Anaesthetic considerations in children with congenital heart disease undergoing non-cardiac surgery

A Nationwide Analysis of the Impact of Cardiopulmonary Anomalies on Cleft Palate Surgical Outcomes

OBJECTIVE

To increase awareness and improve perioperative care of patients with cleft palate (CP) and coexisting cardiopulmonary anomalies.

DESIGN

Retrospective cohort.

SETTING

Multi-center.

PATIENTS/PARTICIPANTS

Patients who underwent surgical repair of CP between 2012-2020 identified in the American College of Surgeons National Surgical Quality Improvement Program Pediatric Data File. Chi-squared analysis and Student's t-test were implemented to make associations between congenital heart disease (CHD) and congenital pulmonary disease (CPD) and postoperative complications. Multiple logistic regression was performed to identify associations between CP and CHD/CPD while controlling for age, gender, and ASA class. C2 values were used to assess the logistic regressions, with a significance level of 0.05 indicating statistical significance.

MAIN OUTCOMES MEASURES

Length of stay (LOS), perioperative complications (readmission, reoperation, reintubation, wound dehiscence, cerebrovascular accidents, and mortality).

RESULTS

9 96 181 patients were identified in the database, 17 786 of whom were determined to have CP, of whom 16.0% had congenital heart defects (CHD) and 13.2% had congenital pulmonary defects (CPD). Patients with CHD and CPD were at a significantly greater risk of increased LOS and all but one operative complication rate (wound dehiscence) relative to patients with CP without a history of CHD and CPD.

CONCLUSION

This study suggests that congenital cardiopulmonary disease is associated with increased adverse outcomes in the setting of CP repair. Thus, heightened clinical suspicion for coexisting congenital anomalies in the presence of CP should prompt referring providers to perform a comprehensive and multidisciplinary evaluation to ensure cardiopulmonary optimization prior to surgical intervention.

Anesthetic Challenges in an Infant With Tetralogy of Fallot Posted for Non-cardiac Surgery: A Case Report and Literature Review

The goal of this article is to provide an up-to-date and comprehensive review of the current perioperative anesthetic management of pediatric patients with congenital heart disease (CHD) undergoing non-cardiac surgery. This report discusses a case of a nine-month-old female with Tetralogy of Fallot who was scheduled for non-cardiac surgery for anorectal malformation stage 1 and stage 2 repair. This case study discusses how to adjust perioperative anesthesia care in cases of left-to-right shunt, right-to-left shunt, and complex cardiac disease. In addition, the author discusses special considerations such as pulmonary hypertension, newborns with CHD undergoing extracardiac surgery, and the importance of regional anesthesia in children with CHD undergoing non-cardiac surgery.

The patient with congenital heart disease in ambulatory surgery

The number of patients with congenital heart disease (CHD) undergoing ambulatory surgery is increasing. Deciding whether a CHD patient is suitable for an ambulatory procedure is still challenging. Several factors must be considered, including the type of planned procedure, the complexity of the underlying pathology, the American Society of Anesthesiologists' Physical Status classification of the patient, and other patient-specific factors, including comorbidity, chronic complications of CHD, medication, coagulation disorders, and issues related to the presence of a pacemaker (PM) or cardioverter-defibrillator. Numerous studies reported higher perioperative mortality and morbidity rates in surgical patients with CHD than non-CHD patients. However, most of these studies were conducted in a cohort of hospitalized patients and may not reflect the ambulatory setting. The current review aims to provide the anesthesiologist with an overview and practical recommendations on selecting and managing a CHD patient scheduled for an ambulatory procedure.

Anaesthetic management of a toddler with uncorrected tetralogy of Fallot undergoing surgery for epidural haematoma

The literature on the anaesthetic management of a toddler presenting to the emergency department with an acute epidural haematoma with an uncorrected tetralogy of Fallot is sparse and management can be challenging. The main anaesthetic goals are to increase or maintain systemic vascular resistance and decrease pulmonary vascular resistance for cardiovascular stability, while maintaining cerebral perfusion pressure and decreasing intracranial pressure for cerebral protection. Thus, a balanced approach is desirable while managing such cases from emergency to the intensive care unit.

Anaesthesia management for cleft lip in a child with unrepaired Tetralogy of Fallot in Malawi: a case report

Background

Children with clefts lips often present with cardiac abnormalities, among them the tetralogy of Fallot. Anaesthesia for patients with unrepaired Tetralogy of Fallot coming for a non-cardiac surgery represents an additional risk of increased perioperative morbidity and mortality.

Case presentation

We present a case of a 8 years old boy with unrepaired Tetralogy of Fallot scheduled for cleft lip repair. The Child was referred to Mercy James Centre for Paediatric Surgery and Intensive Care from an Operation Smile Mission campaign. Anaesthesia consisted of a balanced general anaesthesia combined with regional anaesthesia by an infraorbital nerve block. The child developed hypercyanotic spells postoperatively which were successfully managed with noradrenaline, morphine, fluid, and oxygen therapy.

Conclusion

Children with unrepair Tetralogy of Fallot coming for non-cardiac surgery have increased risk of complications during anaesthesia. The anaesthesia provider should be aware and ready to manage them promptly.

Anaesthetic management of a patient with complex, cyanotic congenitally corrected transposition of great arteries for electrophysiological study and thermoablation

Congenitally corrected transposition of great arteries (ccTGA) is a rare congenital heart disease, and little literature is available that describes its anaesthetic management. We present the perioperative management of a patient with complex, cyanotic ccTGA who underwent electrophysiological study with catheter ablation under general anaesthesia. Good understanding of the patient's complex cardiac anatomy and physiology and multidisciplinary communication are vital to facilitate the successful care of the patient.

Anesthetic Management in an Infant with Dandy–Walker Syndrome Presenting with Acyanotic Heart Disease and Hydrocephalous Post-COVID-19 Recovery: A Rare Experience

We report a case of hydrocephalus with Dandy–Walker malformation in a 2-month-old girl child recently recovered from COVID-19. The child was detected to have acyanotic heart disease with left-to-right shunt and severe pulmonary arterial hypertension during the preoperative evaluation process for ventriculoperitoneal (VP) shunt placement. We share our experience of the perioperative management for pulmonary artery banding (PAB) and patent ductus arteriosus ligation as a part of staged cardiac corrective surgery, followed by VP shunt to relieve hydrocephalus in the single setting. Our management was focused on the preservation of the normal cerebral and cardiac physiology to prevent rise in intracranial pressure and pulmonary artery pressure. A multidisciplinary team, consisting of cardiac- and neuroanesthesiologists and cardiac and neurosurgeons, was involved in management of the case. Diligent maintenance of airway, stable hemodynamics, meticulous ventilation, along with postoperative ICU management helped in the successful outcome of this unique case.

Risk Recognition and Multidisciplinary Approach for Non-Cardiac Surgeries in Paediatric Cardiac Patients: A Retrospective Observational Study

Background

Congenital heart disease (CHD), a structural and functional heart disease, is the commonest birth defect with an incidence of one in 125 live births worldwide with ventricular septal defect (VSD), atrial septal defect (ASD) and tetralogy of Fallot (TOF) constituting the majority. Surgery for associated extra-cardiac anomalies (airway, skeletal, genitourinary, and gastrointestinal) may be required in 30% of these patients. Delivery of uneventful anaesthesia in these children requires an understanding of not only paediatric anaesthesia but also of the pathophysiology of the cardiac lesion and its associated risks.

Aims

The purpose of this retrospective review was to highlight the approach to the anaesthetic management and outcomes of patients with significant cardiac lesions presenting for non-cardiac surgeries.

Material and methods

A retrospective chart review of all children with congenital heart disease (CHD) (repaired or unrepaired) who were posted for a non-cardiac surgery in this tertiary care Paediatric super-specialty hospital from January 1, 2018 to December 31, 2019 was carried out. Data on demographics, peri-operative management, and clinical course was retrieved.

Inclusion criteria were paediatric patients (0-18 years) of either gender with a diagnosis of a CHD (repaired or unrepaired) undergoing any non-cardiac surgeries (NCS) under anaesthesia/Monitored Anaesthesia Care (MAC).

Exclusion criteria were procedures only under local anaesthesia (LA) or a minor procedure done solely under sedation not involving an anaesthesiologist.

Results

During the study period, we found five eligible cases who underwent a total of six procedures. Five procedures were elective and one was an emergency. Preoperative optimization was conducted by a multidisciplinary team including paediatric surgeons, anaesthesiologists, physicians, and cardio-thoracic surgeons. Anaesthesia was conducted by at least a consultant paediatric anaesthesiologist. Overall all patients tolerated anaesthesia well without any adverse events or complications. All six anaesthetic encounters were safe and uneventful.

Managing the Adult Patient with Congenital Heart Disease

The focus of this article is noncardiac surgery in the adult with congenital heart disease (CHD). The purpose is to provide the general and pediatric anesthesiologist with a basic overview of the most common congenital cardiac lesions, their long-term sequelae, and expected perioperative concerns during noncardiac surgery. Because of the very heterogeneous nature of CHD, it is difficult to make a single article a comprehensive guide for every lesion and its associated perioperative concerns. The authors hope to provide those who are not specifically trained in congenital cardiac anesthesia the basic principles and a greater understanding of each defect.

Perioperative Management of Subarachnoid Hemorrhage in a Patient with Alagille Syndrome and Unrepaired Tetralogy of Fallot: Case Report

Alagille syndrome (ALGS) is a genetic disorder associated with multisystem dysfunction involving the hepatic, cardiovascular, and neurologic systems. Tetralogy of Fallot (TOF), a congenital cardiac anomaly, is commonly found in these patients. Patients with ALGS may also have an increased risk of cerebrovascular abnormalities and bleeding. Ruptured cerebral aneurysm and subarachnoid hemorrhage (SAH) may be developed, increasing the incidence of morbidity and mortality. Advances in neuroimaging and neurosurgery have allowed early identification and treatment of such vascular abnormalities, improving patients’ outcomes and reducing life-threatening complications such as intracranial bleeding. Authors describe the perioperative management of a patient with ALGS and TOF who was admitted to the emergency department due a ruptured intracranial aneurysm with concomitant SAH. Surgical treatment included diagnostic cerebral arteriography with coil embolization of a left posterior communicating artery aneurysm, and placement of right external ventricular drain (EVD). The combination of neuroprotective anesthetic techniques, fast emergence from anesthesia, and maintenance of intraoperative hemodynamic stability led to a successful perioperative management. A multidisciplinary approach in specialized centers is essential for the treatment of patients with SAH, especially in patients with ALGS and complex congenital heart disease such as TOF.

Prevalence of congenital cardiac anomalies in patients with cleft lip and palate - Its implications in surgical management

Background

Cleft lip and palate is one of the most common congenital craniofacial deformities seen in children. Various congenital anomalies are reported in the literature to be associated with cleft lip and palate. Cardiac anomalies are one of the most common congenital disorders associated in cleft lip and palate patientsIt includes Cyanotic and acyanotic cardiac diseases likel fallot's tetralogy, transposition of greater vessels, atresia of tricuspid, total anomalous pulmonary venous return (TAPVR), truncus arteriosus, ebstein's anomaly, hypoplastic left heart syndrome and pulmonary atresia, patent ductus arteriosus, ventricular septal defect, atrial septal defect, pulmonary stenosis, aortic stenosis and coarctation of aorta.

Aim

To study the prevalence of congenital cardiac anomalies in cleft lip and palate patients.

Objectives

To study different types of congenital cardiac anomalies/defects in patients with cleft lip and palate and its implications in surgical management.

Materials and Methods

This is a retrospective study carried out for a period of one year. In the present study medical records of 200 patients with cleft lip and palate were evaluated and analyzed for presence of congenital cardiac anomalies.

Results

Out of 200 patients of cleft lip and palate, 30 patients (15%) were associated with congenital cardiac anomalies with male to female ratio of 1:1. Associated congenital cardiac anomalies were most frequently seen in unilateral cleft palate patients (21.05%) The most common cardiac anomaly was Ventricular septal defect (36.6%).

Congenital Heart Disease in Cleft Lip and Palate Patients: How Common Is the Association?

Aims and Objectives:

To determine the prevalence of congenital heart disease in patients with orofacial cleft in a Nigerian population.

Materials and Methods:

A retrospective review of all the case files of patients with orofacial cleft managed at the Dental and Maxillofacial Surgery unit of the Aminu Kano Teaching Hospital between 2007 and 2014. Data were analyzed using SPSS version 16.

Results:

A total of 133 patients with cleft lip and palate were seen during the period of study comprising 77 males and 56 females, giving an M:F ratio of 1:0.7. The age range was 15 days–36 years with a mean age of 6 years. There were five cases of congenital heart disease made up of two males and three females, giving a prevalence of 3.76 per cent.

Conclusion:

This study showed that the prevalence of congenital heart disease in patients with orofacial cleft was low. However, the need for routine echocardiography in all orofacial cleft patients especially children should not be overlooked.

Conducting Prolonged General Anesthesia without Intravenous Access in a Child with Hypoplastic Left Heart Syndrome

Children with chronic medical conditions often need multiple intravenous (IV) access instances during their hospitalizations, both peripheral and central. Obtaining a working IV in this patient population undergoing general anesthesia can be challenging. In our case report, we describe a method of administering general anesthesia in an infant with partially repaired hypoplastic left heart syndrome without IV access.

Congenital heart diseases and anaesthesia

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.

Periprocedural Management of Vein of Galen Aneurysmal Malformation Patients: An 11-Year Experience

Context:

The vein of Galen aneurysmal malformation (VGAM) is a rare arteriovenous malformation where a dilated median prosencephalic vein provides a low-resistance conduit for intracerebral blood flow resulting in high-output cardiac failure, severe pulmonary hypertension, with or without central nervous system symptoms secondary to hydrocephalus, in the neonatal and pediatric population.

Aim:

This study aims to analysis of the anesthetic management of this unique subset of patients with VGAM.

Settings and Design:

This was a retrospective analysis of case series of VGAM patients admitted between January 2005 and June 2016 in our Institute.

Subjects and Methods:

Case records of VGAM patients were reviewed for the anesthetic technique and medications administered. The incidence of intra-and post-procedural complications and their management and outcomes were analyzed.

Statistical Analysis:

Parametric data were expressed as mean and standard deviation. Descriptive statistics was used for describing associated pathologies, drugs and monitors used during the procedure, incidence of any adverse events, and the treatment protocol.

Results:

Twenty-one patients underwent treatment for the VGAM. There were a total of forty anesthetics administered for embolization, diagnostic angiography, and magnetic resonance imaging. Eighty-five percent had increased head circumference, 40% had associated focal neurological deficits, and 15% had seizures as presenting symptoms. Cardiac anomalies were seen in 41% of the patients, and difficult airway was anticipated in 38% of the patients. The majority of the patients had inhalational induction (62.2%) and inhalation maintenance (84.4%) of anesthesia. Intraprocedural adverse events were noted in 43% and postprocedure complications in 38% of the patients.

Conclusion:

Anesthetic management for embolization of VGAM with a combination of opioids and inhalational agents helps in minimizing the incidence of intraprocedural adverse events and provides a better hemodynamic profile.

The prevalence of congenital heart defects in infants with cholestatic disorders of infancy: a single-centre study

BACKGROUND

There is deficiency of data about congenital heart defects (CHDs) in cholestatic disorders of infancy other than Alagille syndrome (AGS). We aimed to define the prevalence and types of CHDs in infants with various causes of cholestatic disorders of infancy.

METHODS

This cross-sectional study was conducted on 139 infants presenting with cholestasis whether surgical or non-surgical. The study was carried out at the Pediatric Hepatology Unit, Cairo University Children's Hospital, Egypt. Full examination and investigations were done in an attempt to reach an aetiologic diagnosis for cholestasis, in addition to a comprehensive echocardiographic study.

RESULTS

The age at the onset of cholestasis ranged from 1 day to 7 months. Males constituted 61.2%. Biliary atresia (BA) was diagnosed in 39 patients (28%), AGS in 16 patients (11.5%), 27 patients had miscellaneous diagnoses and 57 cases had indeterminate aetiology. CHDs were detected in 55 patients (39.5%). Shunt lesions were detected in 24 patients (43.6%), pulmonary stenosis in 18 patients (32.7%) and combined lesions in 9 patients (16.4%). Three patients (5.5%) had abnormal cardiac situs. Only seven patients had clinical presentation suggestive of CHD. CHDs were detected in 14 patients with BA (35.9%), 15 patients with AGS (93.7%) and 26 patients in the remaining group (30.9%).

CONCLUSION

CHDs are not uncommon among cholestatic infants and are mostly asymptomatic. Echocardiographic examination of cholestatic infants is recommended particularly for patients with BA before undergoing hepatic portoenterostomy as presence of CHD may impact the anaesthetic planning and affect the outcome of hepatobiliary surgery.

Rats with Chronic, Stable Pulmonary Hypertension Tolerate Low Dose Sevoflurane Inhalation as Well as Normal Rats Do

BACKGROUND

The effects of low concentration of sevoflurane on right ventricular (RV) function and intracellular calcium in the setting of pulmonary arterial hypertension (PAH) have not been investigated clearly. We aim to study these effects and associated signaling pathways in rats with PAH.

METHODS

Hemodynamics were assessed with or without sevoflurane inhalation in established PAH rats. We analysis the classic RV function parameters and RV-PA coupling efficiency using steady-state PV loop recordings. The protein levels of SERCA2, PLB and p-PLB expression was analyzed by western blot to assess their relevance in PAH.

RESULTS

Rats with PAH presented with RV hypertrophy and increased pulmonary arterial pressure. The values of Ea, R/L ratio, ESP, SW, PRSW, +dP/dtmax and the slope of the dP/dtmax-EDV relationship increased significantly in PAH rats (P<0.05). Sevoflurane induced a concentration-dependent decrease of systemic and pulmonary blood pressure, HR, RV contractility, and increased the R/L ratio in both groups. Sevoflurane reduced the expression of SERCA2 and increased the expression of PLB in both groups. Interestingly, sevoflurane only reduced the p-PLB/PLB ratio in PAH rats, not in normal rats.

CONCLUSIONS

Rats with chronic, stable pulmonary hypertension tolerate low concentrations of sevoflurane inhalation as well as normal rats do. It may be related to the modulation of the SERCA2-PLB signaling pathway.

Anesthetic considerations in a child with unrepaired D-transposition of great arteries undergoing noncardiac surgery

D-transposition of great arteries (D-TGA) is the most common cyanotic congenital heart disease diagnosed at birth. There is ventriculoarterial discordance leading to parallel circulation. The postnatal survival depends on intercirculatory mixing of oxygenated and deoxygenated blood at various levels through atrial septal defect, ventricular septal defect or patent ductus arteriosus. The anesthesiologist must have an understanding of concepts of shunting and other long-term consequences of transposition of great arteries (TGA) in order to tailor the anesthetic technique to optimize the hemodynamic variables and oxygenation in the perioperative period. The preoperative evaluation includes echocardiography to delineate the type of TGA, associated lesions and extent and direction of shunts. Oxygen saturation is influenced by the ratio of pulmonary vascular resistance (PVR) to systemic vascular resistance. Thus, care should be taken to avoid an increase in PVR which can lead to decreased pulmonary blood flow leading to hypoxia. We report a case of an 8-year-old child with unrepaired D-TGA, who presented to us for craniotomy for drainage of brain abscess.

Neurodevelopmental implications of the general anesthesia in neonate and infants

Each year, about six million children, including 1.5 million infants, in the United States undergo surgery with general anesthesia, often requiring repeated exposures. However, a crucial question remains of whether neonatal anesthetics are safe for the developing central nervous system (CNS). General anesthesia encompasses the administration of agents that induce analgesic, sedative, and muscle relaxant effects. Although the mechanisms of action of general anesthetics are still not completely understood, recent data have suggested that anesthetics primarily modulate two major neurotransmitter receptor groups, either by inhibiting N-methyl-D-aspartate (NMDA) receptors, or conversely by activating γ-aminobutyric acid (GABA) receptors. Both of these mechanisms result in the same effect of inhibiting excitatory activity of neurons. In developing brains, which are more sensitive to disruptions in activity-dependent plasticity, this transient inhibition may have longterm neurodevelopmental consequences. Accumulating reports from preclinical studies show that anesthetics in neonates cause cellular toxicity including apoptosis and neurodegeneration in the developing brain. Importantly, animal and clinical studies indicate that exposure to general anesthetics may affect CNS development, resulting in long-lasting cognitive and behavioral deficiencies, such as learning and memory deficits, as well as abnormalities in social memory and social activity. While the casual relationship between cellular toxicity and neurological impairments is still not clear, recent reports in animal experiments showed that anesthetics in neonates can affect neurogenesis, which could be a possible mechanism underlying the chronic effect of anesthetics. Understanding the cellular and molecular mechanisms of anesthetic effects will help to define the scope of the problem in humans and may lead to preventive and therapeutic strategies. Therefore, in this review, we summarize the current evidence on neonatal anesthetic effects in the developmental CNS and discuss how factors influencing these processes can be translated into new therapeutic strategies.

New aspects of anesthetic management in congenital heart disease "common arterial trunk"

Now-a-days truncus arteriosus has been known as "common arterial trunk" (CAT) and is an uncommon congenital cardiac defect presenting in about 1-3% congenital heart disease. Environmental and genetic factors effects on incidence of CAT and other conotruncal anomalies. The majority patients with CAT and 22q11 deletion have other anomalies such as hypoplasia or aplasia of the thymus or parathyroid glands and immune deficits (T-cell deficiency), calcium metabolism disorder (hypocalcemia), palatal defects, learning and speech disorder, craniofacial anomalies, and neuropsychological abnormalities. CAT without surgical treatment frequently involves early severe pulmonary arterial hypertension (PAH) or early death from heart failure and associated conditions. Therefore, without corrective surgical repair, most CAT patients die in the initial years of life. In numerous centers early surgical repair associated with superior than 80% long-standing survival. Anesthesiologist must be performs comprehensive preoperative evaluation of infants or neonates with this disorder. In CAT patient exactly hemodynamic monitoring and suitable techniques to regulate pulmonary vascular resistance and systemic vascular resistance and cardiac function are more important than the select of a special anesthetic drug. Therefore, anesthetic drugs should be carefully administrated and titrate and under monitoring. Management of CAT after surgical repair depends on the adequacy of treatment, cardiac function, level of PAH, and degree of bleeding. Inotropic support is frequently necessary after the cardiac ischemia associated to the surgical repair. Pulmonary vasodilator drugs were used to PAH treatment.