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The Year in Review: Anesthesia for Congenital Heart Disease 2013 Richard J. Ing and Mark D. Twite SEMIN CARDIOTHORAC VASC ANESTH 2014 18: 17 DOI: 10.1177/1089253214522328 The online version of this article can be found at: http://scv.sagepub.com/content/18/1/17
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522328 research-article2014
SCVXXX10.1177/1089253214522328Seminars in Cardiothoracic and Vascular AnesthesiaIng and Twite
The Perioperative Year in Review-2013
The Year in Review: Anesthesia for Congenital Heart Disease 2013
Seminars in Cardiothoracic and Vascular Anesthesia 2014, Vol. 18(1) 17–23 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1089253214522328 scv.sagepub.com
Richard J. Ing, MBBCh, FCA(SA)1,2 and Mark D. Twite, MB BChir FRCP1,2
Abstract Congenital cardiac anesthesiology is a young and rapidly growing subspecialty. It embraces a large spectrum of congenital and acquired heart diseases, which now affect the entire life span of patients from “cradle to grave.” One of the challenges faced by congenital cardiac anesthesiologists is reading the large amount of relevant literature from the fields of cardiology, cardiac surgery, intensive care medicine, and anesthesiology. This review highlights some of the current themes in the literature during the past year. Keywords cardiac anesthesia, children, congenital heart disease, cardiac surgery, heart
Introduction It is challenging to keep up to date with the latest literature in cardiac anesthesiology. Many excellent articles have been published in 2013, but unfortunately it is not possible to review them all. This article reviews selected publications, which have been published in peer-reviewed journals during the past year. The following terms were used to search the US National Library of Medicine PubMed database: congenital heart disease, anesthesia, and surgery. Additional filters used were as follows: publication in the previous 18 months and articles limited to the human species. The following 5 themes emerged that are of interest to cardiac anesthesiologists caring for adults and children with acquired and congenital heart disease (CHD): outcomes data, hemodynamic monitoring, the cardiac catheterization laboratory, dexmedetomidine, and adult CHD. In addition to the many published articles over the past year, there are many new excellent textbooks in the fields of cardiac surgery, cardiology, and cardiac anesthesia. One new reference book, which stands out, is Pediatric and Congenital Cardiology, Cardiac Surgery and Intensive Care, which has 400 contributing experts in the field. It is perhaps the most current and comprehensive reference book in our specialty spanning 3572 pages over 6 volumes and it is continually updated as an electronic version.1
developed world. In countries with emerging economies, such as India, this is an encouraging trend. One center in India recently reported their results for the stage I Norwood procedure in 7 hypoplastic left heart syndrome patients.2 In this small series, 4 out of 5 survivors successfully completed the Glenn procedure. In the developed world, although surgical outcomes for the stage I Norwood procedure continue to improve, management of postoperative tachyarrhythmias in stage I Norwood patients with Sano shunts remain clinically challenging. One center reports a 50% incidence of tachyarrhythmias after Norwood procedure.3 This high incidence of tachyarrhythmias is most likely related to the ventriculotomy performed for the Sano shunt and the need for inotropes postoperatively. These arrhythmias resulted in a longer hospital and intensive care unit stay, but no increase in mortality.3 Continuing with this theme, a retrospective review of 73 procedures performed in 40 patients with hypoplastic left heart syndrome undergoing noncardiac surgery, found an adverse complication rate of 15% and a postoperative intensive care unit admission rate of 18%.4 A further study in this area found that perioperative inotrope use, and preoperative angiotensinconverting enzyme inhibitor or digoxin administration, increased morbidity under anesthesia for noncardiac surgery in children with complex CHD prior to stage II 1
Outcomes in Children With Congenital Heart Disease Outcomes for patients with complex single ventricle anatomy continue to improve in both the developed and less
Children’s Hospital Colorado, Aurora, CO, USA University of Colorado Denver, Aurora, CO, USA
2
Corresponding Author: Mark D. Twite, Children’s Hospital Colorado, 13123 East 16th Avenue, B090, Aurora, CO 80045, USA. Email: [email protected]
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palliation.5 In another series of 39 general anesthetics administered to 31 patients for noncardiac surgery following Fontan palliation, the anesthetic risk to these complex patients is not diminished with 31% experiencing complications.6 Christensen et al7 soberly remind us of the need for heightened vigilance in all children, but especially children with CHD, in the postanesthesia care unit. They found that the respiratory system was the contributing cause of cardiopulmonary arrest (CPA) in 44% of 27 CPA events. Nonsurvival with CPA was associated with a cardiac or hemodynamic cause, older age, CPA occurring at night or during the weekend or CPA in a nonpediatric setting.7 Documenting and sharing outcome data is vital to improve our clinical practice for patients with CHD. Although in its infancy, the first 24 months of data entry from “The Joint Congenital Cardiac Anesthesia Society (CCAS)–Society of Thoracic Surgeons (STS) Congenital Cardiac Anesthesia Database” has recently been published.8 Information on 13 796 cardiac surgical procedures (with and without cardiopulmonary bypass and placement of support devices such as ventricular assist devices) and 3354 cardiac catheterization laboratory procedures (diagnostic, interventional, and electrophysiology) are presented. The initial results validate the concept of a joint anesthesia and surgical database. The study authors report that data entry is often incomplete, and many centers have yet to start recording complete anesthesia data sets for noncardiac surgery, which as indicated earlier, is a time of increased risk for patients with CHD undergoing general anesthesia. The reported incidence of anesthesia related adverse events are low, 2.5% for surgical cases and 1.2% for cardiac catheterization laboratory procedures. With this low incidence of anesthesia-related adverse events in these relatively low-volume procedures, a multisite, interdisciplinary database is the most reasonable approach to capture a sufficient number of patient encounters in a timely manner to support outcomes analysis, quality assessment and improvement.8 Any safe outcome of general anesthesia in children starts with excellent control of the airway. Heinrich et al9 report on 1177 laryngoscopy views over a 6-year period in children undergoing cardiac surgery. They conclude that the incidence of a Cormack and Lehane grade III or IV view is more than twice as high in children with CHD compared with a previously reported series in general pediatric surgery patients.9 It is likely in the near future, that study findings such as this will be supported by large data sets from The Joint CCAS–STS Congenital Cardiac Anesthesia Database.8
Invasive Hemodynamic Monitoring Vigilance and correctly interpreting large quantities of information from monitors is the cornerstone of safe
anesthesia practice. Cardiac anesthesiologists are heavy users of monitoring technology and there is often more than one choice of monitor for the same physiological parameter. Near-infrared cerebral spectroscopy (NIRS) is a good example of this. At present there are 3 commercially available NIRS devices—INVOS (Covidien Corporation, Mansfield, MA), FORE-SIGHT (CAS Medical Systems [CASMED], Branford, CT), and EQUANOX (Nonin Medical Inc, Plymouth, MN)—that are cleared by the Food and Drug Administration for use in pediatrics and adults. These 3 devices differ with respect to design, hardware, and algorithm to determine regional cerebral oxygen saturation. Congenital cardiac anesthesiologists often help validate monitoring technology that is initially developed for the larger adult market for use in pediatrics. Kreeger et al10 report on the validation of the Nonin NIRS EQUANOX device with a new pediatric sensor. The study authors report that the EQUANOX pediatric NIRS sensor accurately measures the absolute value of cerebral saturation in children over a wide range of oxygenation and subject characteristics, offering advantages in assessment of cerebral hypoxia–ischemia in patients with CHD.10 Further studies and reviews add to the growing body of literature on the positive role of perioperative cerebral NIRS to guide management of hemodynamic instability and cardiac arrest.11,12 Older monitoring technology, such as end-tidal carbon dioxide levels, still remains critical to our daily practice. Steward13 reminds us of the pioneering work of Digby Leigh14 in 1957 when he and his colleagues described the role of alveolar carbon dioxide analysis as a surrogate monitor of pulmonary blood flow. Newer monitoring technologies help explain commonly observed clinical findings. Brown et al15 used esophageal Doppler to help explain the hemodynamic compromise often observed when children are turned into the prone position for spinal surgery. They found that a median reduction of 0.5 L min−1 m2 (18.5%) in cardiac index occurs most notably because of a reduction in stroke volume index. 15 Children with CHD and myocardial dysfunction often undergo invasive hemodynamic monitoring as part of their anesthetic plan. The technique of intravascular line placement is important to minimize complications. Despite the reminder by Troianos et al16 about the Society of Cardiovascular Anesthesiologists published guidelines for performing ultrasound-guided central venous access, adoption of this technique remains only at 25% to 30%. Use of routine ultrasound for arterial cannulation in children does not yet have strong support in the literature, but it can be very helpful as a rescue technique.16 Various techniques to help during central venous line placement have been advocated, including passive leg elevation with the Trendelenburg position and longitudinal ultrasound detection of centrally placed guide wires prior to dilation and cannula insertion.17,18
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Ing and Twite Despite the current trend to avoid upper body central venous access in infants with univentricular hearts undergoing cardiac surgery, Miller et al19 recently report on the safety and efficacy in 235 infants undergoing 261 cardiac operations with no upper body central vein stenosis or thrombosis detected. In terms of lower body venous access, deciding on which femoral vein to cannulate for central venous access can be difficult at times. Ozbek et al20 used computer axial tomography to study 90 consecutive pediatric patients and showed that the left femoral vein may be a better choice as the incidence of femoral artery overlap over the femoral vein is significantly lower on the left side.
Cardiac Catheterization Laboratory The themes in the literature for this section include cardiac arrest in the catheterization laboratory, renal protection, arrhythmia ablation, echocardiographic guidance, and sedation techniques during atrial septal defect device closure in children. During the past 13 years, the frequency of perioperative cardiac arrest for noncardiac and cardiac surgery in children with and without CHD has been reported to occur in 0.027 to 5.7 per 100 procedures.21-25 The highest rate of cardiac arrest occurs in patients with severe pulmonary hypertensive disease in the cardiac catheterization laboratory.23,24 Odegard et al26 reported on cardiac arrest requiring chest compressions in 7289 cardiac catheterization procedures in patients with CHD over a 6-year period. The frequency of cardiac arrest was 0.96 per 100 procedures with an overall survival of 81%.26 Children younger than 12 months and those patients undergoing interventional procedures had the highest incidence of cardiac arrest. The study authors attribute 7 of the cardiac arrests to be directly related to the use of anesthesia and they highlight the need for good communication in the cardiac catheterization laboratory in order to anticipate and manage critical events promptly when they occur.26 Acute kidney injury (AKI) occurs in up to 40% of patients following cardiac surgery with the use of cardiopulmonary bypass.27 Predicting AKI in children younger than 1 year following cardiac surgery by using plasma biomarkers remains elusive.28 An initial postoperative plasma lactate level higher than 4.5 mmol/L in one retrospective study has been shown to be associated with a greater need for peritoneal dialysis.29 Bianchi et al30 studied multiple factors as potential predictors of AKI in children following cardiac surgery. They report a retrospective study of 277 patients aged ≤12 years undergoing cardiac catheterization angiography and cardiac surgery in the same hospital stay.30 Children younger than 2 years and those receiving 4.6 ± 2.6 g/kg of iodine, compared with 2.8 ± 2.2 g/kg, were more likely to suffer kidney injury. Importantly, they found that the amount of iodine administered was an
independent predictor of postoperative AKI with a 16 % relative risk increase per each additional gram per kilogram administered. The study authors suggest that limiting the amount of iodine contrast received by children in the cardiac catheterization laboratory, who will undergo cardiac surgery during the same hospital admission, may help prevent AKI.30 Two recent reviews highlight how anesthetic drugs may interfere with studies in the electrophysiological laboratory.31,32 Arrhythmia ablation and the placement and testing of pacemakers and implantable defibrillators, requires a careful balanced anesthetic approach. Too light an anesthetic may result in patient movement and loss of the mapped pathways, but too deep an anesthetic may make it difficult to map the aberrant electrical pathway.31,32 The choice of drugs used may also be important with Char et al33 reporting on the negative chronotropic effects of dexmedetomidine in the electrophysiology laboratory in children aged 5 to 17 years. However, this negative chronotropy may be attenuated by the co-administration of ketamine.33 Traditionally, during closure of an atrial septal defect (ASD) in the cardiac catheterization laboratory, the patient will be intubated in order to facilitate imaging of the ASD with transesophageal echocardiography (TEE).34 Adopting an alternative approach, Hanslik et al35 report a 92% successful percutaneous ASD device closure rate in 174 patients using TEE in children who were not intubated. The anesthetic drugs used included propofol and ketamine.35 Ülgey et al36 also report a series of 46 children who were not intubated in the cardiac catheterization laboratory for percutaneous ASD device closure using TEE. In this study, intravenous ketamine and propofol were compared with dexmedetomidine and propofol. The combination of ketamine and propofol was found to offer excellent procedural conditions and superior hemodynamic stability.36 The next logical step, taken by Erdem et al,37 is to use transthoracic echocardiography (TTE) instead of TEE. In a series of 349 patients, Erdem et al37 report that by using TTE, 61% of patients had significantly shorter procedure and fluoroscopy times.
Dexmedetomidine Dexmedetomidine is a short-acting, highly selective α-2 agonist with a 1600:1, α-2 receptor:α-1 receptor binding ratio.38,39 It is approved by the Food and Drug Administration for use in adults and it is administered offlabel in children.40 Dexmedetomidine is widely used for anesthetic premedication, sedation, anxiolysis, general anesthesia, and to treat emergence delirium.38,39 In the past year, there were a number of publications on the expanded perioperative use of dexmedetomidine. Ji et al39 report on the use of dexmedetomidine in 568 out of 1134 patients undergoing coronary artery bypass
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grafting plus valvular or other procedures on cardiopulmonary bypass. They found a decrease in in-hospital length of stay (1.23% vs 4.59%), postoperative 30-day mortality (1.76% vs 5.12%), and 1-year mortality (3.17% vs 7.95%), and a decreased incidence of postoperative delirium in those patients receiving perioperative dexmedetomidine.39 In this study however, a higher rate of AKI in those patients receiving dexmedetomidine was noted. This is a thoughtprovoking study as more pediatric and adult cardiac surgical patients are receiving dexmedetomidine in the perioperative period and the causes of AKI in postoperative patients are likely multifactorial. The authors recommend that a randomized prospective clinical trial be conducted.39 The advantages of using dexmedetomidine as an adjunct anesthetic agent in the operating room include facilitating early extubation and helping to decrease the incidence of arrhythmias. Dexmedetomidine has been reported to decrease the amount of morphine used in the operating room during off-pump coronary artery bypass grafting.41 In another study of 582 adult patients undergoing cardiac surgery, propofol and dexmedetomidine were compared. There was earlier extubation in the dexmedetomidine group.42 The antiarrhythmic effect of dexmedetomidine has recently been shown with the termination of reentrant supraventricular tachycardia in 15 patients, median age of 10 days, administered dexmedetomidine, mean dose 0.7 ± 0.3 µg/kg, for a total of 27 episodes of supraventricular tachycardia.43 A review of the antiarrhythmic mechanisms of dexmedetomidine and its effects in the pediatric patient with CHD, has also recently been published.44 Three studies looked at the safety of dexmedetomidine use in children with CHD. One study examined the prolonged administration (>96 hours) of dexmedetomidine in a pediatric cardiac intensive care unit and showed it to be safe and possibly desirable with an associated decrease in opioid and benzodiazepine requirements and decreased inotropic support.45 In another study Friesen et al46 report on the hemodynamic response to dexmedetomidine loading in children with and without pulmonary hypertension. Initial dexmedetomidine loading was associated with significant systemic vasoconstriction and hypertension, but a similar response was not observed in the pulmonary vasculature, even in children with pulmonary hypertension.46 Lam et al47 report on the safe administration of dexmedtomidine to 21 patients with end-stage heart failure, with doses of 0.1 to 1.0 µg/kg/h, for a median duration of 193 hours during in-hospital patient stays prior to orthotopic heart transplantation. 47 It is prudent to remember that no medication is without side effects, and dexmedetomidine is no exception. Takata et al48 report on dexmedetomidine-induced atrioventricular block followed by cardiac arrest during atrial pacing in a 56-year-old man
after cardiac surgery. Zhang et al49 previously reported on bradycardia and asystole during dexmedetomidine infusion in an 18-year-old double lung transplant recipient. Six cases of bradycardia and asystole during a 3-month period in neurosurgical patients were also recently reviewed by Bharati et al.50
Adults With Congenital Heart Disease The successful advances in the medical and surgical management of children with CHD, has resulted in a growing population of adult survivors with congenital heart disease (ACHD).51 It is currently estimated that there are 3 million adults in the United States and 1.8 million adults in Europe with ACHD.52,53 Similar to the increased anesthetic risks found in children with CHD undergoing noncardiac surgery the same is also true for adults. Maxwell et al51 studied 10,004 ACHD patients retrospectively with a matched comparison cohort of 37 581 adult patients. They found that ACHD patients experience increased perioperative morbidity and mortality when compared to the matched control cohort. As with the pediatric CHD population, these authors recommend the use of large prospective databases to gather more information about the risk factors for ACHD patients undergoing surgery.51 Although the ACHD population continues to grow, it is not clear that there has been adequate changes in anesthesia training to address the skill set required by congenital cardiac anesthesiologists caring for the spectrum of disease from “cradle to grave.” To address these concerns, Maxwell et al54 looked at the knowledge and attitudes of 118 anesthesia providers at a single center, assessing their comfort level to safely take care of ACHD patients for noncardiac surgery. The authors found a low comfort level for providers caring for patients with ACHD and conclude that improved training and protocols are needed for anesthesia providers.54 The ACHD patient with heart failure is very challenging to care for. Heart failure develops insidiously and its management can be very different in certain subgroups of ACHD patients. In a recent review, Dinardo55 discusses the demographics, diagnosis, functional capacity, and treatment of heart failure in patients with ACHD. Similarly, the anesthetic management of pregnant patients with complex CHD or pulmonary hypertension is equally challenging. Maxwell et al56 review the types of anesthetics used and the outcomes in pregnant women with ACHD or pulmonary hypertension. They report on 107 anesthetics in 65 patients over a 12-year period and found the 85% to 95% of patients received neuraxial anesthesia for all forms of infant delivery, 43% of cases had a caesarian section, and 28% of patients received invasive monitoring as part of the anesthetic plan.56 Yet again, the authors recommend a
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Ing and Twite large prospective database be developed to acquire and share data about the anesthetic risk for pregnant patients with complex CHD. Jooste et al57 review the anesthetic management of patients with single ventricle anatomy and physiology who are pregnant, weighing the risk–benefit ratio of regional and general anesthesia. The peripartum management of the patient with ACHD is further reviewed by Ortman.58
Conclusion This review article selected articles published during the past 18 months and developed 5 themes: outcomes data, hemodynamic monitoring, the cardiac catheterization laboratory, dexmedetomidine and adult congenital heart disease. Although not a comprehensive review of the literature, this article does highlight some of the current topics of interest to congenital cardiac anesthesiologists. Our hope is that the introduction of these topics will act as a catalyst for further analysis of the articles cited and foster discussion. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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septal defects in children and adults. Int J Cardiovasc Imaging. 2013;29:53-61. 38. Khan ZP, Ferguson CN, Jones RM. Alpha-2 and imidazoline receptor agonists. Their pharmacology and therapeutic role. Anaesthesia. 1999;54:146-165. 39. Ji F, Li Z, Nguyen H, et al. Perioperative dexmedetomidine improves outcomes of cardiac surgery. Circulation. 2013;127:1576-1584. 40. Tobias JD, Gupta P, Naguib A, Yates AR. Dexmedetomidine: applications for the pediatric patient with congenital heart disease. Pediatr Cardiol. 2011;32:1075-1087. 41. Khalil MA, Abdel Azeem MS. The impact of dexmedetomidine infusion in sparing morphine consumption in off-pump coronary artery bypass grafting. Semin Cardiothorac Vasc Anesth. 2013;17:66-71. 42. Curtis JA, Hollinger MK, Jain HB. Propofol-based versus dexmedetomidine-based sedation in cardiac surgery patients. J Cardiothorac Vasc Anesth. 2013;27:1289-1294. 43. Chrysostomou C, Morell VO, Wearden P, Sanchez-de Toledo J, Jooste EH, Beerman L. Dexmedetomidine: therapeutic use for the termination of reentrant supraventricular tachycardia. Congenit Heart Dis. 2013;8:48-56. 44. Tobias JD, Chrysostomou C. Dexmedetomidine: antiar rhythmic effects in the pediatric cardiac patient. Pediatr Cardiol. 2013;34:779-785. 45. Gupta P, Whiteside W, Sabati A, et al. Safety and efficacy of prolonged dexmedetomidine use in critically ill children with heart disease*. Pediatr Crit Care Med. 2012;13:660-666. 46. Friesen RH, Nichols CS, Twite MD, et al. The hemodynamic response to dexmedetomidine loading dose in children with and without pulmonary hypertension. Anesth Analg. 2013;117:953-959. 47. Lam F, Ransom C, Gossett JM, et al. Safety and efficacy of dexmedetomidine in children with heart failure. Pediatr Cardiol. 2013;34:835-841. 48. Takata K, Adachi YU, Suzuki K, Obata Y, Sato S, Nishiwaki K. Dexmedetomidine-induced atrioventricular block followed by cardiac arrest during atrial pacing: a case report and review of the literature [published online August 16, 2013]. J Anesth. doi:10.1007/s00540-013-1676-7. 49. Zhang X, Schmidt U, Wain JC, Bigatello L. Bradycardia leading to asystole during dexmedetomidine infusion in an 18 year-old double-lung transplant recipient. J Clin Anesth. 2010;22:45-49. 50. Bharati S, Pal A, Biswas C, Biswas R. Incidence of cardiac arrest increases with the indiscriminate use of dexmedetomidine: a case series and review of published case reports. Acta Anaesthesiol Taiwan. 2011;49:165-167. 51. Maxwell BG, Wong JK, Kin C, Lobato RL. Perioperative outcomes of major noncardiac surgery in adults with congenital heart disease. Anesthesiology. 2013;119:762-769. 52. Rouine-Rapp K, Russell IA, Foster E. Congenital heart disease in the adult. Int Anesthesiol Clin. 2012;50:16-39. 53. Moons P, Meijboom FJ, Baumgartner H, et al. Structure and activities of adult congenital heart disease programmes in Europe. Eur Heart J. 2010;31:1305-1310. 54. Maxwell BG, Williams GD, Ramamoorthy C. Know ledge and attitudes of anesthesia providers about noncardiac
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Ing and Twite surgery in adults with congenital heart disease [published online May 7, 2013]. Congenit Heart Dis. 2014;9:45-53. 55. Dinardo JA. Heart failure associated with adult congenital heart disease. Semin Cardiothorac Vasc Anesth. 2013;17: 44-54. 56. Maxwell BG, El-Sayed YY, Riley ET, Carvalho B. Peripa rtum outcomes and anaesthetic management of parturients
with moderate to complex congenital heart disease or pulmonary hypertension*. Anaesthesia. 2013;68:52-59. 57. Jooste EH, Haft WA, Ames WA, Sherman FS, Vallejo MC. Anesthetic care of parturients with single ventricle physiology. J Clin Anesth. 2013;25:417-423. 58. Ortman AJ. The pregnant patient with congenital heart disease. Semin Cardiothorac Vasc Anesth. 2012;16:220-234.
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The Year in Review: Anesthesia for Congenital Heart Disease 2013 Richard J. Ing and Mark D. Twite SEMIN CARDIOTHORAC VASC ANESTH 2014 18: 17 DOI: 10.1177/1089253214522328 The online version of this article can be found at: http://scv.sagepub.com/content/18/1/17
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522328 research-article2014
SCVXXX10.1177/1089253214522328Seminars in Cardiothoracic and Vascular AnesthesiaIng and Twite
The Perioperative Year in Review-2013
The Year in Review: Anesthesia for Congenital Heart Disease 2013
Seminars in Cardiothoracic and Vascular Anesthesia 2014, Vol. 18(1) 17–23 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1089253214522328 scv.sagepub.com
Richard J. Ing, MBBCh, FCA(SA)1,2 and Mark D. Twite, MB BChir FRCP1,2
Abstract Congenital cardiac anesthesiology is a young and rapidly growing subspecialty. It embraces a large spectrum of congenital and acquired heart diseases, which now affect the entire life span of patients from “cradle to grave.” One of the challenges faced by congenital cardiac anesthesiologists is reading the large amount of relevant literature from the fields of cardiology, cardiac surgery, intensive care medicine, and anesthesiology. This review highlights some of the current themes in the literature during the past year. Keywords cardiac anesthesia, children, congenital heart disease, cardiac surgery, heart
Introduction It is challenging to keep up to date with the latest literature in cardiac anesthesiology. Many excellent articles have been published in 2013, but unfortunately it is not possible to review them all. This article reviews selected publications, which have been published in peer-reviewed journals during the past year. The following terms were used to search the US National Library of Medicine PubMed database: congenital heart disease, anesthesia, and surgery. Additional filters used were as follows: publication in the previous 18 months and articles limited to the human species. The following 5 themes emerged that are of interest to cardiac anesthesiologists caring for adults and children with acquired and congenital heart disease (CHD): outcomes data, hemodynamic monitoring, the cardiac catheterization laboratory, dexmedetomidine, and adult CHD. In addition to the many published articles over the past year, there are many new excellent textbooks in the fields of cardiac surgery, cardiology, and cardiac anesthesia. One new reference book, which stands out, is Pediatric and Congenital Cardiology, Cardiac Surgery and Intensive Care, which has 400 contributing experts in the field. It is perhaps the most current and comprehensive reference book in our specialty spanning 3572 pages over 6 volumes and it is continually updated as an electronic version.1
developed world. In countries with emerging economies, such as India, this is an encouraging trend. One center in India recently reported their results for the stage I Norwood procedure in 7 hypoplastic left heart syndrome patients.2 In this small series, 4 out of 5 survivors successfully completed the Glenn procedure. In the developed world, although surgical outcomes for the stage I Norwood procedure continue to improve, management of postoperative tachyarrhythmias in stage I Norwood patients with Sano shunts remain clinically challenging. One center reports a 50% incidence of tachyarrhythmias after Norwood procedure.3 This high incidence of tachyarrhythmias is most likely related to the ventriculotomy performed for the Sano shunt and the need for inotropes postoperatively. These arrhythmias resulted in a longer hospital and intensive care unit stay, but no increase in mortality.3 Continuing with this theme, a retrospective review of 73 procedures performed in 40 patients with hypoplastic left heart syndrome undergoing noncardiac surgery, found an adverse complication rate of 15% and a postoperative intensive care unit admission rate of 18%.4 A further study in this area found that perioperative inotrope use, and preoperative angiotensinconverting enzyme inhibitor or digoxin administration, increased morbidity under anesthesia for noncardiac surgery in children with complex CHD prior to stage II 1
Outcomes in Children With Congenital Heart Disease Outcomes for patients with complex single ventricle anatomy continue to improve in both the developed and less
Children’s Hospital Colorado, Aurora, CO, USA University of Colorado Denver, Aurora, CO, USA
2
Corresponding Author: Mark D. Twite, Children’s Hospital Colorado, 13123 East 16th Avenue, B090, Aurora, CO 80045, USA. Email: [email protected]
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palliation.5 In another series of 39 general anesthetics administered to 31 patients for noncardiac surgery following Fontan palliation, the anesthetic risk to these complex patients is not diminished with 31% experiencing complications.6 Christensen et al7 soberly remind us of the need for heightened vigilance in all children, but especially children with CHD, in the postanesthesia care unit. They found that the respiratory system was the contributing cause of cardiopulmonary arrest (CPA) in 44% of 27 CPA events. Nonsurvival with CPA was associated with a cardiac or hemodynamic cause, older age, CPA occurring at night or during the weekend or CPA in a nonpediatric setting.7 Documenting and sharing outcome data is vital to improve our clinical practice for patients with CHD. Although in its infancy, the first 24 months of data entry from “The Joint Congenital Cardiac Anesthesia Society (CCAS)–Society of Thoracic Surgeons (STS) Congenital Cardiac Anesthesia Database” has recently been published.8 Information on 13 796 cardiac surgical procedures (with and without cardiopulmonary bypass and placement of support devices such as ventricular assist devices) and 3354 cardiac catheterization laboratory procedures (diagnostic, interventional, and electrophysiology) are presented. The initial results validate the concept of a joint anesthesia and surgical database. The study authors report that data entry is often incomplete, and many centers have yet to start recording complete anesthesia data sets for noncardiac surgery, which as indicated earlier, is a time of increased risk for patients with CHD undergoing general anesthesia. The reported incidence of anesthesia related adverse events are low, 2.5% for surgical cases and 1.2% for cardiac catheterization laboratory procedures. With this low incidence of anesthesia-related adverse events in these relatively low-volume procedures, a multisite, interdisciplinary database is the most reasonable approach to capture a sufficient number of patient encounters in a timely manner to support outcomes analysis, quality assessment and improvement.8 Any safe outcome of general anesthesia in children starts with excellent control of the airway. Heinrich et al9 report on 1177 laryngoscopy views over a 6-year period in children undergoing cardiac surgery. They conclude that the incidence of a Cormack and Lehane grade III or IV view is more than twice as high in children with CHD compared with a previously reported series in general pediatric surgery patients.9 It is likely in the near future, that study findings such as this will be supported by large data sets from The Joint CCAS–STS Congenital Cardiac Anesthesia Database.8
Invasive Hemodynamic Monitoring Vigilance and correctly interpreting large quantities of information from monitors is the cornerstone of safe
anesthesia practice. Cardiac anesthesiologists are heavy users of monitoring technology and there is often more than one choice of monitor for the same physiological parameter. Near-infrared cerebral spectroscopy (NIRS) is a good example of this. At present there are 3 commercially available NIRS devices—INVOS (Covidien Corporation, Mansfield, MA), FORE-SIGHT (CAS Medical Systems [CASMED], Branford, CT), and EQUANOX (Nonin Medical Inc, Plymouth, MN)—that are cleared by the Food and Drug Administration for use in pediatrics and adults. These 3 devices differ with respect to design, hardware, and algorithm to determine regional cerebral oxygen saturation. Congenital cardiac anesthesiologists often help validate monitoring technology that is initially developed for the larger adult market for use in pediatrics. Kreeger et al10 report on the validation of the Nonin NIRS EQUANOX device with a new pediatric sensor. The study authors report that the EQUANOX pediatric NIRS sensor accurately measures the absolute value of cerebral saturation in children over a wide range of oxygenation and subject characteristics, offering advantages in assessment of cerebral hypoxia–ischemia in patients with CHD.10 Further studies and reviews add to the growing body of literature on the positive role of perioperative cerebral NIRS to guide management of hemodynamic instability and cardiac arrest.11,12 Older monitoring technology, such as end-tidal carbon dioxide levels, still remains critical to our daily practice. Steward13 reminds us of the pioneering work of Digby Leigh14 in 1957 when he and his colleagues described the role of alveolar carbon dioxide analysis as a surrogate monitor of pulmonary blood flow. Newer monitoring technologies help explain commonly observed clinical findings. Brown et al15 used esophageal Doppler to help explain the hemodynamic compromise often observed when children are turned into the prone position for spinal surgery. They found that a median reduction of 0.5 L min−1 m2 (18.5%) in cardiac index occurs most notably because of a reduction in stroke volume index. 15 Children with CHD and myocardial dysfunction often undergo invasive hemodynamic monitoring as part of their anesthetic plan. The technique of intravascular line placement is important to minimize complications. Despite the reminder by Troianos et al16 about the Society of Cardiovascular Anesthesiologists published guidelines for performing ultrasound-guided central venous access, adoption of this technique remains only at 25% to 30%. Use of routine ultrasound for arterial cannulation in children does not yet have strong support in the literature, but it can be very helpful as a rescue technique.16 Various techniques to help during central venous line placement have been advocated, including passive leg elevation with the Trendelenburg position and longitudinal ultrasound detection of centrally placed guide wires prior to dilation and cannula insertion.17,18
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Ing and Twite Despite the current trend to avoid upper body central venous access in infants with univentricular hearts undergoing cardiac surgery, Miller et al19 recently report on the safety and efficacy in 235 infants undergoing 261 cardiac operations with no upper body central vein stenosis or thrombosis detected. In terms of lower body venous access, deciding on which femoral vein to cannulate for central venous access can be difficult at times. Ozbek et al20 used computer axial tomography to study 90 consecutive pediatric patients and showed that the left femoral vein may be a better choice as the incidence of femoral artery overlap over the femoral vein is significantly lower on the left side.
Cardiac Catheterization Laboratory The themes in the literature for this section include cardiac arrest in the catheterization laboratory, renal protection, arrhythmia ablation, echocardiographic guidance, and sedation techniques during atrial septal defect device closure in children. During the past 13 years, the frequency of perioperative cardiac arrest for noncardiac and cardiac surgery in children with and without CHD has been reported to occur in 0.027 to 5.7 per 100 procedures.21-25 The highest rate of cardiac arrest occurs in patients with severe pulmonary hypertensive disease in the cardiac catheterization laboratory.23,24 Odegard et al26 reported on cardiac arrest requiring chest compressions in 7289 cardiac catheterization procedures in patients with CHD over a 6-year period. The frequency of cardiac arrest was 0.96 per 100 procedures with an overall survival of 81%.26 Children younger than 12 months and those patients undergoing interventional procedures had the highest incidence of cardiac arrest. The study authors attribute 7 of the cardiac arrests to be directly related to the use of anesthesia and they highlight the need for good communication in the cardiac catheterization laboratory in order to anticipate and manage critical events promptly when they occur.26 Acute kidney injury (AKI) occurs in up to 40% of patients following cardiac surgery with the use of cardiopulmonary bypass.27 Predicting AKI in children younger than 1 year following cardiac surgery by using plasma biomarkers remains elusive.28 An initial postoperative plasma lactate level higher than 4.5 mmol/L in one retrospective study has been shown to be associated with a greater need for peritoneal dialysis.29 Bianchi et al30 studied multiple factors as potential predictors of AKI in children following cardiac surgery. They report a retrospective study of 277 patients aged ≤12 years undergoing cardiac catheterization angiography and cardiac surgery in the same hospital stay.30 Children younger than 2 years and those receiving 4.6 ± 2.6 g/kg of iodine, compared with 2.8 ± 2.2 g/kg, were more likely to suffer kidney injury. Importantly, they found that the amount of iodine administered was an
independent predictor of postoperative AKI with a 16 % relative risk increase per each additional gram per kilogram administered. The study authors suggest that limiting the amount of iodine contrast received by children in the cardiac catheterization laboratory, who will undergo cardiac surgery during the same hospital admission, may help prevent AKI.30 Two recent reviews highlight how anesthetic drugs may interfere with studies in the electrophysiological laboratory.31,32 Arrhythmia ablation and the placement and testing of pacemakers and implantable defibrillators, requires a careful balanced anesthetic approach. Too light an anesthetic may result in patient movement and loss of the mapped pathways, but too deep an anesthetic may make it difficult to map the aberrant electrical pathway.31,32 The choice of drugs used may also be important with Char et al33 reporting on the negative chronotropic effects of dexmedetomidine in the electrophysiology laboratory in children aged 5 to 17 years. However, this negative chronotropy may be attenuated by the co-administration of ketamine.33 Traditionally, during closure of an atrial septal defect (ASD) in the cardiac catheterization laboratory, the patient will be intubated in order to facilitate imaging of the ASD with transesophageal echocardiography (TEE).34 Adopting an alternative approach, Hanslik et al35 report a 92% successful percutaneous ASD device closure rate in 174 patients using TEE in children who were not intubated. The anesthetic drugs used included propofol and ketamine.35 Ülgey et al36 also report a series of 46 children who were not intubated in the cardiac catheterization laboratory for percutaneous ASD device closure using TEE. In this study, intravenous ketamine and propofol were compared with dexmedetomidine and propofol. The combination of ketamine and propofol was found to offer excellent procedural conditions and superior hemodynamic stability.36 The next logical step, taken by Erdem et al,37 is to use transthoracic echocardiography (TTE) instead of TEE. In a series of 349 patients, Erdem et al37 report that by using TTE, 61% of patients had significantly shorter procedure and fluoroscopy times.
Dexmedetomidine Dexmedetomidine is a short-acting, highly selective α-2 agonist with a 1600:1, α-2 receptor:α-1 receptor binding ratio.38,39 It is approved by the Food and Drug Administration for use in adults and it is administered offlabel in children.40 Dexmedetomidine is widely used for anesthetic premedication, sedation, anxiolysis, general anesthesia, and to treat emergence delirium.38,39 In the past year, there were a number of publications on the expanded perioperative use of dexmedetomidine. Ji et al39 report on the use of dexmedetomidine in 568 out of 1134 patients undergoing coronary artery bypass
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grafting plus valvular or other procedures on cardiopulmonary bypass. They found a decrease in in-hospital length of stay (1.23% vs 4.59%), postoperative 30-day mortality (1.76% vs 5.12%), and 1-year mortality (3.17% vs 7.95%), and a decreased incidence of postoperative delirium in those patients receiving perioperative dexmedetomidine.39 In this study however, a higher rate of AKI in those patients receiving dexmedetomidine was noted. This is a thoughtprovoking study as more pediatric and adult cardiac surgical patients are receiving dexmedetomidine in the perioperative period and the causes of AKI in postoperative patients are likely multifactorial. The authors recommend that a randomized prospective clinical trial be conducted.39 The advantages of using dexmedetomidine as an adjunct anesthetic agent in the operating room include facilitating early extubation and helping to decrease the incidence of arrhythmias. Dexmedetomidine has been reported to decrease the amount of morphine used in the operating room during off-pump coronary artery bypass grafting.41 In another study of 582 adult patients undergoing cardiac surgery, propofol and dexmedetomidine were compared. There was earlier extubation in the dexmedetomidine group.42 The antiarrhythmic effect of dexmedetomidine has recently been shown with the termination of reentrant supraventricular tachycardia in 15 patients, median age of 10 days, administered dexmedetomidine, mean dose 0.7 ± 0.3 µg/kg, for a total of 27 episodes of supraventricular tachycardia.43 A review of the antiarrhythmic mechanisms of dexmedetomidine and its effects in the pediatric patient with CHD, has also recently been published.44 Three studies looked at the safety of dexmedetomidine use in children with CHD. One study examined the prolonged administration (>96 hours) of dexmedetomidine in a pediatric cardiac intensive care unit and showed it to be safe and possibly desirable with an associated decrease in opioid and benzodiazepine requirements and decreased inotropic support.45 In another study Friesen et al46 report on the hemodynamic response to dexmedetomidine loading in children with and without pulmonary hypertension. Initial dexmedetomidine loading was associated with significant systemic vasoconstriction and hypertension, but a similar response was not observed in the pulmonary vasculature, even in children with pulmonary hypertension.46 Lam et al47 report on the safe administration of dexmedtomidine to 21 patients with end-stage heart failure, with doses of 0.1 to 1.0 µg/kg/h, for a median duration of 193 hours during in-hospital patient stays prior to orthotopic heart transplantation. 47 It is prudent to remember that no medication is without side effects, and dexmedetomidine is no exception. Takata et al48 report on dexmedetomidine-induced atrioventricular block followed by cardiac arrest during atrial pacing in a 56-year-old man
after cardiac surgery. Zhang et al49 previously reported on bradycardia and asystole during dexmedetomidine infusion in an 18-year-old double lung transplant recipient. Six cases of bradycardia and asystole during a 3-month period in neurosurgical patients were also recently reviewed by Bharati et al.50
Adults With Congenital Heart Disease The successful advances in the medical and surgical management of children with CHD, has resulted in a growing population of adult survivors with congenital heart disease (ACHD).51 It is currently estimated that there are 3 million adults in the United States and 1.8 million adults in Europe with ACHD.52,53 Similar to the increased anesthetic risks found in children with CHD undergoing noncardiac surgery the same is also true for adults. Maxwell et al51 studied 10,004 ACHD patients retrospectively with a matched comparison cohort of 37 581 adult patients. They found that ACHD patients experience increased perioperative morbidity and mortality when compared to the matched control cohort. As with the pediatric CHD population, these authors recommend the use of large prospective databases to gather more information about the risk factors for ACHD patients undergoing surgery.51 Although the ACHD population continues to grow, it is not clear that there has been adequate changes in anesthesia training to address the skill set required by congenital cardiac anesthesiologists caring for the spectrum of disease from “cradle to grave.” To address these concerns, Maxwell et al54 looked at the knowledge and attitudes of 118 anesthesia providers at a single center, assessing their comfort level to safely take care of ACHD patients for noncardiac surgery. The authors found a low comfort level for providers caring for patients with ACHD and conclude that improved training and protocols are needed for anesthesia providers.54 The ACHD patient with heart failure is very challenging to care for. Heart failure develops insidiously and its management can be very different in certain subgroups of ACHD patients. In a recent review, Dinardo55 discusses the demographics, diagnosis, functional capacity, and treatment of heart failure in patients with ACHD. Similarly, the anesthetic management of pregnant patients with complex CHD or pulmonary hypertension is equally challenging. Maxwell et al56 review the types of anesthetics used and the outcomes in pregnant women with ACHD or pulmonary hypertension. They report on 107 anesthetics in 65 patients over a 12-year period and found the 85% to 95% of patients received neuraxial anesthesia for all forms of infant delivery, 43% of cases had a caesarian section, and 28% of patients received invasive monitoring as part of the anesthetic plan.56 Yet again, the authors recommend a
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Ing and Twite large prospective database be developed to acquire and share data about the anesthetic risk for pregnant patients with complex CHD. Jooste et al57 review the anesthetic management of patients with single ventricle anatomy and physiology who are pregnant, weighing the risk–benefit ratio of regional and general anesthesia. The peripartum management of the patient with ACHD is further reviewed by Ortman.58
Conclusion This review article selected articles published during the past 18 months and developed 5 themes: outcomes data, hemodynamic monitoring, the cardiac catheterization laboratory, dexmedetomidine and adult congenital heart disease. Although not a comprehensive review of the literature, this article does highlight some of the current topics of interest to congenital cardiac anesthesiologists. Our hope is that the introduction of these topics will act as a catalyst for further analysis of the articles cited and foster discussion. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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