Perioperative events in children with pulmonary hypertension undergoing non-cardiac procedures

Perioperative and Long-Term Outcomes in Infants Undergoing a Tracheostomy from a Neonatal Intensive Care Unit

OBJECTIVE

The purpose of this study was to identify risk factors for perioperative complications and long-term morbidity in infants from the neonatal intensive care unit (NICU) presenting for a tracheostomy.

METHODS

This single-center retrospective cohort study included infants in the NICU presenting for a tracheostomy from August 2011 to December 2019. Primary outcomes were categorized as either a perioperative complication or long-term morbidity. A severe perioperative complication was defined as having either (1) an intraoperative cardiopulmonary arrest, (2) an intraoperative death, (3) a postoperative cardiopulmonary arrest within 30 days of the procedure, or (4) a postoperative death within 30 days of the procedure. Long-term morbidities included (1) the need for gastrostomy tube placement within the tracheostomy hospitalization and (2) the need for diuretic therapy, pulmonary hypertensive therapy, oxygen, or mechanical ventilation at 12 and 24 months following the tracheostomy.

RESULTS

One-hundred eighty-three children underwent a tracheostomy. The mean age at tracheostomy was 16.9 weeks while the mean post-conceptual age at tracheostomy was 49.7 weeks. The incidence of severe perioperative complications was 4.4% (n = 8) with the number of pulmonary hypertension medication classes preoperatively (OR: 3.64, 95% CI: (1.44-8.94), p = 0.005) as a significant risk factor. Approximately 81% of children additionally had a gastrostomy tube placed at the time of the tracheostomy, and 62% were ventilator-dependent 2 years following their tracheostomy.

CONCLUSION

Our study provides critical perioperative complications and long-term morbidity data to neonatologists, pediatricians, surgeons, anesthesiologists, and families in the expected course of infants from the NICU presenting for a tracheostomy.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:1945-1954, 2024.

Perioperative Considerations for Pediatric Patients With Congenital Heart Disease Presenting for Noncardiac Procedures: A Scientific Statement From the American Heart Association

Continuous advances in pediatric cardiology, surgery, and critical care have significantly improved survival rates for children and adults with congenital heart disease. Paradoxically, the resulting increase in longevity has expanded the prevalence of both repaired and unrepaired congenital heart disease and has escalated the need for diagnostic and interventional procedures. Because of this expansion in prevalence, anesthesiologists, pediatricians, and other health care professionals increasingly encounter patients with congenital heart disease or other pediatric cardiac diseases who are presenting for surgical treatment of unrelated, noncardiac disease. Patients with congenital heart disease are at high risk for mortality, complications, and reoperation after noncardiac procedures. Rigorous study of risk factors and outcomes has identified subsets of patients with minor, major, and severe congenital heart disease who may have higher-than-baseline risk when undergoing noncardiac procedures, and this has led to the development of risk prediction scores specific to this population. This scientific statement reviews contemporary data on risk from noncardiac procedures, focusing on pediatric patients with congenital heart disease and describing current knowledge on the subject. This scientific statement also addresses preoperative evaluation and testing, perioperative considerations, and postoperative care in this unique patient population and highlights relevant aspects of the pathophysiology of selected conditions that can influence perioperative care and patient management.

Effect of end-tidal carbon dioxide level on the optic nerve sheath diameter measured by transorbital ultrasonography in anesthetized pediatric patients: A randomized trial

BACKGROUND

Intraoperative hypercapnia and hypocapnia are common during pediatric anesthesia, and the cerebral blood flow and intracranial pressure may be affected by the partial pressure of arterial carbon dioxide. Transorbital ultrasound measurement of the optic nerve sheath diameter is a simple and non-invasive method for intracranial pressure assessment. The objective of this study was to evaluate the effect of end-tidal carbon dioxide (E_T CO₂ ) on optic nerve sheath diameter in a healthy anesthetized pediatric population.

METHODS

Pediatric patients scheduled for elective surgery under general anesthesia and mechanical ventilation in the supine position were enrolled and divided into four subgroups; age <2 years, 2-6 years, 6-12 years, and 12-18 years. Mechanical ventilation was adjusted to achieve target E_T CO₂ levels in a randomized sequence (40-35-45-40 mmHg or 40-45-35-40 mmHg). Three minutes after reaching each target E_T CO₂ level, transorbital ultrasound images of optic nerve sheath diameter were obtained and analyzed. The primary outcome was the optic nerve sheath diameter at each E_T CO₂ level.

RESULTS

Sixty-four pediatric patients were enrolled and analyzed. At E_T CO₂  = 40 mmHg, the optic nerve sheath diameter was 5.6 ± 0.6 mm, 6.4 ± 0.5 mm, 6.8 ± 0.6 mm, and 7.1 ± 0.5 mm in children aged <2 years, 2-6 years, 6-12 years, and 12-18 years, respectively. The overall percent decreases in the optic nerve sheath diameter was -5.6 ± -4.3% (95% CI; -6.7 to -4.5%) at E_T CO₂  = 35 mmHg while the overall percent increases of optic nerve sheath diameter (ONSD) was 4.9 ± 5.1% (95% CI; 3.6 to 6.1%) at E_T CO₂  = 45 mmHg compared with those at E_T CO₂  = 40 mmHg. Spearman rank correlation analysis indicated that there were weak to moderate correlation between E_T CO₂ and the optic nerve sheath diameter (correlation coefficient [p-value] = .355 [.004], .318 [.014], .373 [<.001], and .420 [<.001] in children aged <2 years, 2-6 years, 6-12 years, and 12-18 years, respectively).

CONCLUSIONS

The optic nerve sheath diameter measured by transorbital ultrasound showed rapid reactivity from E_T CO₂ 35 to 45 mmHg in healthy pediatric patients under inhalation general anesthesia.

Anesthetic Management in Adults with Congenital Heart Disease

PURPOSE OF REVIEW

Adults with congenital heart disease (ACHD) are a complex and growing population that presents numerous challenges for anesthetic management. This review summarizes special considerations for anesthetic management in ACHD.

RECENT FINDINGS

The adult patient with congenital heart disease may require anesthetic care for multiple surgeries and interventions throughout their lifetime. The cardiac and extracardiac manifestations of ACHD have important perioperative implications that affect anesthetic management. Recent American Heart Association/American College of Cardiology and European Society of Cardiology guidelines endorse a multidisciplinary, team-based approach to care. The cardiac anesthesiologist, endorsed as part of this multidisciplinary team, must have a thorough understanding of congenital heart disease pathophysiology and common extra-cardiac manifestations of ACHD. Safe anesthetic management in adult congenital heart disease should incorporate a multi-disciplinary approach to patient care. Anesthesiologists and centers with special expertise in ACHD care should be utilized or consulted whenever possible.

Anesthesia in Children With Pulmonary Hypertension: Clinically Significant Serious Adverse Events Associated With Cardiac Catheterization and Noncardiac Procedures

OBJECTIVES

To determine the incidence of clinically significant serious adverse events in a contemporary population of pediatric patients with pulmonary hypertension who require anesthesia and identify factors associated with adverse outcomes.

DESIGN

A retrospective, cross-sectional study.

SETTING

A single-center quaternary-care freestanding children's hospital in the northeastern United States.

PARTICIPANTS

Pediatric patients with pulmonary hypertension based on hemodynamic criteria on cardiac catheterization during a 3-year period from 2015 to 2018.

INTERVENTIONS

Anesthesia care for cardiac catheterization, noncardiac surgery, and diagnostic imaging.

MEASUREMENTS AND MAIN RESULTS

Two hundred forty-nine children underwent 862 procedures, 592 for cardiac catheterization and 278 for noncardiac surgery and diagnostic imaging. The median age was 1.6 years, and the weight was 9.5 lbs. On index catheterization, median pulmonary artery pressure was 36 mmHg, and the pulmonary vascular resistance was 5.1 indexed Wood units. Ten percent of anesthetics were performed with a natural airway, and 80% used volatile anesthetics. Serious adverse events occurred in 26% of procedures (confidence interval [CI], 22%-30%). The rate of periprocedural cardiac arrest was 8 per 1,000 anesthetic administrations. In multivariate analysis, younger age (adjusted odds ratio [aOR], 1.4 per year; CI, 1.1-1.9; p = 0.01), location in the catheterization laboratory (aOR, 5.1; CI, 1.7-16; p = 0.004), and longer procedure duration (aOR, 1.3 per 30 minutes; CI, 1.1-1.4; p = 0.001) were associated with serious adverse events. Patients with a tracheostomy in place were less likely to experience an adverse event (aOR, 0.1; CI, 0.04-0.5; p = 0.001). The primary anesthetic technique was not associated with adverse events. Interventional cardiac catheterization was associated with an increased incidence of adverse events compared with diagnostic catheterization (42% v 21%; OR, 2.23; CI, 1.5-3.3; p < 0.001).

CONCLUSIONS

Serious adverse events were common in this cohort. Careful planning to minimize anesthesia time in young children with pulmonary hypertension should be undertaken, and these factors considered in designing risk mitigation strategies.

Moyamoya disease associated with pediatric pulmonary hypertension-a case report

Moyamoya disease (MD) is a rare vaso-occlusive disorder that primarily affects intracranial cerebral arteries. The involvement of extracranial vessels is unusual. However, there are previous reports suggesting MD to be a systemic disorder, causing disease manifestations in vessels of other parts of the body. We report the case of a female patient with MD and multiple episodes of ischemic strokes followed by bypass surgery of cerebral arteries during infancy. Due to corresponding ischemic lesions the girl showed global retardation of psychomotor development and central right sided movement disorder. At the age of 10 years the girl was admitted to our hospital with recurrent syncope. While cranial MRI excluded any newly added ischemic lesions, electrocardiography revealed evidence of right ventricular hypertrophy, and subsequent echocardiography then indicated pulmonary hypertension, which was confirmed by cardiac catheterization. Despite an upfront combination pulmonary vasodilating therapy, the pulmonary vascular disease appeared to be progressive. Genetic analysis showed heterozygous c.12341C>T mutation in the RNF213 gene. This case presentation demonstrates that pulmonary arterial hypertension is a rare comorbidity in patients with MD, especially in patients with genetic predictors such as the RNF213 mutation. Thus, regular echocardiographic screening for early signs of pulmonary arterial hypertension in patients with MD should be part of regular clinical work-up. Early detection and treatment of pulmonary arterial hypertension in MD might help to improve the long-term outcome in the individual patient.

Update on Perioperative Pediatric Pulmonary Hypertension Management

Pediatric pulmonary hypertension is a disease that has many etiologies and can present anytime during childhood. Its newly revised hemodynamic definition follows that of adult pulmonary hypertension: a mean pulmonary artery pressure >20 mmHg. However, the pediatric definition stipulates that the elevated pressure must be present after the age of three months. The definition encompasses many different etiologies, and diagnosis often involves a combination of noninvasive and invasive testing. Treatment often is extrapolated from adult studies or based on expert opinion. Moreover, although general anesthesia may be required for pediatric patients with pulmonary hypertension, it poses certain risks. A thoughtful, multidisciplinary approach is needed to deliver excellent perioperative care.

Anesthesia for Major Surgery in the Neonate

Perioperative risk of morbidity and mortality for neonates is significantly higher than that for older children and adults. At particular risk are neonates born prematurely, neonates with major or severe congenital heart disease, and neonates with pulmonary hypertension. Presently no consensus exists regarding the safest anesthetic regimen for neonates. Regional anesthesia appears to be safe, but does not reduce the overall risk of postoperative apnea. Former preterm infants require postoperative observation for apnea. The anesthesiologist caring for the neonate for major surgery should be knowledgeable of the unique physiology of the neonate and maintain the highest level of vigilance throughout.

Monitored Anesthesia Care of Two Patients with Highly Elevated Subpulmonic Ventricular Pressure due to Adult Congenital Heart Disease

Procedural sedation and analgesia for patients with adult congenital heart disease (ACHD) and highly elevated subpulmonic ventricular pressure require proper anesthesia care to prevent a pulmonary hypertensive crisis. We describe the monitored anesthesia care (MAC) of two patients with ACHD (a complete atrioventricular septal defect and congenitally corrected transposition of the great arteries) and highly elevated subpulmonic ventricular pressure. In both patients, preprocedural transthoracic echocardiography was useful for detecting severely elevated subpulmonic ventricular pressure. The MAC involved the infusion of propofol, dexmedetomidine, and fentanyl. Norepinephrine was continuously administered from the preanesthetic period. No hemodynamic instability or respiratory depression was observed during the MAC. Continuous administration of norepinephrine from the preinduction period was helpful for preventing hypotension. We added dexmedetomidine to our MAC regimen of propofol and fentanyl because it exerts both sedative and analgesic effects. Dexmedetomidine does not cause respiratory depression; thus, our MAC regimen is believed to be theoretically safe for patients with ACHD and elevated subpulmonic ventricular pressure. Our findings suggest that safe MAC for patients with ACHD and highly elevated subpulmonic ventricular pressure may require careful consideration of the anesthetic regimen and close observation by adequately trained personnel, which is best provided at regional ACHD centers.

Postnatal Ultrasound to Determine the Surgical Strategy for Congenital Diaphragmatic Hernia

OBJECTIVES

To compare defect sizes in congenital diaphragmatic hernia (CDH) measured by postnatal ultrasound (US) between neonates who underwent thoracoscopic surgery and neonates who underwent open surgery and between neonates who underwent primary repair and those who underwent patch repair; additionally, to compare the accuracy of US diagnosis with that of surgical diagnosis for the location of the diaphragmatic hernia and the hernial contents.

METHODS

We included 8 neonates who underwent preoperative US evaluations of CDH. We compared anterior-to-posterior diaphragm defect sizes between thoracoscopic and open surgery approaches and between primary and patch repair by using the Mann-Whitney U test. The diaphragm was divided into 3 segments: anterior, lateral, and posterior. We evaluated the location of the diaphragmatic hernia and the hernial contents.

RESULTS

Four neonates who underwent open surgery had larger diaphragmatic hernias than those who underwent thoracoscopic surgery (mean ± SD, 30.5 ± 5.6 versus 16.3 ± 3.3 mm; P = .030). They were also larger in neonates who underwent patch repair than in those who underwent primary repair (33.0 ± 3.0 versus 17.6 ± 4.2 mm; P = .037). Detection of anterior and lateral diaphragm segments was consistent between US and surgical findings. Three of 4 neonates who underwent open surgery and all 3 neonates who underwent patch repair did not show the lateral segment. The hernial contents were also consistent between US and surgical findings.

CONCLUSIONS

Postnatal US examinations of neonates with CDH could provide surgeons with useful information to determine the surgical approach and repair method. However, since our study cohort was small, further studies are needed with a larger number of neonates with CDH.

Deep Tracheal Extubation Using Dexmedetomidine in Children With Congenital Heart Disease Undergoing Cardiac Catheterization: Advantages and Complications

Objective. Deep tracheal extubation using dexmedetomidine is safe and provides smooth recovery in children with congenital heart disease undergoing cardiac catheterization. Design. Single-institution, retrospective study of prospectively collected data. Participants. All patients aged between 1 month and 5 years who underwent general endotracheal anesthesia for diagnostic and interventional cardiac catheterizations in the cardiac catheterization suite from January 2015 (change in standard operating procedure) through October 2016 (approval of institutional review board for study). Measurement and Main Results. One hundred and eighty-nine patients (81%) of the 232 patients who underwent cardiac catheterization during the study period were noted to undergo deep tracheal extubation. Cyanotic heart disease was present in 87 patients (46%), history of prematurity in 51 (27%), and pulmonary hypertension in 26 (14%) patients. A documented smooth recovery in the postoperative care unit (PACU) requiring no additional analgesics or sedatives was observed in 91% of the patients. The majority of patients required no airway support after deep extubation (n = 140, 74%, P = .136). The presence of pulmonary hypertension (odds ratio = 4.45, P = .035) and presence of a cough on the day of the procedure (odds ratio = 7.10, P = .03) were significantly associated with the use of oxygen or use of oral airway for greater than 20 minutes in the PACU. After extubation, there were no reported events of aspiration, the use of noninvasive positive pressure ventilation, reintubation, heart block, or systemic hypotension requiring treatment or cardiac arrest. Conclusions. Deep extubation using dexmedetomidine in infants and toddlers after cardiac catheterization is feasible and enables smooth postoperative recovery with minimal adverse effects.

Spectrum of Current Management of Pediatric Pulmonary Hypertensive Crisis

Pulmonary hypertension is a growing pediatric problem and children may present with pulmonary hypertensive crisis-a life-threatening emergency requiring acute interventions. The aim of this study was to characterize the broad spectrum of care provided in North American PICUs for children who present with pulmonary hypertensive crisis.

DESIGN

Electronic cross-sectional survey. Survey questions covered the following: demographics of the respondents, institution, and patient population; pulmonary hypertension diagnostic modalities; pulmonary hypertension-specific pharmacotherapies; supportive therapies, including sedation, ventilation, and inotropic support; and components of multidisciplinary teams.

SETTING

PICUs in the United States and Canada.

SUBJECTS

Faculty members from surveyed institutions.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

The response rate was 50% of 99 identified institutions. Of the respondents, 82.2% were pediatric intensivists from large units, and 73.9% had over a decade of experience beyond training. Respondents provided care for a median of 10 patients/yr with acute pulmonary hypertensive crisis. Formal echocardiography protocols existed at 61.1% of institutions with varying components reported. There were no consistent indications for cardiac catheterization during a pulmonary hypertensive crisis admission. All institutions used inhaled nitric oxide, and enteral phosphodiesterase type 5 inhibitor was the most frequently used additional targeted vasodilator therapy. Milrinone and epinephrine were the most frequently used vasoactive infusions. Results showed no preferred approach to mechanical ventilation. Fentanyl and dexmedetomidine were the preferred sedative infusions. A formal pulmonary hypertension consulting team was reported at 51.1% of institutions, and the three most common personnel were pediatric cardiologist, pediatric pulmonologist, and advanced practice nurse.

CONCLUSIONS

The management of critically ill children with acute pulmonary hypertensive crisis is diverse. Findings from this survey may inform formal recommendations - particularly with regard to care team composition and pulmonary vasodilator therapies - as North American guidelines are currently lacking. Additional work is needed to determine best practice, standardization of practice, and resulting impact on outcomes.

Anesthesia in Pediatric Patients With Congenital Heart Disease Undergoing Noncardiac Surgery: Defining the Risk

The incidence of moderate to severe congenital heart disease (CHD) in the United States is estimated to be 6 per 1,000 live-born, full-term infants. Recent advances in pediatric cardiology, surgery, and critical care have improved significantly the survival rates of patients with CHD leading to an increase in prevalence in both children and adults. Children with CHD significant enough to require cardiac surgery frequently also undergo noncardiac surgical procedures. With this increased demand for procedures that require anesthesia, all anesthesiologists, and more specifically, pediatric anesthesiologists will encounter patients with repaired or unrepaired CHD and other cardiac diseases in their practice. They often are faced with the question, "Is this patient too high risk for anesthesia?" The objective of this literature review is to provide a greater understanding of patients at high risk and to quantify the risk for patients, their families, and clinicians. In addition, specific high-risk lesions (single ventricle, Williams-Beuren syndrome, pulmonary hypertension, cardiomyopathies, and ventricular assist devices) are described.

Current understanding and perioperative management of pediatric pulmonary hypertension

Pediatric pulmonary hypertension is a complex disease with multiple, diverse etiologies affecting the premature neonate to the young adult. Pediatric pulmonary arterial hypertension, whether idiopathic or associated with congenital heart disease, is the most commonly discussed form of pediatric pulmonary hypertension, as it is progressive and lethal. However, neonatal forms of pulmonary hypertension are vastly more frequent, and while most cases are transient, the risk of morbidity and mortality in this group deserves recognition. Pulmonary hypertension due to left heart disease is another subset increasingly recognized as an important cause of pediatric pulmonary hypertension. One aspect of pediatric pulmonary hypertension is very clear: anesthetizing the child with pulmonary hypertension is associated with a significantly heightened risk of morbidity and mortality. It is therefore imperative that anesthesiologists who care for children with pulmonary hypertension have a firm understanding of the pathophysiology of the various forms of pediatric pulmonary hypertension, the impact of anesthesia and sedation in the setting of pulmonary hypertension, and anesthesiologists' role as perioperative experts from preoperative planning to postoperative disposition. This review summarizes the current understanding of pediatric pulmonary hypertension physiology, preoperative risk stratification, anesthetic risk, and intraoperative considerations relevant to the underlying pathophysiology of various forms of pediatric pulmonary hypertension.

Risk associated with anesthesia for noncardiac surgery in children with congenital heart disease

Database analysis has indicated that perioperative cardiac arrest occurs with increased frequency in children with congenital heart disease. Several case series and large datasets from ACS NSQIP have identified subgroups at the highest risk. Consistently, patients with single ventricle physiology (especially prior to cavopulmonary anastomosis), severe/supra-systemic pulmonary hypertension, complex lesions, and cardiomyopathy with significantly reduced ventricular function have been shown to be at increased risk for adverse events. Based on these results, algorithms for assessing risk have been proposed. How hospitals and health care systems apply these guidelines to provide safe care for these challenging patient groups requires the application of modern quality improvement techniques. Each institution should develop a system which reflects local expertise and resources.

Noncardiac surgery in the congenital heart patient

More children with congenital heart disease are surviving and require noncardiac surgery. A high-yield summary of congenital heart anatomy and pathophysiology is presented to contextualize these patients for surgeons. Preoperative planning including risk stratification, anesthetic management and timing of elective surgery are discussed. Specific intraoperative considerations for particular cases, such as the use of laparoscopy and thoracic surgery, are reviewed. Postoperative outcomes and recommended management required to mitigate complications are summarized.