Predictors of successful early extubation following congenital cardiac surgery in neonates and infants

Predictors of Post-Operative Hospital Length of Stay Following Complete Repair of Tetralogy of Fallot in a Pediatric Cohort in the North of England

We sought to estimate the median post-operative length of stay (PLOS) and predictors of PLOS following tetralogy of Fallot (ToF) repair at a specialist surgical center in the North of England. The local National Congenital Heart Disease Audit dataset was used to identify patients aged < 2 years who underwent surgical repair for ToF between 1 January 1986 and 13 May 2022. Coefficients representing the median change in PLOS (days) according to predictors were estimated using Quantile regression. There were 224 patients (59.4% male, median age = 9 months, interquartile range (IQR) 5-13 months) with a median PLOS of 9 days (IQR 7-13). In the univariable regression, age (months) and weight (kg) at operation (β =  - 0.17, 95% CI: - 0.33, - 0.01) and (β =  - 0.53, 95% CI: - 0.97, - 0.10), previous (cardiac or thoracic) procedure (β = 5, 95% CI:2.38, 7.62), procedure urgency (elective vs urgent) (β = 2.8, 95% CI:0.39, 5.21), bypass time (mins) (β = 0.03, 95% CI:0.01, 0.05), cross-clamp time (mins) (β = 0.03, 95% CI:0.01, 0.06) and duration of post-operative intubation (days) (β = 0.81, 95% CI:0.67, 0.96), were significantly associated with PLOS. Previous procedure and intubation time remained significant in multivariable analyses. Some patient and operative factors can predict PLOS following complete ToF repair. Information on PLOS is important for health professionals to support parents in preparing for their child's discharge and to make any necessary practical arrangements. Health commissioners can draw on evidence-based guidance for resource planning. The small sample size may have reduced the power to detect small effect sizes, but this regional study serves as a foundation for a larger national study.

A ROTEM-guided algorithm aimed to reduce blood product utilization during neonatal and infant cardiac surgery

BACKGROUND

Neonates and infants undergoing cardiac surgery tend to receive high volumes of blood products. The use of rotational thromboelastometry (ROTEM^®) has been shown to reduce the administration of blood products in adults after cardiac surgery. We sought to develop a targeted administration of blood products based on ROTEM^® to reduce blood product utilization during and after neonatal and infant cardiac surgery.

METHODS

We conducted a retrospective review of data from a single center for neonates and infants undergoing congenital cardiac surgery using cardiopulmonary bypass (CPB) from September 2018-April 2019 (control group). Then, using a ROTEM^® algorithm, we collected data prospectively between April-November 2021 (ROTEM group). Data collected included age, weight, gender, procedure, STAT score, CPB time, aortic cross-clamp time, volume, and type of blood products administered in the operating room and cardiothoracic intensive care unit (CTICU). In addition, ROTEM^® data, coagulation profile in CTICU, chest tube output at 6 and 24 hours, use of factors concentrate, and thromboembolic complications were recorded.

RESULTS

The final cohort of patients included 28 patients in the control group and 40 patients in the ROTEM group. The cohort included neonates and infants undergoing the following procedures: arterial switch, aortic arch augmentation, Norwood procedure, and comprehensive stage II procedure. There were no differences in the demographics or procedure complexity between the two groups. Patients in the ROTEM^® group received fewer platelets (36 ± 12 vs. 49 ± 27 mL/kg, p 0.028) and cryoprecipitate (8 ± 3 vs. 15 ± 10 mL/kg, p 0.001) intraoperatively when compared to the control group.

CONCLUSION

The utilization of ROTEM^® may have contributed to a significant reduction in some blood product administration during cardiac surgery for infants and neonates. ROTEM^® data may play a role in reducing blood product administration in neonatal and infant cardiac surgery.

One-year experience after adoption of an on-table extubation protocol following pediatric cardiac surgery

OBJECTIVE

To report our initial experience with on-table extubation following cardiac surgery for congenital heart disease, assessing its efficacy and safety, and the potential for fast-tracking these patients through the intensive care unit (ICU).

METHODS

We decided to implement a multidisciplinary protocol aiming toward on-table extubation following congenital cardiac surgery at our hospital. Between December 2018 and January 2020, 376 patients underwent congenital cardiac surgery. The management strategy involved choosing the patients preoperatively, a specific anesthetic technique, application of a standard extubation protocol, multidisciplinary team approach, and perioperative echocardiogram for assessment of surgical repair. Relevant data were collected and analyzed.

RESULTS

Out of the 376 patients who underwent congenital cardiac surgery during the study period, 44 patients were extubated on-table. Although a majority of these patients belonged to Risk Adjustment for Congenital Heart Surgery-1 score (RACHS-1) 1 and 2 categories, 18% of the patients who were extubated on-table were of RACHS-3 category. This included a wide spectrum of anatomical substrates such as endocardial cushion defects, pulmonary venous anomalies, single ventricle physiology, valvular defects, and others such as cor triatriatum and sinus of Valsalva aneurysm. There was no in-hospital mortality related to on-table extubation. Only one patient was reintubated following on-table extubation resulting in a reintubation rate of 2.27% among those patients extubated on-table. The patients extubated on-table had a shorter ICU stay (25.89 ± 7.20 h) compared with those patients who underwent delayed extubation (59.30 ± 6.80 h). The duration of the hospital stay was also significantly reduced in these patients (91.09 ± 20.40 h) leading to an earlier discharge compared with those patients who underwent delayed extubation (134.40 ± 16.20 h).

CONCLUSION

On-table extubation is an attractive alternative in limited-resource environments to enhance recovery in patients following congenital cardiac malformations. Owing to the lack of significant comorbidities such as Chronic Obstructive Pulmonary Disease (COPD) in this patient population, corrective surgery for cardiac malformation usually optimizes the cardiorespiratory status. This results in more chances of successful extubation immediately following surgery. However, this requires proper perioperative planning, a careful discussion about the choice of patients, adoption of an extubation protocol, and most importantly, a multidisciplinary team approach. It is associated with low morbidity and mortality, with reduced length of stay in the ICU and hospital. This preliminary study demonstrated that on-table extubation is feasible following congenital cardiac surgery at our center and greatly reduces the intensive care requirements. This article focuses mainly on the decision-making process which determines the ideal candidates for on-table extubation and the anesthetic protocol implemented in a low-resource environment to enable the same.

Influence of Early Extubation Location on Outcomes Following Pediatric Cardiac Surgery

OBJECTIVES

Early extubation following pediatric cardiac surgery is common, but debate exists whether location affects outcome, with some centers performing routine early extubations in the operating room (odds ratio) and others in the cardiac ICU. We aimed to define early extubation practice variation across hospitals and assess impact of location on hospital length-of-stay and other outcomes.

DESIGN

Secondary analysis of the Pediatric Cardiac Critical Care Consortium registry.

SETTING

Twenty-eight Pediatric Cardiac Critical Care Consortium hospitals.

PATIENTS

Patients undergoing Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality category 1-3 operations between August 2014 and February 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We defined early extubation as extubation less than 6 hours after postoperative admission. Hospitals were categorized based on the proportion of their early extubation patients who underwent an odds ratio extubation. Categories included low- (< 50% of early extubation, n = 12), medium- (50%-90%, n = 8), or high- (> 90%, n = 8) frequency odds ratio early extubation centers. The primary outcome of interest was postoperative hospital length-of-stay. We analyzed 16,594 operations (9,143 early extubation, 55%). Rates of early extubation ranged from 16% to 100% across hospitals. Odds ratio early extubation rates varied from 16% to 99%. Patient characteristics were similar across hospital odds ratio early extubation categories. Early extubation rates paralleled the hospital odds ratio early extubation rates-77% patients underwent early extubation at high-frequency odds ratio extubation centers compared with 39% at low-frequency odds ratio extubation centers (p < 0.001). High- and low-frequency odds ratio early extubation hospitals had similar length-of-stay, cardiac arrest rates, and low mortality. However, high-frequency odds ratio early extubation hospitals used more noninvasive ventilation than low-frequency hospitals (15% vs. 9%; p < 0.01), but had fewer extubation failures (3.6% vs. 4.5%; p = 0.02).

CONCLUSIONS

Considerable variability exists in early extubation practices after low- and moderate-complexity pediatric cardiac surgery. In this patient population, hospital length-of-stay did not differ significantly between centers with different early extubation strategies based on location or frequency.

Intraoperative Extubation Post Arterial Switch Operation for Transposition of the Great Arteries With Intact Ventricular Septum: A One-Year, Single Center Experience

We sought to examine the clinical impact of intraoperative extubation (IE) in neonates undergoing the arterial switch operation (ASO) for D-transposition of the great arteries with intact ventricular septum (dTGA/IVS). This was a single center retrospective study of patients who underwent ASO for dTGA/IVS in the 12 months after an institutional change in practice favoring IE when clinically feasible. A control group was obtained by identifying the same number of consecutive patients with dTGA/IVS who underwent ASO immediately prior to this institutional change in practice, none of whom were extubated intraoperatively. Primary outcome measures included morbidity, mortality, length of hospital and intensive care unit stay and reintubation rates. There were no significant differences in the preoperative and operative characteristics between the 2 groups. Of the 10 patients who underwent ASO for dTGA/IVS in the 12 months post institutional change in practice, all (100%) were extubated intraoperatively and none (0%) required reintubation. The median length of intensive care unit stay was 2 days for both the intraoperative and non-IE groups (mean 2.2 and 3 days respectively). The median length of stay in hospital was 4 days in the IE group and 5.5 days in the non-IE group (mean 4.5 and 6 days respectively). No patients died and there was no significant difference in morbidity between the 2 groups. Our data suggests IE post ASO for dTGA/IVS is safe and displays a statistically insignificant trend toward earlier discharge from hospital.

A Sufentanil-Based Rapid Cardiac Anesthesia Regimen in Children Undergoing Percutaneous Minimally-Invasive Intraoperative Device Closure of Ventricular Septal Defect

Objective

To assess the effectiveness and safety of fast-track cardiac anesthesia using the short-acting opioid sufentanil in children undergoing intraoperative device closure of ventricular septal defect (VSD).

Methods

This retrospective clinical study included 65 children who underwent intraoperative device closure of VSD between January 2017 and June 2017. Patients were diagnosed with isolated perimembranous VSD by transthoracic echocardiography. Then, they were divided into two groups, group F (n=30), whose patients were given sufentanil-based fast-track cardiac anesthesia, and group C (n=35), whose patients were given conventional cardiac anesthesia. Perioperative clinical data were analyzed.

Results

No significant differences were found between the preoperative clinical parameters and intraoperative hemodynamic indices between the two groups. In group C, compared with group F, the postoperative duration of mechanical ventilation, the length of stay in the intensive care unit, the length of hospital stay, and the hospital costs were significantly increased.

Conclusion

In this retrospective study at a single center, sufentanil-based fast-track cardiac anesthesia was shown to be a safe and effective technique for minimally-invasive intraoperative device closure of VSD in children, which was performed with reduced in-hospital costs.

Assessment of Common Criteria for Awake Extubation in Infants and Young Children

BACKGROUND

Practice patterns surrounding awake extubation of pediatric surgical patients remain largely undocumented. This study assessed the value of commonly used predictors of fitness for extubation to determine which were most salient in predicting successful extubation following emergence from general anesthesia with a volatile anesthetic in young children.

METHODS

This prospective, observational study was performed in 600 children from 0 to 7 yr of age. The presence or absence of nine commonly used extubation criteria in children were recorded at the time of extubation including: facial grimace, eye opening, low end-tidal anesthetic concentration, spontaneous tidal volume greater than 5 ml/kg, conjugate gaze, purposeful movement, movement other than coughing, laryngeal stimulation test, and oxygen saturation. Extubations were graded as Successful, Intervention Required, or Major Intervention Required using a standard set of criteria. The Intervention Required and Major Intervention Required outcomes were combined as a single outcome for analysis of predictors of success.

RESULTS

Successful extubation occurred in 92.7% (556 of 600) of cases. Facial grimace odds ratio, 1.93 (95% CI, 1.03 to 3.60; P = 0.039), purposeful movement odds ratio, 2.42 (95% CI, 1.14 to 5.12; P = 0.022), conjugate gaze odds ratio, 2.10 (95% CI, 1.14 to 4.01; P = 0.031), eye opening odds ratio, 4.44 (95% CI, 1.06 to 18.64; P= 0.042), and tidal volume greater than 5 ml/kg odds ratio, 2.66 (95% CI, 1.21 to 5.86; P = 0.015) were univariately associated with the Successful group. A stepwise increase in any one, in any order, of these five predictors being present, from one out of five and up to five out of five yielded an increasing positive predictive value for successful extubation of 88.3% (95% CI, 82.4 to 94.3), 88.4% (95% CI, 83.5 to 93.3), 96.3% (95% CI, 93.4 to 99.2), 97.4% (95% CI, 94.4 to 100), and 100% (95% CI, 90 to 100).

CONCLUSIONS

Conjugate gaze, facial grimace, eye opening, purposeful movement, and tidal volume greater than 5 ml/kg were each individually associated with extubation success in pediatric surgical patients after volatile anesthetic. Further, the use of a multifactorial approach using these predictors, may lead to a more rational and robust approach to successful awake extubation.

Staged Versus Complete Repair in the Symptomatic Neonate With Tetralogy of Fallot

BACKGROUND

The optimal management of tetralogy of Fallot (TOF) in symptomatic neonates remains unknown. We compared outcomes for those undergoing palliation vs complete repair in the neonatal period.

METHODS

In a retrospective cohort study of symptomatic neonates with TOF who had a neonatal complete repair (group 1, n = 112) or staged repair (group 2, n = 26) from 2000 to 2013, we compared outcomes at 4 time points: neonatal complete repair vs palliation (group 1 vs 2A), neonatal vs later complete repair (group 1 vs 2B), the single vs combined admissions to achieve a complete repair (group 1 vs group 2A + 2B), and cumulative events 2 years after complete repair for both groups.

RESULTS

Demographics, anatomy, comorbidities, surgical approach, and mortality were similar between groups 1 and 2. Group 1 had a longer duration of cardiopulmonary bypass and deep hypothermic circulatory arrest and more postprocedure cardiac events compared with group 2A; a longer duration of intubation, intensive care, and postprocedure hospital stay compared with groups 2A and 2B; and a longer total hospital stay compared with group 2B. With combined admissions for group 2, there was no difference in the total duration of intensive care, total hospital stay, or reinterventions compared with group 1.

CONCLUSIONS

Both management options result in similar survival; however, early morbidity was greater with neonatal complete repair. The impact of increased neonatal exposures, such as cardiopulmonary bypass, deep hypothermic circulatory arrest, and intensive care, on neurocognitive development requires further study but should be considered when choosing an optimal strategy.

An evolving anesthetic protocol fosters fast tracking in pediatric cardiac surgery: A comparison of two anesthetic techniques

Background:

The past two decades have seen rapid development of new surgical techniques for repair as well as palliation of complex congenital heart diseases. For a better patient outcome, minimal postoperative ventilation remains one of the most important endpoints of an effectual perioperative management.

Aims and Objectives:

The aim of this randomized open-label trial was to compare postoperative extubation time and intensive care unit (ICU) stay when two different anesthetic regimens, comprising of induction with ketamine and low-dose fentanyl versus high-dose fentanyl, are used, in pediatric patients undergoing corrective/palliative surgery.

Materials and Methods:

Patients with congenital cardiac defects, under 14 years of age undergoing cardiac surgery under cardiopulmonary bypass (CPB) and epidural analgesia, were enrolled into two groups – Group K (ketamine with low-dose fentanyl) and Group F (high-dose fentanyl) – over a period of 10 months, starting from January 2018. The effect of both these drugs on postoperative extubation time and ICU stay was compared using Mann–Whitney U-test.

Results:

A total of 70 patients were assessed with equal distribution in both the groups. In Group K, 32 of 35 patients were extubated in the operation room, whereas extubation time in Group F was18.1 ± 11 h. Total ICU stay in Group K and Group F was 45.2 ± 30.1 and 60.1 ± 24.5 h, respectively (P = 0.02). Systolic blood pressure was significantly higher in Group K.

Conclusion:

Ketamine along with low-dose fentanyl, when used for anesthetic induction, in comparison to high-dose fentanyl, reduces postoperative extubation time and ICU stay, in pediatric patients undergoing corrective/palliative surgery under CPB and epidural analgesia for congenital cardiac defects.

Changes in Anesthetic and Postoperative Sedation-Analgesia Practice Associated With Early Extubation Following Infant Cardiac Surgery: Experience From the Pediatric Heart Network Collaborative Learning Study

OBJECTIVES

The Pediatric Heart Network sponsored the multicenter Collaborative Learning Study that implemented a clinical practice guideline to facilitate early extubation in infants after repair of isolated coarctation of the aorta and tetralogy of Fallot. We sought to compare the anesthetic practice in the operating room and sedation-analgesia management in the ICU before and after the implementation of the guideline that resulted in early extubation.

DESIGN

Secondary analysis of data from a multicenter study from January 2013 to April 2015. Predefined variables of anesthetic, sedative, and analgesia exposure were compared before and after guideline implementation. Propensity score weighted logistic regression analysis was used to determine the independent effect of intraoperative dexmedetomidine administration on early extubation.

SETTING

Five children's hospitals.

PATIENTS

A total of 240 study subjects who underwent repair of coarctation of the aorta or tetralogy of Fallot (119 preguideline implementation and 121 postguideline implementation).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Clinical practice guideline implementation was accompanied by a decrease in the median total intraoperative dose of opioids (49.7 vs 24.0 µg/kg of fentanyl equivalents, p < 0.001) and benzodiazepines (1.0 vs 0.4 mg/kg of midazolam equivalents, p < 0.001), but no change in median volatile anesthetic agent exposure (1.3 vs 1.5 minimum alveolar concentration hr, p = 0.25). Intraoperative dexmedetomidine administration was associated with early extubation (odds ratio 2.5, 95% CI, 1.02-5.99, p = 0.04) when adjusted for other covariates. In the ICU, more patients received dexmedetomidine (43% vs 75%), but concomitant benzodiazepine exposure decreased in both the frequency (66% vs 57%, p < 0.001) and cumulative median dose (0.5 vs 0.3 mg/kg of ME, p = 0.003) postguideline implementation.

CONCLUSIONS

The implementation of an early extubation clinical practice guideline resulted in a reduction in the dose of opioids and benzodiazepines without a change in volatile anesthetic agent used in the operating room. Intraoperative dexmedetomidine administration was independently associated with early extubation. The total benzodiazepine exposure decreased in the early postoperative period.

Early Experiences with Ultra-Fast-Track Extubation after Surgery for Congenital Heart Disease at a Single Center

Background

Early extubation after cardiovascular surgery has some clinical advantages, including reduced hospitalization costs. Herein, we review the results of ultra-fast-track (UFT) extubation, which refers to extubation performed on the operating table just after the operation, or within 1-2 hours after surgery, in patients with congenital cardiac disease.

Methods

We performed UFT extubation in patients (n=72) with a relatively simple congenital cardiac defect or who underwent a simple operation starting in September 2016. To evaluate the feasibility and effectiveness of our recently introduced UFT extubation strategy, we retrospectively reviewed 195 patients who underwent similar operations for similar diseases from September 2015 to September 2017, including the 1-year periods immediately before and after the introduction of the UFT extubation protocol. Propensity scores were used to assess the effects of UFT extubation on length of stay (LOS) in the intensive care unit (ICU), hospital LOS, and medical costs.

Results

After propensity-score matching using logistic regression analysis, 47 patients were matched in each group. The mean ICU LOS (16.3±28.6 [UFT] vs. 28.0±16.8 [non-UFT] hours, p=0.018) was significantly shorter in the UFT group. The total medical costs (182.6±3.5 [UFT] vs. 187.1±55.6 [non-UFT] ×100,000 Korean won [KRW], p=0.639) and hospital stay expenses (48.3±13.6 [UFT] vs. 54.8±29.0 [non-UFT] ×100,000 KRW, p=0.164) did not significantly differ between the groups.

Conclusion

UFT extubation decreased the ICU LOS and mechanical ventilation time, but was not associated with postoperative hospital LOS or medical expenses in patients with simple congenital cardiac disease.

Early extubation in pediatric heart surgery across a spectrum of case complexity: Impact on hospital length of stay and chest tube days

Early extubation is increasingly common in congenital heart surgery, but there are limited outcomes data across the spectrum of case complexity. We performed a retrospective review of 201 pediatric operations using cardiopulmonary bypass between 2012 and 2014. Patients extubated in the operating room or immediately on arrival to the ICU were compared to those extubated by traditional protocols. In-hospital mortality, major complications, need for re-intubation, hospital length of stay, and chest-tube days were compared between groups and by Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery Congenital Heart Surgery (STAT) mortality category. Outcome measures of hospital length of stay and chest tube days were analyzed using multivariable regression modeling. Early extubation subjects were older, weighed more, had shorter bypass and aortic cross-clamp time, more often received caudal anesthesia, and had shorter hospital length of stay and fewer chest tube days. Subjects not extubated early had more chromosomal abnormalities, more preoperative co-morbidities, and had more major complications. Inhospital death, major complications, and re-intubation were rare outcomes for both groups across all STAT categories. Multivariable regression analysis showed that cardiopulmonary bypass time was a significant predictor of hospital length of stay and chest tube days. Hospital LOS and chest tube days were significantly lower for the early extubation group in both the unadjusted and adjusted analyses. Early extubation can be performed safely in congenital heart surgery across a spectrum of case complexity. No increased early mortality or re-intubation was observed with early extubation although there were important differences between the groups that merits further study. The potential benefits of early extubation include decreased hospital length of stay and fewer chest tube days, particularly in young children and patients with long bypass times.

A Retrospective Analysis of the Influence of Ventricular Morphology on the Perioperative Outcomes After Fontan Surgery

OBJECTIVES

The objectives of this study were to evaluate the effect of ventricular morphology on perioperative outcomes during Fontan surgery.

DESIGN

Retrospective cohort study.

SETTING

Single standing, not-for-profit pediatric hospital.

PARTICIPANTS

A total of 72 patients who underwent Fontan surgery using cardiopulmonary bypass without aortic cross-clamp between January 1, 2009 and December 31, 2014.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The patients were divided into 3 categories depending on their single-ventricle lesions: (1) LV group (n = 20): left dominant and hypoplastic right ventricle; (2) RV group (n = 37): right dominant and hypoplastic left ventricle; and (3) BV group (n = 15): biventricular or indeterminate dominance. Perioperative major adverse events were collected based on the Society of Thoracic Surgeons database. The need for perioperative allogeneic blood transfusions also was determined. The mean age was 3.3±1.7 years and the mean weight was 13.6±4.0 kg. All patients had extracardiac lateral tunnel or conduit Fontan procedures. Sixty-nine of the patients (96%) underwent tracheal extubation in the operating room. Anesthesia, surgery, and CPB times were 326±68, 239±73, and 70±41 minutes, respectively. Eleven patients (15%) required allogeneic blood products intraoperatively, while 30 patients (42%) required allogeneic blood products during the perioperative period. Length of cardiac intensive care unit stay and hospital stay (median [IQR]) were 1 [1,2] and 12 [9,18] days, respectively. There was no mortality and no significant differences between groups in major postoperative complications, anesthetic or surgical variables.

CONCLUSIONS

No difference in the immediate perioperative outcomes was noted based on ventricular morphology.

Learning From Experience: Improving Early Tracheal Extubation Success After Congenital Cardiac Surgery

OBJECTIVES

The many advantages of early tracheal extubation following congenital cardiac surgery in young infants and children are now widely recognized. Benefits include avoiding the morbidity associated with prolonged intubation and the consequences of sedation and positive pressure ventilation in the setting of altered cardiopulmonary physiology. Our practice of tracheal extubation of young infants in the operating room following cardiac surgery has evolved and new challenges in the arena of postoperative sedation and pain management have appeared.

DESIGN

Review our institutional outcomes associated with early tracheal extubation following congenital cardiac surgery.

PATIENTS

Inclusion criteria included all children less than 1 year old who underwent congenital cardiac surgery between October 1, 2010, and October 24, 2013.

MEASUREMENTS AND MAIN RESULTS

A total of 416 patients less than 1 year old were included. Of the 416 patients, 234 underwent tracheal extubation in the operating room (56%) with 25 requiring reintubation (10.7%), either immediately or following admission to the cardiothoracic ICU. Of the 25 patients extubated in the operating room who required reintubation, 22 failed within 24 hours of cardiothoracic ICU admission; 10 failures were directly related to narcotic doses that resulted in respiratory depression.

CONCLUSIONS

As a result of this review, we have instituted changes in our cardiothoracic ICU postoperative care plans. We have developed a neonatal delirium score, and have adopted the "Kangaroo Care" approach that was first popularized in neonatal ICUs. This provision allows for the early parental holding of infants following admission to the cardiothoracic ICU and allows for appropriately selected parents to sleep in the same beds alongside their postoperative children.

Patient and procedural characteristics for successful and failed immediate tracheal extubation in the operating room following cardiac surgery in infancy

BACKGROUND

Immediate extubation in the operating room after congenital heart surgery is practiced with rising frequency at many cardiac institutions to decrease costs and complications. Infants less than one year of age are also increasingly selected for this 'fast track'. However, factors for patient selection, success, or failure of this practice have not been well defined in this population, yet are critical for patient safety.

OBJECTIVE

To identify selection criteria, patient and procedural characteristics for successful or failed very early endotracheal extubation in the operating room immediately following infant heart surgery.

METHODS

A retrospective analysis was performed for 326 consecutive patients undergoing neonatal and infant heart surgery from 2009 to 2012. Extubation and reintubation data were taken from the institutional Society of Thoracic Surgeons database and patients' charts. Patient characteristics were derived using multivariable logistic regression models.

RESULTS

Very early extubation in the operating room was performed for 130 of 326 neonates and infants (40%). Weight >4 kg, lesser procedural complexity, and absence of trisomy 21 were identified as significant predictors for attempted very early extubation. Of these patients, 12% required reintubation within 48 h following surgery, predominantly due to respiratory failure or for mediastinal re-exploration. Greater procedural complexity was associated with failed extubations. Reintubation was associated with prolonged hospitalization.

CONCLUSIONS

Extubation immediately after infant heart surgery in the operating room can be safely achieved. However, our data suggest that patients undergoing more complex procedures should be selected more conservatively for immediate early extubation.

The relationship between in-house attending coverage and nighttime extubation following congenital heart surgery*

OBJECTIVES

Many cardiac ICUs have instituted 24/7 attending physician in-house coverage, which theoretically may allow for more expeditious weaning from ventilation and extubation. We aimed to determine whether this staffing strategy impacts rates of nighttime extubation and duration of mechanical ventilation.

DESIGN

National data were obtained from the Virtual PICU System database for all patients admitted to the cardiac ICU following congenital heart surgery in 2011 who required postoperative mechanical ventilation. Contemporaneous data from our local institution were collected in addition to the Virtual PICU System data. The combined dataset (n = 2,429) was divided based on the type of nighttime staffing model in order to compare rates of nighttime extubation and duration of mechanical ventilation between units that used an in-house attending staffing strategy and those that employed nighttime residents, fellows, or midlevel providers only.

MEASUREMENTS AND MAIN RESULTS

Institutions that currently use 24/7 in-house attending coverage did not demonstrate statistically significant differences in rates of nighttime extubation or the duration of mechanical ventilation in comparison to units without in-house attendings. Younger patients cared for in non-in-house attending units were more likely to require reintubation.

CONCLUSIONS

Pediatric patients who have undergone congenital heart surgery can be safely and effectively extubated without the routine presence of an attending physician. The utilization of nighttime in-house attending coverage does not appear to have significant benefits on the rate of nighttime extubation and may not reduce the duration of mechanical ventilation in units that already use in-house residents, fellows, or other midlevel providers.

The role of different anesthetic techniques in altering the stress response during cardiac surgery in children: a prospective, double-blinded, and randomized study

OBJECTIVES

Our goal was to evaluate the role of three anesthetic techniques in altering the stress response in children undergoing surgery for repair of congenital heart diseases utilizing cardiopulmonary bypass in the setting of fast tracking or early tracheal extubation. Furthermore, we wanted to evaluate the correlation between blunting the stress response and the perioperative clinical outcomes.

DESIGN

Prospective, randomized, double-blinded study.

SETTING

Single center from December 2008 to May of 2011.

PATIENTS

Forty-eight subjects (low-dose fentanyl plus placebo, n = 16; high-dose fentanyl plus placebo, n = 17; low-dose fentanyl plus dexmedetomidine, n = 15) were studied between ages 30 days to 3 years old who were scheduled to undergo repair for a ventricular septal defect, atrioventricular septal defect, or Tetralogy of Fallot.

METHODS

Children undergoing surgical repair of congenital heart disease were randomized to receive low-dose fentanyl (10 mcg/kg; low-dose fentanyl), high-dose fentanyl (25mcg/kg; high-dose fentanyl), or low-dose fentanyl plus dexmedetomidine (as a 1 mcg/kg loading dose followed by infusion at 0.5mcg/kg/hr until separation from cardiopulmonary bypass. In addition, patients received a volatile anesthetic agent as needed to maintain hemodynamic stability. Blood samples were tested for metabolic, hormonal and cytokine markers at baseline, after sternotomy, after the start of cardiopulmonary bypass, at the end of the procedure and at 24 hours postoperatively.

MEASUREMENTS AND MAIN RESULTS

Forty-eight subjects (low-dose fentanyl plus placebo, n = 16; high-dose fentanyl plus placebo, n = 17; low-dose fentanyl plus dexmedetomidine, n = 15) were studied. Subjects in the low-dose fentanyl plus placebo group had significantly higher levels of adrenocorticotropic hormone, cortisol, glucose, lactate, and epinephrine during the study period. The lowest levels of stress markers were seen in the high-dose fentanyl plus placebo group both over time (adrenocorticotropic hormone, p= 0.01; glucose, p = 0.007) and at individual time points (cortisol and lactate at the end of surgery, epinephrine poststernotomy; p < 0.05). Subjects in the low-dose fentanyl plus dexmedetomidine group had lower lactate levels at the end of surgery compared with the low-dose fentanyl plus placebo group (p < 0.05). Although there were no statistically significant differences in plasma cytokine levels between the three groups, the low-dose fentanyl plus placebo group had significantly higher interleukin-6:interleukin-10 ratio at 24 hours postoperatively (p < 0.0001). In addition, when compared with the low-dose fentanyl plus placebo group, the low-dose fentanyl plus dexmedetomidine group showed a lower norepinephrine level from baseline at poststernotomy, after the start of cardiopulmonary bypass, and at the end of surgery (p ≤ 0.05). Subjects in the low-dose fentanyl plus placebo group had more postoperative narcotic requirement (p = 0.004), higher prothrombin time (p ≤ 0.03), and more postoperative chest tube output (p < 0.05). Success of fast tracking was not significantly different between groups (low-dose fentanyl plus placebo 75%, high-dose fentanyl plus placebo 82%, low-dose fentanyl plus dexmedetomidine 93%; p = 0.39).

CONCLUSIONS

The use of low-dose fentanyl was associated with the greatest stress response, most coagulopathy, and highest transfusion requirement among our cohorts. Higher dose fentanyl demonstrated more favorable blunting of the stress response. When compared with low-dose fentanyl alone, the addition of dexmedetomidine improved the blunting of the stress response, while achieving better postoperative pain control.

Pain management after comprehensive stage 2 repair for hypoplastic left heart syndrome

Achieving optimal pain control for children after complex cardiac surgery can be challenging. Recently, the hybrid approach to palliation of hypoplastic left heart syndrome (HLHS) was introduced as an alternative to the classic Norwood procedure. The second stage of the hybrid approach is a complex procedure known as comprehensive stage 2 (CS2). The authors have noted that pain control after the CS2 procedure is particularly difficult to manage. This report presents a review of the authors' pain management strategy in this clinical scenario and evaluates its efficacy. The medical records of patients who underwent CS2 repair of the hybrid procedure for HLHS between June 2008 and August 2011 were retrospectively reviewed. As a comparative group with a similar physiology, patients undergoing an isolated Glenn procedure also were reviewed. In addition to demographic data, the intraoperative use of narcotics and other adjunct medications for analgesia and sedation was recorded. Postoperatively, the mode of analgesia, the total opioid administered during the first 48 h postoperatively, and the nursing-assessed patient pain scores were recorded. Any adverse drug effect or need to adjust the analgesic regimen was recorded, as well as the timing of tracheal extubation. During the study period, 36 patients ranging in age from 4 to 14 months underwent the CS2 procedure, and 21 patients underwent a Glenn procedure. After CS2 repair, fentanyl was the opioid initially prescribed for all but 2 of the 21 patients managed with the nurse-controlled analgesia (NCA) delivery method and 15 patients managed with continuous infusion. After the Glenn shunt, all patients were prescribed NCA, with 20 patients receiving fentanyl and 1 patient receiving hydromorphone. The use of intraoperative dexmedetomidine caused a decrease in the total narcotic requirements, although this did not reach a statistical significance for either the extubated or intubated patients after CS2. The extubated patients who underwent the Glenn procedure received a smaller total equivalent dose of fentanyl during the first 24 h (29.02 ± 10.6 μg/kg) than did the extubated patients after the CS2 procedure, who received an average of 37.92 ± 8.5 μg/kg (P = 0.02). During the second 24 h, the extubated Glenn patients continued to receive less fentanyl, at an average dose of 7.02 ± 11.5 μg/kg compared with 27.7 ± 23.1 μg/kg for the CS2 patients (P = 0.02). The extubated patients who underwent the Glenn procedure required less NCA time (33.68 ± 17.7) than the CS2 patients (57.9 ± 31.8 h) (P = 0.04). Dexmedetomidine use with the CS2 patients resulted in a trend toward lowering of the total fentanyl dose, but this did not reach statistical significance. The intubated patients who received dexmedetomidine after the CS2 procedure had less NCA time (61.7 ± 39.2 vs. 128.1 ± 100 h; P = 0.02). After the CS2 procedure for palliation of HLHS, patients experience a complex pain profile that differs from the pain associated with the traditional Glenn procedure. This group of patients generally can be managed with fentanyl NCA. Achieving a balance between a proper level of analgesia and sedation in the setting of early tracheal extubation to optimize postoperative physiology can be challenging. The preliminary data suggest that improvements in pain management should be investigated given that more than 30 % of the pain scores in the CS2 group were in the moderate to severe range compared with 18 % after the Glenn procedure.

Pain management after surgery for single-ventricle palliation using the hybrid approach

The hybrid pathway for the management of patients with hypoplastic left heart syndrome was pioneered at our institution and is the preferred approach compared with the traditional Norwood pathway. Patients undergoing this surgery are generally <6 months of age, and pain management in this age group after surgery for complex congenital heart disease (CHD) may be particularly challenging. We retrospectively reviewed our pain-management strategy after stage 1 hybrid procedure (HS1) and evaluated its efficacy, especially in the setting of early tracheal extubation. We retrospectively reviewed the records of patients receiving fentanyl analgesia after HS1 palliation for single-ventricle anatomy between June 2008 and August 2011. In addition to demographic data, we also recorded the mode of analgesia, total fentanyl administered during the first 48 postoperative hours, and total hours of fentanyl use. Other data collected included pain scores, adverse effects, time of tracheal extubation, and use of adjunctive medications, such as dexmedetomidine. Nurse-controlled analgesia (NCA) with fentanyl was used in 21 of the 33 patients in the study cohort, with the remainder receiving a continuous fentanyl infusion. NCA-fentanyl was the method of choice in 12 of the 13 patients whose tracheas were extubated in the operating room versus 9 of 20 patients who received postoperative mechanical ventilation and tracheal intubation (p = 0.0093). During the first and second 24 h after surgery, fentanyl requirements were lower in patients whose tracheas were extubated (11.8 ± 7.6 vs. 20.6 ± 18.1 and 6.6 ± 10.3 vs. 24.3 ± 20.4 μg/kg, respectively). Adverse effects were noted in 3 of the 33 patients (9%) and included one episode each of respiratory depression requiring reintubation of the trachea, pruritus, and excessive sedation. Dexmedetomidine was used as an adjunct medication in 5 patients and resulted in decreased fentanyl use (6.3 ± 1.3 vs. 19 ± 15.9 μg/kg in the first 24 postoperative hours and 7.9 ± 3.5 vs. 19 ± 20.3 μg/kg in the second 24 postoperative hours). Fentanyl administered by way of continuous infusion or NCA provided effective postoperative analgesia with a limited adverse effect profile after HS1 surgery in neonates with complex CHD. Fentanyl requirements were lower in patients who achieved early tracheal extubation as well as those who received dexmedetomidine.