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Özçobanoğlu S, Gündüz E, Tekerek NÜ. Comparison of ultrafast and fast track extubation after secundum atrial septal defect surgery in pediatric age group. Acta Chir Belg 2024; 124:217-222. [PMID: 37937527 DOI: 10.1080/00015458.2023.2281097] [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] [Received: 04/17/2023] [Accepted: 11/03/2023] [Indexed: 11/17/2023]
Abstract
BACGROUND Patients who underwent ultrafast track on the operating table and fast track extubation in the pediatric intensive care unit for 2 to 6 h after secundum atrial septal defect surgery in the pediatric age group were compared. METHODS Between January 2013 and February 2017, 60 pediatric patients (24 boys, 36 girls; Mean age 7.5 ± 4.6 years) whose secundum atrial defect was closed were retrospectively analyzed. The patients were separated as those who were extubated on the operating table (Group1,n = 28) and those extubated in the pediatric intensive care unit within 2-6 h postoperatively (Group2,n = 32). RESULTS No difference was found in demographic data and preoperative catheter information between the groups. Cardiopulmonary bypass time was 20(18-25)/27.5(20-30)minutes (p:0.001), the cross-clamp time was 10(10-15)/15(11-20)minutes(p:0.004), the postoperative drainage amount was 50(25-50)/60(32.5-100)ml(p:0.013), the length of stay in the intensive care unit was 1(1--1)/1(1-2)day(p:0.025), the length of stay after intensive care was 3(2-3)/3(3-4)days(p:0.001) and the total hospital stay was 4(3-4)/5(4-5.5) days (p < 0.001), which were respectively shorter for the group 1 compared to 2. Postoperative blood product replacement, positive inotrope support, pericardial effusion, mortality, and morbidity were not detected in either groups. CONCLUSION In this study, it was observed that the UFT extubation was safe for the patients who were operated for secundum ASD, in the pediatric age group, and had a cross-clamp time not exceeding 15 min. It was found that the amount of drainage, length of stay in the intensive care unit, post-intensive care unit, and the total hospital stay of patients extubated on the operating table were shorter.
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Affiliation(s)
- Salih Özçobanoğlu
- Department of Cardiovascular Surgery, Akdeniz University, Antalya, Turkey
| | - Emel Gündüz
- Department of Anesthesiology and Reanimation, Akdeniz University, Antalya, Turkey
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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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Parody Cuerda G, Jiménez Del Valle JR, Fernández López AR, Barquero Aroca JM. Ultra-fast track extubation protocol following cardiovascular surgery: Predictors of failure and outcomes. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:259-268. [PMID: 37150440 DOI: 10.1016/j.redare.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 12/16/2021] [Indexed: 05/09/2023]
Abstract
OBJECTIVES Identifying independent predictor factors of failure of ultra-fast track (UFT) extubation and to compare in-hospital outcomes with UFT extubation versus fast track (FT) extubation after cardiovascular surgery in adults. MATERIAL AND METHODS Retrospective analysis of 1498 consecutive patients aged over 18 years-old undergoing cardiovascular surgery at a single institution. Between December 2014 and December 2016, FT extubation was used (N = 713) while, between December 2016 and December 2018, all patients were preoperatively considered suitable for UFT extubation (N = 785). In this instance, a standardized anaesthetic protocol was applied in all cases. The decision to not extubate in the operating room (OR) was based on intraoperative haemodynamic and ventilation. RESULTS Extubation in the OR was possible in 699 (89%) patients. Significant independent predictors factors of UFT extubation failure were: preoperative NYHA class III-IV, myocardial infarction within two days prior to surgery, preoperative intra-aortic balloon counterpulsation, urgent/emergent surgery, intraoperative transfusion of platelets and intraoperative inotropic and vasopressor support. UFT extubation was associated with lower rates of cardiovascular complications such as congestive cardiac insufficiency (OR: 1,57; 95% CI: 1,13-2,19; p = 0,008) and new-onset postoperatory atrial fibrillation (OR: 1,40; 95% CI: 1,06-1,86; p = 0,020). Patient extubated in the OR presented lower risk of overall complications, shorter intensive care unit stay and higher short-term survival, although, no statistically significance was found when performing the multivariate adjustment. CONCLUSIONS A routine immediate extubation in the OR following adult cardiovascular surgery is a feasible and safe practice, associated with low cardiovascular morbidity.
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Affiliation(s)
- G Parody Cuerda
- Servicio de Cirugía Cardiovascular, Hospital Universitario Virgen Macarena, Sevilla, Spain.
| | - J R Jiménez Del Valle
- Unidad de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - A R Fernández López
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - J M Barquero Aroca
- Servicio de Cirugía Cardiovascular, Hospital Universitario Virgen Macarena, Sevilla, Spain
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Martins RS, Waqar U, Raza HA, Memon MKY, Akhtar S. Assessing Risk Factors for Prolonged Intensive Care Unit Stay After Surgery for Adult Congenital Heart Disease: A Study From a Lower-Middle-Income Country. Cureus 2023; 15:e35606. [PMID: 37007353 PMCID: PMC10063249 DOI: 10.7759/cureus.35606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/05/2023] Open
Abstract
Background Prolonged post-surgery intensive care unit (ICU) stay for congenital heart disease (CHD) has been explored in the pediatric population. However, there is limited data for adult CHD (ACHD), also called grown-up congenital heart (GUCH) disease, especially in low-resource countries where intensive care beds are scarce. This study identifies factors associated with prolonged ICU stay following surgery for ACHD in Pakistan, a lower-middle-income country (LMIC). Methods This retrospective study included all adult patients (⩾18 years) who underwent cardiac surgery with cardiopulmonary bypass for their CHD from 2011-2016 at a tertiary-care private hospital in Pakistan. Prolonged ICU stay was defined as stay >6 days (75th percentile). Regression analysis was used to explore risk factors of prolonged ICU stay. Results A total of 166 patients (53.6% males) with a mean age of 32.05 ± 12.11 years were included. Atrial septal defect repair was the most common surgery (42.2%). Most patients were categorized as Risk Adjustment for Congenital Heart Surgery 1 (RACHS-1) Category 1 (51.8%) and Category 2 (30.1%). Forty-three of 166 patients (25.9%) experienced prolonged ICU stay. Complications occurred in 38.6% of patients postoperatively, with the most common being acute kidney injury (29.5%). On multivariable logistic regression adjusted for age, gender, and RACHS-1 categories, intraoperative inotrope score, cardiopulmonary bypass time, aortic cross-clamp time duration of mechanical ventilation, and postoperative acute kidney injury (AKI) were associated with prolonged ICU stay. Conclusion Surgeons managing ACHD in LMICs must strive for shorter operative durations and the judicious use of intraoperative inotropes in addition to anticipating and promptly managing postoperative complications such as AKI, to minimize ICU stay in countries where intensive care beds are a scarce resource.
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Kaushik J, Vijayakumar R, Soundaravalli B, Shoba M, Jenit O, Anisha S. One-year experience after adoption of an on-table extubation protocol following pediatric cardiac surgery. Ann Card Anaesth 2022; 25:422-428. [PMID: 36254905 PMCID: PMC9732950 DOI: 10.4103/aca.aca_58_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/10/2021] [Accepted: 07/12/2021] [Indexed: 06/16/2023] Open
Abstract
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.
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Affiliation(s)
- Jothinath Kaushik
- Department of Cardiac Anesthesiology, G Kuppuswamy Naidu Memorial Hospital, Coimbatore, Tamil Nadu, India
| | - Raju Vijayakumar
- Department of Cardiac Anesthesiology, G Kuppuswamy Naidu Memorial Hospital, Coimbatore, Tamil Nadu, India
| | | | - Menon Shoba
- Department of Cardiac Surgery, G Kuppuswamy Naidu Memorial Hospital, Coimbatore, Tamil Nadu, India
| | - Osborn Jenit
- Department of Community Medicine, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Shajan Anisha
- Department of Cardiac Surgery, G Kuppuswamy Naidu Memorial Hospital, Coimbatore, Tamil Nadu, India
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Trends in Time to Extubation for Pediatric Postoperative Cardiac Patients and Its Correlation With Changes in Clinical Outcomes: A Virtual PICU Database Study. Pediatr Crit Care Med 2022; 23:544-554. [PMID: 35435884 DOI: 10.1097/pcc.0000000000002950] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Mechanical ventilation is often used in children after cardiac surgery but can impair hemodynamics and cause lung injury. Early extubation may improve ICU length of stay and survival. We aimed to describe trends in early extubation rates and evaluate if centers that more commonly practice early extubation have better severity-adjusted outcomes. DESIGN Retrospective analysis was performed of admissions in the Virtual Pediatric Systems (VPS, LLC) database from 2009 to 2018. Early extubation was defined as patients extubated in the operating room or within 6 hours of PICU admission. SETTING PICUs participating in the VPS database. PATIENTS Children in the VPS database who underwent cardiac surgery. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS Among 69,739 subjects, 20% were neonates, 47% underwent early extubation, 5.3% failed extubation, and 2.5% died. Overall, early extubation rates did not change over the study period. Centers were placed in one of four groups based on their early extubation rate in lower complexity surgeries. Centers that most commonly used early extubation had more ICU-free time among all patients in univariable analysis (lowest early extubation group, 23.8 d [interquartile range, 18.2-25.9 d]; highest early extubation group, 24.7 d [20.0-26.2 d]; p < 0.001). After adjusting for center volume, sex, age, surgical complexity, and preoperative ICU admission, increasing center-level early extubation rates were not associated with more ICU-free days. Higher center-level early extubation rate was not associated with mortality in univariable or multivariable analysis but was associated with decreased extubation failure rate (lowest early extubation group, 6.4%; highest early extubation group, 3.6%; p < 0.001). CONCLUSIONS In this large, multicenter database study, early extubation rates in postoperative cardiac patients did not significantly change between 2009 and 2018. Centers that performed early extubation more frequently did not have shorter ICU stays or difference in mortality rates but did have lower reintubation rates.
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Katz AJ, Lion RP, Martens T, Newcombe J, Razzouk A, Shih W, Amirnovin R, Gordon BM. Pediatric Surgical Pulmonary Valve Replacement Outcomes After Implementation of a Clinical Pathway. World J Pediatr Congenit Heart Surg 2022; 13:420-425. [PMID: 35757942 DOI: 10.1177/21501351221098127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Standardization of perioperative care can reduce resource utilization while improving patient outcomes. We sought to describe our outcomes after the implementation of a perioperative clinical pathway for pediatric patients undergoing elective surgical pulmonary valve replacement and compare these results to previously published national benchmarks. METHODS A retrospective single-center descriptive study was conducted of all pediatric patients who underwent surgical pulmonary valve replacement from 2017 through 2020, after the implementation of a clinical pathway. Outcomes included hospital length of stay and 30-day reintervention, readmission, and mortality. RESULTS Thirty-three patients (55% female, median age 11 [7, 13] years, 32 [23, 44] kg) were included in the study. Most common diagnosis and indication for surgery was Tetralogy of Fallot (61%) with pulmonary valve insufficiency (88%). All patients had prior cardiac surgery. Median hospital length of stay was 2 [2, 2] days, and longest length of stay was three days. There were no 30-day readmissions, reinterventions, or mortalities. Median follow-up time was 19 [9, 31] months. CONCLUSIONS Formalization of a perioperative surgical pulmonary valve replacement clinical pathway can safely promote short hospital length of stay without any short-term readmissions or reinterventions, especially when compared with previously published benchmarks. Such formalization enables the dissemination of best practices to other institutions to reduce hospital length of stay and limit costs.
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Affiliation(s)
- Alex J Katz
- Department of Pediatrics, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Richard P Lion
- Department of Pediatrics, Division of Critical Care, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Timothy Martens
- Department of Cardiovascular and Thoracic Surgery, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Jennifer Newcombe
- Department of Cardiovascular and Thoracic Surgery, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Anees Razzouk
- Department of Cardiovascular and Thoracic Surgery, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Wendy Shih
- School of Public Health, 4608Loma Linda University, Loma Linda, CA, USA
| | - Rambod Amirnovin
- Department of Pediatrics, Division of Critical Care, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Brent M Gordon
- Department of Pediatrics, Division of Cardiology, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
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Beshish AG, Fundora MP, Aronoff E, Rao N, Kelleman MS, Shaw FR, Maher KO, Wolf M. Prevalence, Risk Factors, and Etiology of Extubation Failure in Pediatric Patients After Cardiac Surgery. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0041-1742253] [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
AbstractIn this article, our primary objective was to investigate the prevalence and etiology of extubation failure (EF) in patients following cardiac surgery for congenital heart disease. Secondarily, we examined the association of different risk factors with EF. This was single-center retrospective study in a 27-bed cardiac intensive care unit at a quaternary children's hospital. All patients between 0 and 18 years of age who underwent congenital cardiac surgery from January 2008 to September 2019 were included. During the study period, among 8,750 surgical encounters, 257 (2.9%) failed extubation, defined as reintubation within 48 hours from extubation. EF patients were younger, smaller, more likely to have genetic syndromes, higher Society of Thoracic Surgeons and the European Association for Cardio-Thoracic Surgery (STAT) mortality scores, single-ventricle physiology, longer cardiopulmonary bypass (CPB) and cross-clamp (XC) times, longer mechanical ventilation (MV) duration, and higher mortality (p <0.05). In a univariate analysis, EF patients when compared to matched controls by age, gender, and STAT score, and genetic syndrome, particularly heterotaxy, were associated with increased odds of EF (p <0.05). In a multivariable logistic regression of the entire cohort, the presence of any genetic syndrome was associated with higher odds of EF (p <0.05). In a subgroup of neonates, a univariate analysis was performed and multivariable analysis was attempted, but both did not achieve statistical significance. In summary, EF after congenital cardiac surgery is associated with younger age, lower weight, single-ventricle physiology, longer CPB and XC times, longer duration of MV, and genetic syndromes. Patients failing extubation have increased morbidity and mortality. Recognition of these risk factors may provide clinicians the ability to identify patients at high risk allowing for timely intervention to limit adverse outcomes.
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Affiliation(s)
- Asaad G. Beshish
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Michael P. Fundora
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Elizabeth Aronoff
- Emory University School of Medicine, Atlanta, Georgia, United States
| | - Nikita Rao
- Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Michael S. Kelleman
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Fawwaz R. Shaw
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Kevin O. Maher
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Michael Wolf
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, United States
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Maddali M, Al Shamsi F, Arora N, Venkatachlam R, Sathiya P. Assessment of stress response attenuation with caudal morphine using a surrogate marker during pediatric cardiac surgery. Ann Card Anaesth 2022; 25:61-66. [PMID: 35075022 PMCID: PMC8865338 DOI: 10.4103/aca.aca_6_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Measurement of biomarkers representing sympathetic tone and the surgical stress response are helpful for objective comparison of anesthetic protocols. Aims: The primary aim was to compare changes in chromogranin A levels following pump pediatric cardiac surgery between children who received bolus caudal morphine and those who received a conventional intravenous narcotic-based anesthesia regime. The secondary objectives were to compare hemodynamic responses to skin incision and the magnitude of the rise in blood sugar values between the groups. Settings and Design: A prospective observational study at a tertiary cardiac center. Measurements and Methods: Sixty pediatric cardiac surgical patients were randomized to Group I [n = 30] to receive intravenous narcotic-based anesthesia and Group II [n = 30] to receive single-shot caudal morphine. Baseline and postoperative chromogranin A levels, the hemodynamic response to skin incision, changes in blood sugar levels, and the total intravenous narcotic dose administered were recorded for each participant. Statistical Analysis: Pearson's Chi-squared test was used for comparison of categorized variables, and Mann–Whitney test was used for the analysis of continuous data. Results: Changes in chromogranin A levels and blood sugar levels were comparable in both groups. Group II received a lower narcotic dosage (P ≤ 0.001), and the response to skin incision as reflected by systolic pressure rise was less (P = 0.006). Conclusions: Surgical stress response attenuation was similar to caudal morphine as compared with intravenous narcotic-based anesthesia techniques as reflected by a similar increase in chromogranin A levels.
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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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The utilization of caudal hydromorphone for fast-tracking in congenital cardiac surgery in a tertiary-care Children's hospital: An audit. J Clin Anesth 2021; 72:110314. [PMID: 33895545 DOI: 10.1016/j.jclinane.2021.110314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/17/2021] [Accepted: 04/03/2021] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE Our study sought to audit our institutional practice of routine single-shot caudal epidural hydromorphone injection in children undergoing congenital cardiothoracic surgery to assess perioperative pain control and evaluate for any caudal complications. DESIGN Retrospective observational study of all patients that received a caudal hydromorphone injection as part of the anesthetic for their cardiac surgical operation between January 2017 and July 2019. SETTING Pediatric Cardiothoracic Operating Room (OR), Cardiac Intensive Care Unit. PATIENTS One hundred and twenty-seven patients that received caudal hydromorphone as part of their anesthetic for a cardiac surgical operation. INTERVENTIONS Caudal epidural injection performed immediately following induction of anesthesia utilizing only hydromorphone. MEASUREMENTS The primary outcome was well-controlled pain, defined as a score of <4/10 on rFLACC or verbal pain scoring. Secondary outcome measures included in-OR extubation, pain service duration (from first assessment to "sign-off"), complications related to the caudal block, intensive care unit (ICU) length of stay (LOS), and Hospital LOS. MAIN RESULTS One hundred and nine patients were included in the final analysis. Pain was "well-controlled" on average in 96.3% of patients (105/109). Average pain in the 24-h post-block period was 1.67 (SD = 2.37), with median pain score of 0 [0-3]. Peak pain score remained <4/10 for the entire 24-h post-block period in 22% of patients. 77.1% of caudal hydromorphone patients were extubated in the operating room. The median time to heparinization post-block was 108 min, beyond the ASRA recommendation of 60 min for neuraxial procedures. There were two caudal-related complications: one subcutaneous injection, and one instance of a time to heparinization of less than 60 min (56 min). Neither caudal complication led to patient harm. CONCLUSION Caudal hydromorphone injection can safely contribute to achieving "well-controlled" pain in the pediatric cardiac surgical population when used as a component of a perioperative pain control plan.
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Baehner T, Kiefer N, Ghamari S, Graeff I, Huett C, Pflugradt S, Sendzik B, Heinze I, Mueller M, Schindler E, Duerr GD, Ellerkmann R, Velten M. A National Survey: Current Clinical Practice in Pediatric Anesthesia for Congenital Heart Surgery. World J Pediatr Congenit Heart Surg 2021; 11:257-264. [PMID: 32294007 DOI: 10.1177/2150135120902122] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Providing anesthesia for pediatric patients undergoing congenital cardiac surgery is complex and requires profound knowledge and clinical experience. Prospective studies on best anesthetic management are missing, partially due to different standards. The aim of the present study was to survey the current standard practice in anesthetic management in pediatric cardiac surgical centers in Germany. METHODS All 78 cardiac surgical centers in Germany were reviewed for a congenital cardiac surgery program. Centers with an active program for congenital cardiac surgery were interviewed to participate in the present online questionnaire to assess their current anesthetic practice. RESULTS Twenty-seven German centers running an active program for congenital heart surgery were identified, covering more than 3,000 pediatric cardiac surgeries annually. Of these centers, 96.3% (26/27) participated in our survey. Standard induction agents were etomidate in 26.9% (7/26), propofol in 19.2% (5/26), a combination of benzodiazepines and ketamine in 19.2% (5/26), and barbiturates in 11.5% (3/26). General anesthesia was preferentially maintained using volatile agents, 61.5% (16/26), with sevoflurane being the most common volatile agent within this group, 81.2% (13/16). Intraoperative first-choice/first-line inotropic drug was epinephrine, 53.8% (14/26), followed by milrinone, 23.1% (6/26), and dobutamine 15.4% (4/26). Fast-track programs performing on-table extubation depending on the type of surgical procedure were established at 61.5% (16/26) of the centers. CONCLUSION This study highlights the diversity of clinical standards in pediatric cardiac anesthesia for congenital cardiac surgery in Germany.
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Affiliation(s)
- Torsten Baehner
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University, University Medical Center, Bonn, Germany
| | - Nicholas Kiefer
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University, University Medical Center, Bonn, Germany
| | - Shahab Ghamari
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University, University Medical Center, Bonn, Germany
| | - Ingo Graeff
- Emergency Department, Rheinische Friedrich-Wilhelms-University, University Medical Center, Bonn, Germany
| | - Christopher Huett
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University, University Medical Center, Bonn, Germany
| | - Stefan Pflugradt
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University, University Medical Center, Bonn, Germany
| | - Bjoern Sendzik
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University, University Medical Center, Bonn, Germany
| | - Ingo Heinze
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University, University Medical Center, Bonn, Germany
| | - Matthias Mueller
- Pediatric Heart Centre, Justus-Liebig University, Giessen, Germany
| | - Ehrenfried Schindler
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University, University Medical Center, Bonn, Germany
| | - Georg Daniel Duerr
- Department of Cardiac Surgery, Rheinische Friedrich-Wilhelms-University, University Medical Center, Bonn, Germany
| | - Richard Ellerkmann
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University, University Medical Center, Bonn, Germany.,Department of Anesthesiology, Klinikum Dortmund, Dortmund, Germany
| | - Markus Velten
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University, University Medical Center, Bonn, Germany
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Sahajanandan R, Varsha AV, Kumar DS, Kuppusamy B, Karuppiah S, Shukla V, Thankachen R. Efficacy of paravertebral block in "Fast-tracking" pediatric cardiac surgery - Experiences from a tertiary care center. Ann Card Anaesth 2021; 24:24-29. [PMID: 33938827 PMCID: PMC8081147 DOI: 10.4103/aca.aca_83_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Fast tracking plays a crucial role in reducing perioperative morbidity and financial burden by facilitating early extubation and discharge from hospital. Paravertebral block (PVB) is becoming more popular in paediatric surgeries as an alternative to epidural and caudal analgesia. There is scarcity of data regarding the efficacy and safety of PVB in paediatric cardiac surgery. Methods: We performed a review of records of paediatric cardiac patients who underwent cardiac surgery under general anaesthesia with single shot PVB and compared the analgesia and postoperative outcomes with matched historical controls who underwent cardiac surgery with same anaesthesia protocol without PVB. Results: The data from 200 children were analysed. 100 children who received paravertebral block were compared with a matched historical controls. The median time to extubation was shorter in the PVB group (0 hr, IQR 0-3 hrs) compared to the control group (16 hrs, IQR 4-20 hrs) (P value 0.017*). Intraoperative and postoperative fentanyl requirement was much lower in the PVB group (3.49 (0.91)) compared to the control group (9.86 (1.37)) P value <0.01*. Time to first rescue dose of analgesic was longer (7 hrs vs 5 hrs, P 0.01*), while time to extubation and duration of ICU stay were significantly less in PVB group . Mean postoperative pain scores were significantly lower in the PVB group at the time of ICU admission (0.85 vs 3.12, P 0.001*) till 4 hours (2.11 vs 3.32, P 0.001*). Conclusion: PVB provides an effective and safe anaesthetic approach which can form an important component of “fast-track” care in paediatric cardiac surgery.
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Affiliation(s)
- Raj Sahajanandan
- Department of Anaesthesia, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - A V Varsha
- Department of Cardiothoracic Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - D Sathish Kumar
- Department of Anaesthesia, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Balaji Kuppusamy
- Department of Anaesthesia, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Sathappan Karuppiah
- Department of Cardiothoracic Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Vinayak Shukla
- Department of Cardiothoracic Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Roy Thankachen
- Department of Cardiothoracic Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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Abstract
OBJECTIVES Early extubation following pediatric cardiac surgery is common, but debate exists whether location affects outcome, with some centers performing routine early extubations in the operating room (odds ratio) and others in the cardiac ICU. We aimed to define early extubation practice variation across hospitals and assess impact of location on hospital length-of-stay and other outcomes. DESIGN Secondary analysis of the Pediatric Cardiac Critical Care Consortium registry. SETTING Twenty-eight Pediatric Cardiac Critical Care Consortium hospitals. PATIENTS Patients undergoing Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality category 1-3 operations between August 2014 and February 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We defined early extubation as extubation less than 6 hours after postoperative admission. Hospitals were categorized based on the proportion of their early extubation patients who underwent an odds ratio extubation. Categories included low- (< 50% of early extubation, n = 12), medium- (50%-90%, n = 8), or high- (> 90%, n = 8) frequency odds ratio early extubation centers. The primary outcome of interest was postoperative hospital length-of-stay. We analyzed 16,594 operations (9,143 early extubation, 55%). Rates of early extubation ranged from 16% to 100% across hospitals. Odds ratio early extubation rates varied from 16% to 99%. Patient characteristics were similar across hospital odds ratio early extubation categories. Early extubation rates paralleled the hospital odds ratio early extubation rates-77% patients underwent early extubation at high-frequency odds ratio extubation centers compared with 39% at low-frequency odds ratio extubation centers (p < 0.001). High- and low-frequency odds ratio early extubation hospitals had similar length-of-stay, cardiac arrest rates, and low mortality. However, high-frequency odds ratio early extubation hospitals used more noninvasive ventilation than low-frequency hospitals (15% vs. 9%; p < 0.01), but had fewer extubation failures (3.6% vs. 4.5%; p = 0.02). CONCLUSIONS Considerable variability exists in early extubation practices after low- and moderate-complexity pediatric cardiac surgery. In this patient population, hospital length-of-stay did not differ significantly between centers with different early extubation strategies based on location or frequency.
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Li L, Jiang Y, Zhang W. Sugammadex for Fast-Track Surgery in Children Undergoing Cardiac Surgery: A Randomized Controlled Study. J Cardiothorac Vasc Anesth 2020; 35:1388-1392. [PMID: 32962936 DOI: 10.1053/j.jvca.2020.08.069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/17/2020] [Accepted: 08/31/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the safety and efficacy of sugammadex for fast-track surgery in children undergoing cardiac surgery. DESIGN This was a prospective, randomized, controlled clinical study. SETTING University hospital. PARTICIPANTS The study comprised 60 children undergoing cardiac surgery. INTERVENTIONS The children in group S received sugammadex, 4 mg/kg, for reversal of neuromuscular block, and the children in group N received neostigmine, 30 µg/kg, and atropine, 15 µg/kg. MEASUREMENTS AND MAIN RESULTS The recovery time to a train-of-four of 0.9 and extubation time were significantly shorter in the group S than in group N (3.4 ± 1.2 min v 76.2 ± 20.5 min and 31.0 ± 6.4 min v 125.2 ± 21.6 min, respectively; p < 0.01). The heart rate after drug administration was higher in group S than in group N (102.7 ± 9.4 beats/min v 96.9 ± 8.5 beats/min; p = 0.03), whereas the mean arterial pressure after drug administration was similar in both groups. The length of hospital stay was shorter in group S (5.8 ± 1.0 v 6.5 ± 0.9 days; p = 0.03), and the hospitalization expenses were decreased in group S compared with that of group N ($1,036 ± $114 v $1,286 ± $187; p < 0.01). The incidence of postoperative atelectasis was less in group S than in group N (0 v 20%; p = 0.024). CONCLUSION Sugammadex can shorten the extubation time and reduce the incidence of postoperative atelectasis, with fewer adverse events, in children undergoing cardiac surgery. It may be beneficial to use sugammadex for fast-track surgery in children undergoing cardiac surgery.
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Affiliation(s)
- L Li
- Department of Anesthesiology, Wenzhou Central Hospital, Wenzhou, China
| | - Y Jiang
- Department of Anesthesiology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - W Zhang
- Department of Anesthesiology, Women and Children's Hospital of Jiaxing University, Jiaxing, China.
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Bray JP, Adams DR, Phadke AS, Adams PS. Sugammadex Neuromuscular Blockade Reversal Associated With Lower Postoperative Arterial Carbon Dioxide Levels After Congenital Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 35:154-161. [PMID: 32768253 DOI: 10.1053/j.jvca.2020.07.040] [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: 05/18/2020] [Revised: 07/08/2020] [Accepted: 07/10/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare postoperative arterial blood gas samples and requirement for respiratory support between patients who received sugammadex versus neostigmine reversal before extubation after congenital cardiac surgery. DESIGN Retrospective, cross-sectional study. SETTING Single-center, university-based, tertiary care hospital. PARTICIPANTS Patients with congenital heart disease undergoing surgery with cardiopulmonary bypass. INTERVENTIONS Chart review. MEASUREMENTS AND MAIN RESULTS The first postoperative arterial blood gas measurements were abstracted from electronic medical records, and reintubation or use of positive- pressure respiratory support within the first 24 postoperative hours was documented. Of the 237 charts reviewed, 111 (47%) patients received sugammadex reversal and 126 (53%) received neostigmine. Multivariate models showed that patients with 2-ventricle congenital heart disease who received sugammadex had lower postoperative arterial carbon dioxide partial pressure (PaCO2) values (coefficient -3.1, 95% confidence interval [CI] -5.9 to -0.4; p = 0.026) and required less- noninvasive positive- pressure ventilation (odds ratio 0.3, 95% CI 0.1-0.8; p = 0.021). Single-ventricle congenital heart disease patients who received sugammadex had higher postoperative pH values (coefficient 0.04, 95% CI 0.01-0.06; p = 0.01) and lower PaCO2 values (coefficient -5.2, 95% CI -9.6 to -0.8; p = 0.021). CONCLUSION Sugammadex reversal was associated with lower postoperative PaCO2 values. In addition, sugammadex reversal was associated with less need for noninvasive positive- pressure ventilation in 2-ventricle patients. The magnitude of the effect appears modest, therefore the clinical significance remains unclear. Additional studies focused on investigating particular patient populations, such as infants, single-ventricle congenital heart disease, or patients with pulmonary hypertension, are needed to identify whether these patients appreciate a greater benefit from sugammadex reversal.
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Affiliation(s)
- Jacob P Bray
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Douglas R Adams
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Aparna S Phadke
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Phillip S Adams
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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Samuel R, Froese N, Betts K, Gandhi S. Intraoperative Extubation Post Arterial Switch Operation for Transposition of the Great Arteries With Intact Ventricular Septum: A One-Year, Single Center Experience. Semin Thorac Cardiovasc Surg 2020; 33:134-140. [PMID: 32621961 DOI: 10.1053/j.semtcvs.2020.06.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 06/27/2020] [Indexed: 11/11/2022]
Abstract
We sought to examine the clinical impact of intraoperative extubation (IE) in neonates undergoing the arterial switch operation (ASO) for D-transposition of the great arteries with intact ventricular septum (dTGA/IVS). This was a single center retrospective study of patients who underwent ASO for dTGA/IVS in the 12 months after an institutional change in practice favoring IE when clinically feasible. A control group was obtained by identifying the same number of consecutive patients with dTGA/IVS who underwent ASO immediately prior to this institutional change in practice, none of whom were extubated intraoperatively. Primary outcome measures included morbidity, mortality, length of hospital and intensive care unit stay and reintubation rates. There were no significant differences in the preoperative and operative characteristics between the 2 groups. Of the 10 patients who underwent ASO for dTGA/IVS in the 12 months post institutional change in practice, all (100%) were extubated intraoperatively and none (0%) required reintubation. The median length of intensive care unit stay was 2 days for both the intraoperative and non-IE groups (mean 2.2 and 3 days respectively). The median length of stay in hospital was 4 days in the IE group and 5.5 days in the non-IE group (mean 4.5 and 6 days respectively). No patients died and there was no significant difference in morbidity between the 2 groups. Our data suggests IE post ASO for dTGA/IVS is safe and displays a statistically insignificant trend toward earlier discharge from hospital.
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Affiliation(s)
- Rosh Samuel
- Division of Cardiology, Department of Pediatrics, British Columbia Children's Hospital, 4480 Oak Street, Vancouver, British Columbia, V6H 3V4, Canada.
| | - Norbert Froese
- Division of Pediatric Anesthesia, Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, 4500 Oak Street, Vancouver, British Columbia, V6H 3N1, Canada
| | - Kim Betts
- Faculty of Health Science, School of Public Health, Curtin University, GPO Box U1987, Perth, Western Australia, 6845, Australia
| | - Sanjiv Gandhi
- Division of Pediatric Cardiovascular & Thoracic Surgery, Department of Surgery, Faculty of Medicine, University of British Columbia, 4480 Oak Street, Vancouver, British Columbia, V6H 3V4, Canada
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Effects of sugammadex on postoperative respiratory management in children with congenital heart disease: a randomized controlled study. Biomed Pharmacother 2020; 127:110180. [PMID: 32353822 DOI: 10.1016/j.biopha.2020.110180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 04/07/2020] [Accepted: 04/17/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Early extubation can reduce pulmonary complications in children undergoing cardiac surgery. The aim of this study is to evaluate the effects of sugammadex for postoperative respiratory management in children with congenital heart disease. METHODS Sixty children with congenital heart disease undergoing elective cardiac surgery were divided into group S and group C (30 children in each group). When post tetanic twitches count (PTC) = 1-2 and train-of-four (TOF) = 0, the children in group S received sugammadex4 mg/kg for reversal of neuromuscular block at the end of surgery, and the children in group C received the same volume of normal saline. The recovery time to TOF of 0.9, the mechanical ventilation and extubation times were recorded. On the other side, the hemodynamic parameters before and 5 min after administration, and side effects were also recorded. The levels of C-reactive protein (CRP) and procalcitonin (PCT) before and 24 h after surgery were measured. RESULTS The recovery time to TOF of 0.9 and extubation time were significantly shorter in the group S than in the group C (4.2 ± 1.4 vs 108.2 ± 26.7 min, 66.3 ± 6.5 vs 171.6 ± 23.1 min, respectively, P < 0.01). The CRP and PCT levels were found to be increased in both groups at postoperative 24 h than before surgery. Further, the levels of PCT and CRP at postoperative 24 h were lower in group S when compared to group C (median, 7 vs 17.5 mg/ml, 1.76 vs 5.22 ng/ml, respectively, P < 0.05). There were no statistical differences observed between the two groups (P> 0.05) with respect to side effects. CONCLUSION Sugammadex is rapid and effective in reversing rocuronium-induced neuromuscular block, and significantly reduces the extubation time and the release of postoperative CRP and PCT in children with congenital heart diseases.
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Nasr VG, DiNardo JA. Con: Extubation in the Operating Room After Pediatric Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:2542-2544. [PMID: 32362543 DOI: 10.1053/j.jvca.2020.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 03/01/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA.
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
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20
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Fast tracking after repair of congenital heart defects. Indian J Thorac Cardiovasc Surg 2020; 37:183-189. [PMID: 32421036 PMCID: PMC7222923 DOI: 10.1007/s12055-020-00924-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 12/30/2019] [Accepted: 01/02/2020] [Indexed: 11/20/2022] Open
Abstract
Fast tracking after repair of congenital heart defects (CHD) is a process involving the reduction of perioperative period by timely admission, early extubation after surgery, short intensive care unit (ICU) stay, early mobilisation, and faster hospital discharge. It requires a coordinated multidisciplinary team involvement. In the last 2 decades, many centres have adopted the fast tracking strategy in paediatric cardiac population, safely and successfully extubating patients in the OR with reported benefits in terms of reduced morbidity and ICU/hospital stay. In this manuscript, we will review the literature available on early extubation after repair of CHD and share our experience with this approach.
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Garg RK, Thareen JK, Mehmood A, Nakao M, Basappanavar V, Jain R, Sam M, Khan AA, Di Donato RM. Implementation of On-table Extubation After Pediatric Cardiac Surgery in the Developing World. J Cardiothorac Vasc Anesth 2020; 34:2611-2617. [PMID: 32057669 DOI: 10.1053/j.jvca.2019.11.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 11/07/2019] [Accepted: 11/14/2019] [Indexed: 11/11/2022]
Abstract
In the recent years there has been increasing trend towards the practice of on-table extubation after pediatric cardiac surgery among practitioner in European and non-European countries. In this article we share our experience with on-table extubation among children after cardiac surgery in the developing world supported with the currently available literature.
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Affiliation(s)
- Rajnish K Garg
- Departments of Cardiac Anesthesia, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates.
| | - Jameel K Thareen
- Cardiac Surgery, Al Qassimi Hospital, Sharjah, United Arab Emirates
| | - Akhter Mehmood
- Pediatric Intensive Care, Dubai Hospital, Dubai, United Arab Emirates
| | - Masakazu Nakao
- Cardiac Surgery Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | - Vikram Basappanavar
- Departments of Cardiac Anesthesia, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | - Richie Jain
- Departments of Cardiac Anesthesia, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | - Monsy Sam
- Clinical Perfusion, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | - Abdul Ahad Khan
- Clinical Perfusion, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | - Roberto M Di Donato
- Cardiac Surgery Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
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Xu J, Zhou G, Li Y, Li N. Benefits of ultra-fast-track anesthesia for children with congenital heart disease undergoing cardiac surgery. BMC Pediatr 2019; 19:487. [PMID: 31829170 PMCID: PMC6907131 DOI: 10.1186/s12887-019-1832-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 11/14/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To compare the outcomes of ultra-fast-track anesthesia (UFTA) and conventional anesthesia in cardiac surgery for children with congenital heart disease (CHD) and low birth weight. METHODS One hundred and ninety-four CHD children, aged 6 months to 2 years, weighting 5 to 10 kg, were selected for this study. The 94 boys and 100 girls with the American Society of Anesthesiologists (ASA) physical status III and IV were randomly divided into two groups each consisting of 97 patients, and were subjected to ultra-fast-track and conventional anesthesia for cardiac surgery. For children in UFTA group, sevoflurane was stopped when cardiopulmonary bypass (CPB) started and cis-atracurium was stopped at the beginning of rewarming, and remifentanil (0.3 μg/kg/mim) was then infused. Propofol and remifentanil were discontinued at skin closure. 10 min after surgery, extubation was performed in operating room. For children in conventional anesthesia group, anesthesia was given routinely and they were directly sent to ICU with a tracheal tube. Extubation time, ICU stay and hospital stay after operation were recorded. Sedation-agitation scores (SAS) were assessed and adverse reactions as well as other anesthesia -related events were recorded. RESULTS The extubation time, ICU stay and hospital stay were significantly shorter in UFTA group (P < 0.05) and SAS at extubation was lower in UFTA group than in conventional anesthesia group, but similar in other time points. For both groups, no airway obstruction and other serious complications occurred, and incidence of other anesthesia -related events were low. CONCLUSIONS UFTA shortens extubation time, ICU stay and hospital stay for children with CHD and does not increase SAS and incidence of adverse reactions.
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Affiliation(s)
- Jing Xu
- Department of Anesthesiology, China Emergency General Hospital, 29 Liufangnanli Rd, Beijing, 100028, China
| | - Guanghua Zhou
- Department of Anesthesiology, China Emergency General Hospital, 29 Liufangnanli Rd, Beijing, 100028, China
| | - Yanpei Li
- Department of Anesthesiology, China Emergency General Hospital, 29 Liufangnanli Rd, Beijing, 100028, China.
| | - Na Li
- Department of Anesthesiology, China Emergency General Hospital, 29 Liufangnanli Rd, Beijing, 100028, China.
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Garg RK, Thareen JK, Ramaiah AK, Di Donato RM. On-Table Extubation After Norwood Operation. J Cardiothorac Vasc Anesth 2019; 33:2760-2762. [DOI: 10.1053/j.jvca.2019.01.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Indexed: 11/11/2022]
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Changes in Anesthetic and Postoperative Sedation-Analgesia Practice Associated With Early Extubation Following Infant Cardiac Surgery: Experience From the Pediatric Heart Network Collaborative Learning Study. Pediatr Crit Care Med 2019; 20:931-939. [PMID: 31169762 PMCID: PMC6776694 DOI: 10.1097/pcc.0000000000002005] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The Pediatric Heart Network sponsored the multicenter Collaborative Learning Study that implemented a clinical practice guideline to facilitate early extubation in infants after repair of isolated coarctation of the aorta and tetralogy of Fallot. We sought to compare the anesthetic practice in the operating room and sedation-analgesia management in the ICU before and after the implementation of the guideline that resulted in early extubation. DESIGN Secondary analysis of data from a multicenter study from January 2013 to April 2015. Predefined variables of anesthetic, sedative, and analgesia exposure were compared before and after guideline implementation. Propensity score weighted logistic regression analysis was used to determine the independent effect of intraoperative dexmedetomidine administration on early extubation. SETTING Five children's hospitals. PATIENTS A total of 240 study subjects who underwent repair of coarctation of the aorta or tetralogy of Fallot (119 preguideline implementation and 121 postguideline implementation). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinical practice guideline implementation was accompanied by a decrease in the median total intraoperative dose of opioids (49.7 vs 24.0 µg/kg of fentanyl equivalents, p < 0.001) and benzodiazepines (1.0 vs 0.4 mg/kg of midazolam equivalents, p < 0.001), but no change in median volatile anesthetic agent exposure (1.3 vs 1.5 minimum alveolar concentration hr, p = 0.25). Intraoperative dexmedetomidine administration was associated with early extubation (odds ratio 2.5, 95% CI, 1.02-5.99, p = 0.04) when adjusted for other covariates. In the ICU, more patients received dexmedetomidine (43% vs 75%), but concomitant benzodiazepine exposure decreased in both the frequency (66% vs 57%, p < 0.001) and cumulative median dose (0.5 vs 0.3 mg/kg of ME, p = 0.003) postguideline implementation. CONCLUSIONS The implementation of an early extubation clinical practice guideline resulted in a reduction in the dose of opioids and benzodiazepines without a change in volatile anesthetic agent used in the operating room. Intraoperative dexmedetomidine administration was independently associated with early extubation. The total benzodiazepine exposure decreased in the early postoperative period.
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Alam S, Shalini A, Hegde RG, Mazahir R, Jain A. Predictors and outcome of early extubation in infants postcardiac surgery: A single-center observational study. Ann Card Anaesth 2019; 21:402-406. [PMID: 30333334 PMCID: PMC6206803 DOI: 10.4103/aca.aca_209_17] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objective The objective of the current study was to evaluate the timing of first extubation and compare the outcome of patient extubated early with others; we also evaluated the predictors of early extubation in our cohort. Materials and Methods This prospective cohort study included children <1 year of age undergoing surgery for congenital heart disease. Timing of first extubation was noted, and patients were dichotomized in the group taking 6 h after completion of surgery as cutoff for early extubation. The outcome of the patients extubated early was compared with those who required prolonged ventilation. Variables were compared between the groups, and predictors of early extubation were evaluated using multivariate logistic regression analysis. Results One hundred and ninety-four (33.8%) patients were extubated early including 2 extubation in operating room and 406 (70.7%) were extubated within 24 h. Four (0.7%) patients died without extubation. No significant difference in mortality and reintubation was observed between groups. Patient extubated early had a significant lower incidence of sepsis (P = 0.003) and duration of Intensive Care Unit (ICU) stay (P = 0.000). Age <6 months, risk adjustment for congenital heart surgery category ≥3, cardiopulmonary bypass time ≥80 min, aortic cross-clamp time ≥ 60 min, and vasoactive-inotropic score >10 were independently associated with prolonged ventilation. Conclusion Early extubation in infants postcardiac surgery lowers pediatric ICU stay and sepsis without increasing the risk of mortality or reintubation. Age more than 6 months, less complex of procedure, shorter surgery time, and lower inotropic requirement are independent predictors of early extubation.
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Affiliation(s)
- Shahzad Alam
- Department of Pediatrics, Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India
| | - Akunuri Shalini
- Department of Pediatrics, Narayana Health, Bengaluru, Karnataka, India
| | - Rajesh G Hegde
- Department of Pediatrics, Narayana Health, Bengaluru, Karnataka, India
| | - Rufaida Mazahir
- Department of Pediatrics, Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India
| | - Akanksha Jain
- Department of Pediatrics, Narayana Health, Bengaluru, Karnataka, India
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Monahan A, Guay J, Hajduk J, Suresh S. Regional Analgesia Added to General Anesthesia Compared With General Anesthesia Plus Systemic Analgesia for Cardiac Surgery in Children. Anesth Analg 2019; 128:130-136. [DOI: 10.1213/ane.0000000000003831] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Chaparro H, Abeldaño-Zuñiga RA. Factors associated with early extubation of patients after corrective tetralogy of Fallot. ENFERMERIA INTENSIVA 2018; 30:154-162. [PMID: 30509876 DOI: 10.1016/j.enfi.2018.08.002] [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] [Received: 03/15/2018] [Revised: 06/29/2018] [Accepted: 08/20/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess surgical management and postoperative results associated with early extubation in patients undergoing tetralogy of Fallot corrective surgery at a public hospital in Argentina. METHODS A retrospective review was made from clinical records from patients who underwent corrective surgery for tetralogy of Fallot. A total of 38 clinical records that met the inclusion criteria for the retrospective review were included in the analysis. RESULTS 16% were extubated early. Milrinone was the only drug that showed differences in patients who were extubated early (p=0.01). Extracorporeal circulation time, aortic clamping time, transfusion with cryoprecipitates, saturation of oxygen pressure, and haematocrit at the end of the surgical procedure showed no differences (p>.05). In the postoperative period, the ICU stay was shorter for the patients who were extubated early (p=0.0007), but there were no differences in the total hospital stay (p=0.26). CONCLUSIONS Early extubation in the institution, although found to be low frequency, has proved as a safe and effective alternative to shorten these patients' stay in ICU.
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Affiliation(s)
- H Chaparro
- Hospital de Pediatría SAMIC, Juan P. Garrahan, Buenos Aires, Argentina
| | - R A Abeldaño-Zuñiga
- División de Estudios de Posgrado, Universidad de la Sierra Sur, Oaxaca, México.
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Maharramova M, Taylor K. A Systematic Review of Caudal Anesthesia and Postoperative Outcomes in Pediatric Cardiac Surgery Patients. Semin Cardiothorac Vasc Anesth 2018; 23:237-247. [DOI: 10.1177/1089253218801966] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives. In pediatric cardiac surgery, does caudal anesthesia promote early extubation, reduce pain scores, reduce stress responses, and length of stay (LOS)? Design. A systematic review. Participants. Inclusion criteria included cardiac surgical procedures (with or without cardiopulmonary bypass) in any subject between the ages of full-term newborn and 18 years receiving caudal anesthesia of any medication combination. Searches were conducted with assistance of an Academic librarian from 1947 to July 2017. Methods. Relevant studies selected were randomized trials or cohort studies. Results. The total number of patients was 2159 in 17 studies. There were 8 prospective randomized clinical trials and 9 cohort studies. Caudal medications included dexmedetomidine, bupivacaine, sufentanil, morphine, fentanyl, and neostigmine. Nine studies reported earlier extubation in patients with caudal anesthesia. Cardiopulmonary bypass and surgical duration mitigated early extubation anesthetic strategies. Three of 5 studies showed reduced pain scores and need for opiates, 2 studies showed no difference. Two of 3 studies showed a reduction in stress response. Hemodynamic assessments were improved in 2 studies and unchanged in 3 studies. Four studies showed reduced hospital LOS. Studies are difficult to interpret because of the comparative techniques used. Conclusions. The data quality in this review is too poor to make recommendations regarding incorporation of caudal anesthesia into clinical practice. Caudal anesthesia may be favorable for early extubation, improved pain, and hemodynamics and reduced LOS. There are many other anesthetic alternatives to facilitate early extubation. Our review is limited by heterogeneous populations, variable pain measurement scales, and absent definitions of extubation indicators.
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Richards M, Latham G, Ross F, Eisses M, Geiduschek J, Joffe D. To OTE or Not to OTE: That Is the Question-Current International Trends of on the Table Extubation After Pediatric Cardiac Surgery. J Cardiothorac Vasc Anesth 2018; 33:416-417. [PMID: 30228054 DOI: 10.1053/j.jvca.2018.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Michael Richards
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA
| | - Gregory Latham
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA
| | - Faith Ross
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA
| | - Michael Eisses
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA
| | - Jeremy Geiduschek
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA
| | - Denise Joffe
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA
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Song IK, Kim EH, Lee JH, Kang P, Kim HS, Kim JT. Utility of Perioperative Lung Ultrasound in Pediatric Cardiac Surgery. Anesthesiology 2018; 128:718-727. [DOI: 10.1097/aln.0000000000002069] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Background
Pediatric cardiac patients are at risk for perioperative respiratory insufficiency. The objective of this study was to assess the utility of perioperative lung ultrasound examination in pediatric cardiac surgery.
Methods
In this randomized, controlled trial, children (5 yr old or younger) undergoing cardiac surgery were allocated into a control (n = 61) or intervention (n = 61) group. The control group received only lung ultrasound examinations at the end of surgery and 6 to 12 h after surgery. The intervention group received lung ultrasound examinations and an ultrasound-guided recruitment maneuver depending on ultrasound findings after inducing anesthesia, at the end of surgery, and 6 to 12 h after surgery. Primary outcomes were incidences of intra- and postoperative desaturation, and postoperative pulmonary complications. Multiple comparisons were corrected (P ≤ 0.017) in the primary outcome analysis.
Results
Of the 120 children included in the analysis, postoperative desaturation (64% vs. 27%; P < 0.001; odds ratio [OR], 0.210; 95% CI, 0.097 to 0.456) occurred more in the control group. The incidences of intraoperative desaturation (36% vs. 19%; P = 0.033; OR, 0.406; 95% CI, 0.176 to 0.939) and postoperative pulmonary complications (12% vs. 3%; P = 0.093; OR, 0.271; 95% CI, 0.054 to 1.361) were similar between the groups. Lung ultrasound scores were better in the intervention group than in the control group. Duration of mechanical ventilation was longer in the control group than in the intervention group (38 ± 43 vs. 26 ± 25 h; 95% CI of mean difference, 0 to 25; P = 0.048).
Conclusions
Perioperative lung ultrasound examination followed by ultrasound-guided recruitment maneuver helped decrease postoperative desaturation events and shorten the duration of mechanical ventilation in pediatric cardiac patients.
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Affiliation(s)
- In-Kyung Song
- From the Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (I.-K.S.); and the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea (E.-H.K., J.-H.L., P.K., H.-S.K., J.-T.K.)
| | - Eun-Hee Kim
- From the Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (I.-K.S.); and the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea (E.-H.K., J.-H.L., P.K., H.-S.K., J.-T.K.)
| | - Ji-Hyun Lee
- From the Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (I.-K.S.); and the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea (E.-H.K., J.-H.L., P.K., H.-S.K., J.-T.K.)
| | - Pyoyoon Kang
- From the Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (I.-K.S.); and the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea (E.-H.K., J.-H.L., P.K., H.-S.K., J.-T.K.)
| | - Hee-Soo Kim
- From the Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (I.-K.S.); and the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea (E.-H.K., J.-H.L., P.K., H.-S.K., J.-T.K.)
| | - Jin-Tae Kim
- From the Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (I.-K.S.); and the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea (E.-H.K., J.-H.L., P.K., H.-S.K., J.-T.K.)
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Penk JS, Lefaiver CA, Brady CM, Steffensen CM, Wittmayer K. Intermittent Versus Continuous and Intermittent Medications for Pain and Sedation After Pediatric Cardiothoracic Surgery; A Randomized Controlled Trial. Crit Care Med 2017; 46:123-129. [PMID: 29028762 DOI: 10.1097/ccm.0000000000002771] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Compare continuous infusions of morphine and midazolam in addition to intermittent doses with an intermittent only strategy for pain and sedation after pediatric cardiac surgery. DESIGN Randomized controlled trial. SETTING Advocate Children's Hospital, Oak Lawn, IL. PATIENTS Sixty patients 3 months to 4 years old with early extubation after pediatric cardiac surgery. INTERVENTIONS Patients received a continuous infusion of morphine and midazolam or placebo for 24 hours. Both groups received intermittent morphine and midazolam doses as needed. MEASUREMENTS AND MAIN RESULTS Gender, age, bypass time, and surgical complexity were not different between groups. Scheduled ketorolac and acetaminophen were used in both groups and were not associated with adverse events. The mean, median, and maximum Faces, Legs, Activity, Cry, And Consolability score were not different between groups. There was no significant difference in number of intermittent doses received between groups. The total morphine dose was higher in the continuous/intermittent group (0.90 vs 0.23 mg/kg; p < 0.01). The total midazolam dose was also higher in the continuous/intermittent group (0.90 vs 0.18 mg/kg; p < 0.01). The hospital length of stay was longer in the continuous/intermittent group (8.4 vs 4.9 d; p = 0.04). CONCLUSIONS Pain was not better controlled with the addition of continuous infusions of morphine and midazolam when compared with intermittent dosing only. Use of continuous infusions resulted in a significantly higher total dosage of these medications and a longer length of stay.
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Affiliation(s)
- Jamie S Penk
- All authors: Department of Pediatrics, Advocate Children's Hospital, Oak Lawn, IL
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Abstract
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.
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Abstract
This review will outline the role of visiting cardiac surgical teams in low- and middle-income countries drawing on the collective experience of the authors in a wide range of locations. Requests for assistance can emerge from local programmes at a beginner or advanced stage. However, in all circumstances, careful pre-trip planning is necessary in conjunction with clinical and non-clinical local partners. The clinical evaluation, surgical procedures, and postoperative care all serve as a template for collaboration and education between the visiting and local teams in every aspect of care. Education focusses on both common and patient-specific issues. Case selection must appropriately balance the clinical priorities, safety, and educational objectives within the time constraints of trip duration. Considerable communication and practical challenges will present, and clinicians may need to make significant adjustments to their usual practice in order to function effectively in a resource-limited, unfamiliar, and multilingual environment. The effectiveness of visiting trips should be measured and constantly evaluated. Local and visiting teams should use data-driven evaluations of measurable outcomes and critical qualitative evaluation to repeatedly re-assess their interim goals. Progress invariably takes several years to achieve the final goal: an autonomous self-governing, self-financed, cardiac programme capable of providing care for children with complex CHD. This outcome is consistent with redundancy for the visiting trips model at the site, although fraternal, professional, and academic links will invariably remain for many years.
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Subramaniam K, DeAndrade DS, Mandell DR, Althouse AD, Manmohan R, Esper SA, Varga JM, Badhwar V. Predictors of operating room extubation in adult cardiac surgery. J Thorac Cardiovasc Surg 2017; 154:1656-1665.e2. [DOI: 10.1016/j.jtcvs.2017.05.107] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 05/11/2017] [Accepted: 05/30/2017] [Indexed: 01/26/2023]
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Gaies M, MacLaren G. Eliminating Postoperative Infections on a Budget: Collaborative Quality Improvement for Congenital Heart Surgery in Low- and Middle-Income Countries. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.117.003708. [PMID: 28408717 DOI: 10.1161/circoutcomes.117.003708] [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] [Indexed: 11/16/2022]
Affiliation(s)
- Michael Gaies
- From the University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor (M.G.); Cardiothoracic ICU, National University Health System, Singapore (G.M.); and Paediatric ICU, Royal Children's Hospital, Department of Paediatrics, University of Melbourne, Australia (G.M.).
| | - Graeme MacLaren
- From the University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor (M.G.); Cardiothoracic ICU, National University Health System, Singapore (G.M.); and Paediatric ICU, Royal Children's Hospital, Department of Paediatrics, University of Melbourne, Australia (G.M.)
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Early extubation in pediatric heart surgery across a spectrum of case complexity: Impact on hospital length of stay and chest tube days. PROGRESS IN PEDIATRIC CARDIOLOGY 2016; 45:63-68. [PMID: 28713211 DOI: 10.1016/j.ppedcard.2016.12.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Early extubation is increasingly common in congenital heart surgery, but there are limited outcomes data across the spectrum of case complexity. We performed a retrospective review of 201 pediatric operations using cardiopulmonary bypass between 2012 and 2014. Patients extubated in the operating room or immediately on arrival to the ICU were compared to those extubated by traditional protocols. In-hospital mortality, major complications, need for re-intubation, hospital length of stay, and chest-tube days were compared between groups and by Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery Congenital Heart Surgery (STAT) mortality category. Outcome measures of hospital length of stay and chest tube days were analyzed using multivariable regression modeling. Early extubation subjects were older, weighed more, had shorter bypass and aortic cross-clamp time, more often received caudal anesthesia, and had shorter hospital length of stay and fewer chest tube days. Subjects not extubated early had more chromosomal abnormalities, more preoperative co-morbidities, and had more major complications. Inhospital death, major complications, and re-intubation were rare outcomes for both groups across all STAT categories. Multivariable regression analysis showed that cardiopulmonary bypass time was a significant predictor of hospital length of stay and chest tube days. Hospital LOS and chest tube days were significantly lower for the early extubation group in both the unadjusted and adjusted analyses. Early extubation can be performed safely in congenital heart surgery across a spectrum of case complexity. No increased early mortality or re-intubation was observed with early extubation although there were important differences between the groups that merits further study. The potential benefits of early extubation include decreased hospital length of stay and fewer chest tube days, particularly in young children and patients with long bypass times.
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Miura S, Hamamoto N, Osaki M, Nakano S, Miyakoshi C. Extubation Failure in Neonates After Cardiac Surgery: Prevalence, Etiology, and Risk Factors. Ann Thorac Surg 2016; 103:1293-1298. [PMID: 27720369 DOI: 10.1016/j.athoracsur.2016.08.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 07/20/2016] [Accepted: 08/01/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The purpose of this study was to explore the prevalence, etiology, and risk factors of extubation failure (EF) in post-cardiac surgery neonates. METHODS Neonates (30 days old or younger) who underwent cardiac surgery and were admitted to the cardiac intensive care unit between September 2010 and February 2016 were included. The prevalence and etiology of EF, defined as reintubation within 48 hours, were reviewed. Demographic, operative, and perioperative data were retrospectively collected. Multiple logistic regression models were constructed to identify the risk factors for EF. RESULTS The median age at surgery was 10 days. Extubation failure occurred in 25 of 156 cases (16.0%; 95% confidence interval: 10.6% to 22.7%), because of respiratory dysfunction (n = 16), hemodynamic instability (n = 4), upper airway obstruction (n = 4), or gastrointestinal bleeding (n = 1). Subsequent extubations were successful in 17 cases (68%) because of medical optimization of the causes of reintubation. The remaining 8 cases needed surgical reintervention, including tracheostomy and cardiac surgery. The inhospital mortality rate was 2.6%. In a bivariate analysis, younger age, airway diseases, ventilation before surgery, prolonged mechanical ventilation, and delayed sternal closure were associated with EF. The multivariable analysis identified airway diseases (adjusted odds ratio 18.2, 95% confidence interval: 3.8 to 88.6, p = 0.0003) and mechanical ventilation longer than 7 days (adjusted odds ratio 8.2, 95% confidence interval: 1.9 to 34.9, p = 0.0046) as risk factors for EF. CONCLUSIONS The prevalence of EF is relatively high in neonatal cardiac surgery. The etiologies can be diverse. Extubation of neonates at high risk after cardiac surgery, based on these possible risk factors, requires more diligent approaches.
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Affiliation(s)
- Shinya Miura
- Department of Cardiac Critical Care, Shizuoka Children's Hospital, Shizuoka, Japan.
| | - Nao Hamamoto
- Department of Cardiac Critical Care, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Masaki Osaki
- Department of Cardiac Critical Care, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Satoshi Nakano
- Department of Cardiac Critical Care, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Chisato Miyakoshi
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka, Japan; School of Mathematics and Statistics, University of Sheffield, Sheffield, United Kingdom
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Mahle WT, Nicolson SC, Hollenbeck-Pringle D, Gaies MG, Witte MK, Lee EK, Goldsworthy M, Stark PC, Burns KM, Scheurer MA, Cooper DS, Thiagarajan R, Sivarajan VB, Colan SD, Schamberger MS, Shekerdemian LS. Utilizing a Collaborative Learning Model to Promote Early Extubation Following Infant Heart Surgery. Pediatr Crit Care Med 2016; 17:939-947. [PMID: 27513600 PMCID: PMC5053873 DOI: 10.1097/pcc.0000000000000918] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine whether a collaborative learning strategy-derived clinical practice guideline can reduce the duration of endotracheal intubation following infant heart surgery. DESIGN Prospective and retrospective data collected from the Pediatric Heart Network in the 12 months pre- and post-clinical practice guideline implementation at the four sites participating in the collaborative (active sites) compared with data from five Pediatric Heart Network centers not participating in collaborative learning (control sites). SETTING Ten children's hospitals. PATIENTS Data were collected for infants following two-index operations: 1) repair of isolated coarctation of the aorta (birth to 365 d) and 2) repair of tetralogy of Fallot (29-365 d). There were 240 subjects eligible for the clinical practice guideline at active sites and 259 subjects at control sites. INTERVENTIONS Development and application of early extubation clinical practice guideline. MEASUREMENTS AND MAIN RESULTS After clinical practice guideline implementation, the rate of early extubation at active sites increased significantly from 11.7% to 66.9% (p < 0.001) with no increase in reintubation rate. The median duration of postoperative intubation among active sites decreased from 21.2 to 4.5 hours (p < 0.001). No statistically significant change in early extubation rates was found in the control sites 11.7% to 13.7% (p = 0.63). At active sites, clinical practice guideline implementation had no statistically significant impact on median ICU length of stay (71.9 hr pre- vs 69.2 hr postimplementation; p = 0.29) for the entire cohort. There was a trend toward shorter ICU length of stay in the tetralogy of Fallot subgroup (71.6 hr pre- vs 54.2 hr postimplementation, p = 0.068). CONCLUSIONS A collaborative learning strategy designed clinical practice guideline significantly increased the rate of early extubation with no change in the rate of reintubation. The early extubation clinical practice guideline did not significantly change postoperative ICU length of stay.
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Affiliation(s)
- William T Mahle
- 1Department of Pediatrics, Emory University, Atlanta, GA.2Department of Anesthesia, Children's Hospital of Philadelphia, Philadelphia, PA.3New England Research Institutes, Watertown, MA.4Department of Pediatrics, University of Michigan, Ann Arbor, MI.5Department of Pediatrics, University of Utah, Salt Lake City, UT.6Industrial Engineering Department, Georgia Institute of Technology, Atlanta, GA.7Department of Pediatrics, Baylor College of Medicine, Houston, TX.8National Heart, Lung, and Blood Institute, Bethesda, MD.9Department of Pediatrics, Medical University of South Carolina, Charleston, SC.10Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, OH.11Cardiology Department, Boston Children's Hospital, Boston, MA.12Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada.13Department of Pediatrics, Riley Children's Hospital, Indianapolis, IN
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Gaies M, Tabbutt S, Schwartz SM, Bird GL, Alten JA, Shekerdemian LS, Klugman D, Thiagarajan RR, Gaynor JW, Jacobs JP, Nicolson SC, Donohue JE, Yu S, Pasquali SK, Cooper DS. Clinical Epidemiology of Extubation Failure in the Pediatric Cardiac ICU: A Report From the Pediatric Cardiac Critical Care Consortium. Pediatr Crit Care Med 2015; 16:837-45. [PMID: 26218260 PMCID: PMC4672991 DOI: 10.1097/pcc.0000000000000498] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe the clinical epidemiology of extubation failure in a multicenter cohort of patients treated in pediatric cardiac ICUs. DESIGN Retrospective cohort study using prospectively collected clinical registry data. SETTING Pediatric Cardiac Critical Care Consortium registry. PATIENTS All patients admitted to the CICU at Pediatric Cardiac Critical Care Consortium hospitals. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Analysis of all mechanical ventilation episodes in the registry from October 1, 2013, to July 31, 2014. The primary outcome of extubation failure was reintubation less than 48 hours after planned extubation. Repeated-measures analysis using generalized estimating equations to account for within patient and center correlation was performed to identify risk factors for extubation failure. Adjusted extubation failure rates for each hospital were calculated using logistic regression controlling for patient factors. Of 1,734 mechanical ventilation episodes (1,478 patients at eight hospitals) ending in a planned extubation, there were 100 extubation failures (5.8%). In multivariable analysis, only longer duration of mechanical ventilation was significantly associated with extubation failure (p = 0.01); the failure rate was 4% when ventilated less than 24 hours, 9% after 24 hours, and 13% after 7 days. For 503 patients intubated and extubated in the cardiac operating room, 15 patients (3%) failed extubation within 48 hours (12 within 24 hr). Case-mix-adjusted extubation failure rates ranged from 1.1% to 9.8% across hospitals. Patients failing extubation had greater median cardiac ICU length of stay (15 vs 3 d; p < 0.001) and in-hospital mortality (7.9 vs 1.2%; p < 0.001). CONCLUSIONS Though extubation failure is uncommon overall, there may be opportunities to improve extubation readiness assessment in patients ventilated more than 24 hours. These data suggest that extubation in the operating room after cardiac surgery can be done with a low failure rate. We observed variation in extubation failure rates across hospitals, and future investigation must elucidate the optimal strategies of high-performing centers to reduce ventilation time while limiting extubation failures.
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Affiliation(s)
- Michael Gaies
- 1Division of Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI. 2Department of Pediatrics, Benioff Children's Hospital and University of California San Francisco School of Medicine, San Francisco, CA. 3Department of Critical Care Medicine and Department of Paediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto School of Medicine, Toronto, ON, Canada. 4Division of Critical Care, Department of Anesthesiology and Critical Care Medicine, Cardiac Center at the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 5Division of Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL. 6Department of Pediatrics, Section of Critical Care, Baylor College of Medicine, Texas Children's Hospital, Houston, TX. 7Department of Critical Care Medicine and Cardiology, Children's National Medical Center, Washington, DC. 8Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA. 9Division of Pediatric Cardiac Surgery, Department of Surgery, The Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 10Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD. 11Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA. 12Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 13Michigan Congenital Heart Outcomes Research and Discovery Unit, University of Michigan Congenital Heart Center, Ann Arbor, MI. 14The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Hoda M, Haque A, Aijaz F, Akhtar MI, Rehmat A, Amanullah M, Hasan BS. On-table Extubation after Open Heart Surgery in Children: An Experience from a Tertiary Care Hospital in a Developing Country. CONGENIT HEART DIS 2015; 11:58-62. [DOI: 10.1111/chd.12277] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Mehar Hoda
- Department of Pediatrics; Aga Khan University Hospital; Sindh Pakistan
| | - Anwarul Haque
- Department of Pediatrics; Aga Khan University Hospital; Sindh Pakistan
| | - Fareena Aijaz
- Department of Pediatrics; Aga Khan University Hospital; Sindh Pakistan
| | | | - Amina Rehmat
- Department of Nursing; Aga Khan University Hospital; Sindh Pakistan
| | - Muneer Amanullah
- Department of Surgery; Aga Khan University Hospital; Sindh Pakistan
| | - Babar S. Hasan
- Department of Pediatrics; Aga Khan University Hospital; Sindh Pakistan
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Abstract
Congenital cardiac anesthesiology is a rapidly expanding field at both ends of the life spectrum. The care of the unborn child with congenital heart disease is becoming highly specialized in regional centers that offer advanced imaging techniques, coordinated specialist care, and potentially fetal interventions. As more children with congenital heart disease survive to adulthood, patients and their health care providers are facing new challenges. The growing volume of publications reflects this expanding field of congenital cardiac anesthesiology. This year in review article highlights some developing trends in the literature.
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