Fast-track congenital heart operations: a less invasive technique and early extubation

Comparison of ultrafast and fast track extubation after secundum atrial septal defect surgery in pediatric age group

BACGROUND

Patients who underwent ultrafast track on the operating table and fast track extubation in the pediatric intensive care unit for 2 to 6 h after secundum atrial septal defect surgery in the pediatric age group were compared.

METHODS

Between January 2013 and February 2017, 60 pediatric patients (24 boys, 36 girls; Mean age 7.5 ± 4.6 years) whose secundum atrial defect was closed were retrospectively analyzed. The patients were separated as those who were extubated on the operating table (Group1,n = 28) and those extubated in the pediatric intensive care unit within 2-6 h postoperatively (Group2,n = 32).

RESULTS

No difference was found in demographic data and preoperative catheter information between the groups. Cardiopulmonary bypass time was 20(18-25)/27.5(20-30)minutes (p:0.001), the cross-clamp time was 10(10-15)/15(11-20)minutes(p:0.004), the postoperative drainage amount was 50(25-50)/60(32.5-100)ml(p:0.013), the length of stay in the intensive care unit was 1(1--1)/1(1-2)day(p:0.025), the length of stay after intensive care was 3(2-3)/3(3-4)days(p:0.001) and the total hospital stay was 4(3-4)/5(4-5.5) days (p < 0.001), which were respectively shorter for the group 1 compared to 2. Postoperative blood product replacement, positive inotrope support, pericardial effusion, mortality, and morbidity were not detected in either groups.

CONCLUSION

In this study, it was observed that the UFT extubation was safe for the patients who were operated for secundum ASD, in the pediatric age group, and had a cross-clamp time not exceeding 15 min. It was found that the amount of drainage, length of stay in the intensive care unit, post-intensive care unit, and the total hospital stay of patients extubated on the operating table were shorter.

Ultra-Fast-Track Extubation in Adult Congenital Heart Surgery

Background In pediatric cardiac surgery, perioperative management has evolved from slow weaning of mechanical ventilation in the intensive care unit to "ultra-fast-track" anesthesia with early extubation (EE) in theater to promote a faster recovery. The strategy of EE has not been assessed in adults with congenital heart disease, a growing population of patients who often require surgery. Methods And Results Data were collected retrospectively on all patients >16 years of age who underwent adult congenital heart surgery in our tertiary center between December 2012 and January 2020. Coarsened exact matching was performed for relevant baseline variables. Overall, 711 procedures were performed: 133 (18.7%) patients underwent EE and 578 (81.3%) patients received conventional extubation. After matching, patients who received EE required less inotropic or vasopressor support in the early postoperative period (median Vasoactive-inotropic score 0.5 [0.0-2.0] versus 2.0 [0.0-3.5]; P<0.0001) and had a lower total net fluid balance than patients after conventional extubation (1168±723 versus 847±733 mL; P=0.0002). The overall reintubation rate was low at 0.3%. EE was associated with a significantly shorter postoperative length of stay in higher dependency care units before a "step-down" to ward-based care (48 [45-50] versus 50 [47-69] hours; P=0.004). Lower combined intensive care unit and high dependency unit costs were incurred by patients who received EE compared with patients who received conventional extubation (£3949 [3430-4222] versus £4166 [3893-5603]; P<0.0001). Conclusions In adult patients undergoing surgery for congenital heart disease, EE is associated with a reduced need for postoperative hemodynamic support, a shorter intensive care unit stay, and lower health-care-related costs.

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.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Electronic supplementary material

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

Fast track pediatric thoracic surgery: Toward day-case surgery?

PURPOSE

Thoracoscopic lung resection for congenital pulmonary airway malformation (CPAM) is a safe technique for children. Our purpose was to evaluate the feasibility of a fast-track protocol in such cases.

METHODS

From September 2007 to May 2016, 101 patients underwent a thoracoscopic pulmonary resection of which 83 for CPAM (lobectomy, wedge resection or sequestrectomy). We retrospectively reviewed the characteristics of surgical procedure, postoperative management and complications through three time periods (September 2007-December 2009: n=14, January 2010-March 2013: n=30, April 2013-May 2016: n=39) corresponding to management protocols modifications introducing fast-track pathways.

RESULTS

Through the 3 time periods, median postoperative hospital stay decreases (4, 3, 2days successively, P=0.02). In the third time period, 4 patients underwent surgery in day-case surgery. The overall and surgical complication rates, mainly related to air leakage, remain stable through the 3 time periods (14%, P=0.41 and 10%, P=0.52 respectively). Among the 13 patients without postoperative pleural drainage, one required secondary drainage after a partial resection of an emphysema.

CONCLUSION

Fast-track protocol for children undergoing uncomplicated thoracic surgery for CPAM seems feasible without extra morbidity. Selected patient undergoing thoracoscopic resection of the lung may benefit from the absence of pleural drainage and can be operated on in day-case surgery.

LEVEL OF EVIDENCE

Level III.

Ultra fast-track extubation in heart transplant surgery patients

Background:

Heart transplant surgeries using cardiopulmonary bypass (CPB) typically requires mechanical ventilation in intensive care units (ICU) in post-operation period. Ultra fast-track extubation (UFE) have been described in patients undergoing various cardiac surgeries.

Aim:

To determine the possibility of ultra-fast-track extubation instead of late extubation in post heart transplant patients.

Materials and Methods:

Patients randomly assigned into two groups; Ultra fast-track extubation (UFE) group was defined by extubation inside operating room right after surgery. Late extubation group was defined by patients who were not extubated in operating room and transferred to post operation cardiac care unit (CCU) to extubate.

Results:

The mean cardiopulmonary bypass time was 136.8 ± 25.7 minutes in ultra-fast extubation and 145.3 ± 29.8 minutes in late extubation patients (P > 0.05). Mechanical ventilation duration (days) was 0 days in ultra-fast and 2.31 ± 1.8 days in late extubation. Length of ICU stay was significantly higher in late extubation group (4.2 ± 1.2 days) than the UFE group (1.72 ± 1.5 days) (P = 0.02). In survival analysis there was no significant difference between ultra-fast and late extubation groups (Log-rank test, P = 0.9).

Conclusions:

Patients undergoing cardiac transplant could be managed with “ultra-fast-track extubation”, without increased morbidity and mortality.

Efficacy of Evolving Early-Extubation Strategy on Early Postoperative Functional Recovery in Pediatric Open-Heart Surgery

There has been a paradigm shift toward “fast-track” management with early extubation (EE) in cardiac surgery. Our retrospective, matched case-control study wishes to define the benefits of EE in pediatric congenital heart surgery. We examined 50 consecutive pediatric cardiac surgery patients extubated in the operating room (February 2009 to July 2009) against a control group of delayed-extubation patients. No significant differences were found in preoperative variables except heart failure medication. Significant intraoperative variables included the following: blood products (363 vs 487 mL, P = .023), morphine (62% vs 6%, P < .0001), and inotropes (16% vs 60%, P < .0001) given. Postoperatively significant differences included hospital stay and lower inotrope scores in the early-extubation group (14.89 vs 31.68, P < .0001). The reintubation rate was not significant. EE patients have equivalent hemodynamic profiles shown by a decreased necessity for inotropic support. We conclude that EE is feasible in low-/medium-risk pediatric congenital heart surgery patients.

[Decision on the time for post-operative extubation of maxillofacial surgery patient in the intensive care unit]

OBJECTIVE

Evaluate moment of extubation in maxillofacial post-operative patients admitted to an intensive care unit (ICU) and analyze early complications during their stay.

DESIGN

An observational and prospective study.

SETTING

Third level hospital ICU.

PATIENTS AND METHODS

All patients we underwent maxillofacial surgery and admitted to the ICU for immediate post-operative care from February 2007 to March 2008 were studied. Demographic and clinical data variables of the patients, anesthesic variables prior to surgery and mechanical ventilation and postoperative complications during their stay in the ICU were recorded.

RESULTS

A total of 102 patients were collected during the study. Of these, 58 (55.8%) patients were extubated early (within the first 4 hours of admission). Global rate of complications was 12.5%. Length of mechanical ventilation was longer in patients who required cervical lymph node extraction (p = 0.0031). We found an association between complications and late extubation (p = 0.034; OR = 3.78; 95% CI, 1.16-12.31). The multivariant study showed that late extubation and surgery that required lymph node extraction are predictors of complications.

CONCLUSIONS

In our series, late extubation and the need for cervical lymph node extraction were independent risk factors for complications in ICU. Although early extubation may be hazardous in some cases in the first hours, we have no consistent data to maintain mechanical ventilation longer than needed to recover from the anesthesia.

Caudal Anesthesia in Pediatric Cardiac Surgery: Does It Affect Outcome?

OBJECTIVE

The purpose of this study was to examine the influence of caudal anesthesia on outcomes (pediatric intensive care unit [PICU] length of stay, hospital length of stay, ventilatory time, early extubation rate) in pediatric patients undergoing congenital heart disease repair requiring cardiopulmonary bypass (CPB).

DESIGN

Retrospective.

SETTING

University teaching hospital.

PARTICIPANTS

Pediatric patients undergoing surgery to treat congenital heart disease between 1999 and 2002.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Thirty-four patients with atrial septal defect (ASD), 37 with ventricular septal defect, and 46 with tetralogy of Fallot (TOF) were included in the analysis. No differences were found in preoperative and intraoperative data between caudal and noncaudal group for each disorder. There was no difference between caudal and noncaudal groups in PICU and hospital stay. A statistically significant difference was found in the postoperative ventilatory time in patients with ASD and TOF between caudal and noncaudal groups. The early extubation rate was higher in the TOF caudal group compared with the noncaudal group.

CONCLUSIONS

This retrospective study demonstrated that postinduction placement of caudal anesthesia does not affect PICU or hospital length of stay. A well-controlled prospective study is needed to confirm these findings.

Short Operation Time: An Important Element to Reduce Operative Invasiveness in Pediatric Cardiac Surgery

BACKGROUND

The mini skin incision procedure is considered an important element of minimally invasive cardiac surgery because of its definitive cosmetic advantage. However, the operative hazard of limited exposure may be associated with prolonged operation time and increased surgical insult.

METHODS

A total of 357 consecutive patients undergoing repair of an isolated atrial or ventricular septal defect, in whom the mini skin procedure was applied, were investigated. Patients were grouped by diagnosis and body weight. Univariate and multivariate risk analyses were conducted in the specific patient group undergoing ventricular septal defect repair weighing less than 5 kg.

RESULTS

The operation time was reduced by 21.0% (93.4 to 73.8 minutes) during this time period. Univariate risk analysis revealed that the operation time had a significant correlation with time to extubation (p < 0.0001), catecholamine duration (p = 0.0003), intensive care unit stay (p < 0.0001), hospital stay (p = 0.016), arterio-alveolar oxygen tension difference at the time of extubation (p = 0.0253), and furosemide dose required in the first 24 hours (p = 0.0332). Multiple linear regression analysis revealed that the operation time had an impact on time to extubation, arterio-alveolar oxygen tension difference at the time of extubation, and intensive care unit stay. The length of skin incision was not correlated with any outcome measure.

CONCLUSIONS

The mini skin incision, if associated with prolonged operation time, may increase the overall insult in pediatric cardiac surgery. In order to reduce operative invasiveness, simultaneous effort to reduce, or at least not to increase, the operation time are mandatory.

Extubation failure in pediatric intensive care incidence and outcomes

OBJECTIVES

To evaluate the hypotheses that children requiring reintubation are at an increased risk of prolonged hospitalizations, congenital heart disease, and death compared with age- and disease-severity-matched control patients.

DESIGN

Prospective decision to evaluate all children undergoing extubation over a 5-yr time interval (1997-2001) with retrospective analysis of all failed extubation patients.

SETTING

A large multidisciplinary, dual-site, single-system pediatric intensive care unit caring for critically ill and injured children.

PATIENTS

All children intubated and ventilated during the study period (1997-2001).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Failed extubation was defined as the unanticipated requirement to replace an endotracheal tube within 48 hrs of extubation. One hundred thirty children of 3,193 pediatric intensive care unit patients failed extubation (4.1%). The median age of children who failed extubation was 6.5 months, compared with a median age of 21.3 months in the control population. The median age of failed extubation in children with cardiac disease was 9.3 months. Failed extubation patients had lengthier hospital and pediatric intensive care unit stays, longer duration of mechanical ventilation, and a higher rate of tracheostomy placement than nonfailed extubation patients (p < .001). Children with congenital heart disease who failed extubation had the longest duration of hospitalization (40.0 +/- 5.4 days). Conversely, cardiac patients who did not fail extubation had the shortest length of stay (11.2 +/- 0.4 days).

CONCLUSIONS

In the present trial, 4.1% of mechanically ventilated children failed extubation. Pediatric intensive care unit patients with failed extubation have longer hospital, pediatric intensive care unit, and ventilator courses but are not at increased risk of death relative to nonfailed extubation patients.

Minimal access surgery for the repair of simple congenital heart defects: factors affecting hospital stay after surgery

OBJECTIVE

We reviewed our experience of minimal access surgery to elucidate the efficacy and safety of this approach and determine the factors affecting hospital stay.

METHODS

Seventy-seven patients (age, 11.8 +/- 11.0 years), with body weight of more than 10 kg, were operated using various forms of minimal access approach for repair of simple congenital heart defects [atrial septal defect (ASD) in 40, ventricular septal defect in 37]. These included lower partial sternotomy (n = 68) and mini-thoracotomy (n = 9, ASD only) with limited skin incision of 4-11 cm. The anesthetic protocol was modified to wean all patients from ventilator soon after operation. The protocol of discharge from hospital (critical pass) was 14 days in the early period (n = 30) and 10 days in the late period (n = 47).

RESULTS

There were no hospital or late death, and no hospital re-admission. None of patients required blood transfusion. The endotracheal tube was extubated in the operating room in 48 cases (62%). Twenty-four patients (31%) failed to fulfill conditions of the critical pass. Univariate analysis of factors affecting unfavorably the critical pass demonstrated that the median approach, retention of pericardial effusion and social reasons were statistically significant, while an opened pleura and aortic cross-clamp time were marginally significant. Multivariate analysis indicated that the retention of pericardial effusion was the only significant factor that failed critical pass [p = 0.007, odds ratio (OR) 5.7, 95% confidence interval (CI) 1.61 -19.8]. In addition, a pericardio-pleural fenestration was the only significant factor that affected favorably the pericardial effusion (p = 0.035, OR 0.2, 95% CI 0.47-0.89) by multivariate analysis.

CONCLUSIONS

Our experience demonstrated that minimal access surgery of the simple congenital heart defects provided excellent cosmetic results. Retention of pericardial effusion, possibly due to pericarditis, was a major risk factor of the prolonged hospital stay. The pericardio-pleural fenestration could reduce the risk of retention of effusion.

Use of a new venous cannula for minimally invasive cardiac surgery

Interest in minimally invasive cardiac surgery (MICS) for cardiac disease continues to increase, because it causes less surgical trauma and produces a better cosmetic appearance. We introduced the transxiphoid approach without sternotomy for correction of congenital heart defects. To improve exposure of the cardiac lesion during MICS, we developed a new venous cannula that is made of wire reinforced silicone, with an inflatable balloon attached at the tip. The advantages of this cannula are its extreme flexibility and that a tape does not need to be placed around the vena cava. During a period of 12 months, eight children underwent closure of atrial septal defects. The approach consisted of a 4 to 5 cm low midline incision with division of the xiphoid only. The new venous cannula was used as the superior vena cava cannula, all the patients survived the operation. This new venous cannula provided better exposure during cardiac surgery through a limited incision and is beneficial for minimally invasive cardiac surgery.

Early tracheal extubation after paediatric cardiac surgery: the use of propofol to supplement low-dose opioid anaesthesia

BACKGROUND

After institutional approval and parental consent, 103 children, aged 6 months to 18 years, who were undergoing repair of simple and complex congenital heart lesions using cardiopulmonary bypass (CPB) were studied and compared with a group of 135 children who had undergone similar surgery in our institution in the year before.

METHODS

Anaesthesia for study patients included fentanyl (< 20 microg.kg-1) and isoflurane. Infusions of propofol (median infusion rate 70 microg.kg-1.min-1) and morphine (median infusion rate 20 microg.kg-1.h-1) were started after weaning from CPB and continued postoperatively. Preestablished criteria were used in the intensive care unit (ICU) to assess readiness for tracheal extubation.

RESULTS

Median time from admission to ICU to tracheal extubation was 5 h. Fifty-six children were extubated within 6 h and 73 within 9 h of ICU admission. Mean ICU stay for study patients was 1.7 days [95% confidence interval (CI) 1.2-2.2] and 2.6 days (95% CI 2.3-2.9) in the comparison group (P<0.005).

CONCLUSIONS

We found the propofol regimen to be satisfactory with a shorted ICU stay for these patients.

Postoperative intensive care in cardiac surgery

Postoperative intensive care in cardiac surgery is a growing area, fuelled by the increase in the number of cardiac surgical procedures performed. An increase in the number of patients has resulted in increased resource utilization. Much of the recent research in this field is concerned with the early extubation of cardiac surgical patients, reducing the length of stay in the intensive care unit and predicting which patients will have delayed extubation and a prolonged length of stay. A number of recent studies have been published advocating 'off pump' cardiac surgery as a way of reducing the physiological insult of cardiopulmonary bypass and thereby improving the postoperative course. There is still insufficient evidence that this approach reduces morbidity and intensive care unit length of stay in multi-vessel off-pump coronary artery bypass surgery. The traditional design of post-cardiac surgical intensive care units and high dependency units has also recently been challenged. More flexible integrated units improve cost control and are more suited to modern cardiac surgery.