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Dawes TJW, Woodham V, Sharkey E, McEwan A, Derrick G, Muthurangu V, Moledina S, Hepburn L. Predicting Peri-Operative Cardiorespiratory Adverse Events in Children with Idiopathic Pulmonary Arterial Hypertension Undergoing Cardiac Catheterization Using Echocardiography: A Cohort Study. Pediatr Cardiol 2024:10.1007/s00246-024-03447-3. [PMID: 38512488 DOI: 10.1007/s00246-024-03447-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 02/07/2024] [Indexed: 03/23/2024]
Abstract
General anesthesia in children with idiopathic pulmonary arterial hypertension (PAH) carries an increased risk of peri-operative cardiorespiratory complications though risk stratifying individual children pre-operatively remains difficult. We report the incidence and echocardiographic risk factors for adverse events in children with PAH undergoing general anesthesia for cardiac catheterization. Echocardiographic, hemodynamic, and adverse event data from consecutive PAH patients are reported. A multivariable predictive model was developed from echocardiographic variables identified by Bayesian univariable logistic regression. Model performance was reported by area under the curve for receiver operating characteristics (AUCroc) and precision/recall (AUCpr) and a pre-operative scoring system derived (0-100). Ninety-three children underwent 158 cardiac catheterizations with mean age 8.8 ± 4.6 years. Adverse events (n = 42) occurred in 15 patients (16%) during 16 catheterizations (10%) including cardiopulmonary resuscitation (n = 5, 3%), electrocardiographic changes (n = 3, 2%), significant hypotension (n = 2, 1%), stridor (n = 1, 1%), and death (n = 2, 1%). A multivariable model (age, right ventricular dysfunction, and dilatation, pulmonary and tricuspid regurgitation severity, and maximal velocity) was highly predictive of adverse events (AUCroc 0.86, 95% CI 0.75 to 1.00; AUCpr 0.68, 95% CI 0.50 to 0.91; baseline AUCpr 0.10). Pre-operative risk scores were higher in those who had a subsequent adverse event (median 47, IQR 43 to 53) than in those who did not (median 23, IQR 15 to 33). Pre-operative echocardiography informs the risk of peri-operative adverse events and may therefore be useful both for consent and multi-disciplinary care planning.
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Affiliation(s)
- Timothy J W Dawes
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 1LE, UK.
- UCL Institute of Cardiovascular Science, University College London, London, UK.
| | - Valentine Woodham
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 1LE, UK
| | - Emma Sharkey
- Department of Anaesthesia, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Angus McEwan
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 1LE, UK
| | - Graham Derrick
- UCL Institute of Cardiovascular Science, University College London, London, UK
- Department of Paediatric Cardiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Vivek Muthurangu
- UCL Institute of Cardiovascular Science, University College London, London, UK
| | - Shahin Moledina
- UCL Institute of Cardiovascular Science, University College London, London, UK
- National Paediatric Pulmonary Hypertension Service UK, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Lucy Hepburn
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 1LE, UK
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M S, Jayanthi R, Manne P. Anaesthetic management of a child with Fontan heart undergoing laparoscopic cholecystectomy: A case report. J Perioper Pract 2024; 34:70-74. [PMID: 36867074 DOI: 10.1177/17504589221148025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
The Fontan procedure is a staged palliative surgery performed in children with congenital univentricular heart defects. These individuals are predisposed to a variety of issues due to their altered physiology. Through this article, we would like to describe the evaluation and anaesthetic management of a 14-year-old boy with Fontan circulation who underwent an uneventful laparoscopic cholecystectomy. The key to successful management was a multidisciplinary approach throughout the perioperative period as these patients pose a unique set of problems.
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Affiliation(s)
- Siddharth M
- Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - R Jayanthi
- Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Prasad Manne
- Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
- The Royal College of Surgeons of England, London, UK
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Feng W, Zhang M, Hou J, Die X, Wang Y, Liu R. Clinical characteristics of congenital heart defects in mild congenital anorectal malformation: single-centre experience. BMC Pediatr 2024; 24:71. [PMID: 38245711 PMCID: PMC10799376 DOI: 10.1186/s12887-023-04518-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 12/29/2023] [Indexed: 01/22/2024] Open
Abstract
OBJECTIVE To analyze the clinical characteristics and types of congenital heart defect (CHD) in mild congenital anorectal malformation (CARM), namely the rectoperineal and rectovestibular fistulas. METHODS The retrospective study of 183 patients with mild CARM was conducted with assessments of demographic information, color Doppler echocardiography results, and follow-up data. We performed an analysis of the clinical characteristics of CHD, grouping them based on sex and type of mild CARM. RESULTS Of the 183 patients, rectoperineal fistula occurred in 133 patients (72.7%), while the frequency of CHD was 79.8% (146/183). Ventricular septal defects (VSDs) occur more frequently in patients with rectoperineal fistula compared to those with rectovestibular fistula (1.5% vs. 10%), while the opposite trend was observed for patent ductus arteriosus (PDAs) (39.8% vs. 22.0%). Additionally, males presented higher frequency of PDA (42.7% vs. 26.4%) and self-healing (6 months: 87.2% vs. 42.6%; 12 months: 91.0% vs. 63.2%) than females. However, males had a lower rate of undergoing cardiac surgery (6.4% vs. 17.6%) and a younger median diagnosis age (1 day vs. 9 days). CONCLUSION Our study indicates that there is a necessity for meticulous cardiac assessment and follow-up in neonates diagnosed with mild CARM.
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Affiliation(s)
- Wei Feng
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Structural Birth Defect and Reconstruction, Chongqing, China
| | - Minjie Zhang
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Structural Birth Defect and Reconstruction, Chongqing, China
| | - Jinping Hou
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Structural Birth Defect and Reconstruction, Chongqing, China
| | - Xiaohong Die
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Structural Birth Defect and Reconstruction, Chongqing, China
| | - Yi Wang
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Structural Birth Defect and Reconstruction, Chongqing, China.
| | - Rong Liu
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Structural Birth Defect and Reconstruction, Chongqing, China.
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Foz C, Staffa SJ, Brown ML, DiNardo JA, Nasr VG. Predictors and outcomes of perioperative cardiac arrest in children undergoing noncardiac surgery. BJA OPEN 2023; 8:100244. [PMID: 38126042 PMCID: PMC10730343 DOI: 10.1016/j.bjao.2023.100244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/08/2023] [Indexed: 12/23/2023]
Abstract
Background Perioperative cardiac arrest continues to occur. This study aims to identify risk factors for perioperative cardiac arrest in children presenting for noncardiac surgery and characterise its outcomes. Methods Using the National Surgical Quality Improvement Program (NSQIP) Pediatric Database 2019 and 2020, 261 276 patients were included. Patients ≥18 yr and cardiac surgical procedures were excluded. Exploratory multivariable analysis was performed to identify independent predictors of perioperative cardiac arrest and associated outcomes. Results The overall rate of cardiac arrest was 0.1%, with an intraoperative rate of 0.05% and 48-h postoperative rate of 0.06%. Significant risk factors for perioperative cardiac arrest included age <12 months (adjusted odds ratios [aOR] 3.07, P<0.001), American Society of Anesthesiology Physical Status classification (ASA-PS 3 aOR=2.57, P<0.001; ASA-PS 4 aOR=5.27, P<0.001; ASA-PS 5 aOR=13.1, P<0.001), admission through the emergency room (aOR 1.7, P=0.003), inpatient (aOR 2.19, P=0.008), major and severe cardiac disease (aOR 1.58, P=0.008), impaired cognitive status (aOR 1.54, P=0.009), and longer anaesthesia duration (aOR 1.1 per 30 min, P<0.001). Perioperative cardiac arrest was significantly associated with longer hospital length of stay, reoperation, differences in discharge destination, and 30-day mortality. In addition, patients experiencing postoperative cardiac arrest had a significantly higher rate of in-hospital and 30-day mortality than those experiencing intraoperative cardiac arrest. Conclusions The incidence of cardiac arrest in this study is higher than previously reported. This may be related to selection bias and the rigorous data collection required by NSQIP. Lower 30-day mortality after intraoperative cardiac arrest could be related to prompt recognition and rapid initiation of intraoperative resuscitation. Identification of perioperative risk factors for cardiac arrest is crucial to improve the safety and quality of patient care.
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Affiliation(s)
- Carine Foz
- Department of Anaesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven J. Staffa
- Department of Anaesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Morgan L. Brown
- Department of Anaesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - James A. DiNardo
- Department of Anaesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Viviane G. Nasr
- Department of Anaesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Mackie AS, Bravo-Jaimes K, Keir M, Sillman C, Kovacs AH. Access to Specialized Care Across the Lifespan in Tetralogy of Fallot. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:267-282. [PMID: 38161668 PMCID: PMC10755796 DOI: 10.1016/j.cjcpc.2023.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/05/2023] [Indexed: 01/03/2024]
Abstract
Individuals living with tetralogy of Fallot require lifelong specialized congenital heart disease care to monitor for and manage potential late complications. However, access to cardiology care remains a challenge for many patients, as does access to mental health services, dental care, obstetrical care, and other specialties required by this population. Inequities in health care access were highlighted by the COVID-19 pandemic and continue to exist. Paradoxically, many social factors influence an individual's need for care, yet inadvertently restrict access to it. These include sex and gender, being a member of a racial or ethnic historically excluded group, lower educational attainment, lower socioeconomic status, living remotely from tertiary care centres, transportation difficulties, inadequate health insurance, occupational instability, and prior experiences with discrimination in the health care setting. These factors may coexist and have compounding effects. In addition, many patients believe that they are cured and unaware of the need for specialized follow-up. For these reasons, lapses in care are common, particularly around the time of transfer from paediatric to adult care. The lack of trained health care professionals for adults with congenital heart disease presents an additional barrier, even in higher income countries. This review summarizes challenges regarding access to multiple domains of specialized care for individuals with tetralogy of Fallot, with a focus on the impact of social determinants of health. Specific recommendations to improve access to care within Canadian and American systems are offered.
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Affiliation(s)
- Andrew S. Mackie
- Division of Cardiology, Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Katia Bravo-Jaimes
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Michelle Keir
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Christina Sillman
- Adult Congenital Heart Disease Program, Sutter Heart and Vascular Institute, Sacramento, California, USA
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Huang X, Gao Y, Chen W, Sheng W, Huang G. Noncardiac anomalies in children with congenital heart disease. Front Cardiovasc Med 2023; 10:1293210. [PMID: 38054085 PMCID: PMC10694264 DOI: 10.3389/fcvm.2023.1293210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 10/27/2023] [Indexed: 12/07/2023] Open
Abstract
Introduction Noncardiac anomalies (NCAs) in patients with congenital heart defects (CHDs) are crucial for perioperative management and etiology studies. This study aimed to investigate NCAs in Chinese children with CHDs. Methods Medical records for CHD-diagnosed children hospitalized from 1 January 2015 to 31 December 2019 were collected and subjected to retrospective analyses to excavate potential association rules between CHDs and noncardiac malformations. Results A total of 3,788 CHD patients were included in this study. The main phenotypes of CHD were Ventricular Septal Defect (VSD, 33.69%), Atrial Septal Defect (ASD, 12.72%), and Tetralogy of Fallot (TOF, 5.54%). A total of 887 (23.42%) cases showed noncardiac anomalies, which were mainly associated with the central nervous system (34.61%), nose/ear/mandibular/face (19.39%), genitourinary system (15.78%), and musculoskeletal system (15.56%). Compared to other CHD subtypes, septal defects had a lower percentage of associated NCAs (P = 3.7 × 10-9) while AVSD had a higher percentage (P = 0.0018). Disscussion NCAs are prevalent among CHD-diagnosed children in China, and the spectrums of NCAs in different CHD subcategories were different.
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Affiliation(s)
- Xianghui Huang
- Cardiovascular Center, Children’s Hospital of Fudan University, Shanghai, China
- Fujian Key Laboratory of Neonatal Diseases, Xiamen Children’s Hospital, Fujian, China
| | - Yuan Gao
- Cardiovascular Center, Children’s Hospital of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Birth Defects, Shanghai, China
| | - Weicheng Chen
- Cardiovascular Center, Children’s Hospital of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Birth Defects, Shanghai, China
| | - Wei Sheng
- Cardiovascular Center, Children’s Hospital of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Birth Defects, Shanghai, China
- Unit of Early Intervention of Genetically Related Childhood Cardiovascular Diseases, Shanghai, China
| | - Guoying Huang
- Cardiovascular Center, Children’s Hospital of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Birth Defects, Shanghai, China
- Unit of Early Intervention of Genetically Related Childhood Cardiovascular Diseases, Shanghai, China
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7
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Daene M, De Pauw L, De Meester P, Troost E, Moons P, Gewillig M, Rega F, Van De Bruaene A, Budts W. Outcome of Down patients with repaired versus unrepaired atrioventricular septal defect. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2023. [DOI: 10.1016/j.ijcchd.2023.100452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
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Waldman JC, Whitney GM, Twite MD, Ing RJ. Institutional-Specific Risk Stratification of Children With Congenital Heart Disease Undergoing Noncardiac Procedures. What are the Risks of Anesthesia at Your Institution? J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00276-8. [PMID: 37225548 DOI: 10.1053/j.jvca.2023.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 05/26/2023]
Affiliation(s)
- Jeffrey C Waldman
- Department of Anesthesiology, University of Colorado School of Medicine, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO
| | - Gina M Whitney
- Department of Anesthesiology, University of Colorado School of Medicine, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO
| | - Mark D Twite
- Department of Anesthesiology, University of Colorado School of Medicine, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO
| | - Richard J Ing
- Department of Anesthesiology, University of Colorado School of Medicine, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO
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Baijal RG, Fakarar H, Sinton J, Huang X, Staggers K, Mossad EB. Perioperative Risk Assessment in Children With Congenital Heart Disease Undergoing Noncardiac Procedures. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00226-4. [PMID: 37137750 DOI: 10.1053/j.jvca.2023.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/21/2023] [Accepted: 03/27/2023] [Indexed: 05/05/2023]
Abstract
OBJECTIVES To risk-stratify children with congenital heart disease undergoing noncardiac surgery or diagnostic procedures for perioperative cardiopulmonary complications using the authors' established institutional guidelines. DESIGN A retrospective cohort study. SETTING The study was conducted in an academic, tertiary-care children's hospital. PARTICIPANTS A total of 1,005 children, from birth to 19 years of age with a diagnosis of congenital heart disease, who underwent a noncardiac surgery or diagnostic procedure from January 2017 to December 2018, were included in the study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The incidence of a severe perioperative complication, defined as a perioperative cardiac arrest or death within 30 days of the procedure, was 1.6%. Age, an emergent surgery/procedure, a preoperative renal abnormality, preoperative mechanical ventilation, and a preoperative pericardial effusion were significant for severe perioperative complications, in the multivariate analysis. The area under the receiver operating characteristic curve for severe complications was 0.936. However, the area under the curve for moderate perioperative complications was 0.679, in which moderate complications were defined as (1) an escalation in anticipated postoperative disposition (from planned disposition), (2) an escalation in postoperative disposition (from preoperative location), (3) an escalation of preoperative airway support, (4) an administration of any intraoperative vasoactive medication/infusion, (5) a noncardiac surgery reoperation within 30 days of the procedure (if related to the primary procedure or change in physiology), or (6) unplanned readmission with 24 hours of the procedure. CONCLUSIONS A robust model for severe perioperative complications was developed within the authors' institutional clinical guidelines, identifying 5 predictors for perioperative cardiac arrest or death. The usual markers of critical illness were not found to be predictive of a moderate perioperative complication, regardless of the level of anesthesiologist training, suggesting that many of these children with congenital heart disease undergoing noncardiac procedures can be treated by a general pediatric anesthesiologist rather than a pediatric cardiac anesthesiologist within an institution that has or can establish clinical guidelines for these children.
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Affiliation(s)
- Rahul G Baijal
- Department of Pediatric Anesthesiology, Perioperative, and Pain Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas.
| | - Heydiye Fakarar
- Department of Pediatric Anesthesiology, Perioperative, and Pain Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Jamie Sinton
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Xiofan Huang
- Dan L Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Kristen Staggers
- Dan L Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Emad B Mossad
- Department of Pediatric Anesthesiology, Perioperative, and Pain Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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10
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Stein ML, Bilal MB, Faraoni D, Zabala L, Matisoff A, Mossad EB, Mittnacht AJC, Nasr VG. Selected 2022 Highlights in Congenital Cardiac Anesthesia. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00201-X. [PMID: 37085385 DOI: 10.1053/j.jvca.2023.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 03/24/2023] [Indexed: 04/23/2023]
Abstract
This article is a review of the highlights of pertinent literature of interest to the congenital cardiac anesthesiologist, and was published in 2022. After a search of the United States National Library of Medicine PubMed database, several topics emerged in which significant contributions were made in 2022. The authors of this manuscript considered the following topics noteworthy to be included in this review-intensive care unit admission after congenital cardiac catheterization interventions, antifibrinolytics in pediatric cardiac surgery, the current status of the pediatric cardiac anesthesia workforce in the United States, and kidney injury and renal protection during congenital heart surgery.
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Affiliation(s)
- Mary L Stein
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Musa B Bilal
- Department of Anesthesiology, Perioperative and Pain Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - David Faraoni
- Department of Anesthesiology, Perioperative and Pain Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Luis Zabala
- Department of Anesthesia and Pain Medicine, UT Southwestern School of Medicine, Children's Medical Center Dallas, Dallas, TX
| | - Andrew Matisoff
- Department of Anesthesiology, Perioperative and Pain Medicine, George Washington University, Children's National Hospital, Washington, DC
| | - Emad B Mossad
- Department of Anesthesiology, Perioperative and Pain Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Alexander J C Mittnacht
- Department of Anesthesiology, New York Medical College, Westchester Medical Center, Valhalla, NY.
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
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Ambardekar AP, Furukawa L, Eriksen W, McNaull PP, Greeley WJ, Lockman JL. A Consensus-Driven Revision of the Accreditation Council for Graduate Medical Education Case Log System: Pediatric Anesthesiology Fellowship Education. Anesth Analg 2023; 136:446-454. [PMID: 35773224 DOI: 10.1213/ane.0000000000006129] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Clinical experiences, quantified by case logs, are an integral part of pediatric anesthesiology fellowship programs. Accreditation of pediatric anesthesiology fellowships by the Accreditation Council of Graduate Medical Education (ACGME) and establishment of case log reporting occurred in 1997 and 2009, respectively. The specialty has evolved since then, but the case log system remains largely unchanged. The Pediatric Anesthesiology Program Directors Association (PAPDA) embarked on the development of an evidence-based case log proposal through the efforts of a case log task force (CLTF). This proposal was part of a larger consensus-building process of the Society for Pediatric Anesthesia (SPA) Task Force for Pediatric Anesthesiology Graduate Medical Education. The primary aim of case log revision was to propose an evidence-based, consensus-driven update to the pediatric anesthesiology case log system. METHODS This study was executed in 2 phases. The CLTF, composed of 10 program directors representing diverse pediatric anesthesiology fellowship programs across the country, utilized evidence-based literature to develop proposed new categories. After an approval vote by PAPDA membership, this proposal was included in the nationally representative, stakeholder-based Delphi process executed by the SPA Task Force on Graduate Medical Education. Thirty-seven participants engaged in this Delphi process, during which iterative rounds of surveys were used to select elements of the old and newly proposed case logs to create a final revision of categories and minimums for updated case logs. The Delphi methodology was used, with a two-thirds agreement as the threshold for inclusion. RESULTS Participation in the Delphi process was robust, and consensus was almost completely achieved by round 2 of 3 survey rounds. Participants suggested that total case minimums should increase from 240 to 300 (300-370). Participants agreed (75.86%) that the current case logs targeted the right types of cases, but requirements were too low (82.75%). They also agreed (85.19%) that the case log system and minimums deserved an update, and that this should be used as part of a competency-based assessment in pediatric anesthesia fellowships (96%). Participants supported new categories and provided recommended minimum numbers. CONCLUSIONS The pediatric anesthesiology case log system continues to have a place in the assessment of fellowship programs, but it requires an update. This Delphi process established broad support for new categories and benchmarked minimums to ensure the robustness of fellowship programs and to better prepare the pediatric anesthesiology workforce of the future for independent clinical practice.
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Affiliation(s)
- Aditee P Ambardekar
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Louise Furukawa
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Whitney Eriksen
- Mixed Methods Research Laboratory, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peggy P McNaull
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - William J Greeley
- Departments of Anesthesiology and Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Justin L Lockman
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennyslvania, Philadelphia, Pennsylvania
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12
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Desai KD, Yuan I, Padiyath A, Goldsmith MP, Tsui FC, Pratap JN, Nelson O, Simpao AF. A Narrative Review of Multiinstitutional Data Registries of Pediatric Congenital Heart Disease in Pediatric Cardiac Anesthesia and Critical Care Medicine. J Cardiothorac Vasc Anesth 2023; 37:461-470. [PMID: 36529633 DOI: 10.1053/j.jvca.2022.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022]
Abstract
Congenital heart disease (CHD) is one of the most common birth anomalies. While the care of children with CHD has improved over recent decades, children with CHD who undergo general anesthesia remain at increased risk for morbidity and mortality. Electronic health record systems have enabled institutions to combine data on the management and outcomes of children with CHD in multicenter registries. The application of descriptive analytics methods to these data can improve clinicians' understanding and care of children with CHD. This narrative review covers efforts to leverage multicenter data registries relevant to pediatric cardiac anesthesia and critical care to improve the care of children with CHD.
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Affiliation(s)
- Krupa D Desai
- Department of Anesthesiology, Perioperative Care, and Pain Medicine at NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Ian Yuan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Asif Padiyath
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Michael P Goldsmith
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Fu-Chiang Tsui
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jayant Nick Pratap
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Olivia Nelson
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Allan F Simpao
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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13
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Nasr VG, Markham LW, Clay M, DiNardo JA, Faraoni D, Gottlieb-Sen D, Miller-Hance WC, Pike NA, Rotman C. Perioperative Considerations for Pediatric Patients With Congenital Heart Disease Presenting for Noncardiac Procedures: A Scientific Statement From the American Heart Association. Circ Cardiovasc Qual Outcomes 2023; 16:e000113. [PMID: 36519439 DOI: 10.1161/hcq.0000000000000113] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Continuous advances in pediatric cardiology, surgery, and critical care have significantly improved survival rates for children and adults with congenital heart disease. Paradoxically, the resulting increase in longevity has expanded the prevalence of both repaired and unrepaired congenital heart disease and has escalated the need for diagnostic and interventional procedures. Because of this expansion in prevalence, anesthesiologists, pediatricians, and other health care professionals increasingly encounter patients with congenital heart disease or other pediatric cardiac diseases who are presenting for surgical treatment of unrelated, noncardiac disease. Patients with congenital heart disease are at high risk for mortality, complications, and reoperation after noncardiac procedures. Rigorous study of risk factors and outcomes has identified subsets of patients with minor, major, and severe congenital heart disease who may have higher-than-baseline risk when undergoing noncardiac procedures, and this has led to the development of risk prediction scores specific to this population. This scientific statement reviews contemporary data on risk from noncardiac procedures, focusing on pediatric patients with congenital heart disease and describing current knowledge on the subject. This scientific statement also addresses preoperative evaluation and testing, perioperative considerations, and postoperative care in this unique patient population and highlights relevant aspects of the pathophysiology of selected conditions that can influence perioperative care and patient management.
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14
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Hamilton ARL, Odegard KC, Yuki K. Exploring Noncardiac Surgical Needs From Infancy to Adulthood in Patients With Congenital Heart Disease. J Cardiothorac Vasc Anesth 2022; 36:4364-4369. [PMID: 36216687 DOI: 10.1053/j.jvca.2022.09.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/04/2022] [Accepted: 09/06/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES As life expectancy for patients born with congenital heart disease (CHD) continues to rise, these patients will present increasingly for noncardiac surgery during childhood and adolescence. This study aimed to map the lifespan of noncardiac surgical needs among patients with CHD and explore how these needs may change over time. DESIGN All patients with CHD presenting for noncardiac surgery between 2008 and 2014 were selected for review. SETTING The study was conducted at a single urban academic tertiary pediatric hospital. PARTICIPANTS All patients with CHD presenting for noncardiac surgery during the study period were included and grouped by cardiac diagnosis. INTERVENTIONS Descriptive analysis included patient demographics, CHD diagnosis, procedures performed, and clinical data, including baseline saturation and underlying cardiac function. MEASUREMENTS AND MAIN RESULTS A total of 3,011 noncardiac surgical procedures were performed on patients with CHD during the study period. The most common CHD diagnoses were patent ductus arteriosus (27.6%), ventricular septal defects (24.7%), and patent foramen ovale (24.3%). The median age was 4 years, 87% of all the patients were ≤10 years, and 41% had associated syndromes. Of the patients, 76% underwent a preoperative echocardiogram, and 10% had depressed cardiac function at the time of surgery. The most common procedures performed were ear, nose, and throat (20%), general surgery (14%), and radiology (11%). Intraoperative events were reported in 488 out of 3,010 encounters (16.2%), with the highest rates reported in patients with single-ventricle physiology (55/179; 30.7%). CONCLUSIONS These findings suggested a greater burden of noncardiac surgery in lower age groups, with ear, nose, and throat and general surgery most common in young children and orthopedic and dental procedures increasing in adolescence.
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Affiliation(s)
- A Rebecca L Hamilton
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anaesthesia, Harvard Medical School, Boston, MA; Department of Cell and Molecular Biology, Karolinska Institute, Stockholm, Sweden.
| | - Kirsten C Odegard
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Koichi Yuki
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anaesthesia, Harvard Medical School, Boston, MA
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15
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Keir M, Borman M, Clegg R, Colbert J, Guron N, Harper L, Helmerson D, Patzer J, Reynolds S, Alvarez N. Caring for the Aging Patient With Adult Congenital Heart Disease: A Review of Cardiac and Noncardiac Comorbidities. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2022; 1:274-281. [PMID: 37969485 PMCID: PMC10642149 DOI: 10.1016/j.cjcpc.2022.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 10/12/2022] [Indexed: 11/17/2023]
Abstract
As the demographics of congenital heart disease (CHD) have shifted, there are now more adults living with CHD than children in North America. This presents unprecedented challenges as patients with CHD acquire noncardiac comorbidities and seek care for a variety of reasons, including noncardiac surgery and emergency department (ED) visits. CHD shifts from a one organ problem to a multisystem disease and requires a team of specialists to maintain high-quality longitudinal care. In this review, we summarize the challenges patients with CHD and their providers face as they age. We review the demographics of CHD and health care utilization. We examine the rates of noncardiac comorbidities and the current quality of care received by adult patients with CHD.
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Affiliation(s)
- Michelle Keir
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Meredith Borman
- Section of Gastroenterology, Division of Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robin Clegg
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jillian Colbert
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Nita Guron
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Lea Harper
- Section of Respirology, Division of Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Doug Helmerson
- Section of Respirology, Division of Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jessica Patzer
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Stephen Reynolds
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Nanette Alvarez
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
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16
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Kwiatkowski DM, Ball MK, Savorgnan FJ, Allan CK, Dearani JA, Roth MD, Roth RZ, Sexson KS, Tweddell JS, Williams PK, Zender JE, Levy VY. Neonatal Congenital Heart Disease Surgical Readiness and Timing. Pediatrics 2022; 150:189888. [PMID: 36317977 DOI: 10.1542/peds.2022-056415d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- David M Kwiatkowski
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Molly K Ball
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Fabio J Savorgnan
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - Catherine K Allan
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo College of Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | - Kristen S Sexson
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - James S Tweddell
- Department of Surgery, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Patricia K Williams
- Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Jill E Zender
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - Victor Y Levy
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas
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17
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Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, De Hert S, de Laval I, Geisler T, Hinterbuchner L, Ibanez B, Lenarczyk R, Mansmann UR, McGreavy P, Mueller C, Muneretto C, Niessner A, Potpara TS, Ristić A, Sade LE, Schirmer H, Schüpke S, Sillesen H, Skulstad H, Torracca L, Tutarel O, Van Der Meer P, Wojakowski W, Zacharowski K. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J 2022; 43:3826-3924. [PMID: 36017553 DOI: 10.1093/eurheartj/ehac270] [Citation(s) in RCA: 247] [Impact Index Per Article: 123.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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18
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Muto M, Sugita K, Matsuba T, Kedoin C, Matsui M, Ikoma S, Murakami M, Yano K, Onishi S, Harumatsu T, Yamada K, Yamada W, Matsukubo M, Kawano T, Machigashira S, Torikai M, Kaji T, Ibara S, Imoto Y, Soga Y, Ieiri S. How should we treat representative neonatal surgical diseases with congenital heart disease? Pediatr Surg Int 2022; 38:1235-1240. [PMID: 35838788 DOI: 10.1007/s00383-022-05178-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Representative neonatal surgical diseases are often complicated by congenital heart disease (CHD). We reviewed our decade of experience from the perspective of the prognosis and report on the management of infants with CHD. METHODS Cases with and without CHD between 2011 and 2020 were retrospectively compared. Qualitative data were analyzed using a chi-square test with Yates' correction, and quantitative data were compared using Student's t-test. RESULTS Of the 275 neonatal surgical cases, 36 had CHD (13.1%). Ventricular septal defect was the most common cardiac anomaly, followed by atrial septal defect. Esophageal atresia showed the highest complication rate of CHD (43.8%, 14/32) followed by duodenal atresia (38.5%, 10/26). The mortality rates of patients with and without CHD (22.2% [8/36] vs. 1.3% [3/239]) were significantly different (χ2 = 30.6, p < 0.0001). Of the eight deaths with CHD, six patients had cyanotic complex CHD. Notably, four of these patients died from progression of inappropriate hemodynamics in the remote period after definitive non-cardiac surgery. CONCLUSION Considering its high-mortality, the presence of CHD, especially cyanotic heart disease, is an important issue to consider in the treatment of neonatal surgical diseases. Pediatric surgeons should be alert for changes in hemodynamics after surgery, as these may affect mortality.
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Affiliation(s)
- Mitsuru Muto
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890 -8520, Japan.
| | - Koshiro Sugita
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890 -8520, Japan
| | - Tomoyuki Matsuba
- Department of Cardiovascular Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Chihiro Kedoin
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890 -8520, Japan
| | - Mayu Matsui
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890 -8520, Japan
| | - Shinichiro Ikoma
- Department of Pediatric Surgery, Kagoshima City Hospital, Kagoshima, Japan
| | - Masakazu Murakami
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890 -8520, Japan
| | - Keisuke Yano
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890 -8520, Japan
| | - Shun Onishi
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890 -8520, Japan
| | - Toshio Harumatsu
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890 -8520, Japan
| | - Koji Yamada
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890 -8520, Japan
| | - Waka Yamada
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890 -8520, Japan
| | - Makoto Matsukubo
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890 -8520, Japan
| | - Takafumi Kawano
- Department of Pediatric Surgery, Kagoshima City Hospital, Kagoshima, Japan
| | - Seiro Machigashira
- Department of Pediatric Surgery, Kagoshima City Hospital, Kagoshima, Japan
| | - Motofumi Torikai
- Department of Pediatric Surgery, Kagoshima City Hospital, Kagoshima, Japan
| | - Tatsuru Kaji
- Department of Pediatric Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Satoshi Ibara
- Department of Neonatology, Perinatal Medical Center, Kagoshima City Hospital, Kagoshima, Japan
| | - Yutaka Imoto
- Department of Cardiovascular Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Yoshiharu Soga
- Department of Cardiovascular Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Satoshi Ieiri
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890 -8520, Japan
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19
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Xiao L, Barrowman N, Momoli F, Murto K, Bromwich M, Katz SL. Risk factors for respiratory adverse events after adenoidectomy and tonsillectomy in children with down syndrome: a retrospective cohort study. Eur J Pediatr 2022; 181:2399-2408. [PMID: 35278117 DOI: 10.1007/s00431-022-04438-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/03/2022] [Accepted: 03/05/2022] [Indexed: 11/03/2022]
Abstract
UNLABELLED Obstructive sleep apnea syndrome is a major cause of morbidity in the Down syndrome population and is commonly treated with adenoidectomy and/or tonsillectomy (AT). However, these children are at increased risk for perioperative respiratory adverse events (PRAEs). The objective of this study was to examine risk factors for major PRAEs requiring intervention in children with Down syndrome undergoing AT and to describe their postoperative monitoring environment. This retrospective study included all children with Down syndrome aged 0-18 years who underwent a preoperative polysomnogram followed by AT at a tertiary pediatric institution. Descriptive statistics were used to summarize baseline demographic and clinical characteristics. A multivariable model for prediction of PRAEs was constructed. A priori, it was decided that minimum oxygen saturation, apnea-hypopnea index, and average oxygen saturation asleep would be included, along with medical comorbidities associated with PRAEs at p < 0.2 in univariable analyses. Fifty-eight children were included in this study; twelve had a PRAE. Cardiac disease was associated with PRAEs on univariable analysis (p = 0.03). In multivariable analysis, average oxygen saturation asleep was associated with PRAEs (OR 1.50; 95% confidence interval 1.00, 2.41; p = 0.05). For all of the remaining variables, p > 0.15. Fifty-six children were admitted for monitoring overnight; four were admitted to the intensive care unit and fifty-two were admitted to the ward. CONCLUSIONS A multivariable model found evidence that lower average oxygen saturation while asleep was associated with PRAEs requiring intervention in children with Down syndrome. This study highlights the difficulty in predicting complications in this population. WHAT IS KNOWN • Obstructive sleep apnea syndrome is a major cause of morbidity in the Down syndrome population and is commonly treated with adenoidectomy and/or tonsillectomy. • However, children with Down syndrome are at increased risk for perioperative respiratory adverse events (PRAEs) following adenoidectomy and/or tonsillectomy. WHAT IS NEW • We found that a lower average oxygen saturation asleep is associated with increased odds of PRAEs, adjusting for age, total apnea-hypopnea index, cardiac comorbidity, and minimum oxygen saturation. • This study highlights the difficulty in predicting complications in this population.
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Affiliation(s)
- Lena Xiao
- Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, K1H 8L1, Canada.,University of Ottawa, Ottawa, Canada
| | - Nicholas Barrowman
- University of Ottawa, Ottawa, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Franco Momoli
- University of Ottawa, Ottawa, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada.,Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kimmo Murto
- Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, K1H 8L1, Canada.,University of Ottawa, Ottawa, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Matthew Bromwich
- Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, K1H 8L1, Canada.,University of Ottawa, Ottawa, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Sherri L Katz
- Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, K1H 8L1, Canada. .,University of Ottawa, Ottawa, Canada. .,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada.
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20
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Valencia E, Staffa SJ, Faraoni D, Berry JG, DiNardo JA, Nasr VG. The Role of Chronic Conditions in Outcomes following Noncardiac Surgery in Children with Congenital Heart Disease. J Pediatr 2022; 244:49-57.e8. [PMID: 35074311 DOI: 10.1016/j.jpeds.2022.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 01/16/2023]
Abstract
OBJECTIVES To compare outcomes in children with congenital heart disease (CHD) undergoing noncardiac surgery by presence of chronic conditions and identify associated risk factors. STUDY DESIGN Retrospective analysis of 14 031 children with CHD who underwent noncardiac surgery in the 2016 Healthcare Cost and Utilization Project Kid's Inpatient Database. Multivariable regression was used to assess patient and hospital factors associated with in-hospital mortality and length of stay (LOS). RESULTS Overall, 94% had at least 1 chronic condition. The in-hospital mortality rate was 5.6%. Neonates with CHD only had the highest mortality (15.6%); otherwise, children with CHD and at least 1 chronic condition had higher mortality than patients with CHD only (infant 3.93%, child 1.22%, adolescent 1.04% vs 2.34%, 0%, and 0%). Neonates (OR, 15.5; 95% CI, 7.1-34.1 vs adolescent), number of chronic conditions (OR, 1.34; 95% CI, 1.27-1.42), chronic conditions type (circulatory system; OR 2.46; 95% CI, 2.04-2.98), and low socioeconomic status (OR, 1.36; 95% CI, 1.05-1.77) were associated with increased mortality. The median LOS was 20 days (IQR, 5-66). Those with CHD and at least 1 chronic condition had a greater LOS (21 days; IQR, 5-68) than those with CHD only (9 days; IQR, 3-46). Neonates (adjusted coefficient, 44.3; 95% CI, 40.3-48.3 vs adolescent), Black race (adjusted coefficient, 4.78; 95% CI, 2.27-7.3), chronic condition indicator number (adjusted coefficient, 5.17; 95% CI, 4.56-5.78), and subtype (adjusted coefficient, 23.6; 95% CI, 20.4-26.7) were associated with a prolonged LOS. CONCLUSIONS Most children with CHD who undergo noncardiac surgery have at least 1 chronic condition. Age, chronic conditions type and number, low socioeconomic status, and Black race impart increased risks of in-hospital mortality and prolonged LOS. Further research is needed to evaluate the impact of specific chronic conditions and determine barriers to equitable care.
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Affiliation(s)
- Eleonore Valencia
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - David Faraoni
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Jay G Berry
- Complex Care, Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
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21
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Mahdi EM, Tran NN, Ourshalimian S, Sanborn S, Alquiros MT, Squillaro A, Lascano D, Herrington C, Kelley-Quon LI. Factors Impacting Long-Term Gastrostomy Tube Dependence in Infants with Congenital Heart Disease. J Surg Res 2021; 270:455-462. [PMID: 34800791 DOI: 10.1016/j.jss.2021.09.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 09/09/2021] [Accepted: 09/21/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Infants with congenital heart disease (CHD) often experience oral feeding intolerance requiring gastrostomy (GT). Complications related to GT use are common. The study aim was to identify factors associated with continued GT use at one-year. METHODS A retrospective cohort study was performed at a tertiary children's hospital using the Society of Thoracic Surgeons database and patients' electronic medical record. Infants <1-year with CHD who underwent cardiac and GT surgery between January 2014-October 2019 were identified. Patient demographics, preoperative feeding, clinical variables, and GT use at one-year was evaluated. A separate cohort discharged with a nasogastric tube (NGT) was identified for longitudinal comparisons. RESULTS Of 137 infants who received a GT, 115 (84%) continued using their GT at one-year. Factors associated with continued GT use included lower median percent of goal oral feeding before GT placement (0% IQR 0-6.5 versus 3.7% IQR 0-31), prolonged hospitalization after GT placement (36% versus 14%, P-value = 0.048), and failure to take oral feeds at discharge (69% versus 27%, P-value <0.001). There was no difference in demographics or clinical comorbidities between groups. Clinic/emergency room visits for GT complications were common (72%). Eight infants discharged with a NGT did not require GT placement. CONCLUSIONS Patients with CHD tolerating minimal oral nutrition before GT placement, prolonged hospitalization after GT, and difficulty with oral feeds at discharge were more likely to use their GT at 1-year. Outpatient NGT feeding is feasible for select infants with CHD. Efforts to optimize care for this complex, device-dependent population are warranted to minimize risks and facilitate family engagement for long-term care.
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Affiliation(s)
- Elaa M Mahdi
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nhu N Tran
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Stephanie Sanborn
- Department of Clinical Nutrition and Lactation Services, Children's Hospital Los Angeles, Los Angeles, California
| | - Maria Theresa Alquiros
- Division of Cardiac Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Anthony Squillaro
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Danny Lascano
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Cynthia Herrington
- Division of Cardiac Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California.
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22
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Sebastian R, Ullah S, Motta P, Das B, Zabala L. Anesthetic Considerations in Pediatric Patients With Acute Decompensated Heart Failure. Semin Cardiothorac Vasc Anesth 2021; 26:41-53. [PMID: 34730043 DOI: 10.1177/10892532211044977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Acute decompensated heart failure (ADHF) in pediatrics is a significant cause for morbidity and mortality in children. Congenital heart disease and cardiomyopathy are the leading etiologies of ADHF. It is common for these children to undergo diagnostic, therapeutic, or surgical procedure under anesthesia, which may be associated with significant morbidity and mortality. The importance of preanesthetic multidisciplinary planning with all involved teams, including anesthesia, cardiology, intensive care, perfusion, and cardiac surgery, cannot be emphasized enough. In order to safely manage these patients, it is imperative for the anesthesiologist to understand the complex pathophysiological interactions between cardiopulmonary systems and anesthesia during these procedures. This review discusses the etiology, pathophysiology, clinical manifestations, and perioperative management of these patients.
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Affiliation(s)
- Roby Sebastian
- Department of Anesthesiology and Pain Management, 248024University of Texas Southwestern, Dallas, TX, USA.,Children's Medical Center of Dallas, Anesthesiology and Pain Management, Dallas, TX, USA
| | - Sana Ullah
- Department of Anesthesiology and Pain Management, 248024University of Texas Southwestern, Dallas, TX, USA.,Children's Medical Center of Dallas, Anesthesiology and Pain Management, Dallas, TX, USA
| | - Pablo Motta
- Perioperative and Pain Medicine, 3989Baylor College of Medicine Houston, TX, USA.,Texas Children's Hospital, Arthur S. Keats Division of Pediatric Cardiovascular Anesthesiology, Houston, TX, USA
| | - Bibhuti Das
- Department of Pediatrics, Department of Pediatric Cardiology, 3989Baylor College of Medicine, Austin, TX, USA.,Texas Children's Hospital Austin Specialty Center, Austin, TX, USA
| | - Luis Zabala
- Department of Anesthesiology and Pain Management, 248024University of Texas Southwestern, Dallas, TX, USA.,Children's Medical Center of Dallas, Anesthesiology and Pain Management, Dallas, TX, USA
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Taylor MA, Cutshall ZA, Eldredge RS, Kastenberg ZJ, Russell KW. High ligation in adolescents: Is it enough? J Pediatr Surg 2021; 56:1865-1869. [PMID: 33234290 DOI: 10.1016/j.jpedsurg.2020.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/28/2020] [Accepted: 11/02/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND In adults, the gold standard for surgical repair of an inguinal hernia is a mesh repair, whereas, in children, the standard is high ligation of the hernia sac. However, adolescents represent a "gray zone" between children and adults, and there is no consensus on the most appropriate operation for inguinal hernias in these patients. We aimed to describe the outcomes in adolescents undergoing high ligation for inguinal hernia repair and determine what factors may portend an increased risk of recurrence in this population. METHODS A retrospective cohort study was performed of all children that underwent open high ligation for an inguinal hernia at our tertiary children's hospital from January 2000 to January 2018, who were 12 to 18 years old at the time of surgery. We compared the patient demographic data, medical history, and repair characteristics for the cohort of hernias that developed a recurrence to the cohort that did not. RESULTS During our study period, 256 adolescent patients underwent repair with 11 of those patients having both sides repaired for a total of 267 hernias repaired. The median age at surgery was 14.7 years, and 83.9% of the hernias were in male patients. There was a 6.0% recurrence rate, and all patients that developed recurrence underwent a reoperation. The median time from surgery to reoperation for recurrence was 3.1 years. Patients with recurrence were more likely to have cardiac (25.0% vs. 5.8%, p = 0.02) and gastrointestinal comorbidities (25% vs. 7.1%, p = 0.01). There were no other significant differences between the two cohorts. CONCLUSION High ligation of the hernia sac in adolescents is effective and has an acceptable risk of recurrence while avoiding any additional morbidity that may come from the use of mesh. Patients with cardiac and gastrointestinal comorbidities should be counseled on the higher risk of recurrence.
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Affiliation(s)
- Mark A Taylor
- University of Utah, Department of Surgery, Division of Pediatric Surgery, Salt Lake City, UT, USA.
| | | | | | - Zachary J Kastenberg
- University of Utah, Department of Surgery, Division of Pediatric Surgery, Salt Lake City, UT, USA
| | - Katie W Russell
- University of Utah, Department of Surgery, Division of Pediatric Surgery, Salt Lake City, UT, USA
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Velik‐Salchner C, Tauber H, Rastner V, Pajk W, Mittermayr M, Wally D, Kilo J, Vondrys D, Fries D, Fritz J, Streif W. Administration of fibrinogen concentrate combined with prothrombin complex maintains hemostasis in children undergoing congenital heart repair (a long-term propensity score-matched study). Acta Anaesthesiol Scand 2021; 65:1178-1186. [PMID: 34152599 PMCID: PMC8518112 DOI: 10.1111/aas.13945] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 05/05/2021] [Accepted: 05/26/2021] [Indexed: 12/28/2022]
Abstract
Background Bleeding is a common problem in children with congenital heart disease undergoing major cardiac surgery requiring cardiopulmonary bypass (CPB). Little is known about optimal management with blood products. Objective To investigate clinical outcome and hemostatic effects of fibrinogen concentrate (FC) in combination with prothrombin complex concentrate (PCC) versus standard treatment with fresh frozen plasma (FFP) in children undergoing cardiac surgery. Methods For this single‐institution cohort study, data on 525 children were analyzed. Propensity score matching in 210 children was applied to reduce the impact of various baseline characteristics. Results Three children treated with FC/PCC developed surgical site bleeding requiring surgical revision. One child developed central venous line‐related thrombosis. Blood loss through chest tube drainage was independent of FC/PCC. Coagulation abnormalities were not present in any of these children. Time to extubation and ICU stay did not differ. In the FC/PCC group, children received (median, Q1, Q3) 52 mg/kg (32, 83) FC and 28IU/kg (13, 44) PCC. Fibrinogen concentration was comparable at baseline. On admission to the ICU, fibrinogen was higher in children receiving FC/PCC, namely, 232 mg/dL (196, 280), than in children receiving FFP (186 mg/dL, 149, 224; P < .001). On discharge from the ICU, values did not differ ((FC/PCC 416 mg/dL (288, 501)), non‐FC/PCC 418 mg/dL (272, 585; P = 1.000)). Conclusion FC/PCC was well tolerated and permitted hemostasis to be maintained, even in the very young. We were not able to detect a signal for inferiority of this treatment. We conclude that FC/PCC can safely replace FFP.
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Affiliation(s)
- Corinna Velik‐Salchner
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Helmuth Tauber
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Verena Rastner
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Werner Pajk
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Markus Mittermayr
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Dieter Wally
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Juliane Kilo
- Department of Cardiac Surgery Medical University of Innsbruck Innsbruck Austria
| | - David Vondrys
- Department of Cardiac Surgery Medical University of Innsbruck Innsbruck Austria
| | - Dietmar Fries
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Josef Fritz
- Department of Medical Statistics Informatics and Health Economics Medical University of Innsbruck Innsbruck Austria
| | - Werner Streif
- Department of Paediatrics Medical University of Innsbruck Innsbruck Austria
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25
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Factors associated with the need for airway intervention immediately after extubation from general anesthesia. J Clin Anesth 2021; 73:110365. [PMID: 34087662 DOI: 10.1016/j.jclinane.2021.110365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/17/2021] [Accepted: 05/23/2021] [Indexed: 11/22/2022]
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26
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Andrews JS, Machovec KA. Home is Where the Heart Is: Interstage Home Monitoring in Infants With Single-Ventricle Heart Disease. J Cardiothorac Vasc Anesth 2021; 35:2835-2837. [PMID: 34172368 DOI: 10.1053/j.jvca.2021.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 11/11/2022]
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27
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The Association Between Race and Adverse Postoperative Outcomes in Children With Congenital Heart Disease Undergoing Noncardiac Surgery. Anesth Analg 2021; 134:357-368. [PMID: 33999011 DOI: 10.1213/ane.0000000000005571] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The association between race and perioperative outcomes has been evaluated in adult cardiac surgical and in healthy pediatric patients but has not been evaluated in children with congenital heart disease (CHD) presenting for noncardiac procedures. This study compares the incidence of the primary outcome of 30-day mortality and adverse postoperative outcomes following noncardiac surgery between Black and White children with CHD, stratified by severity. METHODS This is a retrospective study. Comparison of outcomes between Black and White children was performed using the 2012-2018 American College of Surgeons National Surgical Quality Improvement Program Pediatric database and after stratification for severity of CHD and propensity score matching. RESULTS A total of 55,859 patients were included, and divided into 28,601 minor, 23,839 major, and 3419 severe CHD. Black and White children in each category were matched and compared. Following matching in the overall CHD cohort, there were significantly higher rates of the following adverse postoperative outcomes among Black patients as compared to White patients: 30-day mortality (1.84% vs 1.49%; odds ratio [OR], 1.25; 95% confidence interval [CI], 1.05-1.48; P = .014), composite secondary outcomes (19.90% vs 17.88%; OR, 1.14; 95% CI, 1.08-1.21; P < .001), cardiac arrest (1.42% vs 0.98%; OR, 1.46; 95% CI, 1.19-1.79; P < .001), 30-day reoperation (7.59% vs 6.67%; OR, 1.15; 95% CI, 1.05-1.25; P = .002), and reintubation (3.9% vs 2.95%; OR, 1.34; 95% CI, 1.19-1.52; P < .001). No significant statistical interaction between race and CHD severity was found. Following matching and within the minor CHD cohort, Black children had significantly higher rates of composite secondary outcome (17.44% vs 15.60%; OR, 1.15; 95% CI, 1.05-1.25; P = .002), cardiac arrest (1.02% vs 0.53%; OR, 1.94; 95% CI, 1.37-2.76; P < .001), 30-day reoperation (7.19% vs 5.77%; OR, 1.26; 95% CI, 1.11-1.43; P < .001), and thromboembolic complications (0.49% vs 0.23%; OR, 2.17; 95% CI, 1.29-3.63; P = .003) compared to White children. In the major CHD cohort, Black children had significantly higher rates of 30-day mortality (2.75% vs 2.05%; OR, 1.35; 95% CI, 1.08-1.69; P = .008) and reintubation (4.82% vs 3.72%; OR, 1.32; 95% CI, 1.11-1.56; P = .002). There were no statistically significant differences in outcomes in the severe CHD category for 30-day mortality (3.36% vs 3.3%; OR, 1.02; 95% CI, 0.60-1.73; P = .946), composite secondary outcome (22.65% vs 21.36%; OR, 1.08; 95% CI, 0.86-1.36; P = .517) nor the components of the composite secondary outcomes. CONCLUSIONS Race is associated with postoperative mortality and complications in children with minor and major CHD undergoing noncardiac surgery. No significant association was observed between race and postoperative outcomes in patients with severe CHD. This is consistent with previous findings wherein in patients with severe CHD, residual lesion burden and functional status is the leading predictor of outcomes following noncardiac surgery. Nevertheless, there is no evidence that the relationship between race and outcomes differs across the CHD severity categories. Future studies to understand the mechanisms leading to the racial difference, including institutional, clinical, and individual factors are needed.
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Erdoes G, Schindler E, Koster A, Schulte-Uentrop L, von Dossow V, Nasr VG. When Highly Specialized Anesthesia Care is Needed: Comments on the 2020 ESC Guidelines for Management of Adult Congenital Heart Disease. J Cardiothorac Vasc Anesth 2021; 35:2838-2840. [PMID: 34144873 DOI: 10.1053/j.jvca.2021.04.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Gabor Erdoes
- Department of Anaesthesiology and Pain Medicine, Inselspital Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ehrenfried Schindler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Andreas Koster
- Institute of Anesthesiology and Pain Therapy, Heart, and Diabetes Center NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Leonie Schulte-Uentrop
- Zentrum für Anästhesiologie und Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Vera von Dossow
- Institute of Anesthesiology and Pain Therapy, Heart, and Diabetes Center NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Mechanical thrombectomy in a pediatric patient with sedation aided by contralateral intra-arterial propofol injection: feasibility in an extreme condition. Childs Nerv Syst 2021; 37:1785-1789. [PMID: 32856130 DOI: 10.1007/s00381-020-04872-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/23/2020] [Indexed: 12/26/2022]
Abstract
Pediatric patients undergoing mechanical thrombectomy may be challenging for the anesthesiologists as regards the best anesthetic choice, especially if concomitant to severe comorbidities such as heart failure. A 16-year-old patient affected by arrhythmogenic right ventricle dysplasia/cardiomyopathy underwent mechanical thrombectomy. He was not eligible for deep sedation or general anesthesia since he has been suffering from severe heart failure. The patient stillness was obtained by intra-arterial injection of propofol from the contralateral internal carotid artery. The procedure has been well tolerated, without cardiorespiratory impairment. The case stresses the growing importance to tailor a proper anesthesiologic plan during mechanical thrombectomy, especially in extreme conditions.
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Prevention of atelectasis by continuous positive airway pressure in anaesthetised children: A randomised controlled study. Eur J Anaesthesiol 2021; 38:41-48. [PMID: 33009190 DOI: 10.1097/eja.0000000000001351] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) prevents peri-operative atelectasis in adults, but its effect in children has not been quantified. OBJECTIVE The aim of this study was to evaluate the role of CPAP in preventing postinduction and postoperative atelectasis in children under general anaesthesia. DESIGN A randomised controlled study. SETTING Single-institution study, community hospital, Mar del Plata. Argentina. PATIENTS We studied 42 children, aged 6 months to 7 years, American Society of Anesthesiologists physical status class I, under standardised general anaesthesia. INTERVENTIONS Patients were randomised into two groups: Control group (n = 21): induction and emergence of anaesthesia without CPAP; and CPAP group (n = 21): 5 cmH2O of CPAP during induction and emergence of anaesthesia. Lung ultrasound (LUS) imaging was performed before and 5 min after anaesthesia induction. Children without atelectasis were ventilated in the same manner as the Control group with standard ventilatory settings including 5 cmH2O of PEEP. Children with atelectasis received a recruitment manoeuvre followed by standard ventilation with 8 cmH2O of PEEP. Then, at the end of surgery, LUS images were repeated before tracheal extubation and 60 min after awakening. MAIN OUTCOME MEASURES Lung aeration score and atelectasis assessed by LUS. RESULTS Before anaesthesia, all children were free of atelectasis. After induction, 95% in the Control group developed atelectasis compared with 52% of patients in the CPAP group (P < 0.0001). LUS aeration scores were higher (impaired aeration) in the Control group than the CPAP group (8.8 ± 3.8 vs. 3.5 ± 3.3 points; P < 0.0001). At the end of surgery, before tracheal extubation, atelectasis was observed in 100% of children in the Control and 29% of the CPAP group (P < 0.0001) with a corresponding aeration score of 9.6 ± 3.2 and 1.8 ± 2.3, respectively (P < 0.0001). After surgery, 30% of children in the Control group and 10% in the CPAP group presented with residual atelectasis (P < 0.0001) also corresponding to a higher aeration score in the Control group (2.5 ± 3.1) when compared with the CPAP group (0.5 ± 1.5; P < 0.01). CONCLUSION The use of 5 cmH2O of CPAP in healthy children of the studied age span during induction and emergence of anaesthesia effectively prevents atelectasis, with benefits maintained during the first postoperative hour. TRIAL REGISTRY Clinicaltrials.gov NCT03461770.
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31
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Enteral access and fundoplication in children with congenital heart disease. Semin Pediatr Surg 2021; 30:151040. [PMID: 33992312 DOI: 10.1016/j.sempedsurg.2021.151040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Congenital heart disease (CHD) is the most frequently occurring congenital disorder and affects approximately 1% of live births.1,2 Advancements in supportive technology and surgical techniques have allowed many of these children to live into adulthood with reductions in morbidity and mortality.3,4 During infancy, many children with CHD are plagued with co-existing structural anomalies and/or feeding disorders that make adequate oral intake impossible.5 Pediatric surgeons are frequently consulted for enteral access and/or fundoplication to ensure proper growth and development while preventing potential hemodynamic instability caused by significant reflux events. The successful execution of a non-cardiac surgery in a child with significant cardiac risk factors requires the coordination and expertise of multiple providers with a deep understanding of pediatric CHD physiology to ensure a safe outcome. We review critical pre-operative workup, technical operative aspects, and anesthesia considerations in this unique patient population.
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Song IK, Shin WJ. Who are at high risk of mortality and morbidity among children with congenital heart disease undergoing noncardiac surgery? Anesth Pain Med (Seoul) 2021; 16:1-7. [PMID: 33472290 PMCID: PMC7861893 DOI: 10.17085/apm.20090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/07/2020] [Indexed: 11/26/2022] Open
Abstract
With advances in the development of surgical and medical treatments for congenital heart disease (CHD), the population of children and adults with CHD is growing. This population requires multiple surgical and diagnostic imaging procedures. Therefore, general anesthesia is inevitable. In many studies, it has been reported that children with CHD have increased anesthesia risks when undergoing noncardiac surgeries compared to children without CHD. The highest risk group included patients with functional single ventricle, suprasystemic pulmonary hypertension, left ventricular outflow obstruction, and cardiomyopathy. In this review, we provide an overview of perioperative risks in children with CHD undergoing noncardiac surgeries and anesthetic considerations in patients classified as having the highest risk.
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Affiliation(s)
- In-Kyung Song
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won-Jung Shin
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Nasr VG, Staffa SJ, Faraoni D, DiNardo JA. Trends in mortality rate in patients with congenital heart disease undergoing noncardiac surgical procedures at children's hospitals. Sci Rep 2021; 11:1543. [PMID: 33452368 PMCID: PMC7810725 DOI: 10.1038/s41598-021-81161-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/01/2021] [Indexed: 11/09/2022] Open
Abstract
Advances made in pediatric cardiology, cardiac surgery and critical care have significantly improved the survival rate of patients with congenital heart disease (CHD) leading to an increase in children with CHD presenting for noncardiac surgical procedures. This study aims (1) to describe the trend and perioperative mortality rates in patients with CHD undergoing noncardiac surgical procedures at children's hospitals over the past 5 years and (2) to describe the patient characteristics and the most common type of surgical procedures. The Pediatric Health Information System (PHIS) is an administrative database that contains inpatient, observation, and outpatient surgical data from 52 freestanding children's hospitals. Thirty-nine of the 52 hospitals submitted data on all types of patient encounters for the duration of the study from 2015 to 2019. The total numbers of non-cardiac surgical encounters among patients with history of a CHD diagnosis significantly increased each year from 38,272 in 2015 to 45,993 in 2019 (P < 0.001). Despite the increase in case numbers, there has been a significant decline in mortality rates to the most recent incidence of 1.06% in 2019. Careful patient selection and medical optimization of patients aligned with specific expertise at dedicated children's hospitals may lead to improvement in mortality rate. Future studies comparing the outcomes of patients with cardiac disease based on hospital type and volume as well as type of providers may help determine the future of care including potential need for regionalization of noncardiac care for this vulnerable patient population.
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Affiliation(s)
- Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - David Faraoni
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
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Schure A. Anaesthesia risks for non-cardiac procedures in cardiac patients. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.6.s2.2515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The number of patients with complex congenital heart disease (CHD) presenting for non-cardiac procedures is steadily increasing and more and more anaesthesiologists will be asked to participate in their care. This can be a very challenging task and will require adequate planning and preparation, but also some basic scientific inquiries.
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Shah AA, Matisoff A, Deutsch N, Sandler A, Kane T, Petrosyan M. A Team-Based Approach for Children With Congenital Cardiac Disease Undergoing Antireflux Procedure With Gastrostomy. Am Surg 2020; 87:427-431. [PMID: 33026240 DOI: 10.1177/0003134820951472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Laparoscopic Nissen fundoplication with gastrostomy tube (LPNF-GT) placement is often indicated in children with congenital cardiac diseases (CCDs) for nutritional optimization. This study aims to evaluate institutional outcomes of LPNF-GT, with a team-based approach in operative management. METHODS Five years of an institutional database at a tertiary care children's hospital was queried for LPNF-GT in children with CCDs. Descriptive analyses were performed. A national comparison was performed utilizing the 2012-2013 Pediatrics NSQIP database, using propensity score matching. Outcome measures of interest were operative-time, unplanned readmission, and 30-day mortality. RESULTS A team-based approach was utilized in 51 cases. Median operative time was 68.5 (IQR: 48-89) minutes. All patients tolerated tube feeds postoperatively. All patients survived 30 days post surgery. When compared to 136 similarly matched children nationally, the risk-adjusted operative time with a team-based approach was 47.38 (12.43-82.33) minutes shorter (P < .05). There were no statistically significant differences in the likelihood of being in the hospital past 30 days, unplanned readmissions, and mortality (P > .05). CONCLUSION LPNF-GT can be safely performed in children with CCDs. A team-based approach demonstrates improved operative time and achieved similar outcomes when compared nationally.
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Affiliation(s)
- Adil A Shah
- 233494 Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA.,Department of Surgery, Howard University Hospital and College of Medicine, Washington, DC, USA
| | - Andrew Matisoff
- Department of Anesthesiology, Children's National Medical Center, Washington, DC, USA
| | - Nina Deutsch
- Department of Anesthesiology, Children's National Medical Center, Washington, DC, USA
| | - Anthony Sandler
- 233494 Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA
| | - Timothy Kane
- 233494 Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA
| | - Mikael Petrosyan
- 233494 Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA
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36
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Faraoni D, Zou X, DiNardo JA, Nasr VG. Integration of the Intrinsic Surgical Risk With Patient Comorbidities and Severity of Congenital Cardiac Disease Does Not Improve Risk Stratification in Children Undergoing Noncardiac Surgery. Anesth Analg 2020; 131:1083-1089. [PMID: 32925328 DOI: 10.1213/ane.0000000000004906] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The objective of this study is to estimate the surgical risk of noncardiac procedures on the incidence of 30-day mortality in children with congenital heart disease. METHODS Children with congenital heart disease undergoing noncardiac surgery from 2012 to 2016 and included in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric database were included in the derivation cohort, while the 2017 database was used as a validation cohort. Intrinsic surgical risk quartiles were built utilizing 30-day mortality rates for each Current Procedural Terminology code and relative value units to create 2 groups defined as low surgical risk (quartiles 1-3) and high surgical risk procedures (quartile 4). We used multivariable logistic regression to determine the predictors for 30-day mortality including patient comorbidities and intrinsic surgical risk. A partially external validation of the model was performed using the 2017 version of the database. RESULTS We included 37,658 children with congenital heart disease undergoing noncardiac surgery with an incidence of overall 30-day mortality of 1.7% in the derivation cohort and 1.5% in the validation cohort (n = 13,129). Intrinsic surgical risk of procedures represented by Current Procedural Terminology procedural codes and relative value units risk quartiles was significantly associated with 30-day mortality (unadjusted P < .001). Predicted probability of 30-day mortality ranges from 0.2% (95% confidence interval [CI], 0.2-0.2) with no comorbidities to 39.6% (95% CI, 23.2-56.0) when all comorbidities were present among high surgical risk procedures and from 0.3% (95% CI, 0.3-0.3) to 54.8% (95% CI, 39.4-70.1) among low surgical risk procedures. An excellent discrimination was reported for the multivariable model with area under the curve (AUC) of 0.86 (95% CI, 0.85-0.88). High surgical risk was not associated with increased odds of 30-day mortality after adjustment for all other predictors (adjusted odds ratio [OR]: 0.75, 95% CI, 0.62-0.91). We also estimated the discriminative ability of a model that does not include the surgical risk (0.86 [95% CI, 0.84-0.88], with P value for the direct comparison of the AUC of the 2 models = 0.831). The multivariable model obtained from an external validation cohort reported an optimism corrected AUC of 0.88 (95% CI, 0.85-0.91). CONCLUSIONS Our study demonstrates that integration of intrinsic surgical risk to comorbidities and severity of cardiac disease does not improve prediction of 30-day mortality in children undergoing noncardiac surgery. In children with congenital heart disease, patient comorbidities, and severity of the cardiac lesion are the predominant predictors of 30-day mortality.
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Affiliation(s)
- David Faraoni
- From the Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Xue Zou
- Département d' Anesthésie, Hôpital Sainte Justine, Université de Montréal, Montréal, Canada
| | - James A DiNardo
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Wang T, Chen L, Yang T, Huang P, Wang L, Zhao L, Zhang S, Ye Z, Chen L, Zheng Z, Qin J. Congenital Heart Disease and Risk of Cardiovascular Disease: A Meta-Analysis of Cohort Studies. J Am Heart Assoc 2020; 8:e012030. [PMID: 31070503 PMCID: PMC6585327 DOI: 10.1161/jaha.119.012030] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Despite remarkable success in the surgical and medical management of congenital heart disease ( CHD ), some survivors still experience cardiovascular complications over the long term. The goal of this study was to evaluate the association between CHD and risk of cardiovascular disease ( CVD ) by conducting a meta-analysis of cohort studies. Methods and Results A systematic literature search of several databases was conducted through April 2018 to identify studies reporting the risk of CVD , stroke, heart failure, and coronary artery heart disease in CHD survivors. The quality of individual studies was assessed using the Newcastle-Ottawa scale. The overall risk estimates were pooled using fixed-effects meta-analysis. Subgroup analyses were performed to explore possible sources of heterogeneity. Nine cohort studies comprising 684 200 participants were included. The overall combined relative risks for people with CHD compared with the controls were 3.12 (95% CI, 3.01-3.24) for CVD , 2.46 (95% CI, 2.30-2.63) for stroke, 5.89 (95% CI, 5.58-6.21) for heart failure, and 1.50 (95% CI, 1.40-1.61) for coronary artery heart disease. Significant heterogeneity was detected across studies regarding these risk estimates. Heterogeneity in the risk estimate of CVD was explained by geographic region, type of study design, sample source, age composition, and controlled confounders. Conclusions This meta-analysis of cohort studies of CHD found an association of increased risk of CVD in later life, although we cannot determine whether this association is confounded by a risk factor profile of CVD among CHD survivors or whether CHD is an independent risk factor.
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Affiliation(s)
- Tingting Wang
- 1 Department of Epidemiology and Health Statistics Xiangya School of Public Health Central South University Changsha China
| | - Lizhang Chen
- 1 Department of Epidemiology and Health Statistics Xiangya School of Public Health Central South University Changsha China
| | - Tubao Yang
- 1 Department of Epidemiology and Health Statistics Xiangya School of Public Health Central South University Changsha China
| | - Peng Huang
- 2 Department of Cardio-Thoracic Surgery Hunan Children's Hospital Changsha China
| | - Lesan Wang
- 1 Department of Epidemiology and Health Statistics Xiangya School of Public Health Central South University Changsha China
| | - Lijuan Zhao
- 1 Department of Epidemiology and Health Statistics Xiangya School of Public Health Central South University Changsha China
| | - Senmao Zhang
- 1 Department of Epidemiology and Health Statistics Xiangya School of Public Health Central South University Changsha China
| | - Ziwei Ye
- 1 Department of Epidemiology and Health Statistics Xiangya School of Public Health Central South University Changsha China
| | - Letao Chen
- 1 Department of Epidemiology and Health Statistics Xiangya School of Public Health Central South University Changsha China
| | - Zan Zheng
- 1 Department of Epidemiology and Health Statistics Xiangya School of Public Health Central South University Changsha China
| | - Jiabi Qin
- 1 Department of Epidemiology and Health Statistics Xiangya School of Public Health Central South University Changsha China
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Adler AC, Nathan AT. Perioperative Considerations for the Fontan Patient Requiring Noncardiac Surgery. Anesthesiol Clin 2020; 38:531-543. [PMID: 32792182 DOI: 10.1016/j.anclin.2020.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Children and adults with congenital heart disease undergoing noncardiac surgery are at higher risk of perioperative adverse events. Patients have significant comorbidities and syndromic associations that increase perioperative risk further. The complexity of congenital heart disease requires a thorough understanding of lesion-specific pathophysiology in order to provide safe care. Comprehensive multidisciplinary planning and the use of skilled and experienced teams achieve the best outcomes. The anesthesiologist is a perioperative physician charged with providing safe anesthesia care, instituting appropriate hemodynamic monitoring, and determining appropriate postoperative disposition on an individual basis.
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Affiliation(s)
- Adam C Adler
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin Street, Houston, TX 77030, USA.
| | - Aruna T Nathan
- Department of Anesthesia, Stanford University Medical Center, 300 Pasteur Drive, Room H3580, MC 5640, Stanford, CA 94304, USA
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Azadgoli B, Munabi NCO, Fahradyan A, Auslander A, McCullough M, Aflatooni N, Davidson Ward SL, Kumar SR, Sanchez-Lara PA, Swanson J, Magee WP. Congenital Heart Disease in Patients With Cleft Lip/Palate and Its Impact on Cleft Management. Cleft Palate Craniofac J 2020; 57:957-966. [DOI: 10.1177/1055665620924915] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To evaluate characteristics of congenital heart disease (CHD) in patients with cleft lip and/or palate (CL/P) and assess potential associations with cleft outcomes. Design: Retrospective review of all patients with CL/P who underwent primary cleft treatment from 2009 to 2015. Setting: Children’s Hospital Los Angeles, a tertiary hospital. Patients: Exclusion criteria included microform cleft lip diagnosis, international patients, and patients presenting for secondary repair or revision after primary repair at another institution. Main Outcomes Measured: Patient demographics, prenatal and birth characteristics, CL/P characteristics, syndromic status, postoperative complications, and other outcomes were analyzed relative to CHD diagnoses and management. Patients with CL/P with (+CHD) were compared to those without (−CHD) CHD using χ2 tests and analysis of variance. Results: Among 575 patients with CL/P, 83 (14.4%) had CHD. Congenital heart disease rates were significantly higher in patients with cleft palate (CP) compared to other cleft types (χ2, P = .009). Eighty-one (97.6%) out of 83 +CHD patients were diagnosed prior to initial CL/P surgical assessment. Twenty-three (27.7%) +CHD patients required surgical repair of 10 cardiac anomalies prior to cleft care. Congenital heart disease was associated with delayed CP repair and increased rates of fistula in isolated patients with CP. Conclusions: Congenital heart disease is known to be more prevalent in patients with CL/P. These data suggest the condition is particularly increased in patients with CP. Severe forms of CHD are diagnosed and treated prior to cleft care however postoperative fistula may be more common in patients with CHD. Therefore, careful attention is required for patient optimization and palatal flap dissection in patients with coexisting CHD and CL/P.
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Affiliation(s)
- Beina Azadgoli
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Naikhoba C. O. Munabi
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Artur Fahradyan
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, CA, USA
| | - Allyn Auslander
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, CA, USA
| | - Meghan McCullough
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | | | | | - S. Ram Kumar
- Heart Institute, Children’s Hospital Los Angeles, CA, USA
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | | | - Jordan Swanson
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, CA, USA
- Division of Research and Outcomes, Operation Smile International, Virginia Beach, VA, USA
| | - William P. Magee
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, CA, USA
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Chin JW, Macrae JL, Sury MR. Paediatric pre-operative anaesthetic clinic: A survey of consultant-led caseload and outcomes. J Paediatr Child Health 2020; 56:432-438. [PMID: 31614066 DOI: 10.1111/jpc.14655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/13/2019] [Accepted: 09/16/2019] [Indexed: 11/28/2022]
Abstract
AIM The role of pre-operative anaesthetic clinics (POAC) in adult practice is well-established and is developing in paediatric hospitals in the UK. METHODS We carried out a retrospective survey of all patients assessed in our POAC by a consultant, determining the pre-operative problems and the perioperative anaesthetic interventions and outcomes. RESULTS In 2016, 537 patients were seen by a consultant: the median age was 5.5 years (interquartile range 2.2-10.2) and median weight was 18.7 kg (interquartile range 12-28.7). 77% were ASA3 and 4% were ASA4. Seventy-five percent of patients referred for consultant assessment had a problem with at least one of the following four major body systems: cardiac (37%), respiratory (26%), airway (18%) and neurodevelopment (14%), Fifteen percent of these patients had two of these systems affected, and 3% had three or more. The rate of cancellation due to significant risk was 2.6% (n = 14): nine had significant cardiac risk and five had respiratory reasons. The rate of serious perioperative problems was 2.8% (n = 15): six were cardiac, six were respiratory, two neurological and one coagulation. Cardiac and airway problems occurred during anaesthesia, whereas problems relating to respiratory and neurological disease were post-operative. Of the 15 patients with three or more body system problems, 5 were cancelled or had a perioperative complication causing deterioration, 5 had a major complication but recovered fully and 5 proceeded to general anaesthesia (GA) without serious event. There were no deaths during GA or within 30 days. CONCLUSION In the POAC, consultants identified a wide range of GA-related potential problems enabling patients to be investigated, informed and prepared (or cancelled because of excess risk), and for appropriate resources to be allocated to achieve efficient and safe perioperative care.
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Affiliation(s)
- Joel We Chin
- Department of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Jenny L Macrae
- Department of Anaesthesia, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael Rj Sury
- Department of Anaesthesia, Great Ormond Street Hospital for Sick Children, London, United Kingdom
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Przybylski R, Hedequist DJ, Nasr VG, McCann ME, Brustowicz RM, Emans JB, Marshall AC, Brown DW. Adverse Perioperative Events in Children with Complex Congenital Heart Disease Undergoing Operative Scoliosis Repair in the Contemporary Era. Pediatr Cardiol 2019; 40:1468-1475. [PMID: 31350568 DOI: 10.1007/s00246-019-02169-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 07/19/2019] [Indexed: 10/26/2022]
Abstract
Scoliosis is common in children with congenital heart disease (CHD) and may have deleterious effects on quality of life and hemodynamics. Relatively little is known about the outcomes of spinal fusion for scoliosis repair in children with complex CHD. We reviewed all cases of children with CHD undergoing first time spinal fusion excluding those with minor CHD between 1995 and 2015. Seventy-eight patients were identified and included in the study. 97.4% of patients included had undergone prior cardiac surgery and sixteen patients had single ventricle circulations. 17.9% of patients experienced a significant perioperative event defined as an aggregate of the presence of any of the following: need for early unanticipated reoperation, neurologic deficit, postoperative bleeding requiring intervention, end organ dysfunction, or death. There were no deaths in our cohort. 38.5% of patients experienced any adverse event, the majority of which were related to perioperative fluid shifts. Larger preoperative Cobb angle and longer length of spinal fusion were associated with increased risk of significant perioperative event while larger preoperative Cobb angle and longer length of spinal fusion, older age at time of surgery, single ventricle circulation, cyanosis and patients taking cardiac medications at the time of surgery were more likely to experience any adverse event. Operative repair of scoliosis in children with complex CHD has been performed without mortality over a 20-year period in a single institution, albeit with a higher rate of perioperative complication than is seen in the general pediatric population. Patients with large preoperative Cobb angles and cyanotic single ventricle circulations appear to be at the highest risk for perioperative complications.
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Affiliation(s)
- Robert Przybylski
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
| | - Daniel J Hedequist
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Viviane G Nasr
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Mary Ellen McCann
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Robert M Brustowicz
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - John B Emans
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Audrey C Marshall
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - David W Brown
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
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Kedir H, Miller R, Syed F, Hakim M, Walia H, Tumin D, McKee C, Tobias JD. Association between anemia and postoperative complications in infants undergoing pyloromyotomy. J Pediatr Surg 2019; 54:2075-2079. [PMID: 30853249 DOI: 10.1016/j.jpedsurg.2019.01.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 01/06/2019] [Accepted: 01/19/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although preoperative anemia has been suggested to predict postsurgical morbidity and mortality among infants <1 year of age, the data were drawn from heterogeneous patient cohorts including severely ill infants undergoing complex, high-risk procedures. We aimed to determine whether untreated preoperative anemia was associated with increased risk of postoperative complications in infants <1 year of age who underwent pyloromyotomy, a common and relatively simple surgery. METHODS Infants <1 year of age undergoing pyloromyotomy were identified from the American College of Surgeons (ACS) National Surgical Quality Improvement Program-Pediatric database. Preoperative anemia was defined as a hematocrit ≤40% for infants 0-30 days of age and ≤30% for infants more than 30 days of age. Patients who received pre- or postoperative blood transfusions were excluded. RESULTS We identified 2948 patients who met our inclusion criteria, of whom 843 were anemic (29%). The overall rate of complications in this cohort was 6%. The most common postoperative complications were readmission (97 cases), surgical site infection (43), reoperation (39), prolonged hospital stay (24), urinary tract infection (3), 30-day mortality (3) and cardiac arrest (2). We found no differences in the incidence of complications in anemic versus nonanemic patients on bivariate analysis or multivariable logistic regression (adjusted odds ratio = 1.2; 95% confidence interval: 0.8-1.7; P = 0.319). CONCLUSIONS In relatively healthy infants undergoing pyloromyotomy, untreated preoperative anemia was not associated with postoperative compilations and should not be considered a significant risk factor. Level of evidence III.
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Affiliation(s)
- Habib Kedir
- The Ohio State University College of Medicine, The Ohio State University College of Medicine, Columbus, OH; Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH.
| | - Rebecca Miller
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Faizaan Syed
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Mohammed Hakim
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Hina Walia
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Dmitry Tumin
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH; Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Christopher McKee
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH; Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Joseph D Tobias
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH; Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH; Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH
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43
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Nasr VG, Gottlieb EA, Adler AC, Evans MA, Sawardekar A, DiNardo JA, Mossad EB, Mittnacht AJ. Selected 2018 Highlights in Congenital Cardiac Anesthesia. J Cardiothorac Vasc Anesth 2019; 33:2833-2842. [DOI: 10.1053/j.jvca.2019.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 03/05/2019] [Indexed: 01/19/2023]
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Brown ML, DiNardo JA, Nasr VG. Anesthesia in Pediatric Patients With Congenital Heart Disease Undergoing Noncardiac Surgery: Defining the Risk. J Cardiothorac Vasc Anesth 2019; 34:470-478. [PMID: 31345716 DOI: 10.1053/j.jvca.2019.06.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 06/08/2019] [Accepted: 06/10/2019] [Indexed: 01/13/2023]
Abstract
The incidence of moderate to severe congenital heart disease (CHD) in the United States is estimated to be 6 per 1,000 live-born, full-term infants. Recent advances in pediatric cardiology, surgery, and critical care have improved significantly the survival rates of patients with CHD leading to an increase in prevalence in both children and adults. Children with CHD significant enough to require cardiac surgery frequently also undergo noncardiac surgical procedures. With this increased demand for procedures that require anesthesia, all anesthesiologists, and more specifically, pediatric anesthesiologists will encounter patients with repaired or unrepaired CHD and other cardiac diseases in their practice. They often are faced with the question, "Is this patient too high risk for anesthesia?" The objective of this literature review is to provide a greater understanding of patients at high risk and to quantify the risk for patients, their families, and clinicians. In addition, specific high-risk lesions (single ventricle, Williams-Beuren syndrome, pulmonary hypertension, cardiomyopathies, and ventricular assist devices) are described.
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Affiliation(s)
- Morgan L Brown
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA.
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Grogan KL, Goldsmith MP, Masino AJ, Nelson O, Tsui FC, Simpao AF. A Narrative Review of Analytics in Pediatric Cardiac Anesthesia and Critical Care Medicine. J Cardiothorac Vasc Anesth 2019; 34:479-482. [PMID: 31327699 DOI: 10.1053/j.jvca.2019.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 05/20/2019] [Accepted: 06/07/2019] [Indexed: 01/05/2023]
Abstract
Congenital heart disease (CHD) is one of the most common birth anomalies, and the care of children with CHD has improved over the past 4 decades. However, children with CHD who undergo general anesthesia remain at increased risk for morbidity and mortality. The proliferation of electronic health record systems and sophisticated patient monitors affords the opportunity to capture and analyze large amounts of CHD patient data, and the application of novel, effective analytics methods to these data can enable clinicians to enhance their care of pediatric CHD patients. This narrative review covers recent efforts to leverage analytics in pediatric cardiac anesthesia and critical care to improve the care of children with CHD.
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Affiliation(s)
- Kelly L Grogan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael P Goldsmith
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Aaron J Masino
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Olivia Nelson
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Fu-Chiang Tsui
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Allan F Simpao
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Pediatric Risk Stratification Is Improved by Integrating Both Patient Comorbidities and Intrinsic Surgical Risk. Anesthesiology 2019; 130:971-980. [DOI: 10.1097/aln.0000000000002659] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Recently developed risk stratification models for perioperative mortality incorporate patient comorbidities as predictors but fail to consider the intrinsic risk of surgical procedures. In this study, the authors used the American College of Surgeons National Surgical Quality Improvement Program Pediatric database to demonstrate the relationship between the intrinsic surgical risk and 30-day mortality and develop and validate an accessible risk stratification model that includes the surgical procedures in addition to the patient comorbidities and physical status.
Methods
A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program Pediatric database was performed. The incidence of 30-day mortality was the primary outcome. Surgical Current Procedural Terminology codes with at least 25 occurrences were included. Multivariable logistic regression model was used to determine the predictors for mortality including patient comorbidities and intrinsic surgical risk. An internal validation using bootstrap resampling, and an external validation of the model were performed.
Results
The authors analyzed 367,065 surgical cases encompassing 659 unique Current Procedural Terminology codes with an incidence of overall 30-day mortality of 0.34%. Intrinsic risk of surgical procedures represented by Current Procedural Terminology risk quartiles instead of broad categorization was significantly associated with 30-day mortality (P < 0.001). Predicted risk of 30-day mortality ranges from 0% with no comorbidities to 4.7% when all comorbidities are present among low-risk surgical procedures and from 0.07 to 46.7% among high-risk surgical procedures. Using an external validation cohort of 110,474 observations, the multivariable predictive risk model displayed good calibration and excellent discrimination with area under curve (c-index) equals 0.95 (95% CI, 0.94 to 0.96; P < 0.001).
Conclusions
Understanding and accurately estimating perioperative risk by accounting for the intrinsic risk of surgical procedures and patient comorbidities will lead to a more comprehensive discussion between patients, families, and providers and could potentially be used to conduct cost analysis and allocate resources.
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Taylor D, Habre W. Risk associated with anesthesia for noncardiac surgery in children with congenital heart disease. Paediatr Anaesth 2019; 29:426-434. [PMID: 30710405 DOI: 10.1111/pan.13595] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 01/09/2019] [Accepted: 01/22/2019] [Indexed: 12/31/2022]
Abstract
Database analysis has indicated that perioperative cardiac arrest occurs with increased frequency in children with congenital heart disease. Several case series and large datasets from ACS NSQIP have identified subgroups at the highest risk. Consistently, patients with single ventricle physiology (especially prior to cavopulmonary anastomosis), severe/supra-systemic pulmonary hypertension, complex lesions, and cardiomyopathy with significantly reduced ventricular function have been shown to be at increased risk for adverse events. Based on these results, algorithms for assessing risk have been proposed. How hospitals and health care systems apply these guidelines to provide safe care for these challenging patient groups requires the application of modern quality improvement techniques. Each institution should develop a system which reflects local expertise and resources.
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Affiliation(s)
- Dan Taylor
- Department of Paediatric Anaesthesia, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trusts, London, UK
| | - Walid Habre
- Paediatric Anaesthesia Unit, Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospitals of Geneva, Geneva, Switzerland
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Abstract
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.
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Affiliation(s)
| | - J Craig Egan
- Department of Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
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49
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Estimating Surgical Risk in Younger and Older Children With Congenital Heart Disease. J Surg Res 2018; 232:298-307. [DOI: 10.1016/j.jss.2018.06.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 06/05/2018] [Accepted: 06/19/2018] [Indexed: 12/18/2022]
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Outcomes of laparoscopic and open surgery in children with and without congenital heart disease. J Pediatr Surg 2018; 53:1980-1988. [PMID: 29157923 PMCID: PMC5957762 DOI: 10.1016/j.jpedsurg.2017.10.052] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/17/2017] [Accepted: 10/20/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Children with congenital heart disease (CHD) often require noncardiac surgery. We compared outcomes following open and laparoscopic intraabdominal surgery among children with and without CHD. METHODS We performed a retrospective cohort study using the 2013-2015 National Surgical Quality Improvement Project-Pediatrics. We matched 45,012 children <18years old who underwent laparoscopic surgery to 45,012 children who underwent open surgery. We determined the associations between laparoscopic (versus open) surgery and 30-day mortality, in-hospital mortality, 30-day morbidity, and postoperative length-of-stay. RESULTS Among children with minor CHD, laparoscopic surgery was associated with lower 30-day mortality (Odds Ratio [OR] 0.34 [95% Confidence Interval 0.15-0.79]), inhospital mortality (OR 0.42 [0.22-0.81]) and 30-day morbidity (OR 0.61 [0.50-0.73]). As CHD severity increased, this benefit of laparoscopic surgery decreased for 30-day morbidity (ptrend=0.01) and in-hospital mortality (ptrend=0.05), but not for 30-day mortality (ptrend=0.27). Length-of-stay was shorter for laparoscopic approaches for children at cost of higher readmissions. On subgroup analysis, laparoscopy was associated with lower odds of postoperative blood transfusion in all children. CONCLUSIONS Intraabdominal laparoscopic surgery compared to open surgery is associated with decreased morbidity in patients with no CHD and lower morbidity and mortality in patients with minor CHD, but not in those with more severe CHD. LEVEL-OF-EVIDENCE Level III: Treatment Study.
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