Stress response in infants undergoing cardiac surgery: a randomized study of fentanyl bolus, fentanyl infusion, and fentanyl-midazolam infusion.

UNLABELLED: There have been significant changes in the management of neonates and infants undergoing cardiac surgery in the past decade. We have evaluated in this prospective, randomized, double-blinded study the effect of large-dose fentanyl anesthesia, with or without midazolam, on stress responses and outcome. Forty-five patients < 6 mo of age received bolus fentanyl (Group 1), fentanyl by continuous infusion (Group 2), or fentanyl-midazolam infusion (Group 3). Epinephrine, norepinephrine, cortisol, adrenocortical hormone, glucose, and lactate were measured after the induction (T1), after sternotomy (T2), 15 min after initiating cardiopulmonary bypass (T3), at the end of surgery (T4), and after 24 h in the intensive care unit (T5). Plasma fentanyl concentrations were obtained at all time points except at T5. Within each group epinephrine, norepinephrine, cortisol, glucose and lactate levels were significantly larger at T4 (P values < 0.01), but there were no differences among groups. Within groups, fentanyl levels were significantly larger in Groups 2 and 3 (P < 0.001) at T4, and among groups, the fentanyl level was larger only at T2 in Group 1 compared with Groups 2 and 3 (P < 0.006). There were no deaths or postoperative complications, and no significant differences in duration of mechanical ventilation or intensive care unit or hospital stay. Fentanyl dosing strategies, with or without midazolam, do not prevent a hormonal or metabolic stress response in infants undergoing cardiac surgery. IMPLICATIONS: We demonstrated a significant endocrine stress response in infants with well compensated congenital cardiac disease undergoing cardiac surgery, but without adverse postoperative outcome. The use of large-dose fentanyl, with or without midazolam, with the intention of providing "stress free" anesthesia, does not appear to be an important determinant of early postoperative outcome.

Parameters associated with perioperative baffle fenestration closure in the Fontan operation.

OBJECTIVE: To identify clinical parameters indicating perioperative fenestration closure in children who underwent the fenestrated Fontan operation. DESIGN: Retrospective. SETTING: Single children's hospital. PARTICIPANTS: Patients who underwent a fenestrated Fontan operation in 1996 through 1997 (n = 101). INTERVENTION: A fenestrated Fontan operation was performed in children with single-ventricle physiology. MEASUREMENTS AND MAIN RESULTS: Early perioperative closure of the fenestration occurred in 14 patients (group 1), whereas the fenestration remained patent in 87 patients (group 2). The groups were compared by the following parameters: demographics, cardiac catheterization and ultrasound data, and use of aspirin or warfarin preoperatively and intraoperatively by assessing the composition of the cardiopulmonary bypass solution, use of ultrafiltration and antifibrinolytics, protamine dose, last hematocrit on cardiopulmonary bypass, and requirement of blood products. Immediately postoperatively in the intensive care unit (ICU), cardiac filling pressures (central venous and left atrial pressure), coagulation profile, cardiac rhythm, chest tube drainage, length of stay in the ICU, and use of atrial pacing were reviewed. Significant indicators of early fenestration closure in this study as determined by multivariate stepwise logistic regression were a high transpulmonary pressure gradient (p = 0.015) and a higher oxygen saturation (p = 0.001) 1 hour after arrival in the ICU, a low fibrinogen level (p < 0.0001), and the need for temporary atrial pacing (p = 0.029). The fenestration was reopened in 13 patients in group 1. In 101 patients, there was no early mortality, and all patients survived to discharge. CONCLUSION: Factors that correlated with postoperative fenestration closure in the fenestrated Fontan operation in this study were a high transpulmonary pressure gradient and a high oxygen saturation 1 hour after arrival in the ICU, a low fibrinogen level, and the need for temporary atrial pacing.

Intraoperative recurrent laryngeal nerve monitoring during video-assisted throracoscopic surgery for patent ductus arteriosus.

OBJECTIVE: To develop a technique to identify and localize the recurrent laryngeal nerve (RLN) during video-assisted thoracoscopic surgery (VATS) for patent ductus arteriosus. DESIGN: Prospective clinical study. SETTING: Children's hospital. PARTICIPANTS: Sixty infants and children scheduled for elective closure of patent ductus arteriosus. INTERVENTIONS: With parental informed consent, 60 infants and children undergoing elective VATS for patent ductus arteriosus were studied. A thin, pencil-point, Teflon-coated, stimulating probe allowed direct stimulation (<2 mA, 100-msec pulse width) of the left RLN inside the thorax. A commercially available 4-channel neurologic monitor recorded compound evoked electromyograms (EMGs) from the left RLN and right RLN (as control) by needle electrodes placed percutaneously in the neck. Hoarseness, stridor, feeding difficulties, and voice changes were assessed postoperatively. MEASUREMENTS AND MAIN RESULTS: Left RLN EMGs were easily obtained in 59 of the 60 patients. The surgeon correctly identified the RLN visually once in the first 7 patients; this ability subsequently improved. EMG localization of the location or course of the RLN altered dissection, clip size, or clip position in 37 of 59 patients. CONCLUSION: Intraoperative EMG to identify location and route of the RLN was easy to perform, was effective in identifying RLN position, and appeared to facilitate dissection and clipping of the ductus.