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Dou D, Yuan S, Jia Y, Wang Y, Li Y, Wang H, Ding J, Wu X, Bie D, Liu Q, An R, Yan H, Yan F. The protocol of enhanced recovery after cardiac surgery in adult patients: A stepped wedge cluster randomized trial. Am Heart J 2024; 272:48-55. [PMID: 38437910 DOI: 10.1016/j.ahj.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 02/28/2024] [Accepted: 02/28/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND The enhanced recovery after cardiac surgery is a bundle of measurements from preoperative to postoperative phases to improve patients' recovery. METHODS This study is a multicenter, stepwise design, cluster randomized controlled trial. About 3,600 patients presenting during control and intervention periods are eligible if they are aged from 18 to 80 years old awaiting elective cardiac surgery with cardiopulmonary bypass (CPB). About 5 centers are randomly assigned to staggered start dates for one-way crossover from the control phase to the intervention phase. In the intervention periods, patients will receive ERAS strategy including preoperative, intraoperative, and postoperative approaches. During the control phase, patients receive usual care. The primary outcome consists of major adverse cardiac and cerebrovascular events (MACCEs), postoperative pulmonary complications (PPCs), and acute kidney injury (AKI). DISCUSSION This study aims to compare the application of ERAS management protocol and traditional management protocol in adult cardiac surgery under extracorporeal circulation.
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Affiliation(s)
- Dou Dou
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Su Yuan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Yuan Jia
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Yang Wang
- Department of Medical Research & Biometrics Centre, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Yinan Li
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Hongbai Wang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jie Ding
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Xie Wu
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Dongyun Bie
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Qiao Liu
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Ran An
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Haoqi Yan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Fuxia Yan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China.
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Andugala S, McIntosh A, Orchard J, Rahiman S, Miedecke A, Keyser J, Betts K, Marathe S, Alphonso N, Venugopal P. Successful Implementation of Enhanced Recovery After Surgery (ERAS) in Paediatric Cardiac Surgery in Australia. Heart Lung Circ 2024:S1443-9506(24)00063-5. [PMID: 38594127 DOI: 10.1016/j.hlc.2024.01.029] [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: 12/08/2023] [Revised: 01/20/2024] [Accepted: 01/22/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND & AIM Fast-track or enhanced recovery after surgery (ERAS) is a care pathway for surgical patients based on a multidisciplinary team approach aimed at optimising recovery without increasing risk with protocols based on scientific evidence, which is monitored continuously to ensure compliance and improvement. These protocols have been shown to reduce the duration of postoperative mechanical ventilation and intensive care unit (ICU) length of stay (LOS) following paediatric cardiac surgery. We present the first structured implementation of ERAS in paediatric cardiac surgery in Australia. METHODS All patients enrolled in the ERAS pathway between October 2019 and July 2023 were identified. Demographic and perioperative data were collected retrospectively from hospital records for patients operated before June 2021 and prospectively from June 2021. A control group (non-ERAS) was identified using propensity matching from patients who underwent similar procedures and were not enrolled in the ERAS pathway (prior to October 2019). Patients were matched for age, weight, and comprehensive Aristotle score. Outcomes of interest were duration of postoperative mechanical ventilation, ICU LOS, readmission to the ICU, hospital LOS, cardiac reintervention rate, postoperative complication rate, and number of 30-day readmissions. RESULTS Of 1,084 patients who underwent cardiac surgery during the study period (October 2019-July 2023), 121 patients (11.2%) followed the ERAS pathway. The median age at the time of surgery was 4.8 years (interquartile range [IQR] 2.8-8.8 years). The most common procedure was the closure of atrial septal defect (n=58, 47.9%). The median cardiopulmonary bypass and cross-clamp times were 40 min (IQR 28-53.5 minutes) and 24.5 min (IQR 13-34 minutes) respectively. The majority were extubated in the operating theatre (n=108, 89.3%). The median ICU and hospital LOS were 4.5 hrs (IQR 4.1-5.6 hours) and 4 days (IQR 4-5 days) respectively. None of the patients required readmission to the ICU within 24 hrs of discharge from the ICU. Three (3) patients (2.5%) required reintervention. When compared with the non-ERAS group, the duration of postoperative mechanical ventilation, ICU and hospital LOS were significantly lower in the ERAS group. There was no significant difference in the ICU readmission rate, reintervention rate, complication rate, and number of 30-day readmissions between both groups. CONCLUSIONS ERAS after paediatric cardiac surgery is feasible and safe in select patients with low preoperative risk. This pathway reduces the duration of postoperative mechanical ventilation, ICU and hospital LOS without increasing risks, enabling the optimisation of resources.
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Affiliation(s)
- Shalom Andugala
- Queensland Paediatric Cardiac Service, Queensland Children's Hospital, South Brisbane, Qld, Australia; Queensland Paediatric Cardiac Research, Centre for Children's Health Research, South Brisbane, Qld, Australia; School of Clinical Medicine, Children's Health Queensland Clinical Unit, University of Queensland, Brisbane, Qld, Australia
| | - Amy McIntosh
- Queensland Paediatric Cardiac Service, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Jennifer Orchard
- Queensland Paediatric Cardiac Service, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Sarfaraz Rahiman
- Department of Paediatric Intensive Care Medicine, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Anna Miedecke
- Department of Anaesthesia and Pain Management, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Janelle Keyser
- Department of Anaesthesia and Pain Management, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Kim Betts
- School of Population Health, Curtin University, Perth, WA, Australia
| | - Supreet Marathe
- Queensland Paediatric Cardiac Service, Queensland Children's Hospital, South Brisbane, Qld, Australia; Queensland Paediatric Cardiac Research, Centre for Children's Health Research, South Brisbane, Qld, Australia; School of Clinical Medicine, Children's Health Queensland Clinical Unit, University of Queensland, Brisbane, Qld, Australia
| | - Nelson Alphonso
- Queensland Paediatric Cardiac Service, Queensland Children's Hospital, South Brisbane, Qld, Australia; Queensland Paediatric Cardiac Research, Centre for Children's Health Research, South Brisbane, Qld, Australia; School of Clinical Medicine, Children's Health Queensland Clinical Unit, University of Queensland, Brisbane, Qld, Australia
| | - Prem Venugopal
- Queensland Paediatric Cardiac Service, Queensland Children's Hospital, South Brisbane, Qld, Australia; Queensland Paediatric Cardiac Research, Centre for Children's Health Research, South Brisbane, Qld, Australia; School of Clinical Medicine, Children's Health Queensland Clinical Unit, University of Queensland, Brisbane, Qld, Australia.
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Roy N, Parra MF, Brown ML, Sleeper LA, Kossowsky J, Baumer AM, Blitz SE, Booth JM, Higgins CE, Nasr VG, Del Nido PJ, Brusseau R. Erector spinae plane blocks for opioid-sparing multimodal pain management after pediatric cardiac surgery. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00211-3. [PMID: 38493959 DOI: 10.1016/j.jtcvs.2024.03.010] [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: 05/06/2023] [Revised: 02/25/2024] [Accepted: 03/08/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVE Peripheral regional anesthesia is proposed to enhance recovery. We sought to evaluate the efficacy of bilateral continuous erector spinae plane blocks (B-ESpB) for postoperative analgesia and the impact on recovery in children undergoing cardiac surgery. METHODS Patients aged 2 through 17 years undergoing cardiac surgery in the enhanced recovery after cardiac surgery program were prospectively enrolled to receive B-ESpB at the end of the procedure, with continuous infusions via catheters postoperatively. Participants wore an activity monitor until discharge. B-ESpB patients were retrospectively matched with control patients in the enhanced recovery after cardiac surgery program. Outcomes of the matched clusters were compared using exact conditional logistic regression and generalized linear modeling. RESULTS Forty patients receiving B-ESpB were matched to 78 controls. There were no major complications from the B-ESpB or infusions, and operating room time was longer by a median of 31 minutes. While blocks were infusing, patients with B-ESpB received fewer opioids in oral morphine equivalents than controls at 24 hours (0.60 ± 0.06 vs 0.78 ± 0.04 mg/kg; P = .02) and 48 hours (1.13 ± 0.08 vs 1.35 ± 0.06 mg/kg; P = .04), respectively. Both groups had low median pain scores per 12-hour period. There was no difference in early mobilization, length of stay, or complications. CONCLUSIONS B-ESpBs are safe in children undergoing cardiac surgery. When performed as part of a multimodal pain strategy in an enhanced recovery after cardiac surgery program, pediatric patients with B-ESpB experience good pain control and require fewer opioids in the first 48 hours.
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Affiliation(s)
- Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass.
| | - M Fernanda Parra
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Morgan L Brown
- Department of Anaesthesia, Harvard Medical School, Boston, Mass; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass
| | - Lynn A Sleeper
- Departrment of Pediatrics, Harvard Medical School, Boston, Mass; Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Joe Kossowsky
- Department of Anaesthesia, Harvard Medical School, Boston, Mass; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass
| | - Andreas M Baumer
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass
| | | | - Jocelyn M Booth
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass
| | - Connor E Higgins
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Viviane G Nasr
- Department of Anaesthesia, Harvard Medical School, Boston, Mass; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Roland Brusseau
- Department of Anaesthesia, Harvard Medical School, Boston, Mass; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass
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Maddali MM, Al-Mamari AH, Raju S, Sathiya PM. Clinical Variables Specific to Timing of Tracheal Extubation Following Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2024; 15:193-201. [PMID: 37981790 DOI: 10.1177/21501351231204325] [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: 11/21/2023]
Abstract
BACKGROUND The primary objective of this study was to identify specific factors in pediatric cardiac surgical patients when tracheal extubation was performed on the operating table after completion of open-heart surgery (Group-1), postoperatively in the intensive care unit within 6 h (Group-II) or after 6 h (Group-III). The causes of failed extubation, the presence of chromosomal disorders in addition to arterial blood gas analysis parameters at the time of tracheal extubation, and the duration of intensive care unit stay were also evaluated in each group. METHODS In addition to the three groups, Groups I and II were combined as a "fast-track" extubation group. The demographic data, Risk Adjustment for Congenital Heart Surgery (RACHS-1) score, the Society of Thoracic Surgeons - European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Category (STAT Mortality Category), cardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, and vasoactive-inotropic score (VIS) at the time of tracheal extubation along with data related to secondary objectives were recorded for each patient. RESULTS A significant association was found by bivariate analysis between clinical variables and for both operating table and fast-track extubation in terms of age, weight, RACHS-1 score, STAT category, CPB and ACC time, and VIS. A multivariate-adjusted analysis showed weight, lower STAT category, CPB time, and VIS were independent predictors for operating table and fast-track extubation. CONCLUSIONS Younger age, lower weight, higher RACHS-1, STAT category, and VIS, along with longer CPB and ACC, are associated with delay in the timing of tracheal extubation in pediatric cardiac surgical patients.
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Affiliation(s)
- Madan Mohan Maddali
- Department of Cardiac Anesthesia, National Heart Center, Royal Hospital, Muscat, Oman
| | | | - Sowmiya Raju
- Department of Cardiac Anesthesia, National Heart Center, Royal Hospital, Muscat, Oman
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Dou D, Jia Y, Yuan S, Wang Y, Li Y, Wang H, Ding J, Wu X, Bie D, Liu Q, An R, Yan H, Yan F. The protocol of Enhanced Recovery After Cardiac Surgery (ERACS) in congenital heart disease: a stepped wedge cluster randomized trial. BMC Pediatr 2024; 24:22. [PMID: 38183047 PMCID: PMC10768436 DOI: 10.1186/s12887-023-04422-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/14/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND The Enhanced Recovery After Cardiac Surgery (ERACS) programs are comprehensive multidisciplinary interventions to improve patients' recovery. The application of the ERAS principle in pediatric patients has not been identified completely. METHODS This study is a multicenter, stepwise design, cluster randomized controlled trial. 3030 patients presenting during control and intervention periods are eligible if they are aged from 28 days to 6 years old and awaiting elective correction surgery of congenital heart disease with cardiopulmonary bypass. 5 centers are randomly assigned to staggered start dates for one-way crossover from the control phase to the intervention phase. In the intervention periods, patients will receive a bundle strategy including preoperative, intraoperative, and postoperative approaches. During the control phase, patients receive the usual care. The primary outcome consists of major adverse cardiac and cerebrovascular events (MACCEs), postoperative pulmonary complications (PPCs), and acute kidney injury (AKI). DISCUSSION This study aims to explore whether the bundle of ERAS measurements could improve patients' recovery in congenital heart surgery. TRIAL REGISTRATION http://www. CLINICALTRIALS gov . (NCT05914103).
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Affiliation(s)
- Dou Dou
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Yuan Jia
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Su Yuan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Yang Wang
- Department of Medical Research & Biometrics Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Yinan Li
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Hongbai Wang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Jie Ding
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Xie Wu
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Dongyun Bie
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Qiao Liu
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Ran An
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Haoqi Yan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Fuxia Yan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China.
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Murphy T, Brown M, Sale S, Nasr V. Challenges to the Wider Implementation of Pediatric Cardiac Surgical Enhanced Recovery Programs: 'What's in a Name?'. J Cardiothorac Vasc Anesth 2023; 37:2191-2193. [PMID: 37598035 DOI: 10.1053/j.jvca.2023.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 08/21/2023]
Affiliation(s)
- Tim Murphy
- Department of Paediatric Cardiac Anaesthesia, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Morgan Brown
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Steven Sale
- Department of Paediatric Cardiac Anaesthesia, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Viviane Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
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Sussman M, Verma M, Curtis S. Methylprednisolone for Heart Surgery in Infants. N Engl J Med 2023; 388:958-959. [PMID: 36884336 DOI: 10.1056/nejmc2300127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Affiliation(s)
- Maya Sussman
- St. Bartholomew's Hospital, London, United Kingdom
| | - Manish Verma
- St. Bartholomew's Hospital, London, United Kingdom
| | - Sam Curtis
- St. Bartholomew's Hospital, London, United Kingdom
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Post-operative vomiting and enhanced recovery after congenital cardiac surgery. Cardiol Young 2023; 33:260-265. [PMID: 35322768 DOI: 10.1017/s1047951122000592] [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] [Indexed: 11/07/2022]
Abstract
BACKGROUND Post-operative nausea and vomiting is frequent after congenital cardiac surgery. AIMS We sought to determine factors associated to severe post-operative vomiting after congenital cardiac surgery and the effect on post-operative outcomes. METHODS Patients > 30 days of age who underwent elective cardiac surgical repair as part of an enhanced recovery after congenital cardiac surgery programme were retrospectively reviewed. Patient characteristics and perioperative factors were compared by univariate analysis for patients with severe post-operative vomiting, defined as three events or more, and for patients with no-or-mild post-operative vomiting. All variables with a p-value < 0.1 were included in a multivariable model, and major post-operative outcomes were compared using regression analysis. RESULTS From 1 October, 2018 to 30 September, 2019, 430 consecutive patients were included. The median age was 4.8 years (interquartile range 1.2-12.6). Twenty-one per cent of patients (91/430) experienced severe post-operative vomiting. Total intraoperative opioids > 5.0 mg/kg of oral morphine equivalent (adjusted odds ratio 1.72) and post-operative inotropes infusion(s) (adjusted odds ratio 1.64) were identified as independent predictors of severe post-operative vomiting after surgery. Patients suffering from severe post-operative vomiting had increased pulmonary complications (adjusted odds ratio 5.18) and longer post-operative hospitalisation (adjusted coefficient, 0.89). CONCLUSIONS Greater cumulative intraoperative opioids are associated with severe post-operative vomiting after congenital cardiac surgery. Multimodal pain strategies targeting the reduction of intraoperative opioids should be considered during congenital cardiac surgery to enhance recovery after surgery.
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Management of routine postoperative pain for children undergoing cardiac surgery: a Paediatric Acute Care Cardiology Collaborative Clinical Practice Guideline. Cardiol Young 2022; 32:1881-1893. [PMID: 36382361 DOI: 10.1017/s1047951122003559] [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] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pain following surgery for cardiac disease is ubiquitous, and optimal management is important. Despite this, there is large practice variation. To address this, the Paediatric Acute Care Cardiology Collaborative undertook the effort to create this clinical practice guideline. METHODS A panel of experts consisting of paediatric cardiologists, advanced practice practitioners, pharmacists, a paediatric cardiothoracic surgeon, and a paediatric cardiac anaesthesiologist was convened. The literature was searched for relevant articles and Collaborative sites submitted centre-specific protocols for postoperative pain management. Using the modified Delphi technique, recommendations were generated and put through iterative Delphi rounds to achieve consensus. RESULTS 60 recommendations achieved consensus and are included in this guideline. They address guideline use, pain assessment, general considerations, preoperative considerations, intraoperative considerations, regional anaesthesia, opioids, opioid-sparing, non-opioid medications, non-pharmaceutical pain management, and discharge considerations. CONCLUSIONS Postoperative pain among children following cardiac surgery is currently an area of significant practice variability despite a large body of literature and the presence of centre-specific protocols. Central to the recommendations included in this guideline is the concept that ideal pain management begins with preoperative counselling and continues through to patient discharge. Overall, the quality of evidence supporting recommendations is low. There is ongoing need for research in this area, particularly in paediatric populations.
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Einhorn LM, Andrew BY, Nelsen DA, Ames WA. Analgesic Effects of a Novel Combination of Regional Anesthesia After Pediatric Cardiac Surgery: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2022; 36:4054-4061. [PMID: 35995635 PMCID: PMC10497036 DOI: 10.1053/j.jvca.2022.07.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The objective of this study was to determine whether the use of regional anesthesia in children undergoing congenital heart surgery was associated with differences in outcomes when compared to surgeon-delivered local anesthetic wound infiltration. DESIGN A retrospective cohort study. SETTING At a single pediatric tertiary care center. PARTICIPANTS Pediatric patients who underwent primary repair of septal defects between January 1, 2018, and March 31, 2022. INTERVENTIONS The patients were grouped by whether they received surgeon-delivered local anesthetic wound infiltration or bilateral pectointercostal fascial blocks (PIFBs) and a unilateral rectus sheath block (RSB) on the side ipsilateral to the chest tube. MEASUREMENTS AND MAIN RESULTS Using overlap propensity score-weighted models, the authors examined postoperative opioid requirements (morphine milliequivalents per kilogram), pain scores, length of stay, and time under general anesthesia (GA). Eighty-nine patients were eligible for inclusion and underwent analysis. In the first 12 hours postoperatively, the block group used fewer morphine equivalents per kilogram versus the infiltration group, 0.27 ± 0.2 v 0.64 ± 0.42, with a weighted estimated decrease of 0.39 morphine equivalents per kilogram (95% CI -0.52 to -0.25; p < 0.001), and had lower pain scores, 3.2 v 1.6, with a weighted estimated decrease of 1.7 (95% CI -2.3 to -1.1; p < 0.001). The length of stay and time under GA also were shorter in the block group with weighted estimated decreases of 22 hours (95% CI -33 to -11; p = 0.001) and 18 minutes (95% CI -34 to -2; p = 0.03), respectively. CONCLUSIONS Bilateral PIFBs and a unilateral RSB on the side ipsilateral to the chest tube is a novel analgesic technique for sternotomy in pediatric patients. In this retrospective study, these interventions were associated with decreases in postoperative opioid use, pain scores, and hospital length of stay without prolonging time under GA.
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Affiliation(s)
- Lisa M Einhorn
- Department of Anesthesiology, Duke University Medical Center, Durham, NC.
| | - Benjamin Y Andrew
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Derek A Nelsen
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Warwick A Ames
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
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11
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Comparison of Intraoperative and Discharge Residual Lesion Severity in Congenital Heart Surgery. Ann Thorac Surg 2022; 114:1731-1737. [PMID: 35398038 DOI: 10.1016/j.athoracsur.2022.02.081] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/10/2022] [Accepted: 02/22/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND While the predischarge technical performance score (DC-TPS) is significantly associated with outcomes after congenital cardiac surgery, the utility of the intraoperative TPS (IO-TPS) remains unknown. METHODS This was a single-center retrospective review of consecutive patients who underwent congenital cardiac surgery from January 2011 to December 2019. Intraoperative and predischarge echocardiograms were used to assign IO-TPS and DC-TPS, respectively, for each index operation (class 1, no residua; class 2, minor residua; class 3, major residua). Anatomic modules identifying the principal residual lesion were assigned to all class 2/3 patients. Overall and module-specific TPS comparisons were made. Multivariable regression models with IO-TPS and DC-TPS as separate predictors of postoperative outcomes were compared. RESULTS Of 6201 patients, overall agreement between IO-TPS and DC-TPS was observed in 4251 patients (68.6%); scores were likelier to be worse at discharge (P < .001). Paired comparative analyses revealed that among patients with at least class 2 atrioventricular and semilunar valve residua, IO-TPS was likelier to worsen than improve (both P < .001). Class 3 patients had a higher risk of in-hospital/early mortality (IO-TPS: odds ratio, 7.5; 95% CI, 2.4-23; DC-TPS: odds ratio, 6.6; 95% CI, 3.0-15), postdischarge/late mortality (IO-TPS: hazard ratio [HR], 3.1, 95% CI, 1.3-7.1; DC-TPS: HR, 2.3; 95% CI, 1.2-4.4), and late unplanned reintervention (IO-TPS: HR, 2.8; 95% CI, 1.9-4.0; DC-TPS: HR, 3.4; 95% CI, 2.8-4.2) vs class 1 (all P < .05). IO- and DC-TPS models were equivalent fits for predicting early and late mortality; the latter was a marginally better fit for late reintervention. CONCLUSIONS IO-TPS and DC-TPS are both important adjuncts for quality improvement in congenital cardiac surgery.
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12
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Murphy T, Sale SM, Gonzalez Barlatay F, Armstrong C, Parry A, Houghton E, Jerrom T, Schadenberg A. Initial results from an enhanced recovery program for pediatric cardiac surgical patients. Paediatr Anaesth 2022; 32:647-653. [PMID: 35156262 DOI: 10.1111/pan.14418] [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: 07/05/2021] [Revised: 01/07/2022] [Accepted: 02/04/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Over recent years, a number of enhanced recovery programs have appeared in first, adult colorectal surgery, and subsequently many other adult surgical specialties. Increasing interest in this approach to perioperative management in children culminated in the recent development of the first enhanced recovery pathway for pediatric intestinal surgery, endorsed by Enhanced Recovery after Surgery Society (ERAS®). In parallel, there has been increasing interest in the refinement of perioperative management of selected pediatric cardiac surgical patients, invariably referred to as "fast track" management. Initiatives have largely focused on duration of postoperative ventilation rather than on a much wider range of perioperative interventions to optimize recovery and ensure timely discharge after surgery. In our institution, a "Level 1" pediatric cardiac surgical center, we assembled a multidisciplinary team to design a comprehensive enhanced recovery pathway, based on ERAS® methodology, for selected cardiac surgical patients. After a lengthy period of planning, staff education, and preparation, we implemented the pathway at the end of November 2019. METHODS We conducted a prospective audit of the perioperative management and outcomes of the first 88 patients managed according to this enhanced recovery pathway over a 25-month period in our institution. RESULTS The mean age of the patients was 5.8 years (range 0.5-17.9), and the mean weight was 22.4 kg (range 6.6-57.2). Sixty-eight of the 88 patients were cardiopulmonary bypass cases. A total of 54% of patients received all four defined intraoperative anesthetic interventions (intravenous paracetamol, non-steroidal anti-inflammatory drug, antiemetic if aged more than 4 years, and use of a local anesthetic technique). A total of 89% of patients met the target extubation time of 6 h after administration of protamine. Median postoperative intensive care unit length of stay was 23.5 h (range 15.2-89.5). When compared to a historic control group, this represented a 22% reduction in median intensive care unit stay, although the total hospital length of stay remained unchanged. A total of 83% of patients met the target hospital discharge target of the fifth postoperative day. CONCLUSIONS These preliminary results suggest that enhanced recovery pathway implementation for selected pediatric cardiac surgical patients is feasible, with acceptable outcomes. They suggest areas for further development and the potential for wider implementation.
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Affiliation(s)
- Tim Murphy
- Pediatric Cardiac Anesthesia, Bristol Royal Hospital for Children, Bristol, UK
| | - Steven M Sale
- Pediatric Cardiac Anesthesia, Bristol Royal Hospital for Children, Bristol, UK
| | | | | | - Andrew Parry
- Congenital Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | | | - Tom Jerrom
- Pediatric Intensive Care, Bristol Royal Hospital for Children, Bristol, UK
| | - Alvin Schadenberg
- Pediatric Intensive Care, Bristol Royal Hospital for Children, Bristol, UK
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13
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Karacaer F, Biricik E, Ilgınel M, Tunay D, Topçuoğlu Ş, Ünlügenç H. Bilateral erector spinae plane blocks in children undergoing cardiac surgery: A randomized, controlled study. J Clin Anesth 2022; 80:110797. [PMID: 35489304 DOI: 10.1016/j.jclinane.2022.110797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/31/2022] [Accepted: 03/27/2022] [Indexed: 12/12/2022]
Abstract
STUDY OBJECTIVE We aimed to test the hypothesis that erector spinae plane block (ESPB) provides efficient analgesia and reduces postoperative morphine consumption in children undergoing cardiac surgery with median sternotomy. DESIGN A prospective, blinded, randomized, controlled study. SETTING A tertiary university hospital, operating room and intensive care unit. PATIENTS Forty children aged 2-10 years, who underwent cardiac surgery with median sternotomy. The patients were randomly divided into the block group (Group B) and the control group (Group C). INTERVENTIONS Group B (n = 20) were treated with ultrasound-guided bilateral ESPB at the level of the T4-T5 transverse process, whereas no block was administered in Group C (n = 20). In all children, intravenous morphine at 0.05 mg/kg was used whenever the modified objective pain score (MOPS) ≥4 for postoperative analgesia. MEASUREMENTS The MOPS and Ramsay sedation score (RSS) were assessed at 0, 1, 2, 4, 6, 8, 10, 12, 16, 20 and 24 h postoperatively. Total morphine consumption at 24 h, extubation time and length of intensive care unit (ICU) stay was also evaluated and recorded. MAIN RESULTS Bilateral ESPB significantly decreased the consumption of morphine in the first 24 h, postoperatively. During the postoperative 24-h follow-up, 11 children in Group C requested morphine and the cumulative dose of morphine was 0.83 ± 0.91 mg, while 4 children in Group B requested morphine and the cumulative dose of morphine was 0.26 ± 0.59 mg (p = 0.043). There was no significant difference between Groups B and C in terms of MOPS and RSS values, extubation time or length of ICU stay. CONCLUSION Ultrasound-guided bilateral ESPB with bupivacaine provides efficient postoperative analgesia and reduces postoperative morphine consumption at 24 h in children undergoing cardiac surgery.
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Affiliation(s)
- Feride Karacaer
- Department of Anesthesiology and Reanimation, Çukurova University, Adana, Turkey.
| | - Ebru Biricik
- Department of Anesthesiology and Reanimation, Çukurova University, Adana, Turkey
| | - Murat Ilgınel
- Department of Anesthesiology and Reanimation, Çukurova University, Adana, Turkey
| | - Demet Tunay
- Department of Anesthesiology and Reanimation, Çukurova University, Adana, Turkey
| | - Şah Topçuoğlu
- Department of Cardiovascular Surgery, Çukurova University, Adana, Turkey
| | - Hakkı Ünlügenç
- Department of Anesthesiology and Reanimation, Çukurova University, Adana, Turkey
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14
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Buchanan R, Roy N, Parra MF, Staffa SJ, Brown ML, Nasr VG. Race and Outcomes in Patients with Congenital Cardiac Disease in an Enhanced Recovery Program. J Cardiothorac Vasc Anesth 2022; 36:3603-3609. [PMID: 35577651 DOI: 10.1053/j.jvca.2022.04.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/03/2022] [Accepted: 04/07/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Disparities in perioperative outcomes exist. In addition to patient and socioeconomic factors, racial disparities in outcome measures may be related to issues at the provider and institutional levels. Recognizing a potential role of standardized care in mitigating provider bias, this study aims to compare the perioperative sedation and pain management and consequent outcomes in Enhanced Recovery After Surgery (ERAS) cardiac patients of different races undergoing congenital heart surgery at a single quaternary children's hospital. DESIGN A retrospective study. SETTING A single quaternary pediatric hospital. PARTICIPANTS Patients, infants to adults, undergoing elective congenital cardiac surgery and enrolled in the ERAS protocol from October 2018 to December 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the patients, 872 were reviewed and 606 with race information were analyzed. There was no significant difference in intraoperative and postoperative oral morphine equivalent, perioperative sedatives, and regional blockade in Asian or African American patients when compared to White patients. Postoperative pain scores and outcomes among African American and Asian races were also not statistically different when compared to White patients. CONCLUSIONS Racial disparity in perioperative management and outcomes in patients with standardized ERAS protocols does not exist at the authors' institution. Future comparative studies of ERAS noncardiac patients may provide additional information on the role of standardization in reducing implicit bias.
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Affiliation(s)
- Rica Buchanan
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States
| | - Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - M Fernanda Parra
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States
| | - Morgan L Brown
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States.
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15
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Xie Z, Liu J, Yang Z, Tang L, Wang S, Du Y, Yang L. Risk Factors for Post-operative Planned Reintubation in Patients After General Anesthesia: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:839070. [PMID: 35355600 PMCID: PMC8959864 DOI: 10.3389/fmed.2022.839070] [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: 12/19/2021] [Accepted: 02/09/2022] [Indexed: 11/13/2022] Open
Abstract
Background The occurrence of postoperative reintubation (POR) in patients after general anesthesia (GA) is often synonymous with a poor prognosis in patients. This is the first review analyzing scientific literature to identify risk factors of POR after general anesthesia. The purpose of this study was to collect currently published studies to determine the most common and consistent risk factors associated with POR after GA. Methods We have retrieved all relevant research published before April 2021 from PubMed, Embase, Web of Science, and the Cochrane Library electronic databases. These studies were selected according to the inclusion and exclusion criteria. The Z test determined the combined odds ratio (OR) of risk factors. We used OR and its corresponding 95% confidence interval (CI) to identify significant differences in risk factors. The quality of the study was evaluated with the NOS scale, and meta-analysis was carried out with Cochrane Collaboration's Revman 5.0 software. Results A total of 10 studies were included, with a total of 7,789 recipients of POR. We identified 7 risk factors related to POR after GA: ASA ≥ 3 (OR = 3.58), COPD (OR = 2.09), thoracic surgery (OR = 17.09), airway surgery (OR = 9.93), head-and-neck surgery (OR = 3.49), sepsis (OR = 3.50), DVT (OR = 4.94). Conclusion Our meta-analysis showed that ASA ≥ 3, COPD, thoracic surgery, airway surgery, head-and-neck surgery, sepsis and DVT were associated with POR after GA. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?, Identifier: CRD42021252466.
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Affiliation(s)
- Zhiqin Xie
- Department of Nursing, First Affiliated Hospital of Nanchang University, Nanchang, China.,School of Nursing, Nanchang University, Nanchang, China
| | - Jiawen Liu
- School of Nursing, Nanchang University, Nanchang, China
| | - Zhen Yang
- Department of Nursing, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Liping Tang
- Department of Nursing, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shuilian Wang
- Department of Nursing, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yunyu Du
- School of Nursing, Nanchang University, Nanchang, China
| | - Lina Yang
- School of Nursing, Nanchang University, Nanchang, China
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16
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Figueroa-Solano J, Infante-Sánchez K, Espinosa-Guerra K, Astudillo-De Haro ED, Martínez-Albarenga PM, Lesprón-Robles MDC, Molina-Méndez FJ, Miranda-Chávez IO. Early Extubation in Children after Cardiac Surgery. Initial Experience from a Tertiary Care Hospital in Mexico City. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1743177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractEarly extubation (EE) in pediatric cardiac surgery has demonstrated important benefits. However, ventilating them for 24 hours or more (delayed decannulation, DD) is an enduring practice. The objectives of this study were to describe the clinical profiles of EE in our setting and analyze its impact and the factors that prolong mechanical ventilation. Children operated on for cardiac surgery from 2016 to 2017 were included. The information was obtained from an electronic database. Comparisons were performed with Pearson's chi-square test, Student's t-test, or Mann–Whitney U test. Multivariate logistic regression was used to evaluate factors associated with DD. Of 649 cases, 530 were extubated on one occasion. EE was performed in 305 children (57.5%): 97 (31.8%) in the operating room and 208 (68.2%) in the intensive care unit (ICU). Reintubation (RI) occurred in 7.5% with EE and 16.9% with DD (p = 0.001). Fewer complications and ventilation time and decreased ICU and hospital length of stay resulted with EE. Age, presurgical ventilation, emergency surgery, pump time, attempts to weaning from cardiopulmonary bypass, bleeding greater than usual, and CPR in surgery were associated with DD. EE in the National Institute of Cardiology (INC; Spanish acronym) is in the middle category and has shown benefits without compromising the patient; the fear of further complications, RI, or death is unfounded. Although not all children at the INC can be decannulated early, if there are no or minimal risk factors, it should be a priority.
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Affiliation(s)
- Javier Figueroa-Solano
- Department of Pediatric Cardiovascular Intensive Care, National Institute of Cardiology, Ignacio Chávez, Mexico City, Mexico
- Department of Postoperative Care, XXI Century National Medical Center, Mexican Social Security Institute, Hospital of Cardiology, Mexico City, Mexico
| | - Karen Infante-Sánchez
- Department of Cardiovascular Anesthesia, National Institute of Cardiology, Ignacio Chávez, Mexico City, Mexico
| | - Kenia Espinosa-Guerra
- Department of Pediatric Cardiology, National Institute of Cardiology, Ignacio Chávez, Mexico City, Mexico
| | | | | | | | | | - Irma Ofelia Miranda-Chávez
- Department of Pediatric Cardiology, National Institute of Cardiology, Ignacio Chávez, Mexico City, Mexico
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17
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Roy N, Parra MF, Brown ML, Sleeper LA, Carlson L, Rhodes B, Nathan M, Mistry KP, Del Nido PJ. Enhancing Recovery in Congenital Cardiac Surgery. Ann Thorac Surg 2021; 114:1754-1761. [PMID: 34710385 DOI: 10.1016/j.athoracsur.2021.09.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 09/07/2021] [Accepted: 09/09/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND The benefits of a comprehensive enhanced recovery after surgery (ERAS®) program for the congenital heart disease population are largely unknown. We evaluated adherence and outcomes following a recently implemented enhanced recovery program (ERP) in congenital cardiac surgery. METHODS Patients undergoing elective surgery for simple and moderately complex congenital cardiac surgery followed institutional ERP guidelines since 10/2018. Adherence to guidelines over a 12-month period (P2) was compared to implementation data (P1:5 months). The association of outcomes with continuous time was estimated using linear regression. RESULTS Among 559 patients (representing 40% of the cardiac surgical volume) following the ERP over a period of 17 months, no differences in patient characteristics were observed between periods, except higher incidence of prior operations in P2. Adherence to many aspects of guidelines improved from P1 to P2. Notably, operating room extubation: 27% in P2 vs.16% in P1, p=0.006; decrease in median ventilation time: 6.0-hrs (IQR 0-9.2) in P2 vs. 7.6-hrs (IQR 3.8-12.3) in P1, p=0.002. In addition, there was a reduction in opioids, reported as oral morphine equivalents (OME), most significant for intraoperative OME: 5.00 mg/kg (3.11-7.60) in P2 vs. 6.05 mg/kg (3.77-9.78) in P1, p=0.001. There was no difference in overall intensive care unit (ICU) and postoperative length of stay except in lower risk surgeries. Surgical outcomes were similar in the two periods. CONCLUSIONS An enhanced recovery program reduced the use of opioids, led to more OR extubation and reduced mechanical ventilation duration in patients undergoing congenital cardiac surgery.
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Affiliation(s)
- Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - M Fernanda Parra
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Morgan L Brown
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Laura Carlson
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States
| | - Barbara Rhodes
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Kshitij P Mistry
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
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18
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Tempe DK. Transforming the Care of Pediatric Patients Undergoing Cardiac Surgery Is on the Horizon. J Cardiothorac Vasc Anesth 2021; 36:642-644. [PMID: 34625352 DOI: 10.1053/j.jvca.2021.09.019] [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: 09/09/2021] [Accepted: 09/13/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Deepak K Tempe
- Visiting Professor, Institute of Liver and Biliary Sciences, New Delhi, India; Professor of Excellence and Former Dean, Maulana Azad Medical College, New Delhi, India.
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19
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Rickard M, Chua M, Kim JK, Keefe DT, Milford K, Hannick JH, Dos Santos J, Koyle MA, Lorenzo AJ. Evolving trends in peri-operative management of pediatric ureteropelvic junction obstruction: working towards quicker recovery and day surgery pyeloplasty. World J Urol 2021; 39:3677-3684. [PMID: 33660089 DOI: 10.1007/s00345-021-03621-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/30/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To describe the evolution of practice patterns for pediatric pyeloplasty and determine how these changes have impacted length of stay (LOS), reoperation rates and return emergency department (ER) visits. METHODS We reviewed our pyeloplasty database from 2008 to 2020 at a quaternary pediatric referral center and we included children 0-18 years undergoing pyeloplasty. Variables captured included: age, sex, baseline and follow-up anteroposterior diameter (APD) and differential renal function (DRF). We also collected data on the use of drains, catheters and/or stents, nausea and vomiting prophylaxis, opioids, regional anesthesia, and non-opioid analgesia. Outcomes were LOS, reoperation rates and ER visits. RESULTS A total of 554 patients (565 kidneys) were included. Reoperation rate was 7%, redo rate 4% and ER visits 17%. There was a trend towards less opioids, indwelling catheters and internal stents and increasing non-opioid analgesia, externalized stents, and regional anesthesia during the study period. Same-day discharge (SDD) was possible for 88 (16%) children with no differences in reoperation or readmission rates between SDD and admitted (ADM). There was a difference in ER visits (21 [24%] vs. 26 [6%]; p = 0.04) for SDD vs. ADM, respectively. On multivariate analysis, the only predictor of ER visits was younger age. Patients < 7 months were more likely to present to ER (15/41; 37% vs. 6/47, 13%; p = 0.009). Multivariate analysis determined indwelling catheters and opioids were associated with ADM while dexamethasone and ketorolac with SDD. CONCLUSION Progressive changes in care have contributed to a shorter LOS and increasing rates of SDD for pyeloplasty patients. SDD appears to be feasible and does not result in higher complication rates. These data support the development of a pediatric pyeloplasty ERAS protocol to maximize quicker recovery and foster SDD as a goal.
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Affiliation(s)
- Mandy Rickard
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Michael Chua
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Jin Kyu Kim
- Department of Urology, University of Toronto, Toronto, ON, Canada
| | - Daniel T Keefe
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Karen Milford
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Jessica H Hannick
- Division of Pediatric Urology, UH Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Joana Dos Santos
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Martin A Koyle
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Armando J Lorenzo
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
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Improving outcomes after low-risk coronary artery bypass grafting: understanding phase of care mortality analysis, failure to rescue and recent perioperative recommendations. Curr Opin Cardiol 2021; 36:644-651. [PMID: 34397470 DOI: 10.1097/hco.0000000000000896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Avoidable adverse events are responsible for up to 50% of deaths after low-risk coronary artery bypass grafting. This article reviews recent quality improvement efforts to improve outcomes after cardiac surgery. RECENT FINDINGS Systematic quality improvement methodology in cardiac surgery has improved significantly over the past decade. Contemporary efforts with phase of care mortality analysis (POCMA) focus on identifying and addressing root causes for mortality. Each patient's perioperative course is an interconnected sequence of clinical events, decisions, interventions, and treatment responses occurring across five perioperative phases. A single seminal event within a specific phase of care has been found to often trigger the eventual death of a patient. Several groups have made significant improvements to perioperative outcomes by addressing these avoidable mortality trigger events. Failing that, failure to rescue (FTR) metrics can be used to identify institutional factors responsible for poor perioperative outcomes. This ongoing focus on quality improvement serves to further improve outcomes after low-risk cardiac surgery. SUMMARY Modern quality improvement methodology, including POCMA and FTR analysis, has the potential to significantly improve outcomes after cardiac surgery. Larger future studies with multiinstitutional data sharing will be key to facilitate ongoing quality improvement and knowledge translation in this field.
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21
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Murray-Torres TM, Tobias JD, Winch PD. Perioperative Opioid Consumption is Not Reduced in Cyanotic Patients Presenting for the Fontan Procedure. Pediatr Cardiol 2021; 42:1170-1179. [PMID: 33871683 DOI: 10.1007/s00246-021-02598-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 04/01/2021] [Indexed: 12/01/2022]
Abstract
Adequate pain control is a critical component of the perioperative approach to children undergoing repair of congenital heart disease (CHD). The impact of specific anatomic and physiologic disturbances on the management of analgesia has been largely unexplored at the present time. Studies in other pediatric populations have found an association between chronic hypoxemia and an increased sensitivity to the effects of opioid medications. The purpose of this retrospective study was to examine perioperative opioid administration and opioid-associated adverse effects in children undergoing surgical repair of CHD, with a comparison between patients with and without chronic preoperative cyanosis. Patients between the ages of 2 and 5 years whose tracheas were extubated in the operating room were included and were classified in the cyanotic group if they presented for the Fontan completion. The primary outcomes of interest were intraoperative and postoperative opioid administration. Secondary outcomes included pain scores and opioid-related side effects. The study cohort included 156 patients. Seventy-one underwent the Fontan procedure, twelve of which were fenestrated. Fontan patients received fewer opioids intraoperatively (11.33 µg/kg fentanyl equivalents versus 12.56 µg/kg, p = 0.03). However, there were no differences with regards to opioid consumption postoperatively and no correlation between preoperative oxygen saturation and total opioid administration. There were no differences between groups with regards to the respiratory rate nadir, postoperative pain scores, or the incidence of opioid-related side effects. In contrast to other populations with chronic hypoxemia exposure, children with cyanotic CHD did not appear to have increased sensitivity to the effects of opioid medications.
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Affiliation(s)
- Teresa M Murray-Torres
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA
- Department of Anesthesiology, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Peter D Winch
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA.
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.
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22
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Ceneri N, Desai M, Yerebakan C. Developments in perioperative management: The yin to the yang of congenital heart surgery. J Thorac Cardiovasc Surg 2021; 162:432-434. [PMID: 34112501 DOI: 10.1016/j.jtcvs.2021.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 05/08/2021] [Accepted: 05/10/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Nicolle Ceneri
- Division of Cardiac Surgery, Children's National Heart Institute, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Manan Desai
- Department of Cardiothoracic Surgery, Lucile Packard Children's Hospital, Stanford University, Palo Alto, Calif
| | - Can Yerebakan
- Division of Cardiac Surgery, Children's National Heart Institute, The George Washington University School of Medicine and Health Sciences, Washington, DC.
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23
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Fuller S, Kumar SR, Roy N, Mahle WT, Romano JC, Nelson JS, Hammel JM, Imamura M, Zhang H, Fremes SE, McHugh-Grant S, Nicolson SC. The American Association for Thoracic Surgery Congenital Cardiac Surgery Working Group 2021 consensus document on a comprehensive perioperative approach to enhanced recovery after pediatric cardiac surgery. J Thorac Cardiovasc Surg 2021; 162:931-954. [PMID: 34059337 DOI: 10.1016/j.jtcvs.2021.04.072] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 04/26/2021] [Accepted: 04/26/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - S Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, and Department of Pediatrics, Keck School of Medicine of the University of Southern California, Heart Institute, Children's Hospital Los Angeles, Los Angeles, Calif.
| | - Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, Mass
| | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jennifer C Romano
- Departments of Cardiac Surgery and Pediatrics, University of Michigan, CS Mott Children's Hospital, Ann Arbor, Mich
| | - Jennifer S Nelson
- Department of Cardiovascular Services, Nemours Children's Hospital, and Department of Surgery, University of Central Florida College of Medicine, Orlando, Fla
| | - James M Hammel
- Department of Cardiothoracic Surgery, Children's Hospital and Medical Center of Omaha, Omaha, Neb
| | - Michiaki Imamura
- Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Haibo Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sara McHugh-Grant
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Penn
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Penn
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24
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Koutsogiannaki S, Huang SX, Lukovits K, Kim S, Bernier R, Odegard KC, Yuki K. The Characterization of Postoperative Mechanical Respiratory Requirement in Neonates and Infants Undergoing Cardiac Surgery on Cardiopulmonary Bypass in a Single Tertiary Institution. J Cardiothorac Vasc Anesth 2021; 36:215-221. [PMID: 34023203 DOI: 10.1053/j.jvca.2021.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/28/2021] [Accepted: 04/16/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Although neonates and infants undergoing cardiac surgery on cardiopulmonary bypass (CPB) are at high risk of developing perioperative morbidity and mortality, including lung injury, the intraoperative profile of lung injury in this cohort is not well-described. Given that the postoperative course of patients in the pediatric cardiac surgical arena has become increasingly expedited, the objective of this study was to characterize the profiles of postoperative mechanical ventilatory support in neonates and infants undergoing cardiac surgery on CPB and to examine the characteristics of lung mechanics and lung injury in this patient population who are potentially amendable to early postoperative recovery in a single tertiary pediatric institution. DESIGN A retrospective data analysis of neonates and infants who underwent cardiac surgery on cardiopulmonary bypass. SETTING A single-center, university teaching hospital. PARTICIPANTS The study included 328 neonates and infants who underwent cardiac surgery on cardiopulmonary bypass. INTERVENTIONS A subset of 128 patients were studied: 58 patients undergoing ventricular septal defect (VSD) repair, 36 patients undergoing complete atrioventricular canal (CAVC) repair, and 34 patients undergoing bidirectional Glenn (BDG) shunt surgery. MEASUREMENTS AND MAIN RESULTS Of the entire cohort, 3.7% experienced in-hospital mortality. Among all surgical procedures, VSD repair (17.7%) was the most common, followed by CAVC repair (11.0%) and BDG shunt surgery (10.4%). Of patients who underwent VSD repair, CAVC repair, and BDG shunt surgery, 65.5%, 41.7%, and 67.6% were off mechanical ventilatory support within 24 hours postoperatively, respectively. In all three of the surgical repairs, lung compliance decreased after CPB compared to pre-CPB phase. Sixty point three percent of patients with VSD repair and 77.8% of patients with CAVC repair showed a PaO2/FIO2 (P/F) ratio of <300 after CPB. Post- CPB P/F ratios of 120 for VSD patients and 100 for CAVC patients were considered as optimal cutoff values to highly predict prolonged (>24 hours) postoperative mechanical ventilatory support. A higher volume of transfused platelets also was associated with postoperative ventilatory support ≥24 hours in patients undergoing VSD repair, CAVC repair, and BDG shunt surgery. CONCLUSIONS There was a high incidence of lung injury after CPB in neonates and infants, even in surgeries amendable for early recovery. Given that CPB-related factors (CPB duration, crossclamp time) and volume of transfused platelet were significantly associated with prolonged postoperative ventilatory support, the underlying cause of cardiac surgery-related lung injury can be multi-factorial.
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Affiliation(s)
- Sophia Koutsogiannaki
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA; Department of Immunology, Harvard Medical School, Boston, MA
| | - Sheng Xiang Huang
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Karina Lukovits
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Samuel Kim
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Rachel Bernier
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Kirsten C Odegard
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Koichi Yuki
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA; Department of Immunology, Harvard Medical School, Boston, MA.
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25
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Alaeddine M, D'Cunha J. Commentary: Enhanced Recovery After Congenital Cardiac Surgery: Just Say "Yes" to the Benefits of Reduced Opioid Usage. Semin Thorac Cardiovasc Surg 2021; 34:273-274. [PMID: 33610699 DOI: 10.1053/j.semtcvs.2021.01.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/05/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Mohamad Alaeddine
- Division of Cardiovascular Surgery, Phoenix Children's Hospital, Phoenix, Arizona
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona.
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26
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Otu C, Vo V, Staffa SJ, Yuki K, Sullivan CA, Quinonez LG, Brown ML. The Use of Regional Catheters in Children Undergoing Repair of Aortic Coarctation. J Cardiothorac Vasc Anesth 2021; 35:3694-3699. [PMID: 33744113 DOI: 10.1053/j.jvca.2021.02.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The objective was to assess the effectiveness and safety of peripheral regional anesthesia in congenital cardiac surgical patients undergoing thoracotomy for aortic coarctation. DESIGN A retrospective chart review of pediatric patients (<18 years) who underwent surgical repair of congenital heart diseases via thoracotomy between September 2013 and July 2018 was done. Among patients who underwent coarctation repair, a propensity score was used to match patients who received a regional catheter (C) versus traditional medical treatment only (M). SETTING A single center children's hospital. PARTICIPANTS The median age was 172 days (IQR 64-1315) in group C and 176 days (IQR 71-1146) in group M (SMD = 0.07). The median weight was 6.8 kg (IQR 4.8-13.6) in group C and 7.7 kg (4.6-17.4) in group M (SMD = 0.003). MEASUREMENTS AND MAIN RESULT Outcomes assessed were postoperative hospital length of stay, median pain scores in the first 24 and 48 hours, and total morphine equivalent use in the first 24 and 48 hours. Complications related to the catheters were reviewed. The median oral morphine equivalent dose administered in the first 24 hours was lower in group C than group M (0.8 mg/kg, IQR 0.5-1.1 vs. 1.4 mg/kg, IQR 0.9-1.7, p = 0.019). There were no major complications related to the catheters, including hematoma. CONCLUSIONS Peripheral regional catheters may be used to reduce opioid requirements in patients after CoA repair. Due to the low risk of these catheters, they should be considered as part of a pain management strategy for pediatric patients undergoing thoracotomy and should be incorporated into strategies to improve outcomes.
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Affiliation(s)
- Chinedu Otu
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anesthesiology, Perioperative, and Pain medicine, Texas Children's Hospital, Houston, TX
| | - Victoria Vo
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anesthesiology and Perioperative Medicine, Tufts Children's Hospital, Boston, MA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Koichi Yuki
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Cornelius A Sullivan
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Luis G Quinonez
- Division of Cardiac Surgery, Boston Children's Hospital, Boston, MA
| | - Morgan L Brown
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA.
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27
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Frankel WC, Maul TM, Chrysostomou C, Wearden PD, Lowry AW, Baker KN, Nelson JS. A Minimal Opioid Postoperative Management Protocol in Congenital Cardiac Surgery: Safe and Effective. Semin Thorac Cardiovasc Surg 2020; 34:262-272. [PMID: 33333164 DOI: 10.1053/j.semtcvs.2020.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/09/2020] [Indexed: 11/11/2022]
Abstract
There is evidence that reducing opioid exposure in children undergoing cardiac surgery may enhance postoperative recovery. We aimed to describe a minimal opioid postoperative management protocol in children undergoing cardiac surgery and our early outcomes with this strategy. We reviewed the medical records of children (6 months-18 years) who underwent elective cardiac surgery through a median sternotomy with cardiopulmonary bypass at our institution between 2016 and 2018. All patients were managed postoperatively using a standardized protocol. 101 children (median age 5 years) were included and 85% were extubated in the operating room. Although most patients (96%) received opioids postoperatively, opioid requirements decreased steadily over time, with 88%, 58%, and 18% of children receiving opioids on postoperative day 1, 2, and 3, respectively; 41% received no opioids after postoperative day 1. The median cumulative opioid exposure was 0.25 morphine milligram equivalents per kg (interquartile range, 0.10-0.75). Greater than mild pain was rare (<10%) at each time point. The rates of operative mortality and major complication were 0% and 3%, respectively. The median postoperative length of stay was 3 days, and 13% required readmission within 30 days. Age, cardiopulmonary bypass time, and number of benzodiazepine doses were independently associated with cumulative opioid exposure. Any complication, chest tube time, and higher STAT Category were independently associated with prolonged postoperative length of stay. A minimal opioid postoperative management protocol can be safe and effective in children undergoing cardiac surgery. Future prospective studies are needed to determine optimal practice and patient selection.
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Affiliation(s)
| | - Timothy M Maul
- Division of Cardiovascular Surgery, Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida
| | - Constantinos Chrysostomou
- Division of Cardiac Critical Care, Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida; Memorial Care Miller Children's & Women's Hospital, Long Beach, California
| | - Peter D Wearden
- Division of Cardiovascular Surgery, Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida
| | - Adam W Lowry
- Division of Cardiac Critical Care, Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida
| | - Kimberly N Baker
- Division of Cardiac Critical Care, Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida
| | - Jennifer S Nelson
- Division of Cardiovascular Surgery, Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida; Department of Surgery, University of Central Florida College of Medicine, Orlando, Florida.
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28
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Karamlou T. Commentary: A coalition of the willing: Untangling efficiency-penalized reimbursement. J Thorac Cardiovasc Surg 2020; 162:448-450. [PMID: 33172663 DOI: 10.1016/j.jtcvs.2020.10.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 10/09/2020] [Accepted: 10/14/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Tara Karamlou
- Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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29
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Zhu A, Andersen ND, Allareddy V. Commentary: Enhanced recovery program after congenital heart surgery: Promising baby steps. J Thorac Cardiovasc Surg 2020; 160:1322-1323. [DOI: 10.1016/j.jtcvs.2019.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 11/03/2019] [Indexed: 12/24/2022]
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30
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Commentary: The art of medicine versus paint by numbers. J Thorac Cardiovasc Surg 2020; 160:1323-1324. [DOI: 10.1016/j.jtcvs.2019.11.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 11/12/2019] [Indexed: 11/16/2022]
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31
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Roy N, Brown ML, Parra MF, Sleeper LA, Alrayashi W, Nasr VG, Eklund SE, Cravero JP, Del Nido PJ, Brusseau R. Bilateral Erector Spinae Blocks Decrease Perioperative Opioid Use After Pediatric Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 35:2082-2087. [PMID: 33139160 DOI: 10.1053/j.jvca.2020.10.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/03/2020] [Accepted: 10/06/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The present study examined the feasibility and efficacy of continuous bilateral erector spinae blocks for post-sternotomy pain in pediatric cardiac surgery. DESIGN Prospective cohort study; patients were retrospectively matched 1:2 to control patients. Conditional logistic regression was used to compare dichotomous outcomes, and generalized linear models were used for continuous measures, both accounting for clusters. SETTING Quaternary children's hospital, university setting. PARTICIPANTS The study comprised 10 children ages five-to-17 years undergoing elective cardiac surgery requiring cardiopulmonary bypass. INTERVENTIONS Ultrasound-guided bilateral erector spinae blocks at the conclusion of the cardiac surgical procedure, with postoperative infusion of ropivacaine until chest tube removal. Postoperative management otherwise followed standardized guidelines. MEASUREMENTS AND MAIN RESULTS Patient characteristics were similar in the two groups. The median time to completion of the bilateral blocks was 16.0 minutes (interquartile range [IQR] 14.8-19.3), and no major adverse events were identified. Pain scores were low in both groups. Postoperative opioid use at 48 hours, rendered as oral morphine equivalents, was significantly reduced in the patients receiving the blocks. Cluster-adjusted squared-root-transformed means ± standard error were 0.89 ± 0.06 mg/kg for patients receiving the blocks versus 1.05 ± 0.06 mg/kg for control patients (p = 0.04; raw medians 0.81 [IQR 0.41-1.04] v 1.10 [IQR 0.78-1.35] mg/kg, respectively). There were no differences in recovery metrics, length of stay, or complications. CONCLUSIONS Bilateral erector spinae blocks were associated with a reduction in opioid use in the first 48 hours after pediatric cardiac surgery compared with a matched cohort from the enhanced recovery program. Larger studies are needed to determine whether this can result in an improvement in recovery and patient satisfaction.
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Affiliation(s)
- Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Morgan L Brown
- Harvard Medical School, Boston, MA; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - M Fernanda Parra
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Lynn A Sleeper
- Harvard Medical School, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Walid Alrayashi
- Harvard Medical School, Boston, MA; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Viviane G Nasr
- Harvard Medical School, Boston, MA; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Susan E Eklund
- Harvard Medical School, Boston, MA; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Joseph P Cravero
- Harvard Medical School, Boston, MA; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Roland Brusseau
- Harvard Medical School, Boston, MA; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
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32
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Faraoni D, Ng WCK. Pro: Early Extubation After Pediatric Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:2539-2541. [PMID: 32561246 DOI: 10.1053/j.jvca.2020.05.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/18/2020] [Indexed: 12/16/2022]
Affiliation(s)
- David Faraoni
- Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada.
| | - William C K Ng
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada; Department of Anesthesia and Pain Management, University Health Network - Toronto General Hospital, Toronto, Canada
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33
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Del Nido PJ. Minimally Invasive Cardiac Surgical Procedures in Children. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2020; 15:95-98. [PMID: 32352909 DOI: 10.1177/1556984520914283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Pedro J Del Nido
- 1811 Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, MA, USA
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34
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Karamlou T, Najm HK, Latifi S, Sing-Si M. Commentary: False start-Offense: Premature data may cost more than five yards. J Thorac Cardiovasc Surg 2020; 160:1324-1326. [PMID: 32014326 DOI: 10.1016/j.jtcvs.2019.12.086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 12/22/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Tara Karamlou
- Division of Pediatric Cardiac Surgery, Cleveland Clinic and the Heart Vascular Institute, Cleveland, Ohio.
| | - Hani K Najm
- Division of Pediatric Cardiac Surgery, Cleveland Clinic and the Heart Vascular Institute, Cleveland, Ohio
| | - Samir Latifi
- Department of Pediatric Critical Care, Cleveland Clinic Children's, Cleveland, Ohio
| | - Ming Sing-Si
- Department of Cardiac Surgery, Section of Pediatric Cardiovascular Surgery, University of Michigan, C. S. Mott Children's Hospital, Ann Arbor, Mich
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