Initial experience introducing an enhanced recovery program in congenital cardiac surgery

Regional Anesthesia With Fascial Plane Blocks for Pediatric Cardiac Surgery With Sternotomy: A Narrative Review

Undertreated pain in children who undergo sternotomy for cardiac surgery can lead to cardiopulmonary complications, the development of chronic pain, and long-term maladaptive stress response. Opioids have dose-dependent side effects that may interfere with postoperative recovery. With the increasing availability of ultrasound, regional anesthesia is often included in multimodal analgesic approaches. Fascial plane blocks targeting the intercostal nerves or ventral rami are of particular interest for patients requiring full heparinization for cardiopulmonary bypass as they avoid manipulation of neuraxial and noncompressible paravertebral spaces. This narrative review summarizes the literature on fascial plane blocks for pediatric patients undergoing cardiac surgery via midline sternotomy and may serve as a guide for clinicians. Both prospective and retrospective studies are reviewed, as are prior review articles. We describe individual fascial plane block techniques including the transversus thoracic muscle plane, pectointercostal fascial plane, serratus anterior plane, and erector spinae plane blocks and provide clinical considerations for each block. Additionally, we provide an analysis of individual studies stratified by anterior or posterior approach and block type. The majority of described studies examine single-shot blocks; the existing catheter literature, which includes erector spinae plane block catheters, is also included. Our findings suggest that fascial plane blocks decrease intraoperative and postoperative opioid use, pain scores, time to extubation, and length of stay in the intensive care unit and hospital. Notably, prospective studies in this field are small, typically fewer than 100 patients, and overall include a homogenous patient population, focusing primarily on patients with acyanotic congenital heart defects. Nonetheless, despite the limitations of individual studies, there is substantial evidence to support the use of regional anesthesia, particularly for patients in whom early extubation is planned. There is a need for large, prospective multi-center studies to evaluate the effectiveness and safety of specific single-shot block types, optimal local anesthetic dosing strategies compared to active comparators, and generalizability of results across institutions. Future studies should also consider evaluating the role of regional block catheters for continuous local anesthetic infusion and the inclusion of additional surgical populations, including neonates, patients with cyanotic lesions, and those with longer postoperative mechanical ventilation courses.

National practice patterns for the use of regional anesthesia for pediatric cardiac surgery: An analysis of the Society of Thoracic Surgeons congenital heart surgery database

BACKGROUND

Complications associated with suboptimal pain management after pediatric cardiac surgery have increased interest in regional anesthesia (RA). We sought to evaluate national trends and explore the association of RA with postoperative outcomes following pediatric cardiac surgery.

METHODS

Patients <18 years in the Society of Thoracic Surgeons Congenital Cardiac Anesthesia Society Database from 01/2016-05/2023 were analyzed. Non-OR operations and records with missing data on RA were excluded. Data on patients, centers, operations, year, and RA type and medication were collected, and trends over the 8-year study period were analyzed. The association of RA with outcomes was analyzed with multivariable modeling in a subpopulation of children without preoperative risk factors who underwent index atrial and ventricular septal defect (ASD/VSD) repairs and Fontan procedures.

RESULTS

The cohort included 95,514 operations from 62 U.S.

CENTERS

RA was used in 8.4 % (N = 7997) and increased annually from 6.1 % in 2016 to 12.5 % in 2023. Prevalence was highest in cases performed in children 1-11 years, characterized as low risk, and conducted low volume centers. There were statistically significant increases (p < 0.001) in RA use across all age groups and surgical risk categories during the study period. While the number of neuraxial techniques remained constant year-to-year, the number of non-neuraxial techniques (i.e., fascial plane blocks) increased sixfold during the study period. In the sub-analysis cohort (N = 7931), patients with RA for septal defect repairs and Fontan procedures were more likely to be extubated in the OR compared to non-RA patients (p < 0.001). ASD and VSD patients with RA were also more likely to have a short length of stay compared to those without RA (p < 0.001).

CONCLUSIONS

RA use is increasing in pediatric cardiac surgery in the U.S. and may be associated with surgery-specific outcome improvements.

Error Traps in Developing a Pediatric Enhanced Recovery After Surgery (ERAS) Program

Enhanced recovery after surgery (ERAS) pathways have been shown to improve patient outcomes, increase patient satisfaction, and decrease costs. First created and implemented in the adult population, these pathways are now commonplace and continue to expand in the pediatric realm. While there are many proven benefits to ERAS pathways, there continue to be challenges to their proper implementation and long-term success. This article aims to explore common challenges in pediatric ERAS development and implementation, along with strategies to avoid potential pitfalls. Key themes include departmental and institutional support, stakeholder engagement, awareness of pathways, data management and dissemination, and long-term maintenance including Plan-Do-Study-Act (PDSA) cycles. Pathway development teams should be aware of these considerations and potential pitfalls, and focusing on them can promote long-term success for a well-designed pathway.

Proposed Quality Metrics for Congenital Cardiac Anesthesia: A Scoping Review

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

Enhanced Recovery after Surgery (ERAS) in Pediatric Cardiac Surgery: Status Quo of Implementation in Europe

OBJECTIVES

Enhanced recovery after surgery (ERAS) is a multimodal care pathway to enhance recovery after surgery that is well established in various surgical disciplines. In pediatric cardiac surgery, implementation of ERAS protocols remains inconsistent. We conducted a survey of active European pediatric cardiac surgical centers to assess the current state of ERAS concepts and the current practice in perioperative pediatric cardiac care.

DESIGN

Prospective, 79-item, web-based cross-sectional survey.

SETTING

Web-based survey endorsed by the European Association of Cardiothoracic Anesthesiology and Intensive Care.

PARTICIPANTS

Anesthesiologists of European pediatric cardiac surgical centers.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of a total of 98 centers, 50 responded. Eight responses were excluded due to incomplete survey forms or non-European location, leaving 42 responses (42.9%) for statistical analysis. Sixteen of the 42 centers (38.1%) follow an ERAS concept. Only 3 (7.1%) have formalized and detailed the ERAS concept in a written document, covering the entire perioperative period, while 13 (31%) have formalized it solely for the intraoperative period. Regarding regional and local anesthesia, 13 (31%) centers regularly practice regional anesthesia blocks, and 11 (26.2%) centers use wound infiltration by the surgical team.

CONCLUSION

This European survey revealed that implementation of ERAS concepts in pediatric cardiac surgery is generally low, with considerable heterogeneity in clinical practice regarding the timing of extubation, the choice of surgical procedures triggering on-table extubation, the choice of anesthetic drugs and the use of regional anesthesia. More coordinated efforts are needed to implement ERAS concepts in pediatric cardiac surgery and harvest the benefits of ERAS concepts for the pediatric cardiac population.

Early Extubation in Children after Cardiac Surgery. Initial Experience from a Tertiary Care Hospital in Mexico City

Early extubation (EE) in pediatric cardiac surgery has demonstrated important benefits. However, ventilating them for 24 hours or more (delayed decannulation, DD) is an enduring practice. The objectives of this study were to describe the clinical profiles of EE in our setting and analyze its impact and the factors that prolong mechanical ventilation. Children operated on for cardiac surgery from 2016 to 2017 were included. Data were obtained from an electronic database. Comparisons were performed with Pearson's chi-square test, Student's t -test, or Mann-Whitney U test. Multivariate logistic regression was used to evaluate factors associated with DD. Of 649 cases, 530 were extubated on one occasion. EE was performed in 305 children (57.5%): 97 (31.8%) in the operating room and 208 (68.2%) in the intensive care unit (ICU). Reintubation (RI) occurred in 7.5% with EE and 16.9% with DD ( p  = 0.001). Fewer complications and ventilation time and decreased ICU and hospital length of stay resulted with EE. Age, presurgical ventilation, emergency surgery, pump time, attempts to weaning from cardiopulmonary bypass, bleeding greater than usual, and CPR in surgery were associated with DD. EE in the National Institute of Cardiology (INC; Spanish acronym) is in the middle category and has shown benefits without compromising the patient; the fear of further complications, RI, or death is unfounded. Although not all children at the INC can be decannulated early, if there are no or minimal risk factors, it should be a priority.

Erector spinae plane blocks for opioid-sparing multimodal pain management after pediatric cardiac surgery

OBJECTIVE

Peripheral regional anesthesia is proposed to enhance recovery. We sought to evaluate the efficacy of bilateral continuous erector spinae plane blocks (B-ESpB) for postoperative analgesia and the impact on recovery in children undergoing cardiac surgery.

METHODS

Patients aged 2 through 17 years undergoing cardiac surgery in the enhanced recovery after cardiac surgery program were prospectively enrolled to receive B-ESpB at the end of the procedure, with continuous infusions via catheters postoperatively. Participants wore an activity monitor until discharge. B-ESpB patients were retrospectively matched with control patients in the enhanced recovery after cardiac surgery program. Outcomes of the matched clusters were compared using exact conditional logistic regression and generalized linear modeling.

RESULTS

Forty patients receiving B-ESpB were matched to 78 controls. There were no major complications from the B-ESpB or infusions, and operating room time was longer by a median of 31 minutes. While blocks were infusing, patients with B-ESpB received fewer opioids in oral morphine equivalents than controls at 24 hours (0.60 ± 0.06 vs 0.78 ± 0.04 mg/kg; P = .02) and 48 hours (1.13 ± 0.08 vs 1.35 ± 0.06 mg/kg; P = .04), respectively. Both groups had low median pain scores per 12-hour period. There was no difference in early mobilization, length of stay, or complications.

CONCLUSIONS

B-ESpBs are safe in children undergoing cardiac surgery. When performed as part of a multimodal pain strategy in an enhanced recovery after cardiac surgery program, pediatric patients with B-ESpB experience good pain control and require fewer opioids in the first 48 hours.

Impact of an enhanced recovery after surgery program integrating cardiopulmonary rehabilitation on post-operative prognosis of patients treated with CABG: protocol of the ERAS-CaRe randomized controlled trial

BACKGROUND

Coronary artery bypass grafting is associated with a high occurrence of postoperative cardiopulmonary complications. Preliminary evidence suggested that enhanced recovery after surgery can effectively reduce the occurrence of postoperative cardiopulmonary complications. However, enhanced recovery after surgery with systematic integration of cardiopulmonary rehabilitation (ERAS-CaRe) into for Coronary artery bypass grafting has not been evaluated so far. We thus design the ERAS-CaRe randomized-controlled trial to evaluate possible superiority of embedding cardiopulmonary rehabilitation in ERAS over ERAS alone as well as to investigate effects of differential timing of cardiopulmonary rehabilitation within enhanced recovery after surgery (pre-, post-, perio-operative) on post-operative cardiopulmonary complications following Coronary artery bypass grafting surgery.

METHODS

ERAS-CaRe is a pragmatic, randomized-controlled, parallel four-arm, clinical trial. Three hundred sixty patients scheduled for Coronary artery bypass grafting in two Chinese hospitals will be grouped randomly into (i) Standard enhanced recovery after surgery or (ii) pre-operative ERAS-CaRe or (iii) post-operative ERAS-CaRe or (iv) perio-operative ERAS-CaRe. Primary outcome is the occurrence of cardiopulmonary complications at 10 days after Coronary artery bypass grafting. Secondary outcomes include the occurrence of other individual complications including cardiac, pulmonary, stroke, acute kidney injury, gastrointestinal event, ICU delirium rate, reintubation rate, early drainage tube removal rate, unplanned revascularization rate, all-cause mortality, ICU readmission rate, plasma concentration of myocardial infarction-related key biomarkers etc. DISCUSSION: The trial is designed to evaluate the hypothesis that a cardiopulmonary rehabilitation based enhanced recovery after surgery program reduces the occurrence of cardiopulmonary complications following Coronary artery bypass grafting and to determine optimal timing of cardiopulmonary rehabilitation within enhanced recovery after surgery. The project will contribute to increasing the currently limited knowledge base in the field as well as devising clinical recommendations.

TRIAL REGISTRATION

The trial was registered at the Chinese Clinical Trials Registry on 25 August 2023 (ChiCTR2300075125; date recorded: 25/8/2023, https://www.chictr.org.cn/ ).

Early extubation after pediatric cardiac surgery

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

Bilateral Ultrasound-Guided Erector Spinae Plane Block for Management of Acute Postoperative Surgical Pain After Pediatric Cardiac Surgeries Through a Midline Sternotomy

BACKGROUND

Ultrasound (US) guided erector spinae plane block (ESPB) is a safe and effective technique in providing perioperative pain management in pediatrics with a high success rate.

THE AIM OF THIS STUDY

Was to compare the efficacy of bilateral ultrasound-guided erector spinae plane block for management of acute postoperative surgical pain after pediatric cardiac surgeries through a midline sternotomy.

METHODS

One hundred patients aged 4-12 years were randomly assigned into two groups, both groups received general anesthesia followed by bilateral sham erector spinae plane block at the level of T6 transverse process using 0.4 ml/kg normal saline on each side in the control group (group C) or bilateral ultrasound-guided erector spinae plane block at the level of T6 transverse process using 0.4 ml/kg ropivacaine 0.2% with a maximum dose of 2 mg/kg mixed with adrenaline 2 mcg/ml in erector spinae plane block group (group E). The postoperative pain scores were evaluated immediately post-extubation, at 1 hour, 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24 hours after extubation, total consumption of intraoperative fentanyl and time to first rescue analgesic administration were also recorded.

RESULTS

There was a statistically high significant delay in the group E (314.72 ± 45.94) compared with the group C (36.7 ± 7.22) as regards to the mean (SD) of the time of the rescue analgesia (P < 0.001) (with 95% CI), moreover; the number of rescue analgesic was significantly higher in the group C compared with the group E (P < 0.001) (with 95% CI) and the mean (SD) of total intraoperative and postoperative levels fentanyl requirements in the group C were significantly higher compared with the group E (6.47 ± 0.98 and 5.09 ± 0.83) (with 95% CI) in group C versus (4.69 ± 0.71 and 2.31 ± 0.66) (with 95% CI) in group E respectively (P < 0.001) (with 95% CI).

CONCLUSION

Ultrasound-guided bilateral ESPB with ropivacaine and adrenaline delays the postoperative need of analgesia and reduces postoperative fentanyl consumption at 24 h in pediatric patients undergoing cardiac surgery through midline sternotomy.

Efficacy of perioperative pain management in paediatric cardiac surgery: a protocol for a network meta-analysis

INTRODUCTION

Congenital heart disease is a common birth defect, but advancements in diagnosis and treatment have improved survival rates. Enhanced recovery after surgery (ERAS) programmes have emerged in paediatric cardiac surgery. Multimodal pain management, as a vital part of ERAS programmes, has been found to be effective in reducing pain and improving outcomes in cardiac surgery patients. Traditional methods of pain control using high-dose opioids can lead to complications, so nonopioid analgesics and regional anaesthesia techniques are being used to reduce the consumption. However, there is a significant variability in pain management practices in paediatric cardiac surgery. A network meta-analysis (NMA) is needed to comprehensively compare the effects of different analgesic interventions in this population.

METHODS AND ANALYSIS

A comprehensive electronic literature database search will be performed using electronic databases, mainly including PubMed, EMBASE, Web of Science and Cochrane Central Register of Controlled Trials. All randomised controlled trials associated with perioperative pain management for paediatric cardiac surgery will be included. The primary outcome will be visual analogue score or numeric rating scale of pain and total opioid consumption (or equivalent) 24 hours after postoperative tracheal extubation. The Revised Cochrane Risk of Bias Tool will be employed to assess the quality of included articles. A random-effects pairwise meta-analysis will be performed to report the head-to-head comparison. Following the assessment of individual articles, an NMA will be conducted using a Bayesian framework with random-effects' models.

ETHICS AND DISSEMINATION

Ethics approval is not necessary because this study will be based on publications. The results of this study will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42023477520.

Experience Curve With the Cone Procedure for Ebstein's Anomaly: Effect on Cost and Resource Utilization

Background

The volume-outcome relationship is well-known in health care. The Experience Curve, initially developed by the Boston Consulting Group for manufacturing, offers insight on this relationship and has never before been applied to health care.

Objectives

The purpose of this study was to determine the effect of experience on cost and resource utilization for the Cone procedure.

Methods

We performed a retrospective review of patients who underwent Cone reconstruction for Ebstein's anomaly at Boston Children's Hospital between October 2010 and October 2021. Cardiopulmonary bypass time and aortic cross clamp time over time were evaluated using exponential regression to assess the surgeon-level learning curve. At the hospital level, length of stay and cost over time were assessed using exponential regression.

Results

There were 115 patients included in the study. Median hospital length of stay was 7.9 days (IQR: 6.4-10.2 days) with a decline of 3.3% per year. Median intensive care unit [ICU] length of stay was 3.2 days (IQR: 2-5.7 days) with a decline of 10.5% per year. Adjusted direct costs indexed to 2020 prices fell by 4% per year. There was no statistically significant change in cardiopulmonary bypass or aortic cross clamp time. In mediation analysis, the reduction in cost was completely accounted for in the decline in ICU length of stay. ICU length of stay was correlated with duration of intubation.

Conclusions

Increasing familiarity with Ebstein's anomaly and Cone reconstruction led to a reduction in resource utilization.

Successful Implementation of Enhanced Recovery After Surgery (ERAS) in Paediatric Cardiac Surgery in Australia

BACKGROUND & AIM

Fast-track or enhanced recovery after surgery (ERAS) is a care pathway for surgical patients based on a multidisciplinary team approach aimed at optimising recovery without increasing risk with protocols based on scientific evidence, which is monitored continuously to ensure compliance and improvement. These protocols have been shown to reduce the duration of postoperative mechanical ventilation and intensive care unit (ICU) length of stay (LOS) following paediatric cardiac surgery. We present the first structured implementation of ERAS in paediatric cardiac surgery in Australia.

METHODS

All patients enrolled in the ERAS pathway between October 2019 and July 2023 were identified. Demographic and perioperative data were collected retrospectively from hospital records for patients operated before June 2021 and prospectively from June 2021. A control group (non-ERAS) was identified using propensity matching from patients who underwent similar procedures and were not enrolled in the ERAS pathway (prior to October 2019). Patients were matched for age, weight, and comprehensive Aristotle score. Outcomes of interest were duration of postoperative mechanical ventilation, ICU LOS, readmission to the ICU, hospital LOS, cardiac reintervention rate, postoperative complication rate, and number of 30-day readmissions.

RESULTS

Of 1,084 patients who underwent cardiac surgery during the study period (October 2019-July 2023), 121 patients (11.2%) followed the ERAS pathway. The median age at the time of surgery was 4.8 years (interquartile range [IQR] 2.8-8.8 years). The most common procedure was the closure of atrial septal defect (n=58, 47.9%). The median cardiopulmonary bypass and cross-clamp times were 40 min (IQR 28-53.5 minutes) and 24.5 min (IQR 13-34 minutes) respectively. The majority were extubated in the operating theatre (n=108, 89.3%). The median ICU and hospital LOS were 4.5 hrs (IQR 4.1-5.6 hours) and 4 days (IQR 4-5 days) respectively. None of the patients required readmission to the ICU within 24 hrs of discharge from the ICU. Three (3) patients (2.5%) required reintervention. When compared with the non-ERAS group, the duration of postoperative mechanical ventilation, ICU and hospital LOS were significantly lower in the ERAS group. There was no significant difference in the ICU readmission rate, reintervention rate, complication rate, and number of 30-day readmissions between both groups.

CONCLUSIONS

ERAS after paediatric cardiac surgery is feasible and safe in select patients with low preoperative risk. This pathway reduces the duration of postoperative mechanical ventilation, ICU and hospital LOS without increasing risks, enabling the optimisation of resources.

The protocol of enhanced recovery after cardiac surgery in adult patients: A stepped wedge cluster randomized trial

BACKGROUND

The enhanced recovery after cardiac surgery is a bundle of measurements from preoperative to postoperative phases to improve patients' recovery.

METHODS

This study is a multicenter, stepwise design, cluster randomized controlled trial. About 3,600 patients presenting during control and intervention periods are eligible if they are aged from 18 to 80 years old awaiting elective cardiac surgery with cardiopulmonary bypass (CPB). About 5 centers are randomly assigned to staggered start dates for one-way crossover from the control phase to the intervention phase. In the intervention periods, patients will receive ERAS strategy including preoperative, intraoperative, and postoperative approaches. During the control phase, patients receive usual care. The primary outcome consists of major adverse cardiac and cerebrovascular events (MACCEs), postoperative pulmonary complications (PPCs), and acute kidney injury (AKI).

DISCUSSION

This study aims to compare the application of ERAS management protocol and traditional management protocol in adult cardiac surgery under extracorporeal circulation.

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

BACKGROUND

The primary objective of this study was to identify specific factors in pediatric cardiac surgical patients when tracheal extubation was performed on the operating table after completion of open-heart surgery (Group-1), postoperatively in the intensive care unit within 6 h (Group-II) or after 6 h (Group-III). The causes of failed extubation, the presence of chromosomal disorders in addition to arterial blood gas analysis parameters at the time of tracheal extubation, and the duration of intensive care unit stay were also evaluated in each group.

METHODS

In addition to the three groups, Groups I and II were combined as a "fast-track" extubation group. The demographic data, Risk Adjustment for Congenital Heart Surgery (RACHS-1) score, the Society of Thoracic Surgeons - European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Category (STAT Mortality Category), cardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, and vasoactive-inotropic score (VIS) at the time of tracheal extubation along with data related to secondary objectives were recorded for each patient.

RESULTS

A significant association was found by bivariate analysis between clinical variables and for both operating table and fast-track extubation in terms of age, weight, RACHS-1 score, STAT category, CPB and ACC time, and VIS. A multivariate-adjusted analysis showed weight, lower STAT category, CPB time, and VIS were independent predictors for operating table and fast-track extubation.

CONCLUSIONS

Younger age, lower weight, higher RACHS-1, STAT category, and VIS, along with longer CPB and ACC, are associated with delay in the timing of tracheal extubation in pediatric cardiac surgical patients.

The protocol of Enhanced Recovery After Cardiac Surgery (ERACS) in congenital heart disease: a stepped wedge cluster randomized trial

BACKGROUND

The Enhanced Recovery After Cardiac Surgery (ERACS) programs are comprehensive multidisciplinary interventions to improve patients' recovery. The application of the ERAS principle in pediatric patients has not been identified completely.

METHODS

This study is a multicenter, stepwise design, cluster randomized controlled trial. 3030 patients presenting during control and intervention periods are eligible if they are aged from 28 days to 6 years old and awaiting elective correction surgery of congenital heart disease with cardiopulmonary bypass. 5 centers are randomly assigned to staggered start dates for one-way crossover from the control phase to the intervention phase. In the intervention periods, patients will receive a bundle strategy including preoperative, intraoperative, and postoperative approaches. During the control phase, patients receive the usual care. The primary outcome consists of major adverse cardiac and cerebrovascular events (MACCEs), postoperative pulmonary complications (PPCs), and acute kidney injury (AKI).

DISCUSSION

This study aims to explore whether the bundle of ERAS measurements could improve patients' recovery in congenital heart surgery.

TRIAL REGISTRATION

http://www.

CLINICALTRIALS

gov . (NCT05914103).

Post-operative vomiting and enhanced recovery after congenital cardiac surgery

BACKGROUND

Post-operative nausea and vomiting is frequent after congenital cardiac surgery.

AIMS

We sought to determine factors associated to severe post-operative vomiting after congenital cardiac surgery and the effect on post-operative outcomes.

METHODS

Patients > 30 days of age who underwent elective cardiac surgical repair as part of an enhanced recovery after congenital cardiac surgery programme were retrospectively reviewed. Patient characteristics and perioperative factors were compared by univariate analysis for patients with severe post-operative vomiting, defined as three events or more, and for patients with no-or-mild post-operative vomiting. All variables with a p-value < 0.1 were included in a multivariable model, and major post-operative outcomes were compared using regression analysis.

RESULTS

From 1 October, 2018 to 30 September, 2019, 430 consecutive patients were included. The median age was 4.8 years (interquartile range 1.2-12.6). Twenty-one per cent of patients (91/430) experienced severe post-operative vomiting. Total intraoperative opioids > 5.0 mg/kg of oral morphine equivalent (adjusted odds ratio 1.72) and post-operative inotropes infusion(s) (adjusted odds ratio 1.64) were identified as independent predictors of severe post-operative vomiting after surgery. Patients suffering from severe post-operative vomiting had increased pulmonary complications (adjusted odds ratio 5.18) and longer post-operative hospitalisation (adjusted coefficient, 0.89).

CONCLUSIONS

Greater cumulative intraoperative opioids are associated with severe post-operative vomiting after congenital cardiac surgery. Multimodal pain strategies targeting the reduction of intraoperative opioids should be considered during congenital cardiac surgery to enhance recovery after surgery.

Management of routine postoperative pain for children undergoing cardiac surgery: a Paediatric Acute Care Cardiology Collaborative Clinical Practice Guideline

BACKGROUND

Pain following surgery for cardiac disease is ubiquitous, and optimal management is important. Despite this, there is large practice variation. To address this, the Paediatric Acute Care Cardiology Collaborative undertook the effort to create this clinical practice guideline.

METHODS

A panel of experts consisting of paediatric cardiologists, advanced practice practitioners, pharmacists, a paediatric cardiothoracic surgeon, and a paediatric cardiac anaesthesiologist was convened. The literature was searched for relevant articles and Collaborative sites submitted centre-specific protocols for postoperative pain management. Using the modified Delphi technique, recommendations were generated and put through iterative Delphi rounds to achieve consensus.

RESULTS

60 recommendations achieved consensus and are included in this guideline. They address guideline use, pain assessment, general considerations, preoperative considerations, intraoperative considerations, regional anaesthesia, opioids, opioid-sparing, non-opioid medications, non-pharmaceutical pain management, and discharge considerations.

CONCLUSIONS

Postoperative pain among children following cardiac surgery is currently an area of significant practice variability despite a large body of literature and the presence of centre-specific protocols. Central to the recommendations included in this guideline is the concept that ideal pain management begins with preoperative counselling and continues through to patient discharge. Overall, the quality of evidence supporting recommendations is low. There is ongoing need for research in this area, particularly in paediatric populations.

Analgesic Effects of a Novel Combination of Regional Anesthesia After Pediatric Cardiac Surgery: A Retrospective Cohort Study

OBJECTIVE

The objective of this study was to determine whether the use of regional anesthesia in children undergoing congenital heart surgery was associated with differences in outcomes when compared to surgeon-delivered local anesthetic wound infiltration.

DESIGN

A retrospective cohort study.

SETTING

At a single pediatric tertiary care center.

PARTICIPANTS

Pediatric patients who underwent primary repair of septal defects between January 1, 2018, and March 31, 2022.

INTERVENTIONS

The patients were grouped by whether they received surgeon-delivered local anesthetic wound infiltration or bilateral pectointercostal fascial blocks (PIFBs) and a unilateral rectus sheath block (RSB) on the side ipsilateral to the chest tube.

MEASUREMENTS AND MAIN RESULTS

Using overlap propensity score-weighted models, the authors examined postoperative opioid requirements (morphine milliequivalents per kilogram), pain scores, length of stay, and time under general anesthesia (GA). Eighty-nine patients were eligible for inclusion and underwent analysis. In the first 12 hours postoperatively, the block group used fewer morphine equivalents per kilogram versus the infiltration group, 0.27 ± 0.2 v 0.64 ± 0.42, with a weighted estimated decrease of 0.39 morphine equivalents per kilogram (95% CI -0.52 to -0.25; p < 0.001), and had lower pain scores, 3.2 v 1.6, with a weighted estimated decrease of 1.7 (95% CI -2.3 to -1.1; p < 0.001). The length of stay and time under GA also were shorter in the block group with weighted estimated decreases of 22 hours (95% CI -33 to -11; p = 0.001) and 18 minutes (95% CI -34 to -2; p = 0.03), respectively.

CONCLUSIONS

Bilateral PIFBs and a unilateral RSB on the side ipsilateral to the chest tube is a novel analgesic technique for sternotomy in pediatric patients. In this retrospective study, these interventions were associated with decreases in postoperative opioid use, pain scores, and hospital length of stay without prolonging time under GA.

Comparison of Intraoperative and Discharge Residual Lesion Severity in Congenital Heart Surgery

BACKGROUND

While the predischarge technical performance score (DC-TPS) is significantly associated with outcomes after congenital cardiac surgery, the utility of the intraoperative TPS (IO-TPS) remains unknown.

METHODS

This was a single-center retrospective review of consecutive patients who underwent congenital cardiac surgery from January 2011 to December 2019. Intraoperative and predischarge echocardiograms were used to assign IO-TPS and DC-TPS, respectively, for each index operation (class 1, no residua; class 2, minor residua; class 3, major residua). Anatomic modules identifying the principal residual lesion were assigned to all class 2/3 patients. Overall and module-specific TPS comparisons were made. Multivariable regression models with IO-TPS and DC-TPS as separate predictors of postoperative outcomes were compared.

RESULTS

Of 6201 patients, overall agreement between IO-TPS and DC-TPS was observed in 4251 patients (68.6%); scores were likelier to be worse at discharge (P < .001). Paired comparative analyses revealed that among patients with at least class 2 atrioventricular and semilunar valve residua, IO-TPS was likelier to worsen than improve (both P < .001). Class 3 patients had a higher risk of in-hospital/early mortality (IO-TPS: odds ratio, 7.5; 95% CI, 2.4-23; DC-TPS: odds ratio, 6.6; 95% CI, 3.0-15), postdischarge/late mortality (IO-TPS: hazard ratio [HR], 3.1, 95% CI, 1.3-7.1; DC-TPS: HR, 2.3; 95% CI, 1.2-4.4), and late unplanned reintervention (IO-TPS: HR, 2.8; 95% CI, 1.9-4.0; DC-TPS: HR, 3.4; 95% CI, 2.8-4.2) vs class 1 (all P < .05). IO- and DC-TPS models were equivalent fits for predicting early and late mortality; the latter was a marginally better fit for late reintervention.

CONCLUSIONS

IO-TPS and DC-TPS are both important adjuncts for quality improvement in congenital cardiac surgery.

Initial results from an enhanced recovery program for pediatric cardiac surgical patients

BACKGROUND

Over recent years, a number of enhanced recovery programs have appeared in first, adult colorectal surgery, and subsequently many other adult surgical specialties. Increasing interest in this approach to perioperative management in children culminated in the recent development of the first enhanced recovery pathway for pediatric intestinal surgery, endorsed by Enhanced Recovery after Surgery Society (ERAS®). In parallel, there has been increasing interest in the refinement of perioperative management of selected pediatric cardiac surgical patients, invariably referred to as "fast track" management. Initiatives have largely focused on duration of postoperative ventilation rather than on a much wider range of perioperative interventions to optimize recovery and ensure timely discharge after surgery. In our institution, a "Level 1" pediatric cardiac surgical center, we assembled a multidisciplinary team to design a comprehensive enhanced recovery pathway, based on ERAS® methodology, for selected cardiac surgical patients. After a lengthy period of planning, staff education, and preparation, we implemented the pathway at the end of November 2019.

METHODS

We conducted a prospective audit of the perioperative management and outcomes of the first 88 patients managed according to this enhanced recovery pathway over a 25-month period in our institution.

RESULTS

The mean age of the patients was 5.8 years (range 0.5-17.9), and the mean weight was 22.4 kg (range 6.6-57.2). Sixty-eight of the 88 patients were cardiopulmonary bypass cases. A total of 54% of patients received all four defined intraoperative anesthetic interventions (intravenous paracetamol, non-steroidal anti-inflammatory drug, antiemetic if aged more than 4 years, and use of a local anesthetic technique). A total of 89% of patients met the target extubation time of 6 h after administration of protamine. Median postoperative intensive care unit length of stay was 23.5 h (range 15.2-89.5). When compared to a historic control group, this represented a 22% reduction in median intensive care unit stay, although the total hospital length of stay remained unchanged. A total of 83% of patients met the target hospital discharge target of the fifth postoperative day.

CONCLUSIONS

These preliminary results suggest that enhanced recovery pathway implementation for selected pediatric cardiac surgical patients is feasible, with acceptable outcomes. They suggest areas for further development and the potential for wider implementation.

Bilateral erector spinae plane blocks in children undergoing cardiac surgery: A randomized, controlled study

STUDY OBJECTIVE

We aimed to test the hypothesis that erector spinae plane block (ESPB) provides efficient analgesia and reduces postoperative morphine consumption in children undergoing cardiac surgery with median sternotomy.

DESIGN

A prospective, blinded, randomized, controlled study.

SETTING

A tertiary university hospital, operating room and intensive care unit.

PATIENTS

Forty children aged 2-10 years, who underwent cardiac surgery with median sternotomy. The patients were randomly divided into the block group (Group B) and the control group (Group C).

INTERVENTIONS

Group B (n = 20) were treated with ultrasound-guided bilateral ESPB at the level of the T4-T5 transverse process, whereas no block was administered in Group C (n = 20). In all children, intravenous morphine at 0.05 mg/kg was used whenever the modified objective pain score (MOPS) ≥4 for postoperative analgesia.

MEASUREMENTS

The MOPS and Ramsay sedation score (RSS) were assessed at 0, 1, 2, 4, 6, 8, 10, 12, 16, 20 and 24 h postoperatively. Total morphine consumption at 24 h, extubation time and length of intensive care unit (ICU) stay was also evaluated and recorded.

MAIN RESULTS

Bilateral ESPB significantly decreased the consumption of morphine in the first 24 h, postoperatively. During the postoperative 24-h follow-up, 11 children in Group C requested morphine and the cumulative dose of morphine was 0.83 ± 0.91 mg, while 4 children in Group B requested morphine and the cumulative dose of morphine was 0.26 ± 0.59 mg (p = 0.043). There was no significant difference between Groups B and C in terms of MOPS and RSS values, extubation time or length of ICU stay.

CONCLUSION

Ultrasound-guided bilateral ESPB with bupivacaine provides efficient postoperative analgesia and reduces postoperative morphine consumption at 24 h in children undergoing cardiac surgery.

Race and Outcomes in Patients with Congenital Cardiac Disease in an Enhanced Recovery Program

OBJECTIVES

Disparities in perioperative outcomes exist. In addition to patient and socioeconomic factors, racial disparities in outcome measures may be related to issues at the provider and institutional levels. Recognizing a potential role of standardized care in mitigating provider bias, this study aims to compare the perioperative sedation and pain management and consequent outcomes in Enhanced Recovery After Surgery (ERAS) cardiac patients of different races undergoing congenital heart surgery at a single quaternary children's hospital.

DESIGN

A retrospective study.

SETTING

A single quaternary pediatric hospital.

PARTICIPANTS

Patients, infants to adults, undergoing elective congenital cardiac surgery and enrolled in the ERAS protocol from October 2018 to December 2020.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the patients, 872 were reviewed and 606 with race information were analyzed. There was no significant difference in intraoperative and postoperative oral morphine equivalent, perioperative sedatives, and regional blockade in Asian or African American patients when compared to White patients. Postoperative pain scores and outcomes among African American and Asian races were also not statistically different when compared to White patients.

CONCLUSIONS

Racial disparity in perioperative management and outcomes in patients with standardized ERAS protocols does not exist at the authors' institution. Future comparative studies of ERAS noncardiac patients may provide additional information on the role of standardization in reducing implicit bias.

Risk Factors for Post-operative Planned Reintubation in Patients After General Anesthesia: A Systematic Review and Meta-Analysis

Background

The occurrence of postoperative reintubation (POR) in patients after general anesthesia (GA) is often synonymous with a poor prognosis in patients. This is the first review analyzing scientific literature to identify risk factors of POR after general anesthesia. The purpose of this study was to collect currently published studies to determine the most common and consistent risk factors associated with POR after GA.

Methods

We have retrieved all relevant research published before April 2021 from PubMed, Embase, Web of Science, and the Cochrane Library electronic databases. These studies were selected according to the inclusion and exclusion criteria. The Z test determined the combined odds ratio (OR) of risk factors. We used OR and its corresponding 95% confidence interval (CI) to identify significant differences in risk factors. The quality of the study was evaluated with the NOS scale, and meta-analysis was carried out with Cochrane Collaboration's Revman 5.0 software.

Results

A total of 10 studies were included, with a total of 7,789 recipients of POR. We identified 7 risk factors related to POR after GA: ASA ≥ 3 (OR = 3.58), COPD (OR = 2.09), thoracic surgery (OR = 17.09), airway surgery (OR = 9.93), head-and-neck surgery (OR = 3.49), sepsis (OR = 3.50), DVT (OR = 4.94).

Conclusion

Our meta-analysis showed that ASA ≥ 3, COPD, thoracic surgery, airway surgery, head-and-neck surgery, sepsis and DVT were associated with POR after GA.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?, Identifier: CRD42021252466.

Enhancing Recovery in Congenital Cardiac Surgery

BACKGROUND

The benefits of a comprehensive enhanced recovery after surgery (ERAS®) program for the congenital heart disease population are largely unknown. We evaluated adherence and outcomes following a recently implemented enhanced recovery program (ERP) in congenital cardiac surgery.

METHODS

Patients undergoing elective surgery for simple and moderately complex congenital cardiac surgery followed institutional ERP guidelines since 10/2018. Adherence to guidelines over a 12-month period (P2) was compared to implementation data (P1:5 months). The association of outcomes with continuous time was estimated using linear regression.

RESULTS

Among 559 patients (representing 40% of the cardiac surgical volume) following the ERP over a period of 17 months, no differences in patient characteristics were observed between periods, except higher incidence of prior operations in P2. Adherence to many aspects of guidelines improved from P1 to P2. Notably, operating room extubation: 27% in P2 vs.16% in P1, p=0.006; decrease in median ventilation time: 6.0-hrs (IQR 0-9.2) in P2 vs. 7.6-hrs (IQR 3.8-12.3) in P1, p=0.002. In addition, there was a reduction in opioids, reported as oral morphine equivalents (OME), most significant for intraoperative OME: 5.00 mg/kg (3.11-7.60) in P2 vs. 6.05 mg/kg (3.77-9.78) in P1, p=0.001. There was no difference in overall intensive care unit (ICU) and postoperative length of stay except in lower risk surgeries. Surgical outcomes were similar in the two periods.

CONCLUSIONS

An enhanced recovery program reduced the use of opioids, led to more OR extubation and reduced mechanical ventilation duration in patients undergoing congenital cardiac surgery.

Evolving trends in peri-operative management of pediatric ureteropelvic junction obstruction: working towards quicker recovery and day surgery pyeloplasty

OBJECTIVE

To describe the evolution of practice patterns for pediatric pyeloplasty and determine how these changes have impacted length of stay (LOS), reoperation rates and return emergency department (ER) visits.

METHODS

We reviewed our pyeloplasty database from 2008 to 2020 at a quaternary pediatric referral center and we included children 0-18 years undergoing pyeloplasty. Variables captured included: age, sex, baseline and follow-up anteroposterior diameter (APD) and differential renal function (DRF). We also collected data on the use of drains, catheters and/or stents, nausea and vomiting prophylaxis, opioids, regional anesthesia, and non-opioid analgesia. Outcomes were LOS, reoperation rates and ER visits.

RESULTS

A total of 554 patients (565 kidneys) were included. Reoperation rate was 7%, redo rate 4% and ER visits 17%. There was a trend towards less opioids, indwelling catheters and internal stents and increasing non-opioid analgesia, externalized stents, and regional anesthesia during the study period. Same-day discharge (SDD) was possible for 88 (16%) children with no differences in reoperation or readmission rates between SDD and admitted (ADM). There was a difference in ER visits (21 [24%] vs. 26 [6%]; p = 0.04) for SDD vs. ADM, respectively. On multivariate analysis, the only predictor of ER visits was younger age. Patients < 7 months were more likely to present to ER (15/41; 37% vs. 6/47, 13%; p = 0.009). Multivariate analysis determined indwelling catheters and opioids were associated with ADM while dexamethasone and ketorolac with SDD.

CONCLUSION

Progressive changes in care have contributed to a shorter LOS and increasing rates of SDD for pyeloplasty patients. SDD appears to be feasible and does not result in higher complication rates. These data support the development of a pediatric pyeloplasty ERAS protocol to maximize quicker recovery and foster SDD as a goal.

Improving outcomes after low-risk coronary artery bypass grafting: understanding phase of care mortality analysis, failure to rescue and recent perioperative recommendations

PURPOSE OF REVIEW

Avoidable adverse events are responsible for up to 50% of deaths after low-risk coronary artery bypass grafting. This article reviews recent quality improvement efforts to improve outcomes after cardiac surgery.

RECENT FINDINGS

Systematic quality improvement methodology in cardiac surgery has improved significantly over the past decade. Contemporary efforts with phase of care mortality analysis (POCMA) focus on identifying and addressing root causes for mortality. Each patient's perioperative course is an interconnected sequence of clinical events, decisions, interventions, and treatment responses occurring across five perioperative phases. A single seminal event within a specific phase of care has been found to often trigger the eventual death of a patient. Several groups have made significant improvements to perioperative outcomes by addressing these avoidable mortality trigger events. Failing that, failure to rescue (FTR) metrics can be used to identify institutional factors responsible for poor perioperative outcomes. This ongoing focus on quality improvement serves to further improve outcomes after low-risk cardiac surgery.

SUMMARY

Modern quality improvement methodology, including POCMA and FTR analysis, has the potential to significantly improve outcomes after cardiac surgery. Larger future studies with multiinstitutional data sharing will be key to facilitate ongoing quality improvement and knowledge translation in this field.

Perioperative Opioid Consumption is Not Reduced in Cyanotic Patients Presenting for the Fontan Procedure

Adequate pain control is a critical component of the perioperative approach to children undergoing repair of congenital heart disease (CHD). The impact of specific anatomic and physiologic disturbances on the management of analgesia has been largely unexplored at the present time. Studies in other pediatric populations have found an association between chronic hypoxemia and an increased sensitivity to the effects of opioid medications. The purpose of this retrospective study was to examine perioperative opioid administration and opioid-associated adverse effects in children undergoing surgical repair of CHD, with a comparison between patients with and without chronic preoperative cyanosis. Patients between the ages of 2 and 5 years whose tracheas were extubated in the operating room were included and were classified in the cyanotic group if they presented for the Fontan completion. The primary outcomes of interest were intraoperative and postoperative opioid administration. Secondary outcomes included pain scores and opioid-related side effects. The study cohort included 156 patients. Seventy-one underwent the Fontan procedure, twelve of which were fenestrated. Fontan patients received fewer opioids intraoperatively (11.33 µg/kg fentanyl equivalents versus 12.56 µg/kg, p = 0.03). However, there were no differences with regards to opioid consumption postoperatively and no correlation between preoperative oxygen saturation and total opioid administration. There were no differences between groups with regards to the respiratory rate nadir, postoperative pain scores, or the incidence of opioid-related side effects. In contrast to other populations with chronic hypoxemia exposure, children with cyanotic CHD did not appear to have increased sensitivity to the effects of opioid medications.

The Characterization of Postoperative Mechanical Respiratory Requirement in Neonates and Infants Undergoing Cardiac Surgery on Cardiopulmonary Bypass in a Single Tertiary Institution

OBJECTIVES

Although neonates and infants undergoing cardiac surgery on cardiopulmonary bypass (CPB) are at high risk of developing perioperative morbidity and mortality, including lung injury, the intraoperative profile of lung injury in this cohort is not well-described. Given that the postoperative course of patients in the pediatric cardiac surgical arena has become increasingly expedited, the objective of this study was to characterize the profiles of postoperative mechanical ventilatory support in neonates and infants undergoing cardiac surgery on CPB and to examine the characteristics of lung mechanics and lung injury in this patient population who are potentially amendable to early postoperative recovery in a single tertiary pediatric institution.

DESIGN

A retrospective data analysis of neonates and infants who underwent cardiac surgery on cardiopulmonary bypass.

SETTING

A single-center, university teaching hospital.

PARTICIPANTS

The study included 328 neonates and infants who underwent cardiac surgery on cardiopulmonary bypass.

INTERVENTIONS

A subset of 128 patients were studied: 58 patients undergoing ventricular septal defect (VSD) repair, 36 patients undergoing complete atrioventricular canal (CAVC) repair, and 34 patients undergoing bidirectional Glenn (BDG) shunt surgery.

MEASUREMENTS AND MAIN RESULTS

Of the entire cohort, 3.7% experienced in-hospital mortality. Among all surgical procedures, VSD repair (17.7%) was the most common, followed by CAVC repair (11.0%) and BDG shunt surgery (10.4%). Of patients who underwent VSD repair, CAVC repair, and BDG shunt surgery, 65.5%, 41.7%, and 67.6% were off mechanical ventilatory support within 24 hours postoperatively, respectively. In all three of the surgical repairs, lung compliance decreased after CPB compared to pre-CPB phase. Sixty point three percent of patients with VSD repair and 77.8% of patients with CAVC repair showed a PaO₂/F_IO₂ (P/F) ratio of <300 after CPB. Post- CPB P/F ratios of 120 for VSD patients and 100 for CAVC patients were considered as optimal cutoff values to highly predict prolonged (>24 hours) postoperative mechanical ventilatory support. A higher volume of transfused platelets also was associated with postoperative ventilatory support ≥24 hours in patients undergoing VSD repair, CAVC repair, and BDG shunt surgery.

CONCLUSIONS

There was a high incidence of lung injury after CPB in neonates and infants, even in surgeries amendable for early recovery. Given that CPB-related factors (CPB duration, crossclamp time) and volume of transfused platelet were significantly associated with prolonged postoperative ventilatory support, the underlying cause of cardiac surgery-related lung injury can be multi-factorial.

The Use of Regional Catheters in Children Undergoing Repair of Aortic Coarctation

OBJECTIVE

The objective was to assess the effectiveness and safety of peripheral regional anesthesia in congenital cardiac surgical patients undergoing thoracotomy for aortic coarctation.

DESIGN

A retrospective chart review of pediatric patients (<18 years) who underwent surgical repair of congenital heart diseases via thoracotomy between September 2013 and July 2018 was done. Among patients who underwent coarctation repair, a propensity score was used to match patients who received a regional catheter (C) versus traditional medical treatment only (M).

SETTING

A single center children's hospital.

PARTICIPANTS

The median age was 172 days (IQR 64-1315) in group C and 176 days (IQR 71-1146) in group M (SMD = 0.07). The median weight was 6.8 kg (IQR 4.8-13.6) in group C and 7.7 kg (4.6-17.4) in group M (SMD = 0.003).

MEASUREMENTS AND MAIN RESULT

Outcomes assessed were postoperative hospital length of stay, median pain scores in the first 24 and 48 hours, and total morphine equivalent use in the first 24 and 48 hours. Complications related to the catheters were reviewed. The median oral morphine equivalent dose administered in the first 24 hours was lower in group C than group M (0.8 mg/kg, IQR 0.5-1.1 vs. 1.4 mg/kg, IQR 0.9-1.7, p = 0.019). There were no major complications related to the catheters, including hematoma.

CONCLUSIONS

Peripheral regional catheters may be used to reduce opioid requirements in patients after CoA repair. Due to the low risk of these catheters, they should be considered as part of a pain management strategy for pediatric patients undergoing thoracotomy and should be incorporated into strategies to improve outcomes.

A Minimal Opioid Postoperative Management Protocol in Congenital Cardiac Surgery: Safe and Effective

There is evidence that reducing opioid exposure in children undergoing cardiac surgery may enhance postoperative recovery. We aimed to describe a minimal opioid postoperative management protocol in children undergoing cardiac surgery and our early outcomes with this strategy. We reviewed the medical records of children (6 months-18 years) who underwent elective cardiac surgery through a median sternotomy with cardiopulmonary bypass at our institution between 2016 and 2018. All patients were managed postoperatively using a standardized protocol. 101 children (median age 5 years) were included and 85% were extubated in the operating room. Although most patients (96%) received opioids postoperatively, opioid requirements decreased steadily over time, with 88%, 58%, and 18% of children receiving opioids on postoperative day 1, 2, and 3, respectively; 41% received no opioids after postoperative day 1. The median cumulative opioid exposure was 0.25 morphine milligram equivalents per kg (interquartile range, 0.10-0.75). Greater than mild pain was rare (<10%) at each time point. The rates of operative mortality and major complication were 0% and 3%, respectively. The median postoperative length of stay was 3 days, and 13% required readmission within 30 days. Age, cardiopulmonary bypass time, and number of benzodiazepine doses were independently associated with cumulative opioid exposure. Any complication, chest tube time, and higher STAT Category were independently associated with prolonged postoperative length of stay. A minimal opioid postoperative management protocol can be safe and effective in children undergoing cardiac surgery. Future prospective studies are needed to determine optimal practice and patient selection.

Bilateral Erector Spinae Blocks Decrease Perioperative Opioid Use After Pediatric Cardiac Surgery

OBJECTIVE

The present study examined the feasibility and efficacy of continuous bilateral erector spinae blocks for post-sternotomy pain in pediatric cardiac surgery.

DESIGN

Prospective cohort study; patients were retrospectively matched 1:2 to control patients. Conditional logistic regression was used to compare dichotomous outcomes, and generalized linear models were used for continuous measures, both accounting for clusters.

SETTING

Quaternary children's hospital, university setting.

PARTICIPANTS

The study comprised 10 children ages five-to-17 years undergoing elective cardiac surgery requiring cardiopulmonary bypass.

INTERVENTIONS

Ultrasound-guided bilateral erector spinae blocks at the conclusion of the cardiac surgical procedure, with postoperative infusion of ropivacaine until chest tube removal. Postoperative management otherwise followed standardized guidelines.

MEASUREMENTS AND MAIN RESULTS

Patient characteristics were similar in the two groups. The median time to completion of the bilateral blocks was 16.0 minutes (interquartile range [IQR] 14.8-19.3), and no major adverse events were identified. Pain scores were low in both groups. Postoperative opioid use at 48 hours, rendered as oral morphine equivalents, was significantly reduced in the patients receiving the blocks. Cluster-adjusted squared-root-transformed means ± standard error were 0.89 ± 0.06 mg/kg for patients receiving the blocks versus 1.05 ± 0.06 mg/kg for control patients (p = 0.04; raw medians 0.81 [IQR 0.41-1.04] v 1.10 [IQR 0.78-1.35] mg/kg, respectively). There were no differences in recovery metrics, length of stay, or complications.

CONCLUSIONS

Bilateral erector spinae blocks were associated with a reduction in opioid use in the first 48 hours after pediatric cardiac surgery compared with a matched cohort from the enhanced recovery program. Larger studies are needed to determine whether this can result in an improvement in recovery and patient satisfaction.