Erector spinae plane blocks for opioid-sparing multimodal pain management after pediatric cardiac surgery

OBJECTIVE

Peripheral regional anesthesia is proposed to enhance recovery. We sought to evaluate the efficacy of bilateral continuous erector spinae plane blocks (B-ESpB) for postoperative analgesia and the impact on recovery in children undergoing cardiac surgery.

METHODS

Patients aged 2 through 17 years undergoing cardiac surgery in the enhanced recovery after cardiac surgery program were prospectively enrolled to receive B-ESpB at the end of the procedure, with continuous infusions via catheters postoperatively. Participants wore an activity monitor until discharge. B-ESpB patients were retrospectively matched with control patients in the enhanced recovery after cardiac surgery program. Outcomes of the matched clusters were compared using exact conditional logistic regression and generalized linear modeling.

RESULTS

Forty patients receiving B-ESpB were matched to 78 controls. There were no major complications from the B-ESpB or infusions, and operating room time was longer by a median of 31 minutes. While blocks were infusing, patients with B-ESpB received fewer opioids in oral morphine equivalents than controls at 24 hours (0.60 ± 0.06 vs 0.78 ± 0.04 mg/kg; P = .02) and 48 hours (1.13 ± 0.08 vs 1.35 ± 0.06 mg/kg; P = .04), respectively. Both groups had low median pain scores per 12-hour period. There was no difference in early mobilization, length of stay, or complications.

CONCLUSIONS

B-ESpBs are safe in children undergoing cardiac surgery. When performed as part of a multimodal pain strategy in an enhanced recovery after cardiac surgery program, pediatric patients with B-ESpB experience good pain control and require fewer opioids in the first 48 hours.

Predictors and outcomes of perioperative cardiac arrest in children undergoing noncardiac surgery

Background

Perioperative cardiac arrest continues to occur. This study aims to identify risk factors for perioperative cardiac arrest in children presenting for noncardiac surgery and characterise its outcomes.

Methods

Using the National Surgical Quality Improvement Program (NSQIP) Pediatric Database 2019 and 2020, 261 276 patients were included. Patients ≥18 yr and cardiac surgical procedures were excluded. Exploratory multivariable analysis was performed to identify independent predictors of perioperative cardiac arrest and associated outcomes.

Results

The overall rate of cardiac arrest was 0.1%, with an intraoperative rate of 0.05% and 48-h postoperative rate of 0.06%. Significant risk factors for perioperative cardiac arrest included age <12 months (adjusted odds ratios [aOR] 3.07, P<0.001), American Society of Anesthesiology Physical Status classification (ASA-PS 3 aOR=2.57, P<0.001; ASA-PS 4 aOR=5.27, P<0.001; ASA-PS 5 aOR=13.1, P<0.001), admission through the emergency room (aOR 1.7, P=0.003), inpatient (aOR 2.19, P=0.008), major and severe cardiac disease (aOR 1.58, P=0.008), impaired cognitive status (aOR 1.54, P=0.009), and longer anaesthesia duration (aOR 1.1 per 30 min, P<0.001). Perioperative cardiac arrest was significantly associated with longer hospital length of stay, reoperation, differences in discharge destination, and 30-day mortality. In addition, patients experiencing postoperative cardiac arrest had a significantly higher rate of in-hospital and 30-day mortality than those experiencing intraoperative cardiac arrest.

Conclusions

The incidence of cardiac arrest in this study is higher than previously reported. This may be related to selection bias and the rigorous data collection required by NSQIP. Lower 30-day mortality after intraoperative cardiac arrest could be related to prompt recognition and rapid initiation of intraoperative resuscitation. Identification of perioperative risk factors for cardiac arrest is crucial to improve the safety and quality of patient care.

Anaesthesia for non-cardiac surgery in children and young adults with Fontan physiology

INTRODUCTION

Patients with Fontan physiology require non-cardiac surgery. Our objectives were to characterise perioperative outcomes of patients with Fontan physiology undergoing non-cardiac surgery and to identify characteristics which predict discharge on the same day.

MATERIALS AND METHOD

Children and young adults with Fontan physiology who underwent a non-cardiac surgery or an imaging study under anaesthesia between 2013 and 2019 at a single-centre academic children's hospital were reviewed in a retrospective observational study. Continuous variables were compared using the Wilcoxon rank sum test, and categorical variables were analysed using the Chi-square test or Fisher's exact test. Multivariable logistic regression analysis results are presented by adjusted odds ratios with 95% confidence intervals and p values.

RESULTS

182 patients underwent 344 non-cardiac procedures with anaesthesia. The median age was 11 years (IQR 5.2-18), 56.4% were male. General anaesthesia was administered in 289 (84%). 125 patients (36.3%) were discharged on the same day. On multivariable analysis, independent predictors that reduced the odds of same-day discharge included the chronic condition index (OR 0.91 per additional chronic condition, 95% CI 0.76-0.98, p = 0.022), undergoing a major surgical procedure (OR 0.17, 95% CI 0.05-0.64, p = 0.009), the use of intraoperative inotropes (OR 0.48, 95% CI 0.25-0.94, p = 0.031), and preoperative admission (OR = 0.24, 95% CI: 0.1-0.57, p = 0.001).

DISCUSSION

In a contemporary cohort of paediatric and young adults with Fontan physiology, 36.3% were able to be discharged on the same day of their non-cardiac procedure. Well selected patients with Fontan physiology can undergo anaesthesia without complications and be discharged same day.

Predictors of anesthesia ready time: Analysis and benchmark data

Objective

Patients undergoing congenital cardiac surgery require induction of anesthesia. Our objective was to identify the median anesthesia ready time and the predictors of this time.

Methods

By using the Society of Thoracic Surgeons Congenital Heart Surgery Database, we identified patients who underwent cardiopulmonary bypass procedures from 2017 to 2021. Univariate and multivariable regression modeling to predict the anesthesia ready time was performed using mixed-effects linear regression.

Results

After exclusion of outliers, 44,418 cases were analyzed. The median anesthesia ready time was 51 minutes (interquartile range, 38-66). On multivariable analysis, independent predictors of a longer anesthesia ready time included decreasing weight (0.3 min/10 kg, 95% CI, 0.1-0.6; P = .011), prematurity (1.5 minutes, 95% CI, 0.8-2.2; P < .001), and presence of chromosomal abnormality (3.4 minutes, 95% CI, 1.5-5.2; P < .001). An increase in the duration in anesthesia ready time was seen with increasing Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery mortality category with an additional 7.8 minutes (95% CI, 5.2-10.4; P < .001) for a Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery 5 procedure compared with Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery 1. Emergency versus elective case designation was associated with an anesthesia ready time reduction of 3.6 minutes (95% CI, 1.1-6.1; P = .005), and an afternoon case start was associated with an anesthesia ready time reduction of 4.2 minutes (95% CI, 2.8-5.6; P < .001). The presence of an anesthesia trainee increased the anesthesia ready time by 3.8 minutes (95% CI, 2.6-5.0; P < .001). The presence of an airway in situ decreased the anesthesia ready time by 3.6 minutes (95% CI, 1.6-5.5; P < .001), whereas an in situ arterial line decreased the anesthesia ready time by 7.4 minutes (95% CI, 4.6-10.2; P < .001). Placement of a central venous line increased the anesthesia ready time by 8.5 minutes (95% CI, 5.9-11.1; P < .001).

Conclusions

The median anesthesia ready time was 51 minutes. For patients with characteristics associated with prolonged anesthesia ready time, consideration should be given to allocation of additional anesthesia staffing to improve efficiency.

A Review of Biventricular Repair for the Congenital Cardiac Anesthesiologist

The management of children with a borderline ventricle has been debated for many years. The pursuit of a biventricular repair in these children aims to avoid the long-term sequelae of single ventricle palliation. There is a lack of anesthesia literature relating to the care of this complex heterogenous patient population. Anesthesiologists caring for these patients should have an understanding on the many different forms of physiology and the impact on provision of anesthesia and hemodynamic parameters, the goals of biventricular staging and completion as well as the pre-operative, intra-operative, and post-operative considerations relating to this high-risk group of patients.

A reciprocal translocation involving Aspergillus nidulans snxAHrb1/Gbp2 and gyfA uncovers a new regulator of the G2-M transition and reveals a role in transcriptional repression for the setBSet2 histone H3-lysine-36 methyltransferase

Aspergillus nidulans snxA, an ortholog of Saccharomyces cerevisiae Hrb1/Gbp2 messenger RNA shuttle proteins, is-in contrast to budding yeast-involved in cell cycle regulation, in which snxA1 and snxA2 mutations as well as a snxA deletion specifically suppress the heat sensitivity of mutations in regulators of the CDK1 mitotic induction pathway. snxA mutations are strongly cold sensitive, and at permissive temperature snxA mRNA and protein expression are strongly repressed. Initial attempts to identify the causative snxA mutations revealed no defects in the SNXA protein. Here, we show that snxA1/A2 mutations resulted from an identical chromosome I-II reciprocal translocation with breakpoints in the snxA first intron and the fourth exon of a GYF-domain gene, gyfA. Surprisingly, a gyfA deletion and a reconstructed gyfA translocation allele suppressed the heat sensitivity of CDK1 pathway mutants in a snxA+ background, demonstrating that 2 unrelated genes, snxA and gyfA, act through the CDK1-CyclinB axis to restrain the G2-M transition, and for the first time identifying a role in G2-M regulation for a GYF-domain protein. To better understand snxA1/A2-reduced expression, we generated suppressors of snxA cold sensitivity in 2 genes: (1) loss of the abundant nucleolar protein Nsr1/nucleolin bypassed the requirement for snxA and (2) loss of the Set2 histone H3 lysine36 (H3K36) methyltransferase or a nonmethylatable histone H3K36L mutant rescued hypomorphic snxA mutants by restoring full transcriptional proficiency, indicating that methylation of H3K36 acts normally to repress snxA transcription. These observations are in line with known Set2 functions in preventing excessive and cryptic transcription of active genes.

Race and Outcomes in Patients with Congenital Cardiac Disease in an Enhanced Recovery Program

OBJECTIVES

Disparities in perioperative outcomes exist. In addition to patient and socioeconomic factors, racial disparities in outcome measures may be related to issues at the provider and institutional levels. Recognizing a potential role of standardized care in mitigating provider bias, this study aims to compare the perioperative sedation and pain management and consequent outcomes in Enhanced Recovery After Surgery (ERAS) cardiac patients of different races undergoing congenital heart surgery at a single quaternary children's hospital.

DESIGN

A retrospective study.

SETTING

A single quaternary pediatric hospital.

PARTICIPANTS

Patients, infants to adults, undergoing elective congenital cardiac surgery and enrolled in the ERAS protocol from October 2018 to December 2020.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the patients, 872 were reviewed and 606 with race information were analyzed. There was no significant difference in intraoperative and postoperative oral morphine equivalent, perioperative sedatives, and regional blockade in Asian or African American patients when compared to White patients. Postoperative pain scores and outcomes among African American and Asian races were also not statistically different when compared to White patients.

CONCLUSIONS

Racial disparity in perioperative management and outcomes in patients with standardized ERAS protocols does not exist at the authors' institution. Future comparative studies of ERAS noncardiac patients may provide additional information on the role of standardization in reducing implicit bias.

The Practice of Pediatric Cardiac Anesthesiology in the United States

BACKGROUND

With advances in surgical and catheter-based interventions and technologies in patients with congenital heart disease (CHD), the practice of pediatric cardiac anesthesiology has evolved in parallel with pediatric cardiac surgery and pediatric cardiology as a distinct subspecialty over the past 80 years. To date, there has not been an analysis of the distribution of pediatric cardiac anesthesiologists relative to cardiac and noncardiac procedures in the pediatric population. The primary aim is to report the results of a survey and its subsequent analysis to describe the distribution of pediatric cardiac anesthesiologists relative to pediatric cardiac procedures that include surgical interventions, cardiac catheterization procedures, imaging studies (echocardiography, magnetic resonance, computed tomography, positron emission tomography), and noncardiac procedures.

METHODS

A survey developed in Research Electronic Data Capture (REDcap) was sent to the identifiable division chiefs/cardiac directors of 113 pediatric cardiac anesthesia programs in the United States. Data regarding cardiac surgical patients and procedures were collected from the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHD).

RESULTS

This analysis reveals that only 38% (117 of 307) of pediatric cardiac anesthesiologists caring for patients with CHD pursued additional training in pediatric cardiac anesthesiology, while 44% (136 of 307) have gained experience during their clinical practice. Other providers have pursued different training pathways such as adult cardiac anesthesiology or pediatric critical care. Based on this survey, pediatric cardiac anesthesiologists devote 35% (interquartile range [IQR], 20%-50%) of clinical time to the care of patients in the cardiac operating room, 25% (20%-35%) of time to the care of patients in the cardiac catheterization laboratory, 10% (5%-10%) to patient care in imaging locations, and 15% covering general pediatric, adult, or cardiac patients undergoing noncardiac procedures. Attempts to actively recruit pediatric cardiac anesthesiologists were reported by 49.2% (29 of 59) of the institutions surveyed. Impending retirement of staff was anticipated in 17% (10 of 59) of the institutions, while loss of staff to relocation was anticipated in 3.4% (2 of 59) of institutions. Thirty-seven percent of institutions reported that they anticipated no immediate changes in current staffing levels.

CONCLUSIONS

The majority of currently practicing pediatric cardiac anesthesiologists have not completed a fellowship training in the subspecialty. There is, and will continue to be, a need for subspecialty training to meet increasing demand for services especially with increase survival of this patient population and to replace retiring members of the workforce.

Anesthesia in Children With Pulmonary Hypertension: Clinically Significant Serious Adverse Events Associated With Cardiac Catheterization and Noncardiac Procedures

OBJECTIVES

To determine the incidence of clinically significant serious adverse events in a contemporary population of pediatric patients with pulmonary hypertension who require anesthesia and identify factors associated with adverse outcomes.

DESIGN

A retrospective, cross-sectional study.

SETTING

A single-center quaternary-care freestanding children's hospital in the northeastern United States.

PARTICIPANTS

Pediatric patients with pulmonary hypertension based on hemodynamic criteria on cardiac catheterization during a 3-year period from 2015 to 2018.

INTERVENTIONS

Anesthesia care for cardiac catheterization, noncardiac surgery, and diagnostic imaging.

MEASUREMENTS AND MAIN RESULTS

Two hundred forty-nine children underwent 862 procedures, 592 for cardiac catheterization and 278 for noncardiac surgery and diagnostic imaging. The median age was 1.6 years, and the weight was 9.5 lbs. On index catheterization, median pulmonary artery pressure was 36 mmHg, and the pulmonary vascular resistance was 5.1 indexed Wood units. Ten percent of anesthetics were performed with a natural airway, and 80% used volatile anesthetics. Serious adverse events occurred in 26% of procedures (confidence interval [CI], 22%-30%). The rate of periprocedural cardiac arrest was 8 per 1,000 anesthetic administrations. In multivariate analysis, younger age (adjusted odds ratio [aOR], 1.4 per year; CI, 1.1-1.9; p = 0.01), location in the catheterization laboratory (aOR, 5.1; CI, 1.7-16; p = 0.004), and longer procedure duration (aOR, 1.3 per 30 minutes; CI, 1.1-1.4; p = 0.001) were associated with serious adverse events. Patients with a tracheostomy in place were less likely to experience an adverse event (aOR, 0.1; CI, 0.04-0.5; p = 0.001). The primary anesthetic technique was not associated with adverse events. Interventional cardiac catheterization was associated with an increased incidence of adverse events compared with diagnostic catheterization (42% v 21%; OR, 2.23; CI, 1.5-3.3; p < 0.001).

CONCLUSIONS

Serious adverse events were common in this cohort. Careful planning to minimize anesthesia time in young children with pulmonary hypertension should be undertaken, and these factors considered in designing risk mitigation strategies.

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.

Dosing of Opioid Medications During and After Pediatric Cardiac Surgery for Children With Down Syndrome

OBJECTIVE

To determine whether children with Down syndrome (DS) receive higher doses of opioid medications compared with children without DS for repair of complete atrioventricular canal (CAVC).

DESIGN

A retrospective chart review of children with and without DS who underwent primary repair of CAVC. The exclusion criteria included unbalanced CAVC and patients undergoing biventricular staging procedures. The primary outcome was oral morphine equivalents (OME) received in the first 24 hours after surgery. The secondary outcomes included intraoperative OME, OME at 48 and 72 hours, nonopioid analgesic and sedative medications received, pain scores, time to extubation, and length of stay.

SETTING

A pediatric academic medical center in the United States.

PARTICIPANTS

One hundred thirty-one patients with DS and 24 without, all <two years old, who underwent a CAVC repair.

INTERVENTIONS

Not applicable.

MEASUREMENTS AND MAIN RESULTS

Patients with DS were older than patients without DS (median 96.3 days [interquartile range {IQR} 70.7-128.2] v 75.9 days [IQR 49.8-107.3], p = 0.033) but otherwise not statistically different in the baseline characteristics. There was no difference in OME received in the first 24 hours postoperatively between groups (3.01 mg/kg [IQR 1.23-5.43] v 3.57 mg/kg [IQR 1.54-7.06], p = 0.202). OME at 48 and 72 hours was lower in the DS group compared with the control group. Similar amounts of opioid and non-opioid analgesics and sedatives were otherwise given to both groups of patients. Median pain scores did not differ between groups.

CONCLUSIONS

These results suggested that patients with DS undergoing CAVC repair do not have increased opioid requirements compared with a similar control group.

Relationship of Preoperative Thyroid Dysfunction to Clinical Outcomes in Pediatric Cardiac Surgery

CONTEXT

Thyroid function may be assessed in children before cardiac surgery because of concerns that hypothyroidism or thyrotoxicosis might adversely affect cardiac function perioperatively. However, the relationship between preoperative thyroid dysfunction and surgical outcomes is unknown.

OBJECTIVE

Determine the relationship between preoperative thyroid dysfunction and outcomes of pediatric cardiac surgery.

METHODS

Retrospective cohort study (January 2005 to July 2019).

SETTING

Academic pediatric hospital.

PATIENTS

All patients <19 years old who underwent cardiac surgery with cardiopulmonary bypass and had thyrotropin (TSH) measured within 14 days preoperatively. Exclusion criteria included neonates (≤30 days), preoperative extracorporeal life support, salvage operations, or transplantation procedures.

MAIN OUTCOME MEASURES

Subjects were stratified by preoperative TSH concentration (mIU/L): low (<0.5), normal (0.5-5), mildly high (5.01-10), or moderately high (>10). Outcomes were compared among subjects with normal TSH (control) and each group with abnormal TSH concentrations. The primary outcome was 30-day mortality. Secondary outcomes included time to extubation, intensive care unit and hospital length of stay, and operative complications.

RESULTS

Among 592 patients analyzed, preoperative TSH was low in 15 (2.5%), normal in 347 (58.6%), mildly high in 177 (29.9%), and moderately high in 53 (9.0%). Free thyroxine was measured in 77.4% of patients and was low in 0 to 4.4% of subjects, with no differences among TSH groups. Thirty-day mortality was similar among TSH groups. There were no differences in any secondary outcome between patients with abnormal TSH and patients with normal TSH.

CONCLUSION

Preoperative mild to moderate subclinical hypothyroidism was not associated with adverse postoperative outcomes in children undergoing cardiopulmonary bypass procedures.

The Use of Regional Catheters in Children Undergoing Repair of Aortic Coarctation

OBJECTIVE

The objective was to assess the effectiveness and safety of peripheral regional anesthesia in congenital cardiac surgical patients undergoing thoracotomy for aortic coarctation.

DESIGN

A retrospective chart review of pediatric patients (<18 years) who underwent surgical repair of congenital heart diseases via thoracotomy between September 2013 and July 2018 was done. Among patients who underwent coarctation repair, a propensity score was used to match patients who received a regional catheter (C) versus traditional medical treatment only (M).

SETTING

A single center children's hospital.

PARTICIPANTS

The median age was 172 days (IQR 64-1315) in group C and 176 days (IQR 71-1146) in group M (SMD = 0.07). The median weight was 6.8 kg (IQR 4.8-13.6) in group C and 7.7 kg (4.6-17.4) in group M (SMD = 0.003).

MEASUREMENTS AND MAIN RESULT

Outcomes assessed were postoperative hospital length of stay, median pain scores in the first 24 and 48 hours, and total morphine equivalent use in the first 24 and 48 hours. Complications related to the catheters were reviewed. The median oral morphine equivalent dose administered in the first 24 hours was lower in group C than group M (0.8 mg/kg, IQR 0.5-1.1 vs. 1.4 mg/kg, IQR 0.9-1.7, p = 0.019). There were no major complications related to the catheters, including hematoma.

CONCLUSIONS

Peripheral regional catheters may be used to reduce opioid requirements in patients after CoA repair. Due to the low risk of these catheters, they should be considered as part of a pain management strategy for pediatric patients undergoing thoracotomy and should be incorporated into strategies to improve outcomes.

Bilateral Erector Spinae Blocks Decrease Perioperative Opioid Use After Pediatric Cardiac Surgery

OBJECTIVE

The present study examined the feasibility and efficacy of continuous bilateral erector spinae blocks for post-sternotomy pain in pediatric cardiac surgery.

DESIGN

Prospective cohort study; patients were retrospectively matched 1:2 to control patients. Conditional logistic regression was used to compare dichotomous outcomes, and generalized linear models were used for continuous measures, both accounting for clusters.

SETTING

Quaternary children's hospital, university setting.

PARTICIPANTS

The study comprised 10 children ages five-to-17 years undergoing elective cardiac surgery requiring cardiopulmonary bypass.

INTERVENTIONS

Ultrasound-guided bilateral erector spinae blocks at the conclusion of the cardiac surgical procedure, with postoperative infusion of ropivacaine until chest tube removal. Postoperative management otherwise followed standardized guidelines.

MEASUREMENTS AND MAIN RESULTS

Patient characteristics were similar in the two groups. The median time to completion of the bilateral blocks was 16.0 minutes (interquartile range [IQR] 14.8-19.3), and no major adverse events were identified. Pain scores were low in both groups. Postoperative opioid use at 48 hours, rendered as oral morphine equivalents, was significantly reduced in the patients receiving the blocks. Cluster-adjusted squared-root-transformed means ± standard error were 0.89 ± 0.06 mg/kg for patients receiving the blocks versus 1.05 ± 0.06 mg/kg for control patients (p = 0.04; raw medians 0.81 [IQR 0.41-1.04] v 1.10 [IQR 0.78-1.35] mg/kg, respectively). There were no differences in recovery metrics, length of stay, or complications.

CONCLUSIONS

Bilateral erector spinae blocks were associated with a reduction in opioid use in the first 48 hours after pediatric cardiac surgery compared with a matched cohort from the enhanced recovery program. Larger studies are needed to determine whether this can result in an improvement in recovery and patient satisfaction.

Superior Cavopulmonary Connection: Its Physiology, Limitations, and Anesthetic Implications

The superior cavopulmonary connection (SCPC) or "bidirectional Glenn" is an integral, intermediate stage in palliation of single ventricle patients to the Fontan procedure. The procedure, normally performed at 3 to 6 months of life, increases effective pulmonary blood flow and reduces the ventricular volume load in patients with single ventricle (parallel circulation) physiology. While the SCPC, with or without additional sources of pulmonary blood flow, cannot be considered a long-term palliation strategy, there are a subset of patients who require SCPC palliation for a longer interval than the typical patient. In this article, we will review the physiology of SCPC, the consequences of prolonged SCPC palliation, and modes of failure. We will also discuss strategies to augment pulmonary blood flow in the presence of an SCPC. The anesthetic considerations in SCPC patients will also be discussed, as these patients may present for noncardiac surgery from infancy to adulthood.

Comparative analysis of the ileal bacterial composition of post-weaned pigs fed different high-quality protein sources

To further understand the contribution of feedstuff ingredients to gut health in swine, gut histology and intestinal bacterial profiles associated with the use of two high-quality protein sources, microbially enhanced soybean meal (MSBM) and Menhaden fishmeal (FM) were assessed. Weaned pigs were fed one of three experimental diets: (1) basic diet containing corn and soybean meal (Negative Control (NEG)), (2) basic diet + fishmeal (FM; Positive Control (POS)) and (3) basic diet + MSBM (MSBM). Phase I POS and MSBM diets (d 0 to d 7 post-wean) included FM or MSBM at 7.5%, while Phase II POS and MSBM diets (d 8 to d 21) included FM or MSBM at 5.0%. Gastrointestinal tissue and ileal digesta were collected from euthanised pigs at d 21 (eight pigs/diet) to assess gut histology and intestinal bacterial profiles, respectively. Data were analysed using Proc Mixed in SAS, with pig as the experimental unit and pig (treatment) as the random effect. Histological and immunohistochemical analyses of stomach and small intestinal tissue using haematoxylin-eosin, Periodic Acid Schiff/Alcian blue and inflammatory cell staining did not reveal detectable differences in host response to dietary treatment. Ileal bacterial composition profiles were obtained from next-generation sequencing of PCR generated amplicons targeting the V1 to V3 regions of the 16S rRNA gene. Lactobacillus-affiliated sequences were found to be the most highly represented across treatments, with an average relative abundance of 64.0%, 59.9% and 41.80% in samples from pigs fed the NEG, POS and MSBM diets, respectively. Accordingly, the three most abundant Operational Taxonomic Units (OTUs) were affiliated to Lactobacillus, showing a distinct abundance pattern relative to dietary treatment. One OTU (SD_Ssd_00001), most closely related to Lactobacillus amylovorus, was found to be more abundant in NEG and POS samples compared to MSBM (23.5% and 35.0% v. 9.2%). Another OTU (SD_Ssd_00002), closely related to Lactobacillus johnsonii, was more highly represented in POS and MSBM samples compared to NEG (14.0% and 15.8% v. 0.1%). Finally, OTU Sd_Ssd-00011, highest sequence identity to Lactobacillus delbrueckii, was found in highest abundance in ileal samples from MSBM-fed pigs (1.9% and 3.3% v. 11.3, in POS, NEG and MSBM, respectively). There was no effect of protein source on bacterial taxa to the genus level or diversity based on principal component analysis. Dietary protein source may provide opportunity to enhance presence of specific members of Lactobacillus genus that are associated with immune-modulating properties without altering overall intestinal bacterial diversity.

Incidence and predictors of postoperative nausea and vomiting in children undergoing electrophysiology ablation procedures

BACKGROUND

Postoperative nausea and vomiting remains a significant concern for patients undergoing general anesthesia for percutaneous radiofrequency catheter ablation and cryoablation for tachyarrhythmias.

AIM

Our objective was to examine the incidence and risk factors for nausea and vomiting in the recovery room.

METHODS

Children aged > 2 and ≤ 18 years who underwent general anesthesia for a percutaneous radiofrequency catheter ablation or cryoablation for a tachyarrhythmia between January 1, 2013, and January 1, 2016, were retrospectively reviewed. Outcomes included postoperative nausea, vomiting, and a composite of postoperative nausea and vomiting in the recovery room.

RESULTS

We identified 611 patients with a mean age of 13.3 ± 3.9 years, 54.5% male, and a mean length of anesthesia was 3.9 ± 1.0 hours. Vomiting or retching in the postanesthesia care unit occurred in 7.4% of patients and nausea in an additional 12.4%. A composite of nausea and vomiting occurred in 95 patients (15.5%). On multivariable analysis, a subhypnotic propofol infusion (OR 0.45, 95% CI 0.23-0.88, P = .019) and shorter anesthetic duration (OR 0.81 per 30 minutes, 95% CI 0.70-0.94, P = .006) were independently associated with less vomiting in the recovery room. A history of PONV (OR 2.24, 95% CI 1.24-4.05, P = .007) was independently associated with a composite of nausea and vomiting in the recovery room.

CONCLUSIONS

A shorter anesthetic time and a subhypnotic propofol infusion were predictive of a lower rate of postoperative vomiting in patients undergoing general anesthesia for electrophysiologic ablation procedures.

Newer nerve blocks in pediatric surgery

PURPOSE OF THE REVIEW

The purpose of this manuscript is to provide a brief discussion of the current direction in pediatric regional anesthesia, highlighting both newer nerve blocks and techniques and traditional nerve blocks.

RECENT FINDINGS

The number of nerve blocks performed in pediatric patients continues to increase. This growth is likely related in part to the recent focus on perioperative multimodal analgesia, in addition to growing data demonstrating safety and efficacy in this patient population. Multiple studies by the Pediatric Regional Anesthesia Network (PRAN) and the French-Language Society of Pediatric Anesthesiologists (ADARPEF) have demonstrated lack of major complications and general overall safety with pediatric nerve blocks. The growing prevalence of ultrasound-guided regional anesthesia has not only improved the safety profile, but also increased the efficacy of both peripheral nerve blocks and perineural catheters.

SUMMARY

As the push for multimodal analgesia increases and the breadth of pediatric regional anesthesia continues to expand, further large prospective studies will be needed to demonstrate continued efficacy and overall safety.

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.

Never Say Never: The Use of Nitric Oxide in Patients With Obstructed Pulmonary Veins: A Case Report

Pulmonary vein stenosis (PVS) is a progressive disease with pulmonary hypertension (PH) as a major cause of morbidity and mortality. Traditional management of PH with inhaled nitric oxide (iNO) is typically avoided in PVS patients because, while iNO may reduce pulmonary vascular resistance, PH persists as pulmonary blood flow increases in the presence of a downstream resistive lesion. We report 3 cases with primary PVS and PH in which iNO was used to successfully decrease mean pulmonary artery pressures with clinical improvement. Based on this experience, we suggest that iNO can be used to treat PH in select patients with PVS.

Williams Syndrome and Anesthesia for Non-cardiac Surgery: High Risk Can Be Mitigated with Appropriate Planning

Patients with Williams syndrome are considered at high risk for anesthesia-related adverse events. At our institution, all William syndrome patients undergoing cardiac surgical, cardiac catheterization/interventional procedures, and cardiac imaging studies are cared for by cardiac anesthesiologists. All William syndrome patients undergoing non-cardiac surgical, interventional, or imaging studies are cared for by main operating room pediatric anesthesiologists with consultative input from a cardiac anesthesiologist. We reviewed our experience with 75 patients undergoing 202 separate anesthetics for 95 non-cardiac procedures and 107 cardiac procedures from 2012 to 2016. The mean age was 7.5 ± 7.0 years and the mean weight was 22.3 ± 17.0 kg. One hundred and eighty-seven patients had a general anesthetic (92.6%). Medications used included etomidate in 26.2%, propofol in 37.6%, isoflurane in 47.5%, and sevoflurane in 68.3%. Vasopressors and inotropes were required including calcium (22.8%), dopamine (10.4%), norepinephrine (17.3%), phenylephrine (35.1%), vasopressin (0.5%), and ephedrine (5.4%). The median length of stay after anesthesia was 2.8 days (range 0-32). No adverse events occurred in 89.6% of anesthetics. There were two cases of cardiac arrest, one of which required extracorporeal life support for resuscitation. Of the non-cardiac surgical procedures, 95.7% did not have a cardiovascular adverse event. Patients with Williams syndrome are at high risk for anesthesia, especially when undergoing cardiac procedures. The risk can be mitigated with appropriate planning and adherence to the hemodynamic goals for non-cardiac surgical procedures.

Recombinant Factor VIIa Is Associated With Increased Thrombotic Complications in Pediatric Cardiac Surgery Patients

BACKGROUND

Recombinant factor VIIa (rFVIIa) is routinely used as an off-label hemostatic agent in children undergoing cardiac surgery. Despite evidence that rFVIIa use is associated with an increased incidence of thrombotic complications in adult cardiac surgery, the safety of rFVIIa as a rescue hemostatic agent in the pediatric cardiac surgical population is less definitively delineated. In this retrospective study, we used propensity score matching to compare the incidence of thrombotic complications between children treated with rFVIIa and their matched controls.

METHODS

We retrospectively reviewed medical records and pharmacy data from all neonates and children who underwent congenital cardiac surgery between May 1, 2011, and October 31, 2013, at Boston Children's Hospital, and identified those who received rFVIIa during the perioperative period. Using existing knowledge, we chose 10 factors associated with bleeding after cardiac surgery to be used in our propensity score: age, sex, body weight, neonates, prematurity, previous sternotomy, cardiopulmonary bypass time, deep hypothermic circulatory arrest time, aortic cross-clamp time, and the operative surgeon. We then used propensity-matched analysis to match children treated with rFVIIa with 2 controls. The primary outcome was thrombotic complications. Secondary outcomes included reexploration for bleeding, length of cardiac intensive care unit stay, length of hospital stay, and 30-day mortality.

RESULTS

One hundred forty-nine patients received perioperative rFVIIa during the study period. Propensity matching yielded 143 rFVIIa patients matched to 2 control patients each (n = 286). Three control patients were found to have received rFVIIa during the perioperative course and were removed from the analysis, for a total of 283 control patients. The administration of rFVIIa was associated with an increased incidence of thrombotic complications (20% vs 8%; odds ratio [OR]: 3.9 [95% confidence interval {CI}: 2.6-5.9], P < .001). Administration of rFVIIa was associated with a prolonged median length of cardiac intensive care unit stay (8 days [interquartile range {IQR}: 4-24] vs 5 days [IQR: 2-10], P < .001) and prolonged length of hospital stay (20 [IQR: 9-44] vs 11 days [IQR: 7-23], P < .001). No difference in reexploration for bleeding (rFVII = 14% vs controls = 9%; OR: 1.7 [95% CI, 0.92-3.1], P = .12) or 30-day mortality was observed (8% vs 6%; OR 1.3 [95% CI, 0.60-2.89], P = .51).

CONCLUSIONS

This retrospective analysis confirmed that perioperative administration of rFVIIa is associated with an increased incidence of postoperative thrombotic complications in neonates and children undergoing cardiac surgery, without increase in 30-day mortality. In conclusion, rFVIIa should be used with extreme caution in pediatric patients undergoing cardiac surgery.

Evaluation of microbially enhanced soybean meal as an alternative to fishmeal in weaned pig diets

An experimental, microbially enhanced soybean product (MEPRO) was evaluated as a replacement for fishmeal (FM). Assessment of feedstuffs should include estimation of digestibility as well as pig performance and in combination with dietary additives. Digestibility values determined in growing pigs may not apply to nursery pigs; thus, standardized ileal digestibility (SID) of amino acids (AA) in MEPRO and FM were determined using 30±1.6 kg BW ileal-cannulated barrows (n=6) and 9.8±1.2 kg BW barrows (n=37; serial slaughter). Experimental diets included MEPRO, FM and nitrogen free where FM and MEPRO were included as the sole protein source. The SID of AAs was 3% to 5% lower in MEPRO than FM when fed to 30 kg pigs. The SID of arginine and methionine was greater (P<0.05) in MEPRO than FM when fed to 10 kg pigs. The SID of AAs was 12% to 20% lower in FM when fed to 10 v. 30 kg pigs but only 3% to 9% lower in MEPRO. A total of 336 barrows and gilts were weaned at 21 days of age (initial BW=6.1±0.8 kg) and used in a performance trial. Pens of pigs were assigned to one of the six experimental diets (8 pens/diet in two blocks). Treatment diets were fed in Phase I (7 days) and Phase II (14 days) with all pigs fed a common Phase III diet (14 days). Experimental diets included (1) negative control (NEG) containing corn, soybean meal and whey, (2) NEG+acidifier, (3) NEG+FM (POS), (4) POS+acidifier (POS A+), (5) NEG+MEPRO (MEPRO) and (6) MEPRO+acidifier. The FM and MEPRO were included at 7.5% and 5.0% in Phase I and II diets, respectively. Diets were formulated to meet the standard nutrient requirements for weaned pigs. Pig BW and feed disappearance was measured weekly and fecal scores were measured daily for the first 14 days post-weaning as an indicator of post-weaning diarrhea syndrome (PWDS). Performance (BW, daily gain, feed intake and gain : feed) was not significantly different among treatments. Treatment for PWDS occurred on different days in each block. Analysis of fecal score was completed separately by block. Pigs fed the NEG diets had higher (P=0.02) fecal scores than pigs fed the POS diets on days 2 and 3 (block 1) and higher (P<0.05) than pigs fed MEPRO or POS diets and diets with dietary acidifier on days 6 and 3 (block 2). The MEPRO holds promise as an alternative to FM in nursery pig diets.

Patients with single ventricle physiology undergoing noncardiac surgery are at high risk for adverse events

BACKGROUND

Patients with single ventricle physiology are at increased anesthetic risk when undergoing noncardiac surgery.

OBJECTIVE

To review the outcomes of anesthetics for patients with single ventricle physiology undergoing noncardiac surgery.

METHODS

This study is a retrospective chart review of all patients who underwent a palliative procedure for single ventricle physiology between January 1, 2007 and January 31, 2014. Anesthetic and surgical records were reviewed for noncardiac operations that required sedation or general anesthesia. Any noncardiac operation occurring prior to completion of a bidirectional Glenn procedure was included. Diagnostic procedures, including cardiac catheterization, insertion of permanent pacemaker, and procedures performed in the ICU, were excluded.

RESULTS

During the review period, 417 patients with single ventricle physiology had initial palliation. Of these, 70 patients (16.7%) underwent 102 anesthetics for 121 noncardiac procedures. The noncardiac procedures included line insertion (n = 23); minor surgical procedures such as percutaneous endoscopic gastrostomy or airway surgery (n = 38); or major surgical procedures including intra-abdominal and thoracic operations (n = 41). These interventions occurred on median day 60 of life (1-233 days). The procedures occurred most commonly in the operating room (n = 79, 77.5%). Patients' median weight was 3.4 kg (2.4-15 kg) at time of noncardiac intervention. In 102 anesthetics, 26 patients had an endotracheal tube or tracheostomy in situ, 57 patients underwent endotracheal intubation, and 19 patients had a natural or mask airway. An intravenous induction was performed in 77 anesthetics, an inhalational induction in 17, and a combination technique in 8. The median total anesthetic time was 126 min (14-594 min). In 22 anesthetics (21.6%), patients were on inotropic support upon arrival; an additional 24 patients required inotropic support (23.5%), of which dopamine was the most common medication. There were 10 intraoperative adverse events (9.8%) including: arrhythmias requiring treatment (n = 4), conversion from sedation to a general anesthetic (n = 2), difficult airway (n = 1), inadvertent extubation with desaturation and bradycardia (n = 1), hypotension and desaturation (n = 1), and cardiac arrest (n = 1). Postoperative events (<48 h) included ST segment changes requiring cardiac catheterization (n = 1), and cardiorespiratory arrest (n = 1). Age, size, gender, type of cardiac palliation, patient location, procedure location, and type of procedure were not associated with adverse outcome. After 62 anesthetics (60.8%), patients went postoperatively to the cardiac ICU. There were no deaths at 48 h.

CONCLUSION

We observed no mortality during or after noncardiac surgery in a high-risk subgroup of palliated cardiac patients with single ventricle physiology. However, 11.8% of patients had an adverse event associated with their anesthetic.

Coarctation of the aorta: lifelong surveillance is mandatory following surgical repair

OBJECTIVES

The objective of our study was to review the long-term outcomes of patients undergoing surgical repair of aortic coarctation.

BACKGROUND

Surgical repair of aortic coarctation has been performed at the Mayo Clinic, Rochester, Minnesota, for over 60 years.

METHODS

Between 1946 and 2005, 819 patients with isolated coarctation of the aorta underwent primary operative repair. Medical records were reviewed and questionnaires mailed to the patients.

RESULTS

Mean age at repair was 17.2 ± 13.6 years. The majority (83%) had pre-operative hypertension. Operations included simple and extended end-to-end anastomosis (n = 632), patch angioplasty (n = 72), interposition grafting (n = 49), bypass grafting (n = 30), and subclavian flap or "other" (n = 35). Overall early mortality (<30 days) was 2.4%. In the previous 30 years (n = 225), there were no operative deaths. Mean follow-up was 17.4 ± 13.9 years, with a maximum of 59.3 years. Actuarial survival rates were 93.3%, 86.4%, and 73.5% at 10, 20, and 30 years, respectively. When compared to an age- and sex-matched population, long-term survival was decreased (p < 0.001). Older age at repair (>20 yrs) and pre-operative hypertension were associated with decreased survival (p < 0.001). Patients age <9 years age at repair had significantly less hypertension at 5 to 15 years of follow-up (p < 0.001). Rates of freedom from re-intervention on the descending aorta were 96.7%, 92.2%, and 89.4% at 10, 20, and 30 years, respectively. Younger age at time of repair (p < 0.001) and an end-to-end anastomosis technique (p < 0.001) were independently associated with lower rates of re-intervention on the descending aorta.

CONCLUSIONS

Primary repair of isolated coarctation of the aorta was performed with a low rate of mortality. However, long-term survival was reduced compared with that in an age- and sex-matched population, and many patients required further reoperation. These findings emphasize that patients with aortic coarctation need early recognition and intervention, as well as lifelong informed follow-up.

Phenotypic variation and associated predation risk of juvenile common carp Cyprinus carpio

Juvenile common carp Cyprinus carpio were collected from 10 lakes with variable predator abundance over 4 months to evaluate if morphological defences increased with increasing predation risk. Cyprinus carpio dorsal and pectoral spines were longer and body depth was deeper when predators were more abundant, with differences becoming more pronounced from July to October. To determine if morphological plasticity successfully reduced predation risk, prey selection of largemouth bass Micropterus salmoides foraging on deep- and shallow-bodied C. carpio was evaluated in open and vegetated environments. Predators typically selected deep- over shallow-bodied phenotypes in open habitats and neutrally selected both phenotypes in vegetated habitats. When exposed to predators, shallow-bodied C. carpio phenotypes shoaled in open habitat, whereas deep-bodied phenotypes occupied vegetation. Although deep-bodied phenotypes required additional handling time, shallow-bodied phenotypes were more difficult to capture. These results suggest that juvenile C. carpio gradually develop deeper bodies and larger spines as predation risk increases. Morphological defences made it more difficult for predators to consume these prey but resulted in higher vulnerability to predation in some instances.

Polygamain, a new microtubule depolymerizing agent that occupies a unique pharmacophore in the colchicine site

Bioassay-guided fractionation was used to isolate the lignan polygamain as the microtubule-active constituent in the crude extract of the Mountain torchwood, Amyris madrensis. Similar to the effects of the crude plant extract, polygamain caused dose-dependent loss of cellular microtubules and the formation of aberrant mitotic spindles that led to G(2)/M arrest. Polygamain has potent antiproliferative activities against a wide range of cancer cell lines, with an average IC(50) of 52.7 nM. Clonogenic studies indicate that polygamain effectively inhibits PC-3 colony formation and has excellent cellular persistence after washout. In addition, polygamain is able to circumvent two clinically relevant mechanisms of drug resistance, the expression of P-glycoprotein and the βIII isotype of tubulin. Studies with purified tubulin show that polygamain inhibits the rate and extent of purified tubulin assembly and displaces colchicine, indicating a direct interaction of polygamain within the colchicine binding site on tubulin. Polygamain has structural similarities to podophyllotoxin, and molecular modeling simulations were conducted to identify the potential orientations of these compounds within the colchicine binding site. These studies suggest that the benzodioxole group of polygamain occupies space similar to the trimethoxyphenyl group of podophyllotoxin but with distinct interactions within the hydrophobic pocket. Our results identify polygamain as a new microtubule destabilizer that seems to occupy a unique pharmacophore within the colchicine site of tubulin. This new pharmacophore will be used to design new colchicine site compounds that might provide advantages over the current agents.

Treatment of primary nocturnal enuresis in children: a review

Primary nocturnal enuresis is a common childhood disorder. Treatment approaches bridge the psychological and medical fields. A substantial body of literature addresses the various ways of treating enuresis, from pharmaceuticals to behavioural interventions. The medical and psychological literatures have proceeded relatively independently from one another and there has been little interconnection between the US and international literatures, resulting in a lack of discourse and integration among researchers investigating treatment outcomes for enuresis. This review examined the evidence base for treatments of primary nocturnal enuresis in children. Psychological, pharmaceutical and multi-component interventions are discussed. This review sought to provide an integrated interdisciplinary and international perspective on treatment efficacy for nocturnal enuresis by expressly gathering publications from psychological and medical fields, as well as US and international sources. The literature supported the urine alarm as the most effective intervention for nocturnal enuresis and demonstrated the benefit of combining the urine alarm with other components, both behavioural and pharmaceutical. In particular, recent literature showed that the urine alarm, when used in conjunction with antidiuretic medication (i.e. desmopressin), leads to more dry nights earlier in the conditioning process. Disparities between the different literatures were discussed.

Late outcomes of reintervention on the descending aorta after repair of aortic coarctation

BACKGROUND

After repair of aortic coarctation, patients may develop restenosis, aneurysms, and pseudoaneurysms at the site of prior repair. We assessed the outcomes of late reintervention on the descending aorta after aortic coarctation repair.

METHODS AND RESULTS

From March 1954 to July 2008, 130 patients had operations or endovascular procedures on the descending aorta after previous coarctation repair. We excluded patients who had complex left-sided cardiac lesions or interrupted aortic arch. Mean age at reintervention was 32±24 years and 28% were female. The interval between coarctation repair and reintervention was 17±13 years. Seventy-four percent of patients had hypertension. Reasons for reintervention were restenosis (n=122 [94%]), aneurysm (n=4 [3%]), and pseudoaneurysm (n=4 [3%]). Ninety-five patients (73%) underwent operative procedures including an extra-anatomic conduit (n=41), patch repair (n=32), interposition graft (n=14), end-end anastomosis (n=6), and subclavian flap (n=2). Thirty-five patients underwent endovascular treatment (balloon dilatation, n=22 or stenting, n=13). There was no early mortality. In the surgical group, 5 patients required early reoperation for bleeding and 5 patients had early vocal cord paralysis. One patient in the endovascular group had aortic rupture at the time of intervention requiring urgent operation. Survival was 97% at 10 years. At 5 years, freedom from a second repeat procedure on the descending aorta was 96% in the surgical group and 72% in the endovascular group (P<0.001). Five years after reintervention, fewer patients required treatment for hypertension (57% versus 74%, P<0.001) and a median of 1 antihypertensive medication was prescribed compared with a median of 2 medications preintervention.

CONCLUSIONS

Operative and endovascular management of recoarctation can be performed safely with good late outcomes.

Cell Density and Growth Phase as Factors in the Resistance of a Biofilm of Pseudomonas aeruginosa (ATCC 27853) to Iodine

Previous studies have shown that biofilms exhibit enhanced resistance to iodine. Investigations were conducted to determine the relative importance of growth phase versus cell density on biofilm resistance of Pseudomonas aeruginosa (ATCC 27853) to iodine. Cell density is a contributing factor to resistance, whereas growth to the stationary phase is not sufficient to achieve resistance.

A pilot study of electronic cardiovascular operative notes: qualitative assessment and challenges in implementation

BACKGROUND

Our objectives are to describe the contents of cardiovascular surgical operative notes and to develop and test a standards-based structured electronic operative note that might be used for secondary purposes.

STUDY DESIGN

Operative notes were selected for patients who underwent primary, isolated coronary artery bypass grafting (n = 33); aortic valve replacement (n = 33); reoperative coronary artery bypass grafting (n = 11); or aortic valve replacement (n = 11). The content was qualitatively assessed and categorized into 3 sections, ie, technical/procedural, anatomic/physiologic description, and judgment/opinion. An electronic operative note was developed using a standards-based approach to categorize the type of operation.

RESULTS

Average length +/- SD of the operative note was 495 +/- 186 words (range 243 to 1,267 words). The procedural category made up a mean proportion of 73% +/- 12% (range 32% to 95%). The descriptive category was the second largest category in the operative note; mean percentage 22% +/- 8% (range 5% to 43%). The dictation of the judgment portion made up 6% +/- 6% (range 0% to 25%) of the operative note. In the pilot electronic note system, 5 surgeons entered 23 procedures performed on 18 patients (14% of eligible patients). Seventeen (74%) procedures entered by surgeons were in complete agreement with the data for the Society of Thoracic Surgeons database collected by professional abstractors.

CONCLUSIONS

Freeform dictation of cardiovascular notes varied by individual surgeon style and case complexity. Up to 25% of the operative note was dedicated to judgment/opinion, which would be difficult to recreate in a structured data-entry format. An electronic system for entering procedural details can improve efficiency for secondary purposes of data collection but must be carefully implemented to avoid loss of important information.

The adult with congenital heart disease: medical and surgical considerations for management

PURPOSE OF REVIEW

The purpose of the present review is to outline some of the challenges of surgical and medical management in the adult with congenital heart disease (CHD).

RECENT FINDINGS

The number of adult patients with CHD continues to grow. These patients require specialized care and there are few cardiologists and surgeons, as well as other subspecialists (e.g., anesthesia, hepatology, nephrology, etc.) with training who are comfortable in the management of this patient population. When operations on adults with CHD are performed by surgeons trained in congenital cardiac surgery, mortality rates and hospital costs are significantly lower than when performed by adult cardiac surgeons. Reoperations are frequent; peripheral vascular access may be compromised and sternal reentry is more likely to result in cardiac injury. End organ dysfunction, particularly liver and kidney, is not uncommon, further complicating perioperative care. Finally, adults with CHD may have complex psychosocial issues. A comprehensive multidisciplinary team approach can best address all of these issues.

SUMMARY

Adults with CHDs present difficult challenges in the preoperative, intraoperative, and postoperative setting. Regional centers of excellence with congenitally-trained cardiac surgeons, cardiologists, and other medical subspecialists are required to optimize outcome.

Operative strategies for pulmonary artery occlusion secondary to mediastinal fibrosis

BACKGROUND

Fibrosing mediastinitis is a rare disease characterized by an excessive fibrotic reaction in the mediastinum, which may entrap mediastinal structures including the pulmonary arteries. Our objectives were to assess the surgical strategies and outcomes of repair of pulmonary artery occlusion attributable to mediastinal fibrosis.

METHODS

With approval from the Mayo Clinic Institutional Review Board, we identified all patients with fibrosing mediastinitis who underwent an operation for relief of pulmonary artery obstruction between 1980 and 2008. Perioperative data were collected using medical records and late follow-up surveys.

RESULTS

Operative procedures to bypass or reconstruct an obstructed pulmonary artery were performed in 5 patients. Patients' median age was 40 years (range, 27 to 51 years), and all patients were symptomatic and had right ventricular hypertension. In 3 patients, a double-outlet right ventricle was constructed using a valved conduit (porcine valved conduit, n = 1; aortic homograft, n = 2) from the right ventricle to the right pulmonary artery. Two patients required complete reconstruction of the pulmonary artery confluence using a pulmonary homograft in 1 patient and a hybrid technique of autologous pericardial reconstruction and intraoperative stenting in another patient. All patients had a reduction in right ventricular pressures after operation. One patient died perioperatively owing to respiratory failure; the remaining 4 patients were alive at a median follow-up of 7.4 years (range, 0.5 to 14.7 years). One patient required late balloon dilatation of the conduit and distal pulmonary arteries 10 years after initial operation, but the remaining conduits were widely patent at late follow-up. Late functional improvement was limited owing to other complications from mediastinal fibrosis or other comorbidities.

CONCLUSIONS

Treatment of pulmonary artery occlusion attributable to mediastinal fibrosis can be challenging. Successful operative strategies include both creation of a double-outlet right ventricle and complete reconstruction of the pulmonary artery confluence. Hybrid techniques of both conduit placement and stenting should also be considered for patients with occluded pulmonary arteries.

Parity violation constraints using cosmic microwave background polarization spectra from 2006 and 2007 observations by the QUaD polarimeter

We constrain parity-violating interactions to the surface of last scattering using spectra from the QUaD experiment's second and third seasons of observations by searching for a possible systematic rotation of the polarization directions of cosmic microwave background photons. We measure the rotation angle due to such a possible "cosmological birefringence" to be 0.55 degrees +/-0.82 degrees (random) +/-0.5 degrees (systematic) using QUaD's 100 and 150 GHz temperature-curl and gradient-curl spectra over the spectra over the multipole range 200<l<2000, consistent with null, and constrain Lorentz-violating interactions to <2 x 10;{-43} GeV (68% confidence limit). This is the best constraint to date on electrodynamic parity violation on cosmological scales.

Results of mitral valve annuloplasty with a standard-sized posterior band: is measuring important?

OBJECTIVE

This study was undertaken to determine hemodynamic and clinical outcomes of annuloplasty with a standard-sized (63 mm) posterior band in adult patients undergoing mitral valve repair for degenerative valve disease.

METHODS

We studied 511 patients who underwent isolated mitral valve repair for degenerative disease with a 63-mm posterior band used for annuloplasty. Operations were performed between 1994 and 2001, and average follow-up was 4.8 +/- 3.1 years. Echocardiographic data were reviewed, with specific focus on the relationship between patient size and residual mitral regurgitation and gradient.

RESULTS

Mean age at the time of operation was 59.3 +/- 13.5 years, and 72% were male. Body mass index was 25.8 +/- 4.1 kg/m(2), and body surface area was 1.97 +/- 0.24 m(2). Preoperative mean ejection fraction was 64% +/- 7%, and 96% of patients had severe mitral regurgitation on preoperative echocardiography. The 30-day mortality was 0.8%. At hospital discharge, the mean gradient was 4.7 +/- 3.1 mm Hg. Body surface area, body mass index, and weight were not associated with postoperative gradients or residual regurgitation at discharge. At last follow-up, 89% of patients had no or mild regurgitation, and the mean ejection fraction was 58% +/- 9%. At 5 years, survival was 95% and cumulative risk of reoperation was 3%.

CONCLUSION

A standard-sized (unmeasured) posterior annuloplasty band provided excellent intermediate results with good durability. There were neither excess gradients in larger patients nor excess regurgitation in smaller patients. Measured annuloplasty is unnecessary for most adults undergoing mitral valve repair.

Comparison of the outcome of porcine bioprosthetic versus mechanical prosthetic replacement of the tricuspid valve in the Ebstein anomaly

Our objective was to determine the relative merits of using a bioprosthetic porcine valve (BPV) versus a mechanical valve (MechV) when tricuspid valve (TV) replacement is required in patients with Ebstein anomaly. From 1972 to 2006, 333 patients received a BPV and 45 received a MechV. Patient records were reviewed, vital status ascertained, and all patients not known to be deceased were mailed a medical questionnaire or contacted by telephone. Early mortality was not statistically higher for patients who had a MechV (11%) than for those who had a BPV (5%) inserted in the TV position (p = 0.173). The only independent preoperative predictor of operative mortality was moderate to severe left ventricular dysfunction (odds ratio 3.1, p = 0.03); 20-year survival was better in patients who had a BPV (75%) than for those who had a MechV (43%, p = 0.003). On multivariate analysis, after adjusting for ablation of accessory pathways, sinus rhythm at dismissal, and concomitant repair of pulmonary valve stenosis, a BPV remained a predictor of late survival (hazard ratio 0.42, p = 0.004). Survival free of reoperation on the TV at 20 years postoperatively was similar for patients who had a MechV (49%) compared with those who had a BPV (42%) inserted (p = 0.941). A greater percentage of patients who had a MechV reported endocarditis (12% vs 2%), bleeding requiring hospitalization (6% vs 3%), and thrombosis (12% vs 6%); however, none of these differences were statistically significant. In conclusion, a BPV in the tricuspid position was an independent predictor of improved survival. This may be related to the higher incidence of bleeding and thrombotic complications in the patients with MechVs or may be related to differences between the 2 groups. A BPV may offer superior late survival when compared with a MechV when TV replacement is required in patients with Ebstein anomaly, but patient selection must be individualized.

Effect of operation for Ebstein anomaly on left ventricular function

Our objective was to examine the outcomes of patients with left ventricular (LV) dysfunction who underwent operation for Ebstein anomaly. From April 1, 1972 to January 1, 2006, 539 patients with Ebstein anomaly underwent operation at Mayo Clinic. LV function was determined by echocardiography. Of the 495 patients with preoperative echocardiographic assessment of LV function, 50 had moderate or severe LV systolic dysfunction. In patients with LV dysfunction, the tricuspid valve (TV) was repaired in 12 patients and replaced in 36 patients; 1 patient had a 1.5 ventricle repair, and 1 patient had cardiac transplantation. There were 5 early deaths (10%). LV function improved in all but 4 patients after operation. In no patient did LV function worsen after operation. The 1-, 5-, and 10-year survival was 86%, 77%, and 67%, respectively. On univariate analysis, absence of sinus rhythm at dismissal (p = 0.003) was associated with greater overall mortality. For the entire cohort of 539 patients, LV dysfunction was independently predictive of late mortality (hazard ratio 3.76, p <0.001). At late follow-up (mean 6.9 years), 86% of patients were in New York Heart Association class I or II. In conclusion, LV systolic dysfunction occurs infrequently in patients with Ebstein anomaly and is a risk factor for increased late mortality. Although early mortality is greater in patients with LV dysfunction, the late results are favorable. Decreasing LV function should be an indication to promptly restore TV competence rather than a contraindication to TV operation.