Assessment of Risk Factors for a Sustainable “On-Table Extubation” Program in Pediatric Congenital Cardiac Surgery: 5-Year Experience

Proposed Quality Metrics for Congenital Cardiac Anesthesia: A Scoping Review

Congenital cardiac anesthesiologists practice in a unique environment with high risk for morbidity and mortality. Quality metrics can be used to focus clinical initiatives on evidence-based care and provide a target for local quality improvement measures. However, there has been no comprehensive review on appropriate quality metrics for congenital cardiac anesthesia to date. Members of the Quality and Safety Committee for the Congenital Cardiac Anesthesia Society proposed 31 possible candidate topics for metrics. Using a scoping review strategy, 3649 abstracts were reviewed with 30 articles meeting final criteria. Of these, 5 candidate metrics were unanimously proposed for local collection and national benchmarking efforts: use of a structured handover in the intensive care unit, use of an infection prevention bundle, use of blood conservation strategies, early extubation of cardiopulmonary bypass cases, and cardiac arrest under the care of a cardiac anesthesiologist. Many metrics were excluded due to a lack of primary data and perceived complexity beyond the scope of cardiac anesthesia practice. There is a need to develop more primary data including linking process measures with outcomes, developing risk-stratification for our patients, and collecting national data for benchmarking purposes.

Increased physiologic dead space fraction is associated with mortality after comprehensive stage 2 operation

OBJECTIVE

Our objective was to assess the predictive value of physiologic dead space fraction for mortality in patients undergoing the comprehensive stage 2 operation.

METHODS

This was a single-centre retrospective observational study conducted at a quaternary free-standing children's hospital specialising in hybrid palliation of single ventricle cardiac disease. 180 patients underwent the comprehensive stage 2 operation. 76 patients (42%) underwent early extubation, 59 (33%) standard extubation, and 45 (25%) delayed extubation. We measured time to extubation, post-operative outcomes, length of stay and utilised Fine gray models, Youden's J statistic, cumulative incidence function, and logistic regression to analyse outcomes.

RESULTS

Delayed extubation group suffered significantly higher rates of mortality (31.1% vs. 6.8%), cardiac arrest (40.0% vs. 10.2%), stroke (37.8% vs. 11.9%), and need for catheter (28.9% vs. 5.1%) and surgical intervention (24.4% vs. 8.5%) (P < 0.001). Physiologic dead space fraction was significantly higher in the delayed extubation group and in non-survivors with a value of 0.3, which was found to be the discriminatory point by Youden's J statistic. For a 0.1 unit increase in physiologic dead space fraction on post-operative day 1, the odds of a patient expiring increase by a factor of 2.26 (95% CI 1.41-3.97, p < 0.001) and by a factor of 3.79 (95% CI 1.65-11.7, p 0.01) on post-operative day 3.

CONCLUSIONS

Delayed extubation impacts morbidity and mortality in patients undergoing the comprehensive stage 2 operation. Increased physiologic dead space fraction in the first 60 hours after arrival to the ICU is associated with higher mortality.

Early extubation after pediatric cardiac surgery

Early extubation after pediatric cardiac surgery has come full circle from being practiced in the early days of pediatric cardiac surgery, falling out of favor with opioid-heavy cardiostable anesthesia, and resurfacing again in more recent times as part of enhanced recovery after surgery practice. Early extubation is variably defined, but is mostly accepted as extubation that occurs within 6-8 h from the end of surgery. In recent years, the debate has shifted from early extubation in the intensive care unit to immediate extubation in the operating theatre. In this review, we examined the benefits and pitfalls of early and immediate extubation, factors that influence the success of early extubation, and potential guidelines for practice and implementation.

The outcome of surgery for congenital heart disease in India: A systematic review and metanalysis

Background

The mortality risks of children undergoing various cardiac surgeries for congenital heart disease (CHD) in India are not well defined. We conducted a systematic review and meta-analysis to estimate the inhospital mortality of various common CHD surgeries reported in India and compared it to representative data from established Western databases.

Methods and Results

We searched four bibliographic databases for studies published in India over the last 25 years. In total, 135 studies met the inclusion criteria and included 30,587 patients aged from 1 day to 65 years. The pooled mortality rate of 43 Indian studies reporting multiple CHD surgical outcomes is 5.63% (95% confidence interval [CI]: 4.26-7.16; I 2 = 93.9%), whereas the Western data showed a pooled mortality rate of 2.65% (P value for comparison <0.0001). The pooled mortality risk for ventricular septal defect closure and tetralogy of Fallot repair in Indian studies was 2.87% (95% CI: 0.76-5.91; I 2 = 62.4%) and 4.61% (95% CI: 2.0-8.02; I 2 = 87.4%), respectively. The estimated mortality risk was higher than the Western databases for all subcategories studied except for surgeries in the grown-ups with CHD population and coarctation repair.

Conclusions

The estimated mortality risks are higher among Indian patients undergoing cardiac surgery for CHD as compared to Western data. We need prospective multicentric data to document whether the observed excess mortality exists after adjusting for various high-risk features and comorbidities in Indian patients. We need systemic measures to improve the outcomes of CHD surgeries in India.

Perioperative and Anesthetic Considerations in Shone's Complex

Shone's complex is a congenital cardiac disease consisting of the following four lesions: parachute mitral valve, supravalvar mitral ring, subaortic stenosis, and aortic coarctation. Though not all components are required for a diagnosis, the end result is both left ventricular inflow and outflow obstruction, which typically present in patients as congestive heart failure. The complex pathology requires careful management and surgical decision-making to ensure an optimal outcome. This review will focus on the anatomy, physiology, and perioperative anesthetic management of patients with Shone's complex.

Clinical Variables Specific to Timing of Tracheal Extubation Following Pediatric Cardiac Surgery

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.

A retrospective analysis of dexmedetomidine and morphine in the fast-track and ultra-fast-track extubation protocol after congenital cardiac surgery

BACKGROUND AND AIM OF THE STUDY

After congenital cardiac surgery, the duration of mechanical ventilation (MV) is related to the clinical status, type of operation, and the sedative-analgesic agents used postoperatively. This study aims to examine the effects of dexmedetomidine and morphine on the fast-track extubation (FTE) and ultra-fast-track extubation (UFTE) protocol after congenital cardiac surgery.

METHODS

A total of 251 pediatric patients were divided into two groups: 118 patients in the morphine group (Group M) and 133 patients in the dexmedetomidine group (Group D). We retrospectively reviewed medical data including hemodynamic parameters, duration of MV and cardiovascular intensive care unit (CICU), additional sedative/analgesic requirement, adverse events, the need for reintubation, and noninvasive MV, sedation, and pain scores.

RESULTS

The mean mechanical ventilation duration of Group D was significantly shorter than Group M (3.74 ± 0.83 h in Group D, 5.72 ± 1.54 h in Group M, respectively) (p = .001; p < .05). In Group D, the success rate of FTE was 92.5% (n = 123) and UFTE was 7.5% (n = 10) (p = .001). In Group M, the success rate of FTE was 72.9% (n = 86) and UFTE was 0% (n = 0) (p > .05).

CONCLUSIONS

Dexmedetomidine and morphine have clinical benefits which encourage their use for FTE protocol. Dexmedetomidine has more benefits compared to morphine. It can be used in UFTE protocol, besides its use in FTE protocol with fewer side effects.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Trends in Time to Extubation for Pediatric Postoperative Cardiac Patients and Its Correlation With Changes in Clinical Outcomes: A Virtual PICU Database Study

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.

Early Extubation in a Pediatric Cardiac Surgery Program Located at High Altitude

BACKGROUND

Early extubation is performed either in the operating room or in the cardiovascular intensive care unit during the first 24 postoperative hours; however, altitude might possibly affect the process. The aim of this study is the evaluation of early extubation feasibility of patients undergoing congenital heart surgery in a center located at 2,691 m (8,828 ft.) above sea level.

MATERIAL AND METHODS

Patients undergoing congenital heart surgery, from August 2012 through December 2018, were considered for early extubation. The following variables were recorded: weight, serum lactate, presence or not of Down syndrome, optimal oxygenation and acid-base status according to individual physiological condition (biventricular or univentricular), age, bypass time, and ventricular function. Standardized anesthetic management with dexmedetomidine-fentanyl-rocuronium and sevoflurane was used. If extubation in the operating room was considered, 0.08 mL/kg of 0.5% ropivacaine was injected into the parasternal intercostal spaces bilaterally before closing the sternum.

RESULTS

Four hundred seventy-eight patients were operated and 81% were early extubated. Mean pre- and postoperative SaO₂ was 92% and 98%; postoperative SaO₂ for Glenn and Fontan procedures patients was 82% and 91%, respectively. Seventy-three percent of patients who underwent Glenn procedure, 89% of those who underwent Fontan procedure (all nonfenestrated), and 85% with Down syndrome were extubated in the operating room. Reintubation rate in early extubated patients was 3.6%.

CONCLUSION

Early extubation is feasible, with low reintubation rates, at 2,691 m (8,828 ft.) above sea level, even in patients with single ventricle physiology.

Is Early Extubation Associated with Better Outcomes After Neonatal Congenital Heart Disease Surgery?

Early extubation (EE) of children after surgery (occurring within the operating room or ≤ 6 hours postadmission) for congenital heart disease (CHD) has been advocated to improve postoperative care. The objective of this study is to compare outcomes of neonates undergoing EE following CHD surgical repair with those extubated more than 6 hours after surgery. Retrospective cohort study utilizes data from the Virtual Pediatric Systems database. Data from neonates undergoing surgical repair for six common CHD lesions and admitted to 57 pediatric intensive care units (ICUs) between July 1, 2010, and June 30, 2015, were analyzed. A total of 1,274 neonates were analyzed; 100 (7.8%) had EE, and 146 (11.5%) were extubated > 6 hours but ≤ 24 hours. Most patients (80.4%) were extubated > 24 hours. The EE group had higher (p < 0.001) failed extubation rate than patients extubated at any other time; a multivariate analysis of linear regression showed no advantage in length of stay (LOS) of EE compared with those subjects who were extubated in the first 24 hours (p-value: 0.178). Extubation failure was found to impact ICU LOS in this analysis. The ICU LOS was increased by 3.5 days for every failed extubation attempt (p-value: <0.001, 95% confidence interval: 1.6–5.5 days). EE after CHD surgery is possible. Though it appears as an attractive option to decrease potential mechanical ventilation complications, this study of neonates shows that EE might result in worse outcomes than when performing extubation between 6 and 24 hours postoperatively.

Impact of miniaturized cardiopulmonary bypass circuits on ultrafiltration during congenital heart surgery

OBJECTIVE

To investigate whether the miniaturized cardiopulmonary bypass (CPB) system decreased the usage of ultrafiltration (UF), and to explore whether the non-UF with miniaturized CPB strategy could get good clinical results during congenital heart surgery.

METHODS

We performed a retrospective analysis of all patients undergoing congenital heart surgery with CPB at Shenzhen Children's Hospital from 1 May 2015 to 30 September 2019. We classified patients to UF with miniaturized CPB group, non-UF with miniaturized CPB group, UF with conventional CPB group and non-UF with conventional CPB group.

RESULTS

Of the 2145 patients, 721 (33.6%) were in the conventional CPB group, and 1424 (66.4%) were in the miniaturized CPB group. The UF rate was significantly lower in the miniaturized CPB group compared with that in the conventional CPB group (12.5% vs. 76.8%, p < 0.001). Compared with patients in the other groups, patients in the non-UF with miniaturized CPB group had a shorter postoperative MV time (p < 0.05), and a shorter length of stay in the ICU (p < 0.001) and hospital (p < 0.001). The age of children in the UF with miniaturized CPB group was relatively younger (median: 1.5 months, IQR: 0.3-4.6 months), and the preoperative weight was relatively lower (median: 3.9 kg, IQR: 3.2-5.4 kg). Moreover, this group of children had a relatively longer postoperative MV time and length of stay in the ICU and hospital.

CONCLUSION

The miniaturized CPB system could decrease the usage of UF. Good results were achieved in children who did not use UF based on the miniaturized CPB circuit system during congenital heart surgery.

Effect of Albumin Addition to Cardiopulmonary Bypass Prime on Outcomes in Children Undergoing Open-Heart Surgery (EACPO Study)-A Randomized Controlled Trial

BACKGROUND

There is a paucity of literature regarding the association of high oncotic priming solutions for pediatric cardiopulmonary bypass (CPB) and outcomes, and no consensus exists regarding the composition of optimal CPB priming solution. This study aimed to examine the impact of high oncotic pressure priming by the addition of 20% human albumin on outcomes.

METHODS

Double-blinded, randomized controlled study was done in the pediatric cardiac intensive care unit of a tertiary care hospital. Consecutive children with congenital heart diseases admitted for open-heart surgery were randomized into two groups, where the study group received an additional 20% albumin to conventional blood prime before CPB initiation.

RESULTS

We enrolled 39 children in the high oncotic prime (added albumin) group and 37 children in the conventional prime group. In the first 24-hour postoperative period, children in the albumin group had significantly lower occurrence of hypotension (28.2% vs 54%, P = .02), requirement of fluid boluses (25.6% vs 54%, P = .006), and lactate clearance time (6 vs 9 hours, P < .001). Albumin group also had significantly higher platelet count (×10³/µL) at 24 hours (112 vs 91, P = .02). There was no significant difference in intra-CPB hemodynamic parameters and incidence of acute kidney injury. In subgroup analysis based on risk category, significantly decreased intensive care unit stay (4 vs 5 days, P = .04) and hospital stay (5 vs 7 days, P = .002) were found in the albumin group in low-risk category.

CONCLUSION

High oncotic pressure CPB prime using albumin addition might be beneficial over conventional blood prime, and our study does provide a rationale for further studies.

Effect of retrograde autologous priming based on miniaturized cardiopulmonary bypass in children undergoing open heart surgery: A STROBE compliant retrospective observational study

To evaluate the effectiveness of retrograde autologous priming (RAP) based on miniaturized cardiopulmonary bypass (CPB) circuit in children undergoing open heart surgery.We performed a retrospective analysis of all patients (≤15 kg) who underwent open heart surgery with CPB in our center from January 1, 2017, to July 31, 2019. Propensity score matching was used to adjust for significant covariates, and multivariable stratified analysis was used to assess the association of the RAP technique with clinical outcomes.A total of 1111 patients were analyzed. There were 355 (32.0%) children who underwent RAP, and 756 (68.0%) were in the non-RAP group. After propensity score matching, there were a total of 638 patients, with 319 patients in each group. The bloodless priming rate was significantly higher (P = .013), and the ultrafiltration rate was significantly lower (P = .003) in the RAP group than in the non-RAP group. Compared with patients in the non-RAP group, patients in the RAP group had a shorter postoperative mechanical ventilation time (P < .001) and shorter lengths of stay in the intensive care unit (ICU) (P < .001) and the hospital (P < .001). No differences were noted in postoperative hematocrit (P = .920), postoperative 24-hour blood loss (P = .435), and hospital mortality (P = .563). In the stratified analysis, the difference remained statistically significant (P < .05) when the patient weight was >4 kg or the Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery (STAT) category was <3. However, when the patient weight was ≤4 kg or the STAT category was ≥3, there was no significant difference between the 2 groups in terms of bloodless priming, ultrafiltration, postoperative mechanical ventilation time, or length of stay in the ICU or the hospital (P > .05).The RAP technique based on miniaturized CPB system was safe and effective for children who underwent congenital heart surgery. The RAP technique can significantly reduce the priming volume, improve the rate of bloodless priming, and reduce blood product application. It was also associated with a shorter postoperative mechanical ventilation time and shorter lengths of stay in the ICU and the hospital.

Early extubation after thymectomy is good for the patients with myasthenia gravis

Objectives

Patients with myasthenia gravis (MG) often benefit from thymectomy, but the optimal timing of extubation following thymectomy in these patients remains unknown. This study of MG patients compared the effect of early and late extubation following thymectomy on clinical outcome.

Methods

We performed a study of data from 96 patients with MG who received thymectomy procedures, followed by early (< 6 h) or late (> 6 h) extubation, at our institution between October 2011 and November 2017. Patient clinical and demographic characteristics, preoperative data, and postoperative clinical outcomes were analyzed. Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Results

The patients in the early extubation group (n = 53) and late extubation group (n = 43) had similar preoperative clinical and demographic characteristics. However, the early extubation group had a significantly longer duration of MG (24 months vs. 12 months, P < 0.013) and a lower incidence of reintubation (11.3% vs. 37.2%, P = 0.003). Postoperative pulmonary infection was significantly more common in the late extubation group (39.5% vs. 11.3%, P = 0.001; adjusted odds ratio = 6.94, 95% CI 1.24–38.97). Also, patients in the late extubation group had a longer duration of ICU stay (6.4 ± 4.0 h vs. 4.3 ± 1.8 h; P = 0.003) and had a longer adjusted duration of ICU stay by 0.93 days (95% CI 0.02–1.85).

Conclusions

Our analysis of patients with MG who received thymectomy procedures indicated that early extubation was associated with improved clinical outcomes, in particular with reduced risk of postoperative pulmonary infection and reduced ICU stay.

Electronic supplementary material

The online version of this article (10.1007/s10072-019-03941-0) contains supplementary material, which is available to authorized users.

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

Background

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

Methods

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

Results

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

Conclusion

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