The Year in Review: Anesthesia for Congenital Heart Disease 2023.

This review highlights published literature in 2023 that is related to the anesthetic management of patients with congenital heart disease (CHD). Though not inclusive of all topics, 31 articles are discussed and four primary themes emerged: transfusion and hemostasis, outcomes and risk assessment, monitoring, and pharmacology.

The Year in Review: Anesthesia for Congenital Heart Disease 2022.

This review focuses on the literature published during the calendar year 2022 that is of interest to anesthesiologists taking care of children and adults with congenital heart disease (CHD). Four major themes are discussed: enhanced recovery after surgery(ERAS); diversity, equity, and inclusion; the state of pediatric cardiac anesthesiology as a subspecialty in the United States; and neuromonitoring for pediatric cardiac surgery.

Racial and Ethnic Disparities in U.S Children Undergoing Surgery for Congenital Heart Disease: A Narrative Literature Review.

Congenital Heart Disease (CHD) is a significant source of pediatric morbidity and mortality. As in other fields of medicine, studies have demonstrated racial and ethnic disparities in congenital heart disease outcomes. The cause of these outcome disparities is multifactorial, involving biological, behavioral, environmental, sociocultural, and systemic medical factors. Potential contributors include differences in preoperative illness severity secondary to coexisting medical conditions, differences in the rate of prenatal and early postnatal detection of CHD, and delayed access to care, as well as discrepancies in socioeconomic and insurance status, and systemic disparities in hospital care. Understanding the factors that contribute to these disparities is an essential step towards developing strategies to address them. As stewards of the perioperative surgical home, anesthesiologists have an important role in developing institutional policies that mitigate racial disparities. Here, we provide a thorough narrative review of recent research concerning perioperative factors contributing to surgical outcomes disparities for children of all ages with CHD, examine potentially modifiable contributing factors, discuss avenues for future research, and suggest strategies to address disparities both locally and nationally.

The Year in Review: Anesthesia for Congenital Heart Disease 2021.

This review focuses on the literature published during the calendar year 2021 that is of interest to anesthesiologists taking care of children and adults with congenital heart disease. Four major themes are discussed, including cardiovascular disease in children with COVID-19, aortic valve repair and replacement, bleeding and coagulation, and enhanced recovery after surgery (ERAS).

The Anesthesiologist's Perspective and Experience in Global Congenital Cardiac Surgery: Results of a Survey of the Congenital Cardiac Anesthesia Society Membership.

Anesthesiologists are important components of volunteer teams which perform congenital cardiac surgery in low-resource settings throughout the world, but limited data exist to characterize the nature and breadth of their work. A survey of Congenital Cardiac Anesthesia Society (CCAS) members was conducted with the objective of understanding the type of voluntary care being provided, its geographic reach, the frequency of volunteer activities, and factors which may encourage or limit anesthesiologists' involvement in this work. The survey was completed by 108 participants. Respondents reported a total of 115 volunteer trips during the study period, including work in 41 countries on 5 continents. Frequent motivating factors to begin volunteering included invitations from charitable groups, encouragement from senior colleagues, and direct connections to individual locations. Discouraging factors included familial responsibilities, the need to use vacation time, and a lack of support from home institutions. The year 2020 saw a marked decrease in reported volunteer activity, and respondents reported multiple pandemic-related factors which might discourage future volunteer activities. The results of this study demonstrate the global reach of anesthesiologists in providing care for children having cardiac surgery. It also offers insights into the challenges faced by interested individuals, many of which are related to a lack of institutional support. These challenges have only mounted under the COVID-pandemic, leading to a dramatic downturn in volunteer activities. Finally, the survey reinforces the need for better coordination of volunteer activities to optimize clinical impact.

Perioperative and Anesthetic Considerations in Tetralogy of Fallot With Pulmonary Atresia.

Tetralogy of Fallot with pulmonary atresia (ToF-PA) is a rare diagnosis that includes an extraordinarily heterogeneous group of complex anatomical findings with significant implications for physiology and prognosis. In addition to the classic findings of ToF, this particular diagnosis is characterized by complete failure of forward flow from the right ventricle to the pulmonary arterial system. As such, pulmonary blood flow is entirely dependent on shunting from the systemic circulation, most frequently via a patent ductus arteriosus, major aortopulmonary collaterals, or a combination of the two. The pathophysiology of ToF-PA is largely attributable to the abnormalities of the pulmonary vasculature. Ultimately, these patients require operative intervention to create a reliable, controlled source of pulmonary blood flow and ideally complete intracardiac repair. Even after operative correction, these patients remain at risk for pulmonary arterial stenoses and pulmonary hypertension. Although there have been significant advances in surgical and interventional management of ToF-PA leading to dramatic improvements in survival and long-term functional status, there is ongoing debate about the optimal management strategy given the risk of development of irreversible abnormalities of the pulmonary vasculature and the morbidity and mortality associated with sometimes multiple, complex operative interventions often occurring early in infancy. This review will discuss the findings in patients with ToF-PA with a focus on the perioperative and anesthetic management and will highlight challenges faced by the anesthesiologist in caring for these patients.

The Year in Review: Anesthesia for Congenital Heart Disease 2020.

This review focuses on the literature published during the calendar year 2020 that is of interest to anesthesiologists taking care of children and adults with congenital heart disease. Five major themes are discussed, including COVID-19 in children with heart disease, race and outcome disparities in congenital heart disease, Norwood procedure and outcomes, Fontan procedure and outcomes, and neurotoxicity/neurologic outcomes. A total of 59 peer-reviewed articles are discussed.

In Pursuit of an Opioid-Free Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative.

BACKGROUND: Opioids have been a central component of routine adult and pediatric anesthesia for decades. However, the long-term effects of perioperative opioids are concerning. Recent studies show a 4.8%-6.5% incidence of persistent opioid use after surgery in older children and adults. This means that >2 million of the 50 million patients undergoing elective surgeries in the United States each year are likely to develop persistent opioid use. With this in mind, anesthesiologists at Bellevue Clinic and Surgery Center assembled an interdisciplinary quality improvement team focused on 2 goals: (1) develop effective anesthesia protocols that minimize perioperative opioids and (2) add value to clinical services by maintaining or improving perioperative outcomes while reducing costs. This article describes our project and findings but does not attempt to make inferences or generalizations about populations outside our facility. METHODS: We performed a large-scale implementation of opioid-sparing protocols at our standalone pediatric clinic and ambulatory surgery facility, based in part on the prior success of our previously published tonsillectomy and adenoidectomy protocol. Multiple Plan-Do-Study-Act cycles were performed using data captured from the electronic medical record. The percentage of surgical patients receiving intraoperative opioids and postoperative morphine preintervention and postintervention were compared. The following measures were evaluated using statistical process control charts: maximum postoperative pain score, postoperative morphine rescue rate, total postanesthesia care unit minutes, total anesthesia minutes, and postoperative nausea and vomiting rescue rate. Intraoperative analgesic costs were calculated. RESULTS: Between January 2017 and June 2019, 10,948 surgeries were performed at Bellevue, with 10,733 cases included in the analyses. Between December 2017 and June 2019, intraoperative opioid administration at our institution decreased from 84% to 8%, and postoperative morphine administration declined from 11% to 6% using analgesics such as dexmedetomidine, nonsteroidal anti-inflammatory drugs, and regional anesthesia. Postoperative nausea and vomiting rescue rate decreased, while maximum postoperative pain scores, total anesthesia minutes, and total postanesthesia care unit minutes remained stable per control chart analyses. Costs improved. CONCLUSIONS: By utilizing dexmedetomidine, nonsteroidal anti-inflammatory drugs, and regional anesthesia for pediatric ambulatory surgeries at our facility, perioperative opioids were minimized without compromising patient outcomes or value.

Perioperative Cardiothoracic and Vascular Risk in Childhood Cancer and its Survivors.

CHILDREN with cancer and survivors of childhood cancer have an increased risk of cardiovascular disease, and this risk in the perioperative period must be understood. During diagnosis and treatment of pediatric cancer, multiple acute cardiovascular morbidities are possible, including anterior mediastinal mass, tamponade, hypertension, cardiomyopathy,and heart failure. Childhood cancer survivors reaching late childhood and adulthood experience substantially increased rates of cardiomyopathy, heart failure, valvular disease, pericardiac disease, ischemia, and arrhythmias. Despite considerable advances in the understanding and therapeutic options of pediatric malignancies, cardiac disease remains the most common treatment-related, noncancer cause of death in childhood cancer survivors. Increasingly, molecularly targeted agents, including small molecule inhibitors, are being incorporated into pediatric oncology. The acute and chronic risks associated with these newer therapeutic options in children are not yet well-described, which poses challenges for clinicians caring for these patients. In the present review, the unique risks factors, prevention strategies, and treatment of cardiovascular toxicities of the child with cancer and the childhood cancer survivor are examined, with an emphasis on the perioperative period.

Associations between anthropometric indices and outcomes of congenital heart operations in infants and young children: An analysis of data from the Society of Thoracic Surgeons Database.

BACKGROUND: Children with congenital heart disease are at risk for growth failure due to inadequate nutrient intake and increased metabolic demands. We examined the relationship between anthropometric indices of nutrition (height-for-age z-score [HAZ], weight-for-age z-score [WAZ], weight-for-height z-score [WHZ]) and outcomes in a large sample of children undergoing surgery for congenital heart disease. METHODS: Patients in the Society of Thoracic Surgeons Congenital Heart Surgery Database having index cardiac surgery at age 1 month to 10 years were included. Indices were calculated by comparing patients' weight and height to population norms from the World Health Organization and Centers for Disease Control and Prevention. Outcomes included operative mortality, composite mortality or major complication, major postoperative infection, and postoperative length of stay. For each outcome and index, the adjusted odds ratio (aOR) (for mortality, composite outcome, and infection) and adjusted relative change in median (for postoperative length of stay) for a 1-unit decrease in index were estimated using mixed-effects logistic and log-linear regression models. RESULTS: Every unit decrease in HAZ was associated with 1.40 aOR of mortality (95% CI 1.32-1.48), and every unit decrease in WAZ was associated with 1.33 aOR for mortality (95% CI 1.25-1.41). The relationship between WHZ and outcome was nonlinear, with aOR of mortality of 0.84 (95% CI 0.76-0.93) for 1-unit decrease when WHZ ≥ 0 and a nonsignificant association for WHZ < 0. Trends for other outcomes were similar. Overall, the incidence of low nutritional indices was similar for 1-ventricle and 2-ventricle patients. Children between the age of 1 month and 1 year and those with lesions associated with pulmonary overcirculation had the highest incidence of low nutritional indices. CONCLUSIONS: Lower HAZ and WAZ, suggestive of malnutrition, are associated with increased mortality and other adverse outcomes after cardiac surgery in infants and young children. Higher WHZ over zero, suggestive of obesity, is also associated with adverse outcomes.

The Congenital Cardiac Anesthesia Society-Society of Thoracic Surgeons Cardiac Anesthesia Database Collaboration.

Multi-institutional databases and registries have proliferated over the last decade in all specialties of medicine. They may be especially helpful in low-frequency/high-acuity fields such as pediatric and congenital heart diseases. The Society of Thoracic Surgeon's Congenital Heart Surgery Database (STSCHSD) is the largest single data set for the congenital heart disease population and includes contemporaneous data from over 120 programs in the United States (and several outside of the United States), capturing greater than 98% of the congenital cardiac surgical procedures in the United States. In 2010, the Congenital Cardiac Anesthesia Society partnered with the STSCHSD to incorporate anesthesia-related elements into the data set. Voluntary site participation in the anesthesia data has grown steadily. Currently, over 60 sites performing more than 60% of cardiac bypass procedures in the STSCHSD are submitting anesthesia data annually into the STSCHSD. Anesthesia data include perioperative medication usage, modalities for hemodynamic and neurologic monitoring, blood product, antifibrinolytic and procoagulant use, and anesthesia-related adverse events. This special article provides a descriptive summary of relevant findings to date, reflecting the wide variety in anesthesia practice patterns present among institutions and illustrates the functionality of a multisite registry in pediatric cardiac anesthesia which can be utilized both locally and nationally.