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Right Atrial Lines as Primary Access for Postoperative Pediatric Cardiac Patients. Pediatr Cardiol 2023; 44:702-713. [PMID: 36094531 DOI: 10.1007/s00246-022-03000-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/23/2022] [Indexed: 11/27/2022]
Abstract
To characterize the use of right atrial lines (RALs) as primary access in the postoperative care of neonatal and pediatric patients after cardiothoracic surgery and to identify risk factors associated with RAL complications. Observational retrospective cohort study in pediatric cardiac patients who underwent RAL placement in a tertiary children's hospital from January 2011 through June 2018. A total of 692 children with congenital heart disease underwent 815 RAL placements during the same or subsequent cardiothoracic surgeries during the study period. Median age and weight were 22 days (IQR 7-134) and 3.6 kg (IQR 3.1-5.3), respectively. Neonates accounted for 53.5% of patients and those with single-ventricle physiology were 35.4%. Palliation surgery (shunts, cavo-pulmonary connections, hybrid procedures, and pulmonary artery bandings) accounted for 38%. Survival to hospital discharge was 95.5%. Median RAL duration was 11 days (IQR 7-19) with a median RAL removal to hospital discharge time of 0 days (IQR 0-3). Thrombosis and migration were the most prevalent complications (1.7% each), followed by malfunction (1.4%) and infection (0.7%). Adverse events associated with complications were seen in 12 (1.4%) of these RAL placements: decrease in hemoglobin (n = 1), tamponade requiring pericardiocentesis (n = 3), pleural effusion requiring chest tube (n = 2), and need for antimicrobials (n = 6). Multivariable logistic regression showed that RAL duration (OR 1.01, p = 0.006) and palliation surgery (OR 2.38, p = 0.015) were significant and independent factors for complications. The use of RALs as primary access in postoperative pediatric cardiac patients seems to be feasible and safe. Our overall incidence of complications from prolonged use of RALs remained similar or lower to that reported with short-term use of these lines. While RAL duration and palliation surgeries seemed to be associated with complications, severity of illness could be a confounding factor. A prospective assessment of RAL complications may improve outcomes in this medically complex population.
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2
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Babu S, Sreedhar R, Munaf M, Gadhinglajkar SV. Sepsis in the Pediatric Cardiac Intensive Care Unit: An Updated Review. J Cardiothorac Vasc Anesth 2023; 37:1000-1012. [PMID: 36922317 DOI: 10.1053/j.jvca.2023.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 01/25/2023] [Accepted: 02/06/2023] [Indexed: 02/13/2023]
Abstract
Sepsis remains among the most common causes of mortality in children with congenital heart disease (CHD). Extensive literature is available regarding managing sepsis in pediatric patients without CHD. Because the cardiovascular pathophysiology of children with CHD differs entirely from their typical peers, the available diagnosis and management recommendations for sepsis cannot be implemented directly in children with CHD. This review discusses the risk factors, etiopathogenesis, available diagnostic tools, resuscitation protocols, and anesthetic management of pediatric patients suffering from various congenital cardiac lesions. Further research should focus on establishing a standard guideline for managing children with CHD with sepsis and septic shock admitted to the intensive care unit.
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Affiliation(s)
- Saravana Babu
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal institute for medical sciences and technology, Trivandrum, India.
| | - Rupa Sreedhar
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal institute for medical sciences and technology, Trivandrum, India
| | - Mamatha Munaf
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal institute for medical sciences and technology, Trivandrum, India
| | - Shrinivas V Gadhinglajkar
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal institute for medical sciences and technology, Trivandrum, India
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Recommendations for cardiovascular magnetic resonance and computed tomography in congenital heart disease: a consensus paper from the CMR/CCT working group of the Italian Society of Pediatric Cardiology (SICP) and the Italian College of Cardiac Radiology endorsed by the Italian Society of Medical and Interventional Radiology (SIRM) Part I. Radiol Med 2022; 127:788-802. [PMID: 35608758 PMCID: PMC9308607 DOI: 10.1007/s11547-022-01490-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/23/2022] [Indexed: 11/23/2022]
Abstract
Cardiovascular magnetic resonance (CMR) and computed tomography (CCT) are advanced imaging modalities that recently revolutionized the conventional diagnostic approach to congenital heart diseases (CHD), supporting echocardiography and often replacing cardiac catheterization. Nevertheless, correct execution and interpretation require in-depth knowledge of all technical and clinical aspects of CHD, a careful assessment of risks and benefits before each exam, proper imaging protocols to maximize diagnostic information, minimizing harm. This position paper, written by experts from the Working Group of the Italian Society of Pediatric Cardiology and from the Italian College of Cardiac Radiology of the Italian Society of Medical and Interventional Radiology, is intended as a practical guide for applying CCT and CMR in children and adults with CHD, wishing to support Radiologists, Pediatricians, Cardiologists and Cardiac Surgeons in the multimodality diagnostic approach to these patients. The first part provides a review of the most relevant literature in the field, describes each modality's advantage and drawback, making considerations on the main applications, image quality, and safety issues. The second part focuses on clinical indications and appropriateness criteria for CMR and CCT, considering the level of CHD complexity, the clinical and logistic setting and the operator expertise.
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Variation in Advanced Diagnostic Imaging Practice Patterns and Associated Risks Prior to Superior Cavopulmonary Connection: A Multicenter Analysis. Pediatr Cardiol 2022; 43:497-507. [PMID: 34812909 DOI: 10.1007/s00246-021-02746-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/29/2021] [Indexed: 10/19/2022]
Abstract
Single ventricle patients typically undergo some form of advanced diagnostic imaging prior to superior cavopulmonary connection (SCPC). We sought to evaluate variability of diagnostic practice and associated comprehensive risk. A retrospective evaluation across 4 institutions was performed (1/1/2010-9/30/2016) comparing the primary modalities of cardiac catheterization (CC), cardiac magnetic resonance (CMR), and cardiac computed tomography (CT). Associated risks included anesthesia/sedation, vascular access, total room time, contrast agent usage, radiation exposure, and adverse events (AEs). Of 617 patients undergoing SCPC, 409 (66%) underwent at least one advanced diagnostic imaging study in the 60 days prior to surgery. Seventy-eight of these patients (13%) were analyzed separately because of a concomitant cardiac intervention during CC. Of 331 (54%) with advanced imaging and without catheterization intervention, diagnostic CC was most common (59%), followed by CT (27%) and CMR (14%). Primary modality varied significantly by institution (p < 0.001). Median time between imaging and SCPC was 13 days (IQR 3-33). Anesthesia/sedation varied significantly (p < 0.001). Pre-procedural vascular access did not vary significantly across modalities (p = 0.111); procedural access varied between CMR/CT and CC, in which central access was used in all procedures. Effective radiation dose was significantly higher for CC than CT (p < 0.001). AE rate varied significantly, with 12% CC, 6% CMR, and 1% CT (p = 0.004). There is significant practice variability in the use of advanced diagnostic imaging prior to SCPC, with important differences in associated procedural risk. Future studies to identify differences in diagnostic accuracy and long-term outcomes are warranted to optimize diagnostic protocols.
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Revisiting Pediatric NPO Guidelines: a 5-Year Update and Practice Considerations. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00482-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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6
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Nunes MDO, Witt DR, Casey SA, Stanberry LI, Caye DJ, J Chu B, Lindberg BJ, Lesser JR, Han BK. Safety, Efficacy, and Dose Protocol of Metoprolol for Heart Rate Reduction in Pediatric Outpatients Undergoing Cardiac CT Angiography. Arq Bras Cardiol 2021; 116:100-105. [PMID: 33566972 PMCID: PMC8159495 DOI: 10.36660/abc.20190892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 08/05/2020] [Indexed: 11/28/2022] Open
Abstract
Fundamento Qualidade de imagem e dose de radiação são otimizadas com uma frequência cardíaca (FC) lenta e estável na realização de imagens de artérias coronárias durante a angiografia cardíaca por tomografia computadorizada (CCTA, do inglês
cardiac computed tomography angiography
) A segurança, a eficácia e o protocolo para a redução da FC com medicamento betabloqueador ainda não foi bem descrita em uma população de pacientes pediátricos. Objetivo Oferecer um protocolo de dose de metoprolol eficiente a ser usado em pacientes pediátricos externos durante a CCTA. Métodos Realizamos uma revisão retrospectiva de todos os pacientes pediátricos externos que receberam o metoprolol durante a CCTA. As características demográficas e clínicas foram resumidas e a redução média em FC foi estimada utilizando-se um modelo de regressão linear multivariada. As imagens foram avaliadas em uma escala de 1 a 4 (1= ideal). Resultados Um total de 78 pacientes externos passaram a uma CCTA com o uso de metoprolol. A média de idade foi de 13 anos, a média de peso foi de 46 kg, e 36 pacientes (46%) eram do sexo masculino. As doses médias de metoprolol foram 1,5 (IQR 1,1; 1,8) mg/kg, e 0,4 (IQR 0,2; 0,7) mg/kg para administrações orais e intravenosas, respectivamente. O produto dose-comprimento por exame foi de 57 (IQR 30, 119) mGy*cm. A redução média da FC foi 19 (IQR 12, 26) batimentos por minuto, ou 23%. Não foram relatadas complicações ou eventos adversos. Conclusão O uso de metoprolol num cenário de pacientes pediátricos externos para redução da FC antes de uma CCTA é seguro e eficiente. Pode-se reproduzir um protocolo de dose de metoprolol quando for necessário atingir uma FC mais lenta, garantindo tempos de aquisição mais rápidos, imagens mais claras e redução na exposição à radiação nessa população. (Arq Bras Cardiol. 2021; 116(1):100-105)
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Affiliation(s)
| | - Dawn R Witt
- Minneapolis Heart Institute and Foundation, Minnesota - EUA
| | - Susan A Casey
- Minneapolis Heart Institute and Foundation, Minnesota - EUA
| | | | - David J Caye
- Minneapolis Heart Institute and Foundation, Minnesota - EUA
| | | | | | - John R Lesser
- Minneapolis Heart Institute and Foundation, Minnesota - EUA
| | - B Kelly Han
- Minneapolis Heart Institute and Foundation, Minnesota - EUA.,Children's Minnesota, Minneapolis, Minnesota - EUA
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Song IK, Shin WJ. Who are at high risk of mortality and morbidity among children with congenital heart disease undergoing noncardiac surgery? Anesth Pain Med (Seoul) 2021; 16:1-7. [PMID: 33472290 PMCID: PMC7861893 DOI: 10.17085/apm.20090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/07/2020] [Indexed: 11/26/2022] Open
Abstract
With advances in the development of surgical and medical treatments for congenital heart disease (CHD), the population of children and adults with CHD is growing. This population requires multiple surgical and diagnostic imaging procedures. Therefore, general anesthesia is inevitable. In many studies, it has been reported that children with CHD have increased anesthesia risks when undergoing noncardiac surgeries compared to children without CHD. The highest risk group included patients with functional single ventricle, suprasystemic pulmonary hypertension, left ventricular outflow obstruction, and cardiomyopathy. In this review, we provide an overview of perioperative risks in children with CHD undergoing noncardiac surgeries and anesthetic considerations in patients classified as having the highest risk.
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Affiliation(s)
- In-Kyung Song
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won-Jung Shin
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Veronese L, Swanevelder J, Brooks A. Anaesthesia for the child with a univentricular heart: a practical approach. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2021. [DOI: 10.36303/sajaa.2021.27.3.2572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | - J Swanevelder
- Red Cross War Memorial Children’s Hospital, University of Cape Town,
South Africa
| | - A Brooks
- Red Cross War Memorial Children’s Hospital, University of Cape Town,
South Africa
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9
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Vimala S, Krishnakumar M, Goyal A, Sriganesh K, Umamaheswara Rao GS. Perioperative Complications and Clinical Outcomes in Patients with Congenital Cyanotic Heart Disease Undergoing Surgery for Brain Abscess. J Neurosci Rural Pract 2020; 11:375-380. [PMID: 32753800 PMCID: PMC7394637 DOI: 10.1055/s-0040-1709260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background
Brain abscess is a rare neurological complication in patients with congenital cyanotic heart disease (CCHD). Perioperative complications are high in patients with CCHD. We evaluated incidence of and risk factors for perioperative complications and their impact on clinical outcomes in patients with CCHD undergoing brain abscess surgery with monitored anesthesia care (MAC) or general anesthesia (GA).
Methods
In this single-center retrospective cohort study, data were collected from consecutive patients with CCHD who presented with brain abscess and underwent surgery from January 2006 to December 2018. Data regarding demographics, type of CCHD, signs and symptoms of brain abscess and CCHD, type and duration of surgery, details of anesthesia, perioperative complications, and clinical outcomes were collected. Chi-square test was used to analyze nonparametric data and student
t
-test for parametric data.
Results
Of the 402 patients with brain abscess, data of 34 patients with CCHD who underwent brain abscess surgery were analyzed. The mean age at presentation of brain abscess was 15.8 ± 10.8 years and duration of symptoms was 17.3 ± 15.5 days. The incidence of perioperative complications was 82.4% (28/34 patients). Seven patients (20.6%) developed perioperative cyanotic spells which led to cardiac arrest in 5 patients (14.7%) and death in 2 patients (5.9%). Patients on cardiac medications and with high heart rate had higher incidence of cyanotic spells and mortality. Technique of anesthesia did not affect cardiac and neurological outcome.
Conclusions
Perioperative complications are high after brain abscess surgery in patients with CCHD. Perioperative characteristics and outcomes were similar with MAC and GA techniques.
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Affiliation(s)
- Smita Vimala
- Division of Neuroanaesthesiology, Department of Anaesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Mathangi Krishnakumar
- Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Amit Goyal
- Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Kamath Sriganesh
- Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - G S Umamaheswara Rao
- Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
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Patino M, Chandrakantan A. Midgestational Fetal Procedures. CASE STUDIES IN PEDIATRIC ANESTHESIA 2019:197-201. [DOI: 10.1017/9781108668736.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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11
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Weiss SL, Nicolson SC, Naim MY. Clinical Update in Pediatric Sepsis: Focus on Children With Pre-Existing Heart Disease. J Cardiothorac Vasc Anesth 2019; 34:1324-1332. [PMID: 31734080 DOI: 10.1053/j.jvca.2019.10.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 09/23/2019] [Accepted: 10/15/2019] [Indexed: 11/11/2022]
Abstract
SEPSIS REMAINS one of the most common causes of childhood morbidity, mortality, and higher healthcare costs, with over 75,000 hospital admissions in the United States and an estimated 4 million cases worldwide per year. While standardized criteria to define sepsis are in flux, the general concept of sepsis is a severe infection that results in organ dysfunction. Although sepsis can affect previously healthy children, those with certain pre-existing comorbid conditions, including congenital and acquired heart disease, are at higher risk for both developing sepsis and having a poor outcome after sepsis. Multiple specialists including intensivists, cardiologists, surgeons, and anesthesiologists commonly contribute to the management and outcome of sepsis in children. In this article, the authors examine the evolving epidemiology of pediatric sepsis, including the subset of patients with underlying heart disease; contrast pediatric and adult sepsis; review the latest hemodynamic guidelines for management of pediatric septic shock and their application to children with heart disease; discuss the role of mechanical circulatory support; and review key aspects of anesthetic management for children with sepsis.
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Affiliation(s)
- Scott L Weiss
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Mitochondrial and Epigenomic Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Pediatric Sepsis Program, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, PA
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Goodenough CJ, Anderson KT, Smith KE, Hanfland RA, Wadhwa N, Teichgraeber JF, Greives MR. Impact of Cardiac Risk Factors in the Postsurgical Outcomes of Patients With Cleft Palate: Analysis of the 2012-2014 NSQIP Database. Cleft Palate Craniofac J 2018; 56:595-600. [DOI: 10.1177/1055665618799224] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To assess the risk of complication in patients undergoing cleft palate repair with congenital cardiac comorbidities in a large, national cohort. Design: Retrospective review. Patients/Setting: Using the 2012-2014 National Surgical Quality Improvement Program (NSQIP) Pediatric database, patients undergoing cleft palate repair were selected for analysis. Patients with cleft palate repairs were stratified based on the presence or absence congenital cardiac comorbidities. Univariate and stepwise forward logistic regression were conducted. Main Outcome Measures: It is hypothesized that risk of postoperative adverse events in patients with congenital cardiac comorbidities is higher than in patients without cardiac disease. Results: Nationally, between 2012 and 2014, 3240 patients underwent cleft palate repair, 422 (13.0%) with cardiac disease, and 2818 (87.0%) without cardiac disease. Patients with cardiac disease were smaller (10.5 [6.6] kg vs 11.6 [8.6] kg, P < .01) and more likely to be premature (4.6% vs 13.0%, P < .01) compared to those without cardiac disease. Postoperatively, patients with cardiac conditions were more likely to experience an adverse event (8.8% vs 4.2%, P < .01). Specifically, they were more likely to experience reintubation (1.7% vs 0.4%, P < .01), reoperation (2.1% vs 0.6%, P < .01), and longer length of stay (2.7 [7.0] vs 1.6 [2.8] days, P < .01). Rates of surgical site infection and dehiscence were not different. Conclusions: Cleft palate repair in patients with concurrent congenital cardiac defects is a safe procedure but carries elevated risk in the postoperative period as demonstrated in this analysis of the NSQIP-Pediatric database. Technical risks are equivalent. Additional anesthesia and surgical awareness of these potential complications is essential to minimize perianesthesia risks.
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Affiliation(s)
- Christopher J. Goodenough
- Department of General Surgery, McGovern School of Medicine, The University of Texas Health Science Center at Houston and Children’s Memorial Hermann Hospital, Houston, TX, USA
| | - Kathryn T. Anderson
- Department of Pediatric Surgery, McGovern School of Medicine, The University of Texas Health Science Center at Houston and Children’s Memorial Hermann Hospital, Houston, TX, USA
| | - Kari E. Smith
- Division of Pediatric Plastic Surgery, Department of Pediatric Surgery, McGovern School of Medicine, The University of Texas Health Science Center at Houston and Children’s Memorial Hermann Hospital, Houston, TX, USA
| | - Robert A. Hanfland
- Division of Pediatric Cardiac Surgery, Department of Pediatric Surgery, McGovern School of Medicine, The University of Texas Health Science Center at Houston and Children’s Memorial Hermann Hospital, Houston, TX, USA
| | - Nitin Wadhwa
- Division of Pediatric Anesthesia, Department of Anesthesia, McGovern School of Medicine, The University of Texas Health Science Center at Houston and Children’s Memorial Hermann Hospital, Houston, TX, USA
| | - John F. Teichgraeber
- Division of Pediatric Plastic Surgery, Department of Pediatric Surgery, McGovern School of Medicine, The University of Texas Health Science Center at Houston and Children’s Memorial Hermann Hospital, Houston, TX, USA
| | - Matthew R. Greives
- Division of Pediatric Plastic Surgery, Department of Pediatric Surgery, McGovern School of Medicine, The University of Texas Health Science Center at Houston and Children’s Memorial Hermann Hospital, Houston, TX, USA
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Yuki K, Lee S, Staffa SJ, DiNardo JA. Induction techniques for pediatric patients with congenital heart disease undergoing noncardiac procedures are influenced by cardiac functional status and residual lesion burden. J Clin Anesth 2018; 50:14-17. [PMID: 29936283 DOI: 10.1016/j.jclinane.2018.06.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/01/2018] [Accepted: 06/08/2018] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE Appropriate agent selection in patients with congenital heart disease (CHD) undergoing cardiac surgery and catheterization have been extensively reviewed in the literature. To date, there has not been an analysis of induction drug choices made in a large group of CHD patients undergoing non-cardiac procedures and intraoperative events. The primary objective was to characterize induction agent selection in CHD patients undergoing non-cardiac procedures and examine its association with intraoperative events. DESIGN Retrospective chart review analysis. SETTING A single center study. PATIENTS Children with CHD who underwent non-cardiac procedures. INTERVENTION/MEASUREMENT Using the electronic preoperative anesthesia evaluation form we identified 2966 cases performed under general anesthesia. We examined the association between patient characteristics (ASA PS and CHD severity) and induction drugs using multinominal logistic regression test. We also examined the association of induction drugs with intraoperative adverse events using Fisher exact test. MAIN RESULTS Inhalational and intravenous inductions were conducted in 35.7% and 64.3% of general anesthesia cases, respectively. Sevoflurane was the main inhalation induction drug. Propofol was used as the induction agent in 54.3% of cases, while etomidate, midazolam/fentanyl, and ketamine were used as the induction agent in 18.3% 16.6%, and 10.1% of cases, respectively. ASA PS and CHD severity predicted induction drugs better than single ventricle status or ventricular function. Intraoperative inotrope use was seen more frequently in cases induced by ketamine, etomidate or opioids over sevoflurane or propofol. CONCLUSIONS Patients with higher ASA classes and CHD of more severity tend to be induced more with etomidate, ketamine or opioids over sevoflurane or propofol. Use of etomidate, ketamine or opioids was more associated with inotrope use, but there was not significant difference in respiratory events among different induction agents. Causative association needs to be examined in the future.
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Affiliation(s)
- Koichi Yuki
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Cardiac Anesthesia, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Anaesthesia, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
| | - Sandra Lee
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Cardiac Anesthesia, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Anaesthesia, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Cardiac Anesthesia, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Anaesthesia, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Cardiac Anesthesia, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Anaesthesia, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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14
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Han BK, Casey S, Witt D, Leipsic J, Crean A, Nicol E, Semple T, Shambrook J, Prakash A, Banka P, Garberich R, Rigsby C, Hlavacek A, Lesser J. Development of a congenital cardiovascular computed tomography imaging registry: Rationale and implementation. J Cardiovasc Comput Tomogr 2018; 12:263-266. [PMID: 29628189 DOI: 10.1016/j.jcct.2018.03.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 03/14/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The cumulative exposure and risk of anesthesia, vascular access, contrast agents and radiation is emerging as a significant lifelong burden in patients with congenital heart disease (CHD). Latest generation computerized tomographic (CT) scanners are increasingly used for high resolution cardiovascular imaging and have both hardware and post processing radiation dose reduction strategies that can be implemented. Currently, these dose reduction strategies are not uniformly applied and there is a large variability in radiation dose used for the performance of CT in CHD. METHODS We propose the development and implementation of a prospective, multi-center and multi-specialty consortium to measure the variability of use, risk and image quality of CT scans in patients of all ages with CHD. The primary goals of this collaboration are 1) define variability of use, diagnostic quality, and risk of cardiac CT 2) establish best practice guidelines designed to optimize diagnostic image quality with appropriate use of radiation and anesthesia exposure 3) provide institution specific feedback compared with the group norm across participating centers 4) improve the level of evidence for the use of CT in CHD through the collection of prospective and multi-institutional data. CONCLUSIONS Prospective multi-institutional data is needed to inform risk estimates of CT in CHD using current generation scanners and aggressive dose optimization techniques. This registry will provide a platform for future collaboration establishing a multi-modality risk assessment tool specific to patients with CHD.
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Affiliation(s)
- B Kelly Han
- Children's Heart Clinic at Children's Hospitals and Clinics of Minnesota, USA.
| | - Susan Casey
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Dawn Witt
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Jonathon Leipsic
- University of British Columbia, St. Paul's Hospital, Vancouver, BC, Canada
| | | | | | | | | | - Ashwin Prakash
- The Heart Center at Boston Children's Hospital, Boston, MA, USA
| | - Puja Banka
- The Heart Center at Boston Children's Hospital, Boston, MA, USA
| | - Ross Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Cynthia Rigsby
- Ann and Robert H. Lurie's Children's Hospital, Chicago, IL, USA
| | | | - John Lesser
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, USA
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Abstract
PURPOSE OF REVIEW The current review focuses on patients with congenital heart disease (CHD) with regard to recent trends in global demographics, healthcare provision for noncardiac surgery, as well as anesthetic and perioperative care for these patients. RECENT FINDINGS About 40 years after milestones of surgical innovation in CHD, the number of adults with CHD (ACHD) now surpasses those of children with CHD. This development leads to the fact that even patients with complex CHD managed for noncardiac surgery are not restricted to highly specialized centers. However, preoperative risk assessment for anesthesia in these patients is complex due to underlying cardiac morbidity and substantial CHD-associated noncardiac morbidity. In addition to clinical assessment and echocardiography, biomarker measurement may be a clinically useful tool to estimate severity of heart failure in CHD patients. The high negative predictive value of NT-proBNP makes it particularly valuable as a screening tool. Further, morbidity and mortality in ACHD patients are mainly caused by arrhythmias and therefore are also relevant for perioperative management. Adverse events and perioperative death in ACHD patients in cardiac and noncardiac surgery are frequently related to intraoperative anesthetic care. SUMMARY Medical progress in treatment of CHD has shifted morbidity and mortality of these patients largely to adulthood. Future investigations including risk stratification of ACHD patients are necessary to further improve perioperative management, especially for low-risk and high-risk noncardiac management.
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Catheter, MRI and CT Imaging in Newborns with Pulmonary Atresia with Ventricular Septal Defect and Aortopulmonary Collaterals: Quantifying the Risks of Radiation Dose and Anaesthetic Time. Pediatr Cardiol 2018; 39:1308-1314. [PMID: 29744658 PMCID: PMC6153876 DOI: 10.1007/s00246-018-1895-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 05/02/2018] [Indexed: 12/01/2022]
Abstract
A comprehensive understanding of the native pulmonary blood supply is crucial in newborns with pulmonary atresia with ventricular septal defect and aortopulmonary collaterals (PA/VSD/MAPCA). We sought to describe the accuracy in terms of identifying native pulmonary arteries, radiation dose and anaesthetic time associated with multi-modality imaging in these patients, prior to their first therapeutic intervention. Furthermore, we wanted to evaluate the cumulative radiations dose and anaesthetic time over the study period. Patients with PA/VSD/MAPCA diagnosed at < 100 days between 2004 and 2014 were identified. Cumulative radiation dose and anaesthetic times were calculated, with imaging results compared with intraoperative findings. We then calculated the cumulative risks to date for all surviving children. Of 19 eligible patients, 2 had echocardiography only prior to first intervention. The remaining 17 patients underwent 13 MRIs, 4 CT scans and 13 cardiac catheterization procedures. The mean radiation dose was 169 mGy cm2 (47-461 mGy cm2), and mean anaesthetic time was 111 min (33-185 min). 3 children had MRI only with no radiation exposure, and one child had CT only with no anaesthetic. Early cross-sectional imaging allowed for delayed catheterisation, but without significantly reducing radiation burden or anaesthetic time. The maximum cumulative radiation dose was 8022 mGy cm2 in a 6-year-old patient and 1263 min of anaesthetic at 5 years. There is the potential to generate very high radiation doses and anaesthetic times from diagnostic imaging alone in these patients. As survival continues to improve in many congenital heart defects, the important risks of serial diagnostic imaging must be considered when planning long-term management.
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Ganigara A, Ramavakoda CY, Srinivasan CM, Ganigara M. Dilated cardiomyopathy in a child with abdominal neuroblastoma and normal serum catecholamine levels: anaesthetic management and review of literature. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2017. [DOI: 10.1080/22201181.2017.1283742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Anuradha Ganigara
- Department of Pediatric Anesthesiology, Indira Gandhi Institute of Child Health, Bangalore, India
| | | | - Chandana M Srinivasan
- Department of Pediatric Anesthesiology, Indira Gandhi Institute of Child Health, Bangalore, India
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Abstract
Patients with congenital heart diseases (CHDs) are at increased risk of developing complications during anaesthesia. Improvements in medical and surgical management in recent decades have resulted in significantly more children with CHD surviving to adulthood. The aim of this article is to focus on broad classification of CHD and to provide an updated review on the current perioperative anaesthetic management of CHD patients in different settings such as (a) interventional cardiac procedures that have dominated the field, (b) uncorrected patients for non-cardiac surgery and (c) corrected patients for non-cardiac surgery. The complexity of the defects along with a variety of non-cardiac surgery makes it impossible to have one single-anaesthesia technique. Search on Ovid, PubMed, Google Scholar and Medline were done with MeSH terms such as 'congenital heart disease', 'cardiac catheterisation', 'anaesthetic management' and 'non-cardiac surgery' mainly focusing on review articles and controlled studies for preparing the article.
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Affiliation(s)
- Sandip Waman Junghare
- Dr. D. Y. Patil Medical College Hospital and Research Centre, Pimpri, Maharashtra, India
| | - Vinayak Desurkar
- Department of Anaesthesia, Deenanath Mangeshkar Hospital and Research Centre, Pune, Maharashtra, India
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Development and Validation of a Risk Stratification Score for Children With Congenital Heart Disease Undergoing Noncardiac Surgery. Anesth Analg 2016; 123:824-30. [DOI: 10.1213/ane.0000000000001500] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Benkwitz C, Watkins SC, Donahue BS. Assessing the Risks of Noncardiac Surgery for Children With Congenital Heart Disease∗. J Am Coll Cardiol 2016; 67:802-3. [DOI: 10.1016/j.jacc.2015.11.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 11/24/2015] [Indexed: 11/25/2022]
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Post-Operative Outcomes in Children With and Without Congenital Heart Disease Undergoing Noncardiac Surgery. J Am Coll Cardiol 2016; 67:793-801. [DOI: 10.1016/j.jacc.2015.11.057] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 11/03/2015] [Indexed: 11/22/2022]
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Computed Tomography Imaging in Patients with Congenital Heart Disease Part I: Rationale and Utility. An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT). J Cardiovasc Comput Tomogr 2015; 9:475-92. [DOI: 10.1016/j.jcct.2015.07.004] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 07/17/2015] [Indexed: 12/16/2022]
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Brown ML, DiNardo JA, Odegard KC. Patients with single ventricle physiology undergoing noncardiac surgery are at high risk for adverse events. Paediatr Anaesth 2015; 25:846-851. [PMID: 25970232 DOI: 10.1111/pan.12685] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with single ventricle physiology are at increased anesthetic risk when undergoing noncardiac surgery. OBJECTIVE To review the outcomes of anesthetics for patients with single ventricle physiology undergoing noncardiac surgery. METHODS This study is a retrospective chart review of all patients who underwent a palliative procedure for single ventricle physiology between January 1, 2007 and January 31, 2014. Anesthetic and surgical records were reviewed for noncardiac operations that required sedation or general anesthesia. Any noncardiac operation occurring prior to completion of a bidirectional Glenn procedure was included. Diagnostic procedures, including cardiac catheterization, insertion of permanent pacemaker, and procedures performed in the ICU, were excluded. RESULTS During the review period, 417 patients with single ventricle physiology had initial palliation. Of these, 70 patients (16.7%) underwent 102 anesthetics for 121 noncardiac procedures. The noncardiac procedures included line insertion (n = 23); minor surgical procedures such as percutaneous endoscopic gastrostomy or airway surgery (n = 38); or major surgical procedures including intra-abdominal and thoracic operations (n = 41). These interventions occurred on median day 60 of life (1-233 days). The procedures occurred most commonly in the operating room (n = 79, 77.5%). Patients' median weight was 3.4 kg (2.4-15 kg) at time of noncardiac intervention. In 102 anesthetics, 26 patients had an endotracheal tube or tracheostomy in situ, 57 patients underwent endotracheal intubation, and 19 patients had a natural or mask airway. An intravenous induction was performed in 77 anesthetics, an inhalational induction in 17, and a combination technique in 8. The median total anesthetic time was 126 min (14-594 min). In 22 anesthetics (21.6%), patients were on inotropic support upon arrival; an additional 24 patients required inotropic support (23.5%), of which dopamine was the most common medication. There were 10 intraoperative adverse events (9.8%) including: arrhythmias requiring treatment (n = 4), conversion from sedation to a general anesthetic (n = 2), difficult airway (n = 1), inadvertent extubation with desaturation and bradycardia (n = 1), hypotension and desaturation (n = 1), and cardiac arrest (n = 1). Postoperative events (<48 h) included ST segment changes requiring cardiac catheterization (n = 1), and cardiorespiratory arrest (n = 1). Age, size, gender, type of cardiac palliation, patient location, procedure location, and type of procedure were not associated with adverse outcome. After 62 anesthetics (60.8%), patients went postoperatively to the cardiac ICU. There were no deaths at 48 h. CONCLUSION We observed no mortality during or after noncardiac surgery in a high-risk subgroup of palliated cardiac patients with single ventricle physiology. However, 11.8% of patients had an adverse event associated with their anesthetic.
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Affiliation(s)
- Morgan L Brown
- Division of Cardiac Anesthesia, Department of Anesthesiology, Boston Children's Hospital, Boston, MA, USA
| | - James A DiNardo
- Division of Cardiac Anesthesia, Department of Anesthesiology, Boston Children's Hospital, Boston, MA, USA
| | - Kirsten C Odegard
- Division of Cardiac Anesthesia, Department of Anesthesiology, Boston Children's Hospital, Boston, MA, USA
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