Anesthetic technique and postoperative outcome in preterm infants undergoing PDA closure

Bedside Transcatheter Patent Ductus Arteriosus Device Occlusion in an Extremely Low Birth Weight Neonate: A Novel Approach in a High-Risk Population

Extremely low birth weight (ELBW) infants weighing less than 1 kilogram are at a high-risk for delayed patent ductus arteriosus (PDA) closure. Percutaneous PDA closure offers a less invasive approach when compared with surgical PDA closure, which may provide faster recovery times and less transfusion requirements. However, this procedure involves transporting tenuous, unstable patients from the neonatal intensive care unit (NICU) to the catheterization laboratory which introduces many potential risks for the neonate. Performing percutaneous PDA closure at the bedside offers a successful alternative to performing the procedure in the catheterization laboratory and avoiding risk associated with transporting ELBW neonates.

Anesthesia protocols for "bedside" preterm patent ductus arteriosus ligation: A single-institutional experience

Background :

Hemodynamically significant patent ductus arteriosus (PDA) is frequently encountered in preterm infants sometimes requiring surgical attention. Although PDA ligation is regularly performed in the operating room, conducting it at the bedside in a neonatal intensive care unit (NICU) and its anesthetic management remains challenging.

Aim :

We aim to discuss the anesthetic considerations in patients undergoing bedside PDA ligation and describe our experience highlighting the feasibility and safety of this procedure.

Setting and Design :

The study was conducted in the NICU in a tertiary care hospital; This was a retrospective, observational study.

Methods :

Preterm infants scheduled for bedside PDA ligation using a predefined anesthesia protocol between August 2005 and October 2020 were included.

Statistical Analysis Used:

Quantitative data were presented as median with interquartile range and categorical data were presented as numbers and percentage thereof.

Results :

Sixty-six premature infants underwent bedside PDA ligation. Thirty-day mortality was 4.5% (3 infants), but there were no procedural deaths. One (1.5%) patient had intraoperative endotracheal tube dislodgement. Three (4.5%) infants had postoperative pneumothorax requiring an additional chest tube insertion. Twenty-one (32%) patients required initiation of postoperative inotrope/vasodilator therapy within 6 h. Three postligation cardiac syndromes (≥ Grade-III mitral regurgitation with left ventricular dysfunction and hypotension) occurred.

Conclusions :

Although anesthesia for preterm neonates undergoing bedside PDA ligation poses unique challenges, it can be safely conducted by following a predetermined standardized anesthesia protocol. Its successful conduct requires utmost vigilance and pristine understanding of the principles of neonatal and cardiac care.

Anesthetic management of catheter-based patent ductus arteriosus closure in neonates weighing <3 kg: A Retrospective Observational Study

BACKGROUND

The patent ductus arteriosus is a cardiac lesion commonly found in premature neonates. Though surgical closure via thoracotomy is the most definitive treatment option, it is associated with significant morbidity. New catheter-based closure options offer a potentially safer alternative treatment, even in premature neonates. However, no literature reports the anesthetic techniques, challenges, and risks associated with this procedure in this population.

AIM

This study documents the anesthetic challenges and potential complications associated with the management of catheter-based closure of the ductus arteriosus in neonates under 3 kg.

METHODS

This single-center, retrospective study examined patients who underwent catheter-based ductus arteriosus closure between August 2015 and February 2019. A clinical protocol for anesthetic management of these patients was utilized throughout the study period. Clinical outcomes considered were new hemodynamic instability or vasoactive medication requirements, hypothermia, prolonged intubation (>3 days postoperatively), postprocedure acute kidney injury, perioperative red blood cell transfusion, and accidental extubation.

RESULTS

Seventy-six neonates underwent 78 procedures. No patient developed perioperative hemodynamic instability, vasoactive medication requirements, or acute kidney injury. Four patients (5%) required red blood cell transfusion, two (3%) became hypothermic, and one (1%) was accidentally extubated. Closure was achieved in 73 patients (96%) on the first attempt. However, 17 patients (40%) required prolonged periods of mechanical ventilation following the procedure.

CONCLUSION

Despite multiple clinical and logistical challenges, anesthetic risk associated with catheter-based PDA closure in small neonates can be effectively managed through standardized and multidisciplinary care.

A comparison of postoperative outcomes with PDA ligation in the OR versus the NICU: a retrospective cohort study on the risks of transport

Background

Although patent ductus arteriosus (PDA) ligations in the Neonatal Intensive Care Unit (NICU) have been an accepted practice, many are still performed in the Operating Room (OR). Whether avoiding transport leads to improved perioperative outcomes is unclear. Here we aimed to determine whether PDA ligations in the NICU corresponded to higher risk of surgical site infection or mortality and if transport was associated with worsened perioperative outcomes.

Methods

We performed a retrospective cohort study of NICU patients, ≤37 weeks post-menstrual age, undergoing surgical PDA ligation in the NICU or OR. We excluded any infants undergoing device PDA closure. We measured the incidence of perioperative hypothermia, cardiac arrest, decreases in SpO2, hemodynamic instability and postoperative surgical site infection, sepsis and mortality.

Results

Data was collected on 189 infants (100 OR, 89 NICU). After controlling for number of preoperative comorbidities, weight at time of procedure, procedure location and hospital in the mixed-effect model, no significant difference in mortality or sepsis was found (odds ratio 0.31, 95%CI 0.07, 1.30; p = 0.107, and odds ratio 0.40; 95%CI 0.14, 1.09; p = 0.072, respectively). There was an increased incidence of hemodynamic instability on transport postoperatively in the OR group (12.4% vs 2%, odds ratio 6.93; 95% CI 1.48, 35.52; p = 0.014).

Conclusion

PDA ligations in the NICU were not associated with higher incidences of surgical site infection or mortality. There was an increased incidence of hemodynamic instability in the OR group on transport back to the NICU. Larger multicenter studies following long-term outcomes are needed to evaluate the safety of performing all PDA ligations in the NICU.

Keywords

Patent ductus arteriosus, Newborn infant, Neonatal intensive care unit, Surgical wound infection, Postoperative period, Hemodynamics

Reduced narcotic and sedative utilization in a NICU after implementation of pain management guidelines

OBJECTIVE

To assess the opioid and benzodiazepine usage in a level IV NICU after implementation of pain guidelines.

STUDY DESIGN

Guidelines were developed for infants undergoing surgical procedures and infants on mechanical ventilation. Data collected for period 1 (July to December 2013) and period 2 (March to August 2014).

RESULTS

Gestational age, birth weight and infants with hypoxic respiratory failure or requiring major procedures were comparable in two periods. Number of patients exposed to opioids decreased from 62.9% (129/205) in period 1 to 32.8% (82/250) in period 2, P=<0.001. Cumulative dose exposure decreased, opioids in morphine equivalent dose, mg kg^-1 (1.64 (0.38 to 6.94) vs 0.51 (0.04 to 2.33), P=0.002), sedatives in midazolam equivalent, mg kg^-1 (0.16 (0.03 to 7.39) vs 0.10 (0.00 to 4.00), P=0.03). Ten patients required treatment for iatrogenic opioid withdrawal versus only three in post guideline, P=0.02.

CONCLUSIONS

Evidence-based guidelines led to significant reduction in opioids and sedatives exposure, and in the number of infants requiring methadone for iatrogenic narcotic dependence.

The impact of a dedicated patent ductus arteriosus ligation team on neonatal health-care outcomes

OBJECTIVE

The decision to perform patent ductus arteriosus (PDA) ligation is controversial. Patient selection is oftentimes poorly standardized, leading to delays in referral and inappropriate intervention. A system for PDA ligation categorization and triaging process was introduced in 2006 at a quaternary hospital in Canada to streamline referrals and enhance perioperative care. We aimed to evaluate the impact of this dedicated PDA ligation triaging system comparing pre- and postimplementation of this system.

STUDY DESIGN

We performed a retrospective chart review. Demographic and cardiorespiratory data of neonates ⩽30 weeks gestation age at birth, who were referred for and/or had a PDA ligation performed during two distinct epochs (EPOCH 1 (2003 to 2005) and EPOCH 2 (2010 to 2012)), were analyzed. All surgeries were performed at The Hospital for Sick Children, the regional referral center for PDA ligation. The primary outcome was incidence of PDA ligation and procedural cancellations. Secondary outcomes included postoperative need for cardiovascular or respiratory support. Subgroup analysis was performed in neonates <1000 vs >1000 g at the time of surgery during both epochs.

RESULT

A total of 198 neonates underwent surgery with no difference in baseline demographics between epochs. The incidence of PDA ligation as a proportion of total live births under 30 weeks in Central East Region of Ontario was lower in the second epoch (EPOCH 1: 117/1092 (10.7%) vs EPOCH 2: 81/1520 (5.3%)). During the second epoch, 24% of referrals for surgery were canceled after review by our PDA ligation team. There were no overall differences in the proportion of neonates with oxygenation failure, ventilation failure or Post-Ligation Cardiac Syndrome (PLCS), after surgery, between epochs. The proportion of neonates who developed systemic hypotension was higher in patients <1000 g (n=34 (34%) vs n=17 (17.4%), P=0.01) at the time of surgery. In addition, we identified a reduction in the proportion of neonates <1000 g who developed PLCS in EPOCH 2. On the contrary, there was an increase in the proportion of neonates >1000 g who developed ventilation failure in EPOCH 2.

CONCLUSION

The presence of dedicated triaging and management system enhances efficiency of referral process through careful selection of patients for PDA ligation and optimizes perioperative management. We demonstrated a reduction in the incidence of PDA ligation without any negative impact on short-term neonatal morbidity. The use of targeted neonatal echocardiography in the assessment of PDA shunt volume and guiding postoperative decision making is likely to have contributed to these findings.

Ischemic changes associated with a large patent arterial duct in small infants

Infants with a large patent arterial duct (PDA) may develop signs of congestive heart failure secondary to pulmonary overcirculation. As the PVR decreases, the relative pulmonary blood flow (Qp :Qs ) increases and this may cause tachypnea, respiratory distress, failure to thrive, ventricular dysfunction and even ventilator dependency. The diastolic runoff from the systemic circulation may result in intestinal hypoperfusion resulting in necrotizing enterocolitis, and in severe cases, myocardial ischemia. Cardiac ischemia due to coronary steal is a recognized clinical entity. We present two cases of infants who developed coronary artery steal with the use of supplemental oxygen therapy during anesthesia induction for PDA occlusion. These cases highlight the importance of prudent use of supplemental oxygen therapy in infants with large PDAs.

Amplitude electroencephalogram characterization in preterm infants undergoing patent ductus arteriosus ligation

BACKGROUND

Recent studies suggest an increased risk of neurodevelopmental impairment following patent ductus arteriosus surgical ligation. The mechanisms are unclear, but intraoperative stress or pain may contribute. The objectives of this study were to determine if pain, evidenced by an increase in heart rate and blood pressure, during patent ductus arteriosus ligation would be accompanied by an increase in amplitude-integrated electroencephalogram (aEEG) voltage.

METHODS

This was an observational, pilot study of infants born at 22.6-35.1 weeks with patent ductus arteriosus requiring surgical ligation. The aEEG was recorded prior to, during surgery, and for 2 hours following surgery. Mean heart rate, blood pressure, and aEEG voltage were analyzed for each recording period.

RESULTS

Seventeen preterm infants were studied at a mean postmenstrual age of 26.6 weeks. Following anesthetic induction, aEEG became suppressed and remained suppressed during the postoperative period. Heart rate and blood pressure increased significantly intraoperatively. The aEEG voltage did not increase with an increase in heart rate. Infants received between 3.7-47 μg/kg of fentanyl.

CONCLUSIONS

There was no correlation between aEEG voltage and vital sign changes. aEEG is not a useful tool as a marker of pain during patent ductus arteriosus ligation, rather a more standardized approach to pain management should be considered.

Pros and cons of patent ductus arteriosus ligation: hemodynamic changes and other morbidities after patent ductus arteriosus ligation

Although surgical ligation of a persistent patent ductus arteriosus resolves the adverse hemodynamic consequences of the systemic-to-pulmonary shunt and may confer some long-term benefits, it is also associated with both immediate and long-term negative effects. The population that benefits from or is harmed by the procedure is not clearly defined. Although indiscriminate ligation of the patent ductus arteriosus in all patients is not supported by the available information, the recent suggestion declaring the ductus harmless is not supported either. As we await the results of appropriately designed randomized control studies to define the indications for ligation, we must use clinical and echocardiographic indicators of a hemodynamically significant ductus arteriosus and thoughtful assessment of each individual patient to help guide us in addressing this complex problem.