, within the CHD group, the study explored the relationship between these parameters and mortality within six months.

METHODS

Data from 68 cases of prenatally diagnosed CHD were collected from electronic medical records, excluding cases with missing data or additional comorbidities. Only patients delivered by elective cesarean section, without any attempt at labor, were analyzed to avoid potential confounding factors. A control group of 147 healthy newborns was matched for delivery route, maternal age, and gestational week. Apgar scores at 1, 5, and 10 minutes, as well as umbilical cord blood pH, base deficit, and lactate levels, were recorded.

RESULTS

Maternal age, gestational week at delivery, and birth weight were similar between the CHD and control groups. While Apgar score distribution was significantly lower at 1st, 5th, and 10th minutes in the CHD group, umbilical cord blood gas parameters did not show significant differences between groups. Within the CHD group, lower umbilical cord blood pH and larger base deficit were associated with mortality within six months.

CONCLUSION

Newborns with CHD exhibit lower Apgar scores compared to healthy controls, suggesting potential early neonatal challenges. Furthermore, umbilical cord blood pH and base deficit may serve as predictors of mortality within six months in CHD cases. Prospective studies are warranted to validate these findings and integrate them into clinical practice, acknowledging the study's retrospective design and limitations.

Risk factors for unplanned paediatric intensive care unit admission after anaesthesia—an international multicentre study

Objectives

Unplanned intensive care unit (ICU) admissions are associated with near-miss events, morbidity, and mortality. We describe the rate, resource utilization, and outcomes of paediatric patients urgently admitted directly to ICU post-anaesthesia compared to other sources of unplanned ICU admissions.

Methods

We performed a secondary analysis of data from specialist paediatric hospitals in 7 countries. Patients urgently admitted to the ICU post-anaesthesia were combined and matched with 1 to 3 unique controls from unplanned ICU admissions from other locations by age and hospital. Demographic, clinical, and outcome variables were compared using the Wilcoxon rank-sum test for continuous variables and chi-square or Fisher’s exact test for categorical variables. The effect of admission sources on binary outcomes was estimated using univariable conditional logistic regression models with stratification by matched set of anaesthesia and non-anaesthesia admission sources.

Results

Most admissions were <1 year of age and for respiratory reasons. Admissions post-anaesthesia were shorter, occurred later in the day, and were more likely to be mechanically ventilated. Admissions post-anaesthesia were less likely to have had a previous ICU admission (4.8% compared to 11%, P=0.032) or PIM ‘high-risk diagnosis’ (9.5% versus 17.2%, P=0.035) but there was no difference in the number of subsequent ICU admissions. There was no difference in the PIM severity of illness score and no mortality difference between the groups.

Conclusions

Young children and respiratory indications dominated unplanned ICU admissions post-anaesthesia, which was more likely later in the day and with mechanical ventilation.

Hypothermia for cardiogenic encephalopathy in neonates with dextro-transposition of the great arteries

OBJECTIVES

Neonates with dextro-transposition of the great arteries (d-TGA) may experience rapid haemodynamic deterioration and profound hypoxaemia after birth. We report on d-TGA patients with severe acidosis, encephalopathy and their treatment with systemic hypothermia.

METHODS

This study is a single-centre retrospective cohort analysis of newborns with d-TGA.

RESULTS

Ninety-five patients (gestational age ≥35 weeks) with d-TGA and intended arterial switch operation were included. Ten infants (10.5%) with umbilical arterial blood pH > 7.10 experienced profound acidosis (pH < 7.00) within the first 2 h of life. Six of these patients displayed signs of encephalopathy and received therapeutic hypothermia. Apgar scores at 5 min independently predicted the development of neonatal encephalopathy during postnatal transition (unit Odds Ratio 0.17, 95% confidence interval 0.06-0.49, P = 0.001). Infants treated with hypothermia had a more severe preoperative course and required more often mechanical ventilation (100% vs 35%, P = 0.003), treatment with inhaled nitric oxide (50% vs 2.4%, P = 0.002) and inotropic support (67% vs 3.5%, P < 0.001), as compared to non-acidotic controls. The median age at cardiac surgery was 12 (range 6-14) days in cooled infants and 8 (4-59) days in controls (P = 0.088). Postoperative morbidity and total duration of hospitalization were not increased in infants receiving preoperative hypothermia. Mortality in newborns with severe preoperative acidosis was zero.

CONCLUSIONS

Newborn infants with d-TGA have a substantial risk for profound acidosis during the first hours of life. Systemic hypothermia for encephalopathic patients may delay corrective surgery without compromising perioperative outcomes.

Predictors of death after receiving a modified Blalock-Taussig shunt in cyanotic heart children: A competing risk analysis

Objective

To determine risk factors affecting time-to-death ≤90 and >90 days in children who underwent a modified Blalock-Taussig shunt (MBTS).

Methods

Data from a retrospective cohort study were obtained from children aged 0–3 years who experienced MBTS between 2005 and 2016. Time-to-death (prior to Glenn/repair), time-to-alive up until December 2017 without repair, and time-to-progression to Glenn/repair following MBTS were presented using competing risks survival analysis. Demographic, surgical and anesthesia-related factors were recorded. Time-to-death ≤90 days and >90 days was analyzed using multivariate time-dependent Cox regression models to identify independent predictors and presented by adjusted hazard ratios (HR) and 95% confidence intervals (CI).

Results

Of 380 children, 119 died, 122 survived and 139 progressed to Glenn/repair. Time-to-death probability (95% CI) within 90 days was 0.18 (0.14–0.22). Predictors of time-to-death ≤90 days (n = 63) were low weight (<3 kg) (HR 7.6, 95% CI:2.8–20.4), preoperative ventilator support (HR 2.7, 95% CI:1.3–5.6), postoperative shunt thrombosis (HR 5.0, 95% CI:2.4–10.4), bleeding (HR 4.5, 95% CI:2.1–9.4) and renal failure (HR 4.1, 95% CI:1.5–10.9). Predictors of time-to-death >90 days (n = 56) were children diagnosed with pulmonary atresia with ventricular septal defect and single ventricle (compared to tetralogy of fallot) (HR 3.2, 95% CI:1.2–7.7 and HR 3.1, 95% CI:1.3–7.6, respectively), shunt size/weight ratio >1.1 vs <0.65 (HR 6.8, 95% CI:1.4–32.6) and longer duration of mechanical ventilator (HR 1.002, 95% CI:1.001–1.004). Shunt size/weight ratio ≥1.0 (vs <1.0) and ≥0.65 (vs <0.65) were predictors for overall time-to-death in neonates and toddlers, respectively (HR 13.1, 95% CI:2.8–61.4 and HR 7.8, 95% CI:1.7–34.8, respectively).

Conclusions

Perioperative factors were associated with time-to-death ≤90 days, whereas particular cardiac defect, larger shunt size/weight ratio, and longer mechanical ventilation were associated with time-to-death >90 days after receiving MBTS. Larger shunt size/weight ratio should be reevaluated within 90 days to minimize the risk of shunt over flow.

Measurement, consequences and determinants of time to diagnosis in children with new-onset heart failure: A population-based retrospective study (DIACARD study)

BACKGROUND

Time from first symptoms to diagnosis, called time to diagnosis, is related to prognosis in several diseases. The aim of this study was to assess time to diagnosis in children with new-onset heart failure (HF) and assess its consequences and determinants.

METHODS

A retrospective population-based observational study was conducted between 2007 and 2016 in a French tertiary care center. We included all children under 16 years old with no known heart disease, and HF confirmed by echocardiography. With logistic regression used for outcomes and a Cox proportional-hazards model for determinants, analyses were stratified by HF etiology: congenital heart diseases (CHD) and cardiomyopathies/myocarditis (CM).

RESULTS

A total of 117 children were included (median age [interquartile range (IQR)] 25 days (6-146), 50.4% were male, 60 had CHD and 57 had CM). Overall median (IQR) time to diagnosis was 3.3 days (1.0-21.2). The frequency of 1-year mortality was 17% and 1-year neuromotor sequel 18%. Death at 1 year was associated with low birth weight for all patients (adjusted odds ratio 0.24, 95% confidence interval [CI] 0.08-0.68) and time to diagnosis below the median with CM (0.09, 0.01-0.87) but not time to diagnosis above the median for all patients (0.59, 0.13-2.66). Short time to diagnosis was associated with clinical severity on the first day of symptoms for all patients (adjusted hazard ratio 3.39, 95% CI 2.01-5.72), and young age with CM (0.09, 0.02-0.41).

CONCLUSIONS

In children with new-onset HF presenting in our region, median time to diagnosis was short. Long time to diagnosis was not associated with poor outcome.

Delivery room asphyxia in neonates with ductal-dependent congenital heart disease: a retrospective cohort study

OBJECTIVE

We aimed to investigate the clinical course and outcome of newborns with ductal-dependent congenital heart disease (CHD) who suffered from perinatal asphyxia.

STUDY DESIGN

Clinical data of 504 patients with ductal-dependent CHD and perinatal asphyxia were retrospectively analyzed over a 10-year period (2005-2014).

RESULT

Perinatal asphyxia was diagnosed in 17 (3.4%) patients, comprising two nonoverlapping groups: Five infants with intrauterine acidosis (umbilical artery pH < 7.0), and 12 infants with persistent or deteriorating postnatal depression (Apgar score <6 at 10 min of life). Preoperative (41.7%, p < 0.001) and overall mortality (50.0%, p = 0.001) were increased in infants with asphyxia caused by persistent or deteriorating postnatal depression. Apgar scores at 10 min were independently associated with preoperative (OR 0.479, 95% CI 0.342-0.672, p < 0.001) and overall death (OR 0.655, 95% CI 0.537-0.799, p < 0.001).

CONCLUSIONS

Asphyxia caused by postnatally deteriorating depression rather than fetal acidosis is associated with high mortality.

Noncardiac surgery in the congenital heart patient

More children with congenital heart disease are surviving and require noncardiac surgery. A high-yield summary of congenital heart anatomy and pathophysiology is presented to contextualize these patients for surgeons. Preoperative planning including risk stratification, anesthetic management and timing of elective surgery are discussed. Specific intraoperative considerations for particular cases, such as the use of laparoscopy and thoracic surgery, are reviewed. Postoperative outcomes and recommended management required to mitigate complications are summarized.

Outcomes of circumcision in children with single ventricle physiology

PURPOSE

Children with single ventricle physiology (SVP) have been shown to have a high morbidity and mortality after non-cardiac surgical procedures. Elective circumcision is one of the most common pediatric operations with low morbidity and mortality. The purpose of our study was to review our institutional experience with SVP children undergoing circumcisions to determine peri-operative course and outcomes.

METHODS

We performed a retrospective review of children with SVP who underwent an elective circumcision from 2000 to 2017. Children with non-single ventricle physiology or children undergoing circumcision in combination with another case were excluded. Demographics, surgical characteristics, and outcomes were analyzed. Descriptive statistics were performed, all medians were reported with interquartile range.

RESULTS

15 males underwent elective circumcision with a median age at the time of surgery of 1.13 (1.03, 1.38) years. Eighty-four percent underwent their circumcision after their 2nd stage cardiac operation. Most common operative indication was uncomplicated phimosis. Median operative time was 20 (16, 27) mins. Median total length of stay was 229 (185, 242) mins with no admissions. Post-operative complications included two (16%) hematomas with one requiring surgical intervention. There were no deaths.

CONCLUSION

Children with SVP who undergo elective circumcision may have a higher risk of bleeding.

The Utility of Simulation in the Management of Patients With Congenital Heart Disease: Past, Present, and Future

Significant advancements have been made in the diagnosis and management of congenital heart disease (CHD). As a result, a higher percentage of these patients are surviving to adulthood. Despite this improvement in management, these patients remain at higher risk of morbidity and mortality, particularly in the perioperative setting. One new area of interest in these patients is the implementation of simulation-based medical education. Simulation has demonstrated various benefits across high-acuity scenarios encountered in the hospital. In CHD, simulation has been used in the training of pediatrics residents, assessment of intraoperative complications, echocardiography, and anatomic modeling with 3-dimensional printing. Here, we describe the current state of simulation in CHD, its role in training care providers for the management of this population, and future directions of CHD simulation.

Case Report: Emergency awake craniotomy for cerebral abscess in a patient with unrepaired cyanotic congenital heart disease

We report the case of a 39-year-old male with complex cyanotic congenital heart disease undergoing emergency craniotomy for a cerebral abscess. Maintenance of intraoperative hemodynamic stability and adequate tissue oxygenation during anesthesia may be challenging in patients with cyanotic congenital heart disease. In this case, we decided to perform the surgery as an awake craniotomy after interdisciplinary consensus. We discuss general aspects of anesthetic management during awake craniotomy and specific concerns in the perioperative care of patients with congenital heart disease.

Anaesthesia outside of the operating room: the paediatric cardiac catheterization laboratory

PURPOSE OF REVIEW

The focus of cardiac catheterization has changed from principally a diagnostic procedure to providing therapeutic options at various stages of childhood and adult congenital heart disease. The paediatric cardiac catheterization laboratory functions as a 'satellite' operating room. Combined ('hybrid') procedures with interventional cardiologists and cardiac surgeons present additional challenges for anaesthesia. The increased patient and procedure complexity represents higher risk for anaesthesia-related adverse events.

RECENT FINDINGS

This review concentrates on the recent efforts to determine these patient and procedure-related risks. Multicentre registries have been developed, generating information regarding adverse events and patient outcomes. Standardized adverse events ratios allow comparisons between institutions and providers. Models to identify high-risk groups have been developed.

SUMMARY

Advances in paediatric cardiac catheterization have created significant challenges for delivering anaesthesia in this environment. Anaesthetists need to have an integral role in the cardiac catheterization team, understanding and anticipating the risks for patients and leading the organization of workflow. Techniques used to improve systems in the operating room have been introduced to the cardiac catheterization laboratory to promote patient safety.

Outcome of noncardiac surgery in children with congenital heart disease performed outside a cardiac center

OBJECTIVE

The objective of this study was to review the outcome of children with congenital heart disease (CHD) undergoing noncardiac surgery requiring general anesthesia (GA) in a tertiary pediatric center between January 2010 and December 2012.

STUDY DESIGN

A retrospective case note review of children <16years of age with confirmed CHD undergoing a surgical or interventional procedure requiring GA was performed. Patients were categorized into three risk groups according to White and Peyton's anesthetic risk classification of children with CHD undergoing noncardiac surgery [Critical Care and Pain 2012;12:17-22].

RESULTS

117 children with CHD were identified with a total of 240 procedures conducted. 36 procedures were conducted in the high-risk group, 135 in the intermediate-risk group, and 69 in the low-risk group. 40% of these were major operations such as small bowel and colonic procedures. Overall mortality rate at 7days and 30days was 0% and 0.4%, respectively, with a 1% mortality rate in minor procedures and 0% mortality rate in major procedures. There were no unexpected deaths. 17% of procedures resulted in complications. A higher rate of complications was recorded in emergency procedures. 17% of these procedures required admission to the intensive care unit, with the highest admissions rate in the high-risk group. The median duration of hospital stay for the whole cohort was 1day (range of 0-71days).

CONCLUSION

Our study shows that procedures requiring GA can be safely conducted on children from any of the three risk groups in a nonspecialist cardiac center provided that there is close liaison and careful planning between the different specialties.

A meta-analysis of the predictive accuracy of postoperative mortality using the American Society of Anesthesiologists' physical status classification system

BACKGROUND

The American Society of Anesthesiologists' physical status (ASA) tool has been applied to determine compensation, risk adjustment and risk prediction, but little is known about the accuracy and generalizability of this tool for prediction of postoperative mortality.

METHODS

We systematically investigated prior published reports of associations between ASA physical status and mortality to test the hypothesis that ASA physical status will have varying accuracy in prediction of postoperative mortality across surgical populations with varying surgical risk of mortality. We used random effects models and metaregression to account for heterogeneity.

RESULTS

Combining 77 studies with 165,705 patients, the ASA physical status tool demonstrated the following pooled performance (95 % confidence intervals)--sensitivity 0.74 (0.73, 0.74), specificity 0.67 (0.67, 0.67), and area under summary receiver operating curve 0.736 (0.725, 0.747). Metaregression revealed that study death rates and surgical specialty were significant factors.

CONCLUSION

ASA physical status is a better predictor of postoperative mortality in settings with lower rather than higher death rates.

The surgical management of spinal deformity in children with a Fontan circulation

The management of spinal deformity in children with univentricular cardiac pathology poses significant challenges to the surgical and anaesthetic teams. To date, only posterior instrumented fusion techniques have been used in these children and these are associated with a high rate of complications. We reviewed our experience of both growing rod instrumentation and posterior instrumented fusion in children with a univentricular circulation.

Six children underwent spinal corrective surgery, two with cavopulmonary shunts and four following completion of a Fontan procedure. Three underwent growing rod instrumentation, two had a posterior fusion and one had spinal growth arrest. There were no complications following surgery, and the children undergoing growing rod instrumentation were successfully lengthened. We noted a trend for greater blood loss and haemodynamic instability in those whose surgery was undertaken following completion of a Fontan procedure. At a median follow-up of 87.6 months (interquartile range (IQR) 62.9 to 96.5) the median correction of deformity was 24.2% (64.5° (IQR 46° to 80°) vs 50.5° (IQR 36° to 63°)).

We believe that early surgical intervention with growing rod instrumentation systems allows staged correction of the spinal deformity and reduces the haemodynamic insult to these physiologically compromised children. Due to the haemodynamic changes that occur with the completed Fontan circulation, the initial scoliosis surgery should ideally be undertaken when in the cavopulmonary shunt stage.

Cite this article: Bone Joint J 2014;96-B:94–9.

Lung decortication and lobectomy in a child with unrepaired tetralogy of fallot

Patients with uncorrected tetralogy of Fallot (TOF) have been reported as undergoing emergency noncardiac surgeries such as cesarean section, brain abscess drainage, and major abdominal surgery. The uncorrected TOF group presents a great challenge with issues related to long-term effects of chronic hypoxemia and decreased pulmonary blood flow modifying patient physiology. We report a rare case of a child with uncorrected TOF with necrotizing streptococcal pneumonia complicated by empyema and bronchopleural fistula. The child successfully underwent lung decortication and right middle lobectomy in the first stage followed by an intracardiac repair (ICR) 15 days later. This staged approach was directed at controlling the infective focus, improving the pulmonary status, and following it up with a definitive ICR electively.

Primary payer status is significantly associated with postoperative mortality, morbidity, and hospital resource utilization in pediatric surgical patients within the United States

PURPOSE

Current healthcare reform efforts have highlighted the potential impact of insurance status on patient outcomes. The influence of primary payer status (PPS) within the pediatric surgical patient population remains unknown. The purpose of this study was to examine risk-adjusted associations between PPS and postoperative mortality, morbidity, and resource utilization in pediatric surgical patients within the United States.

METHODS

A weighted total of 153,333 pediatric surgical patients were evaluated using the national Kids' Inpatient Database (2003 and 2006): appendectomy, intussusception, decortication, pyloromyotomy, congenital diaphragmatic hernia repair, and colonic resection for Hirschsprung's disease. Patients were stratified according to PPS: Medicare (n=180), Medicaid (n=51,862), uninsured (n=12,539), and private insurance (n=88,753). Multivariable hierarchical regression modeling was utilized to evaluate risk-adjusted associations between PPS and outcomes.

RESULTS

Overall median patient age was 12 years, operations were primarily non-elective (92.4%), and appendectomies accounted for the highest proportion of cases (81.3%). After adjustment for patient, hospital, and operation-related factors, PPS was independently associated with in-hospital death (p<0.0001) and postoperative complications (p<0.02), with increased risk for Medicaid and uninsured populations. Moreover, Medicaid PPS was also associated with greater adjusted lengths of stay and total hospital charges (p<0.0001). Importantly, these results were dependent on operation type.

CONCLUSIONS

Primary payer status is associated with risk-adjusted postoperative mortality, morbidity, and resource utilization among pediatric surgical patients. Uninsured patients are at increased risk for postoperative mortality while Medicaid patients accrue greater morbidity, hospital lengths of stay, and total charges. These results highlight a complex interaction between socioeconomic and patient-related factors, and primary payer status should be considered in the preoperative risk stratification of pediatric patients.

Intraoperative hypercyanosis in a patient with pulmonary artery band: case report and review of the literature

A case of intraoperative cyanosis in a patient with a common atrioventricular canal palliated with a pulmonary artery (PA) band is presented. The patient's physiology was consistent with cyanosis due to inadequate pulmonary blood flow, and responded quickly to typical interventions used for a hypercyanotic episode in a patient with unrepaired Tetralogy of Fallot. Differences and similarities in the physiology of PA banding compared with Tetralogy of Fallot are presented, including a rationale for treatment options for hemodynamic decompensation occurring in the setting of anesthesia and surgery.

Approach to managing children with heart disease for noncardiac surgery

Congenital heart disease is the commonest birth defect, and advances in modern medicine mean 90% of these children now survive to adulthood. Therefore, many children present to their local hospital requiring general anesthesia for common childhood conditions. They pose a challenge for anesthesia because perioperative morbidity and mortality is greater compared with other children. It is impossible to prescribe a formula for anesthetizing children with heart disease because of the complexity of heart defects and the variety of noncardiac surgery. There is also a lack of high-quality data of efficacy of one anesthetic technique over another. Much data come from case series or isolated case reports. In a rapidly advancing field such as cardiac surgery, studies of long-term complications may be out of date by the time they are published, limiting applicability of the results. Because of these factors, claims of efficacy and safety of various approaches to managing children with heart disease for noncardiac surgery must be interpreted cautiously. This narrative review aims to present the evidence concerning a range of anesthetic techniques, the long-term complications of congenital heart disease and suggest a physiological and evidence-based approach to managing these children.

General anesthesia for children with severe heart failure

Severe heart failure in children is uncommon. The anesthetic management of children with this condition is challenging. The authors aimed to identify the frequency with which anesthesia for short noncardiac surgical procedures or investigations was complicated by life-threatening hemodynamic instability and to describe the anesthetic techniques used. This study retrospectively reviewed the anesthetic charts and notes of children admitted acutely with a diagnosis of severe heart failure (fractional shortening of 15% or less) who received general anesthesia for noncardiac surgical or diagnostic interventions during the 3-year period from September 2005 to September 2008. In this study, 21 children received a total of 28 general anesthetics. Two patients (10%) experienced a cardiac arrest, and both required unplanned admission to the authors' pediatric intensive care unit (PICU) postoperatively. A variety of anesthetic techniques was used. In 27 (96%) of the 28 cases, perioperative inotropic support was required. General anesthesia for children with severe heart failure is associated with a significant complication rate and should be administered by anesthetists familiar with managing all aspects of circulatory support for children in an appropriate setting.

Complication of surgery for scoliosis in children with surgically corrected congenital cardiac malformations

INTRODUCTION

There is a high incidence of scoliosis in patients who have undergone cardiothoracic surgery for correction of congenital cardiac disease, this risk being 10 times higher than in the general population.

MATERIALS AND METHODS

So as to analyse the surgical and postoperative complications, we designed a retrospective study to include every child who underwent spinal orthopaedic surgery, and who had previously undergone cardiothoracic surgery because of a congenital cardiac malformation. We excluded those patients who had syndromes associated with the development of scoliosis.

RESULTS

We identified 18 patients with surgically treated congenital cardiac disease who had undergone surgery for scoliosis over a period of 7 years. This group came from a total number of 87 patients undergoing spinal fusion over the same period. Of those with congenitally malformed hearts, 61% had acyanotic lesions, with ventricular septal defect being the most frequent single lesion, present in 40%. All the patients needed blood transfusions during the surgery, with aprotinin used in 73% to reduce the bleeding, and inotropes needed for 4 children. During the immediate postoperative period, 1 patient died in the first 24 hours, while 7 (39%) had different complications, pneumonia in 4, pleural effusions in 2, and rhabdomyolysis in the other, as opposed to a rate of complications of 27% in patients without heart disease.

CONCLUSION

The surgical and postoperative complications in these patients depend on the specific cardiac lesion. A multidisciplinary team with experience in the treatment of congenitally malformed hearts is essential for appropriate management of these patients.

Children with cardiomyopathy: complications after noncardiac procedures with general anesthesia

BACKGROUND

Children with cardiomyopathy (CM) often undergo procedures that require general anesthesia (GA) but little is known about anesthesia-related adverse events or postprocedural outcomes.

METHODS

After approval, all children with CM who underwent nonopen heart surgical procedures and/or diagnostic imaging under GA at a tertiary children's hospital during January 2002 to May 2005 were identified from a clinical database. Based on their preprocedure fractional shortening (FS) on echocardiogram, systemic ventricular dysfunction was categorized as mild (FS 23-28%), moderate (FS 16-22%), or severe (FS < 16%) and those with normal (FS > 28%) were excluded from review.

RESULTS

Twenty-six patients underwent 34 procedures under GA, of whom 13 (38%) had mild or moderate ventricular dysfunction and 21 (62%) had severe dysfunction. Common procedures included pacer/defibrillator placement (43%) and imaging studies (18%). Eighteen complications were noted in 12 patients. Fifteen (83%) complications occurred in patients with severe ventricular dysfunction. One patient with severe ventricular dysfunction died (3% mortality). Hypotension requiring inotropic support was the most frequent complication (61%). Children with severe ventricular dysfunction often required hospital support pre- and postprocedure with 67% requiring intensive care. Hospital stay was longer for patients with severe ventricular dysfunction compared with children with mild or moderate ventricular dysfunction (P = 0.006).

CONCLUSIONS

The 30-day mortality rate was low but complications were common, especially in patients with severe ventricular dysfunction. For these patients, we recommend early consideration of perioperative intensive care support to optimize cardiovascular therapy and monitoring.

Spinal fusion in patients with congenital heart disease. Predictors of outcome

The strong association between congenital heart disease and spinal deformity is well established, but data on the risks and outcome of spinal fusion surgery in patients with congenital heart disease are scarce. The purpose of this study was to identify predictors of perioperative risk and outcome in a large series of children and adolescents with congenital heart disease who underwent spinal fusion for scoliosis or kyphosis. In the authors' retrospective analysis of 74 consecutive patients with congenital heart disease undergoing spinal fusion, there were two deaths (2.7%) and 18 significant complications (24.3%) in the perioperative period. Preoperative cyanosis (arterial oxygen saturation < 90% at rest) with uncorrected or incompletely corrected congenital heart disease was associated with both deaths. Complications occurred in nine of 18 (50%) patients with cyanosis and in 11 of 56 (20%) patients without cyanosis. As judged by multivariate analysis the best predictors of perioperative outcome were the overall physical status of the patient as represented by the American Society of Anesthesiologists' preoperative score and a higher rate of intraoperative blood loss. Seventeen of 43 patients (40%) with an American Society of Anesthesiologists score of 3 or higher experienced complications including two perioperative deaths. Successful spinal fusion and correction were achieved in 97% of patients. Children and adolescents with congenital heart disease can undergo elective spinal fusion with risks that relate to overall cardiac status. Careful assessment of preoperative status by pediatric cardiologists and cardiac anesthesiologists familiar with surgical treatment of patients with congenital heart disease will assist the orthopaedic surgeon in providing the most realistic estimate of risk.

Successful arterial switch operation in a low-birth-weight neonate who had transposition of the great arteries and advanced necrotizing enterocolitis

A low-birth-weight (LBW; 1,940 g) girl was born at the gestational age of 36 weeks without any perinatal insult. Transposition of the great arteries (TGA) with a large patent ductus arteriosus (PDA) and interatrial shunt was detected. Stage IIIB necrotizing enterocolitis (NEC) developed 46 hours after birth. She received ileostomy and drainage. Arterial switch operation was successfully performed at 23 days of age when her weight was 1,900 g. The enterostomy was successfully repaired at 104 days of age.

Patients with congenital heart malformations for noncardiac surgery

Most patients with CHD can be safely anesthetized with regular techniques. Preoperative consultation with appropriate specialists and a well planned anesthetic management is important.