Paediatric cardiac anaesthesia in a developing country. Guatemala Heart Team

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

International quality improvement initiatives

Across the globe, the implementation of quality improvement science and collaborative learning has positively affected the care and outcomes for children born with CHD. These efforts have advanced the collective expertise and performance of inter-professional healthcare teams. In this review, we highlight selected quality improvement initiatives and strategies impacting the field of cardiovascular care and describe implications for future practice and research. The continued leveraging of technology, commitment to data transparency, focus on team-based practice, and recognition of cultural norms and preferences ensure the success of sustainable models of global collaboration.

Short-term medical service trips: a systematic review of the evidence

Short-term medical service trips (MSTs) aim to address unmet health care needs of low- and middle-income countries. The lack of critically reviewed empirical evidence of activities and outcomes is a concern. Developing evidence-based recommendations for health care delivery requires systematic research review. I focused on MST publications with empirical results. Searches in May 2013 identified 67 studies published since 1993, only 6% of the published articles on the topic in the past 20 years. Nearly 80% reported on surgical trips. Although the MST field is growing, its medical literature lags behind, with nearly all of the scholarly publications lacking significant data collection. By incorporating data collection into service trips, groups can validate practices and provide information about areas needing improvement.

An audit of intensive care unit admission in a pediatric cardio-thoracic population in Enugu, Nigeria

INTRODUCTION

The study aimed to perform an audit of intensive care unit admissions in the paediatric cardio-thoracic population in Enugu, Nigeria and examine the challenges and outcome in this high risk group. Ways of improvement based on this study are suggested.

METHODS

The hospital records of consecutive postoperative pediatric cardiothoracic admissions to the multidisciplinary and cardiothoracic intensive care units of the University of Nigeria Teaching Hospital (UNTH) Enugu, Nigeria to determine their Intensive Care Unit management and outcome over a 2 year span--June 2002 to June 2004--were retrospectively reviewed. Data collected included patient demographics, diagnosis, duration of stay in the intensive care unit, therapeutic interventions and outcome.

RESULTS

There were a total of thirty consecutive postoperative paediatric admissions to the intensive care unit over the 2 year study period. The average age of the patients was 5.1 years with a range of 2 weeks to 13 years. Twelve patients had cardiac surgery with cardiopulmonary bypass (CPB), three patients had colon transplant, four patients had pericardiotomy/pericardicectomy, and five patients had diagnostic/therapeutic bronchoscopy. The remaining patients had the following surgeries, thoracotomy for repair of diaphragmatic hernia/decortications, delayed primary repair of esophageal atresia and gastrostomy. Two patients had excision of a cervical teratoma and cystic hygroma. The average duration of stay in the intensive care unit was 6.2 days. Ten patients (33%) received pressor agents for organ support. Five patients (17%) had mechanical ventilation, while twenty-five patients (83%) received oxygen therapy via intranasal cannula or endotracheal tube. Seven patients (23%) received blood transfusion in the ICU. There was a 66% survival rate with ten deaths.

CONCLUSION

Paediatric cardio-thoracic services in Nigeria suffer from the problems of inadequate funding and manpower flight to better paying jobs. Government should invest in their people by introducing insurance schemes for cardiac patients. Training programmes for members of cardio-thoracic units in countries with advanced health care systems and hands on experience should be encouraged. Otherwise for a majority of children with heart disease, it will be a slow painful wait for the inevitable.

Factors associated with early extubation after cardiac surgery in young children

OBJECTIVE

Children undergoing congenital heart surgery require mechanical ventilation. We sought to identify pre- and intraoperative factors (PrO, IO) associated with successful early extubation <24 hrs.

DESIGN AND PATIENTS

We performed a retrospective chart review of children <36 months old who underwent congenital heart surgery from January 1998 to July 1999.

SETTING

Pediatric intensive care unit in a children's hospital.

MEASUREMENTS

Generalized Estimating Equation models were fit to assess the association between PrO and IO and early extubation while accounting for the correlation between surgeries performed on the same patient. Estimated odds ratios (EOR) and 95% confidence intervals were calculated. Multivariable models were constructed using a forward selection process with inclusion criteria of p<.05. Multivariable models, which included PrO and IO variables, were adjusted for procedure group. The area under the receiver operating characteristic curve was computed for each model.

RESULTS

A total of 203 children underwent 219 surgeries; 103 (47%) children were extubated in <24 hrs, with only one (1%) failed extubation. PrO variables associated with successful early extubation included age >6 months (EOR, 6.1), absence of pulmonary hypertension (EOR, 9.1), gestational age >36 wks (EOR, 4.6), and absence of congestive heart failure (EOR, 2.4). IO variables were less likely to be associated with successful early extubation. Our model of PrO variables with multiple factors showed that presence of two factors was associated with an EOR of 4.2 for successful early extubation compared with children with zero or one factor. Presence of three and four factors was associated with an EOR of 18.0 and 76.5, respectively. The area under the receiver operating characteristic curve for this model is 0.816. Incision type, complex vs. simple procedure, and palliative vs. complete repair were not associated with success of early extubation.

CONCLUSIONS

Early extubation is possible in many very young children undergoing congenital heart surgery, with a low rate of failed extubation. The model would be improved by prospective validation with larger numbers at multiple institutions.

Very early extubation in children after cardiac surgery

OBJECTIVE

Very early extubation of children after cardiac surgery has been suggested as a safe alternative to prolonged postoperative intubation but is still not common practice. Studies of early extubation in children may not have described reasons for failure to extubate, or have included nonbypass or only low-risk repairs. We present our experience with very early extubation in an inclusive group of children after cardiac surgery.

DESIGN

Retrospective chart review.

SETTING

University hospital operating room and pediatric intensive care unit (ICU).

PATIENTS

A total of 102 consecutive children (age <18 yrs) undergoing cardiac surgery requiring cardiopulmonary bypass.

MAIN RESULTS

Forty-eight patients were extubated early (88% in the operating room, 12% on arrival in ICU). Patients extubated late were younger (13.8 +/- 26.2 vs. 47.6 +/- 44.5 months), smaller (8.1 +/- 10.7 vs.17.5 +/- 14.2 kg), and had higher ASA scores than patients extubated early (p <.001 for all). The youngest patient extubated early was 2 months old (range, 2-192 months). Paco2 on ICU arrival was higher in the early extubation group (52.4 +/- 6.9 vs. 41.2 +/- 14.7 mm Hg [7.0 +/- 0.9 vs. 5.5 +/- 2.0 kPa], p <.001), and pH was lower (7.27 +/- 0.04 vs. 7.37 +/- 0.16, p <.001). Use of subarachnoid morphine did not affect ability to extubate early. No patients in the early extubation group required special airway support, reintubation, or increased inotropic support after ICU admission.

CONCLUSIONS

Successful early extubation of even young children is possible and easily accomplished in most children undergoing cardiopulmonary bypass, even with complex procedures, but advantages of extubation in the operating room vs. immediate ICU extubation remain unclear. Transient mild-to-moderate mixed acidosis is common and requires no treatment. Full implementation requires acceptance by surgical and ICU staffs.