Benefits of ultra-fast-track anesthesia for children with congenital heart disease undergoing cardiac surgery

Perioperative Outcomes in Congenital Heart Disease: A Review of Clinical Factors Associated With Prolonged Ventilation and Length of Stay in Four Common CHD Operations

OBJECTIVES

Perioperative management strategies and outcomes for low-risk congenital heart disease (CHD) surgery vary between institutions. To date, no consensus exists on standardized management for pediatric patients undergoing cardiac surgery. This study seeks to benchmark the perioperative management of 4 common CHD lesions and explore clinical factors affecting postoperative outcomes.

DESIGN

A retrospective review of CHD procedures performed between 2015 and 2020.

SETTING

The study was conducted at a single academic tertiary pediatric hospital.

PARTICIPANTS

All patients presenting for repair of ventricular septal defects (VSDs), complete atrioventricular canal defects, tetralogy of Fallot (TOF), and transposition of the great arteries (TGA) were reviewed.

INTERVENTIONS

Demographic and clinical data were collected; clinical outcomes were defined as postoperative length of ventilation (LOV) and hospital length of stay, divided into reference and prolonged course groups analyzed for variables associated with differences in outcomes.

MEASUREMENTS AND MAIN RESULTS

We selected 931 patients for review. Prolonged length of ventilation and length of stay in all cohorts were associated with longer operative, cardiopulmonary bypass, and cross-clamp times; higher intraoperative requirements for inotropic support; more blood transfusions and higher opioid administration; lower pH preoperatively and higher lactic acid postoperatively. Worse outcomes were associated with younger age in VSD, older age in TGA, and lower weight in TOF and TGA. Worse outcomes were also associated with a higher preoperative hematocrit in VSD and TOF and elevated preoperative blood glucose in VSD and TGA.

CONCLUSIONS

A better understanding of clinical factors affecting outcomes may facilitate streamlining perioperative management strategies for pediatric patients undergoing low-risk cardiac surgery.

Analgesic Effect and Sleep Quality of Low-Dose Dexmedetomidine in Cardiac Surgical Patients After Ultrafast-Track Extubation: A Randomized Clinical Trial

OBJECTIVE

To compare the analgesic and sleep quality effects of dexmedetomidine infusion versus placebo in patients undergoing cardiac surgery with ultra-fast track extubation.

DESIGN

The randomized, double-blind clinical trial study.

SETTING

At a single academic center hospital.

PARTICIPANTS

We included patients aged 25 to 65 scheduled for elective cardiac surgery under general anesthesia with cardiopulmonary bypass from October 2021 to December 2022.

INTERVENTION

After immediate extubation in the operating room, the patients who were allocated at first after providing their consent to either the dexmedetomidine group (Dex) or the placebo group (Placebo) received continuous infusion of dexmedetomidine (0.2 μg/kg/h) or saline for 12 hours postoperatively.

MEASUREMENTS AND MAIN RESULTS

The groups' demographic and perioperative variables were not statistically significant. Total morphine consumption in milligrams at 12 and 24 hours after administered study drug, total sleep time in hours by BIS value ≤85, and sleep quality with the Richard-Campbell Sleep Questionnaire were compared. The analysis included 22 Dex and 23 Placebo patients. The consumption of morphine was not statistically different between the Dex and Placebo groups at 12 and 24 hours (p = 0.707 and p = 0.502, respectively). The Dex group had significantly longer sleep time (8.7 h [7.8, 9.5]) than the Placebo group (5.8 h [2.9, 8.5]; p = 0.007). The Dex group also exhibited better sleep quality (7.9 [6.7, 8.7] vs 6.6 [5.2, 8.0]; p = 0.038).

CONCLUSIONS

Sedation with low-dose dexmedetomidine infusion for ultra-fast track extubation following cardiac surgery enhances sleep duration and quality.

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.

Optimization of lung ultrasound in ultrafast-track anesthesia for non-cyanotic congenital heart disease surgery

Objective

We aimed to explore the feasibility of lung ultrasound for perioperative assessment and the optimal effect of lung ultrasound in reducing lung complications during non-cyanotic congenital heart disease (CHD) surgery using ultrafast-track anesthesia.

Methods

Sixty patients were treated at Shenzhen Children's Hospital between 2019 and 2020. Of these, 30 patients in group N had an indication for extubation and ultrafast-track anesthesia after congenital heart surgery; the tracheal catheter was removed, and the patients were sent to the cardiac intensive care unit (CICU) for further monitoring and treatment. Another 30 patients were in group L and also had an indication for extubation and ultrafast-track anesthesia; in addition we compared lung ultrasound score (LUS) before and after surgery, when we found the cases that LUS ≥ 15, for whom targeted optimization treatment would be carried out. The tracheal catheter was removed after LUS <15 days before the patients were sent to the CICU. In all cases, the LUS and PaO2/FiO2 ratios (P/F) of both groups were recorded at the time of anesthesia induction (T0), before extubation (T1), and 5 min (T2), 1 h (T3), and 24 h (T4) after extubation. The incidence of pulmonary complications, LUS, and P/F were compared between the two groups.

Results

There was great consistency between LUS and radiographic findings. Comparing the data of the two groups at T2, T3 and T4, the P/F was higher and the LUS was lower in group L than in group N. The incidence of lung complications in group L (18 cases, 60 %) was lower than that in group N (26 cases, 86.7 %, χ2 = 5.46, P = 0.02); comparing LUS between T0 and T3, LUS decreased in a greater number of cases in group L (15, 50 %) than in group N (7 cases, 23.3 %, χ2 = 4.59, P = 0.032).

Conclusion

Lung ultrasonography can effectively help assess lung conditions. Optimization guided by lung ultrasound in ultrafast track anesthesia can significantly reduce postoperative lung complications.

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).

Feasibility and safety of ultra-fast track anesthesia for totally thoracoscopic closure of ventricular septal defect: A randomized controlled trial

Objective

Ultra-fast channel anesthesia (UFTA) can reduce the dosage of opioid narcotic drugs, allow for a rapid postoperative extubation and reduce the harmful stress response during perioperative period. However, there has been limited information about the application of UFTA during thoracoscopic closure of ventricular septal defect (VSD). The aim of this study was to assess the feasibility and safety of UFTA technique in patients undergoing totally thoracoscopic closure of VSD.

Methods

Seventy-eight patients were randomly divided into study (UFTA) and control (standard general anesthesia) group. Totally thoracoscopic closure of VSD was performed in all patients. Extubation in the study and control group was attempted in the operating room and the intensive care unit, respectively.

Results

All patients in the study group were extubated in the operating room immediately after surgery, but 2 (6.1%) required reintubation. All the control group patients were extubated after a period of mechanical ventilation (3.0 ± 3.7 h vs 0 h in the study group, p = 0.001) in the intensive care unit. The intensive care and hospital stays in the study group were shorter than in the control group (4.3 ± 2.5 vs 13.4 ± 4.4 h, p = 0.003, and 5.8 ± 0.8 vs 6.5 ± 1.2 d, p = 0.047). The total costs for the treatment in the study group was lower than in the control group (5264 ± 514 vs 4662 ± 461 US dollars, p = 0.02).

Conclusions

UFTA and operating room extubation was feasible and safe in the majority of patients following totally thoracoscopic closure of VSD. This technique was associated with a shorter intensive care stay and lower overall costs for the surgical treatment.

Effects of Thoracic Paravertebral Block on Postoperative Analgesia in Infants and Small Children undergoing Ultra-Fast Track Cardiac Anesthesia: A Randomized Controlled Trial

OBJECTIVES

To assess whether a preoperative bilateral thoracic paravertebral block (TPVB) would improve postoperative analgesia in infants and small children undergoing open cardiac surgery in the protocol of an ultra-fast track cardiac anesthesia (UFTCA).

DESIGN

A single-center, prospective, randomized, controlled study.

SETTING

At a tertiary children's medical center.

PARTICIPANTS

A total of 180 children undergoing cardiac surgery, aged 1 month to 3 years.

INTERVENTIONS

Patients are allocated randomly to TPVB and parent- and/or nurse-controlled intravenous analgesia (PNCA) group (Group T) or PNCA group (Group P).

MEASUREMENTS AND MAIN RESULTS

The primary outcome is the postoperative pain scores. The secondary outcome are intraoperative consumption of sufentanil, time to extubation, using of neostigmine, cumulative total and invalid PCA attempts in 24 and 48 hours after surgery, hospitalization characteristics, perioperative blood glucose, postoperative arterial oxygen partial pressure, arterial carbon dioxide partial pressure (PaCO₂) and brain natriuretic peptide (BNP). The postoperative pain scores within 24 hours, intraoperative consumption of sufentanil, total, and invalid PCA attempts in 24 and 48 hours, perioperative blood glucose and BNP on the seventh day in Group T were all significantly lower than those in Group P (p < 0.001). The time to extubation, the use of neostigmine, and PaCO₂ on the sixth hour, postoperatively, were significantly smaller in Group T than those in Group P (p < 0.05). There were no significant differences in the hospitalizations between the 2 groups.

CONCLUSIONS

A combination of bilateral single dose TPVB and PNCA pain management is superior to a PNCA pain management alone in infants and small children undergoing open cardiac surgery and contributes to a rapid recovery with preferable perioperative outcomes in the protocol of UFTCA.

The recovery of upper limb function and postoperative pain in children with lateral humeral condyle fractures were examined retrospectively in relation to the effects of brachial plexus block given in conjunction with general anesthesia

OBJECTIVE

To assess in retrospect the effects of brachial plexus block and general anesthesia on children with lateral humeral condyle fractures in terms of postoperative pain and return of upper limb function.

METHODS

Randomly allocated to either the control group (n = 51) or the study group (n = 55) were children with lateral humeral condyle fractures who were admitted to our hospital between October 2020 and October 2021, depending on the surgical anesthetic technique used. The research group had internal fixation surgery with brachial plexus block in addition to anesthesia on the basis of the control group, whereas both groups of children underwent the procedure with general anesthesia alone. Postoperative pain degree, upper extremity functional recovery, occurrence of adverse reactions, etc. RESULTS: The study group had shorter mean times for surgery, anesthesia, propofol dose, return to consciousness, and extubation than the control group did at every measure of statistical significance. The T2 heart rate (HR) and mean arterial pressure (MAP) were both significantly lower than the pre-anesthesia HR and MAP, and the T1, T2, and T3 HR and MAP were all significantly lower in the study group compared to the control group (P < 0.05). The difference between the SpO2 values at T0 and T3 was not statistically significant (P > 0.05); the VAS scores at 4 h, 12 h, and 48 h after surgery were higher than those at 2 h after surgery, and reached the peak at 4 h after surgery; within 2 h, 4 h, and 12 h of surgery At 48 h, the study group had substantially lower VAS ratings than the control group (P < 0.05). Post-treatment Fugl-Meyer scale scores were considerably higher across the board compared to pre-treatment levels in both groups. When compared to the control group, individuals who participated in the flexion-stretching coordinated exercise and the separation exercise had significantly better ratings. Electrocardiogram, blood pressure, respiratory circulation, and hemodynamic parameters all remained within normal limits during the surgical procedure. The study group had a 9.09% reduced incidence of adverse events compared to the control group. 19.61% (P < 0.05).

CONCLUSION

When used in conjunction with general anesthesia, brachial plexus block can help children with lateral humeral condyle fractures regulate perioperative signs, maintain their hemodynamic level, lessen postoperative pain and unpleasant reactions, and improve the function of their upper limbs. Functional recovery, with high safety and effectiveness.

The Impact of Low Cardiac Output on Propofol Pharmacokinetics across Age Groups-An Investigation Using Physiologically Based Pharmacokinetic Modelling

BACKGROUND

pathophysiological changes such as low cardiac output (LCO) impact pharmacokinetics, but its extent may be different throughout pediatrics compared to adults. Physiologically based pharmacokinetic (PBPK) modelling enables further exploration.

METHODS

A validated propofol model was used to simulate the impact of LCO on propofol clearance across age groups using the PBPK platform, Simcyp^® (version 19). The hepatic and renal extraction ratio of propofol was then determined in all age groups. Subsequently, manual infusion dose explorations were conducted under LCO conditions, targeting a 3 µg/mL (80-125%) propofol concentration range.

RESULTS

Both hepatic and renal extraction ratios increased from neonates, infants, children to adolescents and adults. The relative change in clearance following CO reductions increased with age, with the least impact of LCO in neonates. The predicted concentration remained within the 3 µg/mL (80-125%) range under normal CO and LCO (up to 30%) conditions in all age groups. When CO was reduced by 40-50%, a dose reduction of 15% is warranted in neonates, infants and children, and 25% in adolescents and adults.

CONCLUSIONS

PBPK-driven, the impact of reduced CO on propofol clearance is predicted to be age-dependent, and proportionally greater in adults. Consequently, age group-specific dose reductions for propofol are required in LCO conditions.

Effects of Remifentanil and Sufentanil Anesthesia on Cardiac Function and Serological Parameters in Congenital Heart Surgery

In this study, we have investigated feasibility of remifentanil and sufentanil anesthesia in children with congenital heart disease surgery and its effects on cardiac function and serological parameters. For this purpose, a retrospective study was conducted on 120 children with congenital heart disease who underwent repair of ventricular septum or atrial septum in our hospital, specifically from January 2016 to January 2018, and 60 patients in each group were randomly divided into the control and treatment groups, respectively. The control group was anesthetized with sufentanil, and the treatment group was anesthetized with remifentanil. The heart function, serological indexes, and adverse reactions were observed and compared. We have observed that there was no significant difference in HR levels between these groups (P > 0.05), but SDP and DBP values of the two groups were decreased after anesthetic induction (P < 0.05). ACH, cortisol, and lactic acid in the treatment group were significantly lower than those in the control group, and the difference was statistically significant (P < 0.05). The incidence of bradycardia, nausea and vomiting, hypotension, muscle rigidity, and respiratory depression in the treatment group was 16.67% lower than that in the control group (P < 0.05). Remifentanil has less influence on hemodynamics and a better analgesic effect than fentanyl in inhibiting stress response in congenital heart surgery, which provides reference and basis for children congenital heart surgery.

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.

Clinical effect of dexmedetomidine combined with sufentanil on postoperative analgesia for transthoracic device closure of ventricular septal defects in children with ultrafast track anesthesia

Background

To observe the effect of combining dexmedetomidine with sufentanil on postoperative analgesia in children who underwent transthoracic device closure of ventricular septal defects (VSDs) with ultrafast track anesthesia.

Methods

This was a retrospective study. Eighty-seven children who underwent transthoracic device closure of VSDs were retrospectively analyzed. Patients were divided into three groups based on the different drugs used for postoperative patient-controlled analgesia.

Results

No statistically significant differences in hemodynamic parameters were noted among the three groups after surgery (p > 0.05). The FLACC score in the SD2 group was significantly greater than those in the S groups and SD1 groups after surgery (p < 0.001). The Ramsay score in the S group was significantly lower than that of the SD1 and SD2 groups at 6 h (p < 0.001 and p = 0.003), 12 h (p = 0.002 and p = 0.012), and 24 h (p < 0.001 and p < 0.001) after surgery. The pressing frequency of the analgesic pump 48 h after the operation in the SD2 group was significantly greater than that in the other two groups (p < 0.05). The incidences of respiratory depression, nausea, and vomiting in the S group were significantly greater than those in the SD1 and SD2 groups (p < 0.05).

Conclusion

The combination of 0.04 μg/kg/h dexmedetomidine and 0.04 μg/kg/h sufentanil intravenous analgesia was more effective than the other two analgesic strategies in children who underwent transthoracic device closure of ventricular septal defects (VSDs) with ultrafast track anesthesia.

Evaluation of analgesic and sedative effects of remifentanil-based fast-track anesthesia in children undergoing transthoracic device closure of ventricular septal defects

BACKGROUND

This study aimed to evaluate the analgesic and sedative effects of remifentanil-based fast-track cardiac anesthesia in children undergoing transthoracic device closure of ventricular septal defects (VSDs).

METHODS

A retrospective analysis was conducted on 62 children who underwent transthoracic device closure of VSDs from May 2019 to August 2019. The patients were divided into two groups based on the anesthesia methods: group F was given remifentanil-based fast-track cardiac anesthesia, and Group C was given conventional anesthesia. Patient-related clinical data, postoperative analgesia scores, and sedation scores were collected and analyzed.

RESULTS

There was no significant difference in intraoperative hemodynamic changes, bispectral index values, postoperative analgesia scores, sedation scores, or the incidence of adverse events between the two groups. Compared with Group C, the duration of mechanical ventilation and the length of intensive care unit (ICU) and hospital stay in group F were significantly lower.

CONCLUSION

Remifentanil-based fast-track anesthesia can be safely applied in children undergoing transthoracic device closure of VSDs, with acceptable postoperative analgesia and sedation effects and shorter mechanical ventilation times and ICU and hospital stays compared with conventional anesthesia.

Effect of remifentanil-based fast-track anesthesia on postoperative analgesia and sedation in adult patients undergoing transthoracic device closure of ventricular septal defect

Objective

To investigate the effect of remifentanil-based fast-track anesthesia on analgesia and sedation after transthoracic device closure of ventricular septal defects (VSDs) in adult patients.

Methods

A retrospective analysis was performed on 59 patients aged 21–53 years who underwent transthoracic device closure of VSDs from January 2019 to September 2019. According to the different anesthesia strategies, the patients were divided into the R group (using remifentanil-based anesthesia, n = 33) and the S group (using sufentanil-based anesthesia, n = 26). Patient-related clinical data, postoperative analgesia, and sedation scores were collected and analyzed.

Results

There was no significant difference in age, gender, body weight, and operation time between the group R and the group S (P > 0.05). There was also no significant difference in intraoperative hemodynamic changes, BIS scores, postoperative analgesia, and sedation scores between the two groups (P > 0.05). The duration of mechanical ventilation, the length of ICU stay, and hospital stay in the group R were significantly lower than those in the group S (P < 0.05).

Conclusion

Remifentanil-based fast-track anesthesia is effective for adult patients undergoing transthoracic device closure of VSDs, which may shorten the mechanical ventilation duration, the ICU and hospital stay of patients.

Sugammadex for Fast-Track Surgery in Children Undergoing Cardiac Surgery: A Randomized Controlled Study

OBJECTIVE

The purpose of this study was to evaluate the safety and efficacy of sugammadex for fast-track surgery in children undergoing cardiac surgery.

DESIGN

This was a prospective, randomized, controlled clinical study.

SETTING

University hospital.

PARTICIPANTS

The study comprised 60 children undergoing cardiac surgery.

INTERVENTIONS

The children in group S received sugammadex, 4 mg/kg, for reversal of neuromuscular block, and the children in group N received neostigmine, 30 µg/kg, and atropine, 15 µg/kg.

MEASUREMENTS AND MAIN RESULTS

The recovery time to a train-of-four of 0.9 and extubation time were significantly shorter in the group S than in group N (3.4 ± 1.2 min v 76.2 ± 20.5 min and 31.0 ± 6.4 min v 125.2 ± 21.6 min, respectively; p < 0.01). The heart rate after drug administration was higher in group S than in group N (102.7 ± 9.4 beats/min v 96.9 ± 8.5 beats/min; p = 0.03), whereas the mean arterial pressure after drug administration was similar in both groups. The length of hospital stay was shorter in group S (5.8 ± 1.0 v 6.5 ± 0.9 days; p = 0.03), and the hospitalization expenses were decreased in group S compared with that of group N ($1,036 ± $114 v $1,286 ± $187; p < 0.01). The incidence of postoperative atelectasis was less in group S than in group N (0 v 20%; p = 0.024).

CONCLUSION

Sugammadex can shorten the extubation time and reduce the incidence of postoperative atelectasis, with fewer adverse events, in children undergoing cardiac surgery. It may be beneficial to use sugammadex for fast-track surgery in children undergoing cardiac surgery.