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

Operative Complications Following Gastrostomy Tube Placement After Cardiac Surgery During Infancy

INTRODUCTION

Gastrostomy tube (GT) placement is common in infants following repair of congenital heart defects. We aimed to determine rate of operative complications and predictors of short-term GT use to counsel parents regarding the risks and benefits of GT placement.

METHODS

We reviewed infants aged <1 y with congenital heart disease who underwent GT placement after cardiac surgery between 2018 and 2021. Demographics and clinical data were collected and analyzed. Comparisons were made between infants who required the GT for more than 1 y and those who required the GT for less than 1 y.

RESULTS

One hundred thirty three infants were included; 35 (26%) suffered one or more complication including wound infection (4, 3%), granulation tissue (3, 2%), tube dislodgement (10), leakage from the tube (9), unplanned emergency department visit (15), and unplanned readmission (1). Thirty-four infants used the GT for feeds for 1 y or less (26%) including 17 (13%) who used it for 3 mo or less. Fifty-six infants had their GT removed during the study period (42%), 20 of whom required gastrocutaneous fistula closure (36%). Thirty-three infants had a GT placed on or before day of life 30, 17 (52%) used the GT for less than 1 y, and 10 (31%) used it for 3 mo or less.

CONCLUSIONS

GT placement is associated with a relatively high complication and reoperation rate. GT placement in infants aged less than 30 d is associated with shorter duration of use. Risks, benefits, and alternatives such as nasogastric tube feeds should be discussed in the shared decision-making process for selected infants.

A 10-Year Nationwide Analysis of Risk Factors of Readmission and the Implications of Same-Day Discharge Following Velopharyngeal Insufficiency Correcting Surgery

OBJECTIVE

To investigate risk factors for readmission and the implications of same-day discharge for surgical management of velopharyngeal insufficiency (VPI).

DESIGN

Retrospective cohort.

SETTING

Multi-institutional/national.

PATIENTS AND PARTICIPANTS

Patients who underwent VPI-correcting surgery (n = 4479) were identified in the National Surgical Quality Improvement Program Pediatric database from 2012-2021.

MAIN OUTCOMES MEASURE(S)

30-day unplanned readmission.

RESULTS

A total of 3878 (86.6%) patients were admitted inpatient following surgical intervention, while 601 (13.4%) were discharged on the same day. Thirty-day readmission rate was 1.7% across all patients. Based on multivariate logistic regression, patient factors identified as significant predictors of 30-day readmission included ASA class 4 (OR 11.22 [95% CI 1.01-124.91]; p = 0.049), steroid use (OR 7.30 [95% CI 2.22-23.97]; p = 0.001), and gastrointestinal disease (OR 2.48 [95% CI 1.22-5.00]; p = 0.012). Upon interaction analysis, patients with cardiac or neuromuscular disease who were discharged on the same day of surgery were associated with a higher readmission rate than those admitted to the hospital (cardiac disease RR 6.72 [95% CI 1.41-32.06]; p = 0.017) and (neuromuscular disease RR 12.39 [95% CI 1.64-93.59]; p = 0.015).

CONCLUSIONS

Approximately 90% of VPI-correcting procedures are completed inpatient nationwide. Cardiac and/or neuromuscular disease significantly increased the patients' readmission risk when discharged on the same day of surgery. The inpatient setting should remain the best practice as adequate resources are available to mitigate life-threatening complications.

The Delicate Dance of Intraoperative Anesthesia: Addressing Patient and Anesthesiologist Concerns

Background In the realm of surgical procedures, patients and anesthesiologists have distinct concerns that can have an impact on their relationship. Patients are often riddled with anxiety about the unknowns of anesthesia and the possible risks. Anesthesiologists, too, face their own set of concerns. Despite the importance of this interaction, there has been little research on the specific concerns of both parties. Our study aims to fill this gap by describing and comparing the concerns of patients and anesthesiologists in Jordan. Methodology This cross-sectional study evaluated anesthesia-related problems based on specific questionnaires. The responses to the questionnaires were on a voluntary basis. The consent of the participants was granted after the aims of the study were clarified. Data were collected and analyzed using SPSS version 28 (IBM Corp., Armonk, NY, USA). Results A total of 155 Jordanian anesthesiologists and 1,858 participants from the population who had undergone anesthesia participated in the study. In general anesthesia, over 60% of the anesthesiologists were most worried about ventilation and intubation difficulties during anesthesia induction and death at the end of anesthesia. Regarding regional anesthesia, the primary concerns included toxicity from local anesthesia infiltration (64.5%) and total spinal anesthesia (49.0%). Patients were concerned about various anesthesia-related scenarios, with the highest worries about pain (3.41/4), a sharp drop in vital signs (3.40/4), and an irregular heartbeat (3.39/4). Female patients, those with lower incomes, and those with a bachelor's degree reported higher anesthesia concern levels. Additionally, anesthesiologists' mean concern score was significantly lower than that of patients. Conclusions Patients concentrated on pain, a drop in vital signs, and irregular heartbeats, whereas anesthesiologists were worried about ventilation, intubation, and hypoxia. Patients placed more emphasis on personal experiences and social factors than technical issues. Therefore, patient education about anesthesia and discussion about intra and postoperative expectations are imperative to improve the surgical experience and the relationship between patients and anesthesiologists.

The Bacterial Oral Microbiome in Children with Congenital Heart Disease: An Extensive Review

Children with congenital heart disease have poorer oral health compared with healthy children. Oral diseases, such as dental caries and gingivitis, are associated with the oral microbiome. The objective of this review was to find evidence of differences in the bacterial colonization of the oral cavity of children with congenital heart disease (CHD) versus healthy children. A literature review was conducted according to predetermined criteria, including the need for controlled clinical trials. Half of the 14 studies that met the inclusion criteria reported significant differences in bacterial colonization in children with congenital heart disease. A variety of influencing factors were discussed. There is some evidence for alterations in the oral microflora as a result of physiopathological and treatment-related factors in children with CHD, but additional research is required to validate these findings.

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

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

Outcomes of Gastrostomy Tubes in Newborns With Congenital Heart Disease and Comparison of Techniques

INTRODUCTION

Gastrostomy tube (GT) placement for enteral access is one of the most common procedures for infants with numerous conditions such as congenital heart disease (CHD). Discrepancies in the literature exist regarding outcomes of newborns with CHD undergoing GT placement. This study sought to characterize postoperative outcomes and readmission complications in this patient population.

METHODS

The Nationwide Readmission Database was queried from 2010 to 2014 for all newborns who underwent GT placement during their index hospitalization. Newborns with or without CHD other than an isolated atrial or ventricular septal defect were compared using standard statistical tests. A propensity score-matched analysis was performed among newborns with or without CHD using > 100 covariates.

RESULTS

Seven thousand seven hundred thirty six patients underwent GT placement. Newborns with CHD (27%) more frequently underwent open GT (59% versus 55%) and less frequently underwent laparoscopic (17% versus 19%) or percutaneous (24% versus 26%) GT placement compared to those without CHD, P = 0.043. GT-related complications on index admission were similar between groups (7% versus 7%, P = 0.770). Newborns with CHD had higher overall readmission rates (39% versus 31%), more GT-related readmission complications (7% versus 3%), and higher readmission costs ($35,787 versus $20,073) compared to newborns without CHD, all P < 0.001. Laparoscopic GT was associated with the lowest rate of GT-related complications (0%) and overall readmission rates (27%) compared to open or percutaneous endoscopic gastrostomy (all P < 0.001).

CONCLUSIONS

Compared to newborns without CHD, newborns with CHD had higher rates of overall readmissions, readmission costs, and GT-related complications on readmission. The laparoscopic GT approach was underused despite fewer complications and readmissions.

The influence of decreasing variable collection burden on hospital-level risk-adjustment

BACKGROUND

Risk-adjustment is a key feature of the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-Ped). Risk-adjusted model variables require meticulous collection and periodic assessment. This study presents a method for eliminating superfluous variables using the congenital malformation (CM) predictor variable as an example.

METHODS

This retrospective cohort study used NSQIP-Ped data from January 1st to December 31st, 2019 from 141 hospitals to compare six risk-adjusted mortality and morbidity outcome models with and without CM as a predictor. Model performance was compared using C-index and Hosmer-Lemeshow (HL) statistics. Hospital-level performance was assessed by comparing changes in outlier statuses, adjusted quartile ranks, and overall hospital performance statuses between models with and without CM inclusion. Lastly, Pearson correlation analysis was performed on log-transformed ORs between models.

RESULTS

Model performance was similar with removal of CM as a predictor. The difference between C-index statistics was minimal (≤ 0.002). Graphical representations of model HL-statistics with and without CM showed considerable overlap and only one model attained significance, indicating minimally decreased performance (P = 0.058 with CM; P = 0.044 without CM). Regarding hospital-level performance, minimal changes in the number and list of hospitals assigned to each outlier status, adjusted quartile rank, and overall hospital performance status were observed when CM was removed. Strong correlation between log-transformed ORs was observed (r ≥ 0.993).

CONCLUSIONS

Removal of CM from NSQIP-Ped has minimal effect on risk-adjusted outcome modelling. Similar efforts may help balance optimal data collection burdens without sacrificing highly valued risk-adjustment in the future.

LEVEL OF EVIDENCE

Level II prognosis study.

Nine-Year Experience with the Arterial Switch Operation with Closed Coronary Transfer

BACKGROUND

Coronary artery transfer is a critical step of the arterial switch operation (ASO) for transposition of the great arteries (TGA). Strategies for coronary transfer include open transfer before neo-aortic anastomosis or closed transfer after neo-aortic anastomosis. This study reports outcomes of ASO with closed coronary transfer at a single institution.

METHODS

A retrospective analysis was performed of patients undergoing ASO for TGA from November 2006 to September 2015. Closed coronary transfer was universally employed. Patients were classified into simple versus complex coronary anatomy groups. The primary outcome was overall survival. Secondary outcomes included reoperation-free survival, coronary re-intervention, and aortic insufficiency.

RESULTS

Ninety-six consecutive patients underwent ASO for TGA. Median follow-up was 5.8 years. Thirty-five (36%) of patients had complex coronary anatomy, which was associated with significantly longer cardiopulmonary bypass and aortic cross-clamp time. Overall survival was 97.4%, and reoperation-free survival was 83.6%. There was no difference in survival or reoperation-free survival between patients with simple versus complex coronary anatomy. Hispanic ethnicity, side-by-side great arteries, and urgent or emergent operation were significantly associated with the composite outcome of reoperation or mortality. There were no coronary interventions after ASO, and the incidence of moderate or greater aortic insufficiency was 2.1% at hospital discharge and 1.5% in follow-up.

CONCLUSIONS

Closed coronary transfer during ASO has excellent short and mid-term results. Despite variable and often complex coronary anatomy, coronary ischemic events following ASO are avoidable. Closed coronary transfer has a low risk of aortic valve injury or insufficiency.

Behaviour management problems in Finnish children with operated congenital heart disease: a practice-based study

Purpose

This retrospective, practice-based study investigates behaviour management problems (BMPs) in dental care among Finnish children with operated congenital heart disease (CHD).

Methods

All the heart-operated children born between the years 1997 and 1999 were identified in the national ProCardio database (n = 570). Primary dental care records were requested from this population and were eventually received from 211 patients. Information on gender, diagnosis, number of heart operations and perioperative care were collected from the ProCardio database, and the CHDs were categorised as shunting/stenotic/complex/other defects. Data on BMP/dental fear, oral conscious sedation, dental general anaesthesia (DGA) and past and present caries indices at 6, 12 and 15 years (d/D, dmft/DMFT) were assessed.

Results

Notes on behaviour management problems or dental fear were found in 19% of the study population. BMPs in dental care were more frequent among boys. Children with re-operations, longer post-operative intensive care stay and hospitalisation, and complications had not more BMP than others. Those children diagnosed with syndromes had more BMP often than the rest. Past and present caries experience were significantly associated with BMP, need of oral conscious sedation and DGA. Oral conscious sedation, nitrogen oxide sedation and dental general anaesthesia were used in 17/211, 2/221 and 24/211 CHD patients, respectively.

Conclusion

Dental caries remains a main factor associated with BMP in the CHD population. Need for oral conscious sedation and DGA were rather common. To maintain a good oral health and to avoid development of BMP, CHD children benefit from focus in health promotion and preventive care.

Pediatric Anesthesia Severe Adverse Events Leading to Anesthetic Morbidity and Mortality in a Tertiary Care Center in a Low- and Middle-Income Country: A 25-Year Audit

BACKGROUND

The analysis of adverse events, including morbidity and mortality (M&M), helps to identify subgroups of children at risk and to modify clinical practice. There are scant data available from low- and middle-income countries. Our aim was to estimate the proportion of pediatric patients with various severe adverse events in the perioperative period extending to 48 hours and to describe the clinical situations and causes of those events.

METHODS

We reviewed the M&M database of the Department of Anesthesiology between 1992 and 2016. A data collection tool was developed, and the outcomes were standardized. Each case was reviewed independently and subsequently discussed between 2 reviewers to identify a major primary causative factor.

RESULTS

The total number of pediatric cases during this period was 48,828. Seventy-six significant adverse events were identified in 39 patients (8 patients [95% confidence interval {CI}, 5.7-10.9] per 10,000). Thirteen patients had multisystem involvement, and hence the total number of events exceeded the number of patients. Respiratory events were the most common (33.5%). Thirteen patients had perioperative cardiac arrest within 48 hours of surgery (2.6 [95% CI, 1.3-4.3] per 10,000), 7 of these were infants (54%), 5 of whom had congenital heart disease (CHD). Eleven of these 39 patients died within 48 hours (2.0 [95% CI, 1.1-4.0] per 10,000).In 13 cases, anesthesia was assessed to be the predominant cause of morbidity (2.6 per 10,000), whereas in 26 cases, it contributed partially (5.32 per 10,000). There was only 1 death solely related to anesthesia (0.2 per 10,000), and this death occurred before the start of surgery.

CONCLUSIONS

Adverse events were uncommon. Respiratory complications were the most frequent (33%). Infants, especially those with CHD, were identified as at a higher risk for perioperative cardiac arrest, but this association was not tested statistically. Twenty-eight percent of the patients who suffered events died within 48 hours. Increased access to anesthesia drugs and practice improvements resulted in a decline in perioperative cardiac arrests.

Trends in mortality rate in patients with congenital heart disease undergoing noncardiac surgical procedures at children's hospitals

Advances made in pediatric cardiology, cardiac surgery and critical care have significantly improved the survival rate of patients with congenital heart disease (CHD) leading to an increase in children with CHD presenting for noncardiac surgical procedures. This study aims (1) to describe the trend and perioperative mortality rates in patients with CHD undergoing noncardiac surgical procedures at children's hospitals over the past 5 years and (2) to describe the patient characteristics and the most common type of surgical procedures. The Pediatric Health Information System (PHIS) is an administrative database that contains inpatient, observation, and outpatient surgical data from 52 freestanding children's hospitals. Thirty-nine of the 52 hospitals submitted data on all types of patient encounters for the duration of the study from 2015 to 2019. The total numbers of non-cardiac surgical encounters among patients with history of a CHD diagnosis significantly increased each year from 38,272 in 2015 to 45,993 in 2019 (P < 0.001). Despite the increase in case numbers, there has been a significant decline in mortality rates to the most recent incidence of 1.06% in 2019. Careful patient selection and medical optimization of patients aligned with specific expertise at dedicated children's hospitals may lead to improvement in mortality rate. Future studies comparing the outcomes of patients with cardiac disease based on hospital type and volume as well as type of providers may help determine the future of care including potential need for regionalization of noncardiac care for this vulnerable patient population.

Hot Topics in Safety for Pediatric Anesthesia

Anesthesiology is one of the leading medical specialties in patient safety. Pediatric anesthesiology is inherently higher risk than adult anesthesia due to differences in the physiology in children. In this review, we aimed to describe the highest yield safety topics for pediatric anesthesia and efforts to ameliorate risk. Conclusions: Pediatric anesthesiology has made great strides in patient perioperative safety with initiatives including the creation of a specialty society, quality and safety committees, large multi-institutional research efforts, and quality improvement initiatives. Common pediatric peri-operative events are now monitored with multi-institution and organization collaborative efforts, such as Wake Up Safe.

Anesthesia for Major Surgery in the Neonate

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