Incidence and Risk Factors for Perioperative Cardiovascular and Respiratory Adverse Events in Pediatric Patients With Congenital Heart Disease Undergoing Noncardiac Procedures

Association of Previous Cardiac Surgery With Postoperative Pneumonia in Infants Undergoing Abdominal Operations: A Cohort Study

BACKGROUND

Children with congenital heart disease (CHD) often require other, non-cardiac related surgical procedures following their initial cardiac surgery. After full or partial CHD repair, they remain at increased risk of postoperative complications. We examined the association of previous cardiac intervention (surgery or percutaneous catheterization intervention) with postoperative pneumonia in infants undergoing abdominal general surgery.

METHODS

A 1:1 propensity score-matched study was conducted using a retrospective cohort of 104,820 infants (<12 months) who had general abdominal surgeries between 2012 and 2022 in U.S. hospitals participating in the National Surgical Quality Improvement Program. The primary outcome was postoperative pneumonia within 30 days. Secondary outcomes included unplanned reintubation, prolonged mechanical ventilation (>72 h), and extended hospital stay (>75th percentile for the study cohort).

RESULTS

Of the study cohort, 9736 infants (9.3%) had previous cardiac interventions. In the propensity score-matched sample, infants with previous cardiac surgery had increased risks of postoperative pneumonia (1.3% vs 0.8%; adjusted relative risk [RRadj]: 1.64, 95% CI: 1.22, 2.18, p = 0.001), unplanned reintubation (57.8% vs 32.6%; RRadj: 1.77, 95% CI: 1.77, 1.85, p < 0.001), prolonged mechanical ventilation (5.0% vs 2.3%; RRadj: 2.14, 95% CI: 1.83, 2.52, p < 0.001), and prolonged hospital stays (61.0% vs 53.8%; RRadj: 1.13, 95% CI: 1.10, 1.17, p < 0.001).

CONCLUSIONS

A history of previous cardiac intervention carries an increased risk of postoperative pneumonia, unplanned tracheal reintubation, prolonged mechanical ventilation, as well as longer hospital stays following intra-abdominal surgery. Clinicians should closely monitor these patients for respiratory complications after surgery.

LEVEL OF EVIDENCE

II.

Development and validation of a score for prediction of postoperative respiratory complications in infants and children (SPORC-C)

BACKGROUND

In infants and children, postoperative respiratory complications are leading causes of perioperative morbidity, mortality, and increased healthcare utilisation. We aimed to develop a novel score for prediction of postoperative respiratory complications in paediatric patients (SPORC for children).

METHODS

We analysed data from paediatric patients (≤12 yr) undergoing surgery in New York and Boston, USA for score development and external validation. The primary outcome was postoperative respiratory complications within 30 days after surgery, defined as respiratory infection, respiratory failure, aspiration pneumonitis, pneumothorax, pleural effusion, bronchospasm, laryngospasm, and reintubation. Data from Children's Hospital at Montefiore were used to create the score by stepwise backwards elimination using multivariate logistic regression. External validation was conducted using a separate cohort of children who underwent surgery at Massachusetts General Hospital for Children.

RESULTS

The study included data from children undergoing 32,187‬ surgical procedures, where 768 (2.4%) children experienced postoperative respiratory complications. The final score consisted of 11 predictors, and showed discriminatory ability in development, internal, and external validation cohorts with areas under the receiver operating characteristic curve of 0.85 (95% confidence interval: 0.83-0.87), 0.84 (0.80-0.87), and 0.83 (0.80-0.86), respectively.

CONCLUSION

SPORC is a novel validated score for predicting the likelihood of postoperative respiratory complications in children that can be used to predict postoperative respiratory complications in infants and children.

Predicting Peri-Operative Cardiorespiratory Adverse Events in Children with Idiopathic Pulmonary Arterial Hypertension Undergoing Cardiac Catheterization Using Echocardiography: A Cohort Study

General anesthesia in children with idiopathic pulmonary arterial hypertension (PAH) carries an increased risk of peri-operative cardiorespiratory complications though risk stratifying individual children pre-operatively remains difficult. We report the incidence and echocardiographic risk factors for adverse events in children with PAH undergoing general anesthesia for cardiac catheterization. Echocardiographic, hemodynamic, and adverse event data from consecutive PAH patients are reported. A multivariable predictive model was developed from echocardiographic variables identified by Bayesian univariable logistic regression. Model performance was reported by area under the curve for receiver operating characteristics (AUCroc) and precision/recall (AUCpr) and a pre-operative scoring system derived (0-100). Ninety-three children underwent 158 cardiac catheterizations with mean age 8.8 ± 4.6 years. Adverse events (n = 42) occurred in 15 patients (16%) during 16 catheterizations (10%) including cardiopulmonary resuscitation (n = 5, 3%), electrocardiographic changes (n = 3, 2%), significant hypotension (n = 2, 1%), stridor (n = 1, 1%), and death (n = 2, 1%). A multivariable model (age, right ventricular dysfunction, and dilatation, pulmonary and tricuspid regurgitation severity, and maximal velocity) was highly predictive of adverse events (AUCroc 0.86, 95% CI 0.75 to 1.00; AUCpr 0.68, 95% CI 0.50 to 0.91; baseline AUCpr 0.10). Pre-operative risk scores were higher in those who had a subsequent adverse event (median 47, IQR 43 to 53) than in those who did not (median 23, IQR 15 to 33). Pre-operative echocardiography informs the risk of peri-operative adverse events and may therefore be useful both for consent and multi-disciplinary care planning.

Perioperative Risk Assessment in Children With Congenital Heart Disease Undergoing Noncardiac Procedures

OBJECTIVES

To risk-stratify children with congenital heart disease undergoing noncardiac surgery or diagnostic procedures for perioperative cardiopulmonary complications using the authors' established institutional guidelines.

DESIGN

A retrospective cohort study.

SETTING

The study was conducted in an academic, tertiary-care children's hospital.

PARTICIPANTS

A total of 1,005 children, from birth to 19 years of age with a diagnosis of congenital heart disease, who underwent a noncardiac surgery or diagnostic procedure from January 2017 to December 2018, were included in the study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The incidence of a severe perioperative complication, defined as a perioperative cardiac arrest or death within 30 days of the procedure, was 1.6%. Age, an emergent surgery/procedure, a preoperative renal abnormality, preoperative mechanical ventilation, and a preoperative pericardial effusion were significant for severe perioperative complications, in the multivariate analysis. The area under the receiver operating characteristic curve for severe complications was 0.936. However, the area under the curve for moderate perioperative complications was 0.679, in which moderate complications were defined as (1) an escalation in anticipated postoperative disposition (from planned disposition), (2) an escalation in postoperative disposition (from preoperative location), (3) an escalation of preoperative airway support, (4) an administration of any intraoperative vasoactive medication/infusion, (5) a noncardiac surgery reoperation within 30 days of the procedure (if related to the primary procedure or change in physiology), or (6) unplanned readmission with 24 hours of the procedure.

CONCLUSIONS

A robust model for severe perioperative complications was developed within the authors' institutional clinical guidelines, identifying 5 predictors for perioperative cardiac arrest or death. The usual markers of critical illness were not found to be predictive of a moderate perioperative complication, regardless of the level of anesthesiologist training, suggesting that many of these children with congenital heart disease undergoing noncardiac procedures can be treated by a general pediatric anesthesiologist rather than a pediatric cardiac anesthesiologist within an institution that has or can establish clinical guidelines for these children.

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.

[Perioperative Complications in Pediatric Anesthesia]

Perioperative complications are more frequent in younger children, especially under the age of 3 years and in infants. The anatomy and physiology of children cause more respiratory adverse events compared to adult patients. Respiratory adverse events account for 60% of all anesthetic complications. Main risk factors for respiratory adverse events are upper respiratory tract infections. Keeping the airway management as noninvasive as possible helps prevent major complications.Perioperative hypotension can compromise cerebral oxygenation, especially when hypocapnia and anemia are present. Congenital heart disease leads to a higher cardiovascular adverse event rate and should be diagnosed preoperatively whenever possible.Venous and arterial cannulation is more challenging in children and complications are more frequent even for experienced practitioners. Ultrasound is an essential tool for peripheral venous access as well as for central venous catheterization.Medication errors are more common in pediatric than in adult patients. Charts and electronic calculation of dosing can increase safety of prescriptions. Standardized storage of medications at all workplaces, avoiding look-alike medications in the same compartment and storing high-risk medications separately help prevent substitution errors.Emergence delirium and postoperative nausea and vomiting (PONV) are the most frequent postoperative adverse events. For diagnosing emergence delirium, the PAED scale is a helpful tool. Prevention of emergence delirium by pharmacological and general measures plays a key role for patient outcome. Routine prophylaxis of PONV above the age of 3 years is recommended.Frequency and severity of perioperative adverse events in pediatric anesthesia can be reduced by using algorithms and defined processes to allow for structured actions. Efficient communication and organization are mainstays for utilizing all medical options to reduce the risk of complications.

Perioperative Respiratory Adverse Events Among Pediatric Surgical Patients in University Hospitals in Northwest Ethiopia; A Prospective Observational Study

INTRODUCTION

Perioperative respiratory adverse events (PRAEs) are frequent among pediatrics surgical patients and are accountable for 3/4^th of perioperative critical incidents and 1/3^rd of cardiac arrests.

OBJECTIVE

Assess the prevalence and factors associated with PRAEs among pediatric surgical patients in University Hospitals in Northwest Ethiopia, 2020.

METHODOLOGY

After ethical approval obtained prospective observational study was conducted among 210 pediatric surgical patients. Perioperative respiratory adverse events were defined as the occurrence of any episode of single/combination of coughing, breath holding, hypoxemia, laryngospasm and bronchospasm. Bivariate and multivariate binary logistic regression analyses were performed and variables with p < 0.05 at 95% confidence interval were considered as statistically significant.

RESULTS

The prevalence of PRAEs was 26.2% (CI: 20.5-30.9%). A total of 129 episodes of PRAEs were occurred and of them, 89 (69.0%) were occurred in the postoperative period. Desaturation was the predominant adverse event which was observed 61 (47.3%) times. Age <1 year (AOR: 3.6, CI: 1.3-10.0), ASA ≥ 3 (AOR: 5.2, CI: 1.9-22.9), upper respiratory tract infections (URTIs) (AOR: 7.6, CI: 1.9-30.2), secretions in the upper airway (AOR: 4.8, CI: 1.4-15.9) and airway related surgery (AOR: 6.0, CI: 1.5-24.1) were significantly associated with PRAEs.

CONCLUSIONS

Prevalence of PRAEs was high among pediatric surgical patients; the postoperative period was the most critical time for the occurrence of PRAEs and desaturation was the commonest PRAE. Age <1 year, URTIs (recent or active), secretions in the upper airways, ASA ≥ 3 and airway related surgery were significantly associated with PRAEs. Clinicians should perform effective risk assessment, preoperative optimization and preparation for the management of PRAEs.

Anesthesiologist-related factors associated with risk-adjusted pediatric anesthesia-related cardiopulmonary arrest: a retrospective two level analysis

BACKGROUND

Pediatric anesthesia-related cardiac arrest is an uncommon but catastrophic adverse event which has been, in a previous study, associated with anesthesiologist-related factors such as number of days per year providing pediatric anesthesia. We aimed to replicate this and assess other anesthesiologist-related risk factors for anesthesia-related cardiac arrest after adjusting for known underlying risk factors present in the case mix.

METHODS

We analyzed a large retrospectively collected patient cohort of anesthetics administered from 2006 to 2016 to children at a tertiary pediatric hospital. Three reviewers independently reviewed cardiac arrests and categorized whether they appeared to be related to anesthesia care. Anesthesiologist-related factors including academic rank, experience, recent case mix, and days per year delivering pediatric anesthesia were assessed for association with anesthesia-related cardiac arrest after adjustment for underlying case mix.

RESULTS

Cardiac arrest occurred in 240 of 109 775 anesthetics (incidence 22/10 000 anesthetics); 82 (7/10 000 anesthetics) were classified as anesthesia-related. In univariable analyses, anesthesia-related cardiac arrest was associated with age, (infants ≤180 days, p < .001) American Society of Anesthesiologists Physical Status, (>2, p < .001) American Society of Anesthesiologists Physical Status Emergency, (p = .0035) cardiac surgery, (p < .001) operating room location, (p = .0066) and resident/fellow supervision, (p = .009) but none of the anesthesiologist factors. Even after adjusting for age and American Society of Anesthesiologist Status, none of the anesthesiologist factors were associated with anesthesia-related cardiac arrest.

CONCLUSIONS

Case mix explained all associations between higher risk of pediatric anesthesia-related cardiac arrest and anesthesiologist-related variables at our institution.

Adult survivors of moderate and great complexity congenital heart disease undergoing general surgery procedures: How do they fare?

BACKGROUND

Patients with complex congenital heart disease (CHD) are now commonly surviving well into adulthood. We describe the clinical characteristics and outcomes for a cohort of adult patients with moderate and great complexity CHD undergoing general surgery procedures.

METHODS

The electronic records of two tertiary centers were queried to identify adult patients with moderate and great complexity CHD who underwent a general surgery procedure between 2007 and 2017.

RESULTS

118 adult patients were included in the analysis. The mean age was 36 ± 17 years and 49.2% were male. The most common cardiac diagnoses were pulmonary valve anomaly (24.6%), tetralogy of Fallot (18.6%), coarctation of the aorta (15.3%) and common/single ventricle (10.2%). The most common general surgery procedures performed were cholecystectomy (23.7%), herniorrhaphy (23.7%) and colorectal resection (9.3%). In-hospital mortality and morbidity were 2.5% and 11.9%, respectively.

CONCLUSION

Adults survivors of moderate and great complexity CHD undergoing common general surgery procedures in this study experienced excellent in-hospital outcomes.

Who are at high risk of mortality and morbidity among children with congenital heart disease undergoing noncardiac surgery?

With advances in the development of surgical and medical treatments for congenital heart disease (CHD), the population of children and adults with CHD is growing. This population requires multiple surgical and diagnostic imaging procedures. Therefore, general anesthesia is inevitable. In many studies, it has been reported that children with CHD have increased anesthesia risks when undergoing noncardiac surgeries compared to children without CHD. The highest risk group included patients with functional single ventricle, suprasystemic pulmonary hypertension, left ventricular outflow obstruction, and cardiomyopathy. In this review, we provide an overview of perioperative risks in children with CHD undergoing noncardiac surgeries and anesthetic considerations in patients classified as having the highest risk.

Neutrophil and T Cell Functions in Patients with Congenital Heart Diseases: A Review

With a significant improvement of survival in patients with congenital heart disease, we expect to encounter these patients more frequently for various medical issues. Clinical studies indicate that infection can pose higher risk in this cohort than general population. Here, with the hypothesis that more severe infection-related complications in CHD cohort may be linked to their inadequate immune response, we reviewed the current literature regarding neutrophil and T cell functions in patients with congenital heart diseases.

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.

Airway Abnormalities in Patients With Congenital Heart Disease: Incidence and Associated Factors

OBJECTIVES

Airway abnormalities complicate the perioperative course of patients with congenital heart disease (CHD), leading to significant morbidity and mortality. The literature describing airway abnormalities in those patients is scarce. This study aimed to determine the incidence of airway abnormalities in CHD patients and identify associated factors, genetic syndromes, and cardiac diagnoses.

DESIGN

Retrospective study conducted after institutional review board approval.

SETTING

Tertiary children's hospital.

PARTICIPANTS

Patients presenting for cardiac diagnostic, interventional, or surgical procedures from 2012 to 2018. A total of 9,495 encounters were reviewed.

EXCLUSION CRITERIA

age >18 years. Methods/Interventions: Age, weight, sex, intubation technique, number of intubation attempts, and difficult intubation (DI) were recorded. Using the International Classification of Diseases, Ninth and Tenth Revisions codes, genetic syndromes, acquired and congenital airway abnormalities, and cardiac diagnoses were identified. Multivariate generalized estimating equations modeling was used to identify independent predictors of airway abnormalities.

RESULTS

A total of 4,797 patients, with 8,657 encounters were included. The median age was 1.3 years (interquartile range [IQR]: 0.2-6.0) and weight was 9.2 kg (IQR: 4.3-19.2), and 55% were male. A total of 16.7% had at least 1 genetic syndrome; 8.5% had congenital airway abnormalities and 9.7% acquired. Incidence of DI was 1.1%. The most common syndromes were Down, 22q11.2 microdeletion, and CHARGE. The most frequent congenital airway abnormalities were laryngomalacia and bronchomalacia, and the most frequent acquired were partial and total vocal cord paralysis.

CONCLUSION

The likelihood of a coexistent airway abnormality should be considered in premature CHD patients, weight <10 kg, and in those with specific cardiac lesions and a concomitant genetic syndrome. Preoperative identification of patients at high risk of airway abnormalities is useful in planning their perioperative airway management.

Recognizing Risks and Optimizing Perioperative Care to Reduce Respiratory Complications in the Pediatric Patient

There have been significant advancements in the safe delivery of anesthesia as well as improvements in surgical technique; however, the perioperative period can still be high risk for the pediatric patient. Perioperative respiratory complications (PRCs) are some of the most common critical events that can occur in pediatric surgical patients and they can lead to increased length of hospitalization, worsened patient outcomes, and higher hospital and postoperative costs. It is important to determine the various factors that put pediatric patients at increased risk of PRCs. This will allow for more detailed and accurate informed consent, optimized perioperative management strategy, improved allocation of clinical resources, and, hopefully, better patient experience. There are only a few risk prediction models/scoring tools developed for and validated in the pediatric patient population, but they have been useful in helping identify the key factors associated with a high likelihood of developing PRCs. Some of these factors are patient factors, while others are procedure-related factors. Some of these factors may be modified such that the patient’s clinical status is optimized preoperatively to decrease the risk of PRCs occurring perioperatively. Fore knowledge of the factors that are not able to be modified can help guide allocation of perioperative clinical resources such that the negative impact of these non-modifiable factors is buffered. Additional training in pediatric anesthesia or focused expertise in pediatric airway management, vascular access and management of massive hemorrhage should be considered for the perioperative management of the less than 3 age group. Intraoperative ventilation strategy plays a key role in determining respiratory outcomes for both adult and pediatric surgical patients. Key components of lung protective mechanical ventilation strategy such as low tidal volume and moderate PEEP used in the management of acute respiratory distress syndrome (ARDS) in pediatric intensive care units have been adopted in pediatric operating rooms. Adequate post-operative analgesia that balances pain control with appropriate mental status and respiratory drive is important in reducing PRCs.

Anesthesia in Pediatric Patients With Congenital Heart Disease Undergoing Noncardiac Surgery: Defining the Risk

The incidence of moderate to severe congenital heart disease (CHD) in the United States is estimated to be 6 per 1,000 live-born, full-term infants. Recent advances in pediatric cardiology, surgery, and critical care have improved significantly the survival rates of patients with CHD leading to an increase in prevalence in both children and adults. Children with CHD significant enough to require cardiac surgery frequently also undergo noncardiac surgical procedures. With this increased demand for procedures that require anesthesia, all anesthesiologists, and more specifically, pediatric anesthesiologists will encounter patients with repaired or unrepaired CHD and other cardiac diseases in their practice. They often are faced with the question, "Is this patient too high risk for anesthesia?" The objective of this literature review is to provide a greater understanding of patients at high risk and to quantify the risk for patients, their families, and clinicians. In addition, specific high-risk lesions (single ventricle, Williams-Beuren syndrome, pulmonary hypertension, cardiomyopathies, and ventricular assist devices) are described.

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

Database analysis has indicated that perioperative cardiac arrest occurs with increased frequency in children with congenital heart disease. Several case series and large datasets from ACS NSQIP have identified subgroups at the highest risk. Consistently, patients with single ventricle physiology (especially prior to cavopulmonary anastomosis), severe/supra-systemic pulmonary hypertension, complex lesions, and cardiomyopathy with significantly reduced ventricular function have been shown to be at increased risk for adverse events. Based on these results, algorithms for assessing risk have been proposed. How hospitals and health care systems apply these guidelines to provide safe care for these challenging patient groups requires the application of modern quality improvement techniques. Each institution should develop a system which reflects local expertise and resources.